Family History.-One blood relation, father's brother, in an asylum; a maternal aunt with phthisis; otherwise good; both parents alive and well; no brothers or sisters dead.

Past History. Never required a doctor prior to this attack, and enjoyed the best of health. As a child of 16 months she fell down a tank in course of construction, about 10 feet deep, striking her head on some loose bricks. The injury was not considered serious, as there

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was not much bleeding," and a piece of sticking-plaster was applied by a neighbour. She was stunned at the time, and was "pretty bad during the night."

She soon improved, and the matter passed so completely out of the memory of the parents that for some time no cross-questioning of mine could elicit any history of a former injury.

The child was intelligent at school, was not subject to headaches, and showed no symptoms of cerebral irritation. As she got older she was conscious of a dint in her head and often spoke to her parents about it to ask how it was caused, but prior to this incident they always attributed her sensations to imagination.

Examination.With care I detected beneath a mass of hair a minute scar about half-an-inch long and one line broad. This was not tender and was movable on the skull. It was 3-inch above and 2-inch behind the left ext. auditory meatus. No other pathological or abnormal conditition could be discovered in any part of the body.

The progress of the case was rapid. The attacks became more and more frequent, till in October of 1899, nine months after the first attack, they came at intervals of 14 days and less; the prostration following one attack was barely over before another followed. This in spite of large doses of bromides, rest and cessation of all teaching and other mental worries. By this time the attacks had a regular typical course, viz. :—

Description of Attack.-The chief aura was one of sight-seeing flames and vanishing of objects on the right side. There was also a motor aura in the right face and arm and leg. The patient knew that when she felt "live blood" in the face that she must get help and lie down. Then followed loss of consciousness and violent contraction of muscles on the right side of the face, arm, and leg, with occasional movements of the other side during the intensity of the spasm.

She never bit her tongue, but she broke one of the molars on the right side from the grinding of her teeth. Her face became blue and engorged, and her eyes turned up. Never passed urine or defæcated during an attack. She hurt herself on only one occasion, when

she fell out of bed during a night attack. The usual time for the attack was the early morning, before or after getting out of bed.

The question of operation, which I had steadily advocated, was at last forced upon the parents, and at a consultation with Mr. O'Hara decided upon.

Operation, October, 1899-After shaving the head, the scar being then clearly visible, Mr. O'Hara reflected a semilunar flap, and exposed the bone under the scar, when a distinct hole, which the specimen before you demonstrates, became visible, leading through the bone into the cranium. Taking this as a centre, the first trephine hole removed a large piece of thickened and depressed bone, but an exploration with the finger showed that the injury to the inner table extended further than we had reached, and three other trephinings were necessary to remove the large amount of damaged bone which can now be seen in the specimen before you to have been projecting into, and adherent to the dura mater for a distance which you can estimate for yourselves, but I should say half to three-quarters of an inch. The dura mater was slightly torn during the separation of some of the most projecting portions, and was sutured Iwith fine silk. No bone or plate was used, and the wound was closed without drainage. Healing was rapid and perfect, and on the seventh day after the operation there was a typical, though not severe, convulsion, with rise of temperature to 100° F.

From then till December 17th, two months, she was perfectly free from any sign of attack, and on the date mentioned she had an aura, and thought an attack was coming on, but it did not.

From that day till June 10th of this year she never had another attack. She resumed her scholastic duties, and never seemed any the worse for the loss of the large amount of skull which you will see was removed. She had the misfortune to be thrown off her bicycle on to her head, raising a bruise over the site of the operation, but beyond a concussion she suffered no other harm.

The sequel to the case is unfortunate in the extreme, and robs it of much of its personal, if not scientific, interest. She contracted a broncho-pneumonia, following influenza, some six months ago. It rapidly developed into an acute tuberculosis, and she died in the early days of this month; so what would have been the ultimate history of the epilepsy must always remain a matter of conjecture.

The extraordinary feature of the case, to my mind, is not that she should get epilepsy with such an injury or that she should improve when operated on, but that for 22 years after the

injury, such damage as the specimen shows now to have been then sustained, should have failed to cause any symptoms during that time.

(Read before the Victorian Branch British Medical Association.)

A CASE OF sudden DEATH SHORTLY
AFTER CHILDBIRTH.

By C. H. SOUTER, M.B. (Aberdeen), Balaklava, S.A.

I

I WAS called by telephone at 10 a.m. on the 3rd of May, 1902, to see A.M., living about 12 miles away. The message merely stated that the patient had been confined about three hours previously and was then fairly well, but that the placenta had not been expelled, and that the nurse was anxious. I could get no further information. I arrived at the patient's residence at about 11.30. Upon further inquiries I made out that the patient was a primipara, aged 27, in good health, and at the full term of gestation. Pains had commenced 48 hours previously, continued for 12 hours, and then ceased, coming on again some hours later. The labour had been normal so far as the unskilled attendant could tell, and she stated that no more than ordinary hæmorrhage had taken place; it had ceased before my arrival. The patient was somewhat restless, very pale, lying on the back with the head propped up. could not feel any radial pulse. The fingernails were pale blue and the lips also bluish in colour. The pupils were normal, and she said she had no tinnitus, "swimming in the head," nor faintness. Nevertheless the respirations were sighing and about 30 per minute. The heart sounds were feeble and 120 per minute, but no bruit could be heard. No apex beat could be seen or felt. The extremities were cold. No firm contraction of the uterus could be made out from outside, but the patient complained of severe pain in the back. Moderate pressure on the abdomen in such a manner as to grasp the fundus uteri caused the extrusion of some black loose clots and some very dark fluid blood, but not any advance of the cord. Firm pressure had no further effect, nor could I make out any contractions of the womb. There was no appearance to indicate that the hæmorrhage had been other than moderate before my arrival. I examined per vaginam. The placenta was still in the uterus.

The

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and two fingers inside the os, and made steady traction on the placenta, continuing outward pressure. The placenta came slowly away, and was delivered. I found it to be intact, and compressed into the shape of a French" loaf, the membranes also being complete. No bright blood followed, but what little came away was fluid and very dark, almost black. My left hand now failed to make out the uterus at all, and gentle downward pressure caused no responsive contractions; I therefore gave 40 minims of liquid extract of ergot by the mouth. The patient's condition was unchanged, the whole of this proceeding having taken about four minutes. There was a moderate-sized tear in the perinæum, which I brought together with two silkworm gut sutures. I then washed out the vagina (not the uterus) with a pint of hot biniodide of mercury solution (1 in 4,000), followed by a similar quantity of hot sterilized water. Except while stitching and douching (occupying about five minutes) I kept my hand on the abdomen, attempting to grasp the fundus uteri. In a few minutes I made out the latter, which commenced to contract in the normal manner. I had meantime dressed the perinæum, and now applied a binder, preventing as much as possible any movements on the patient's part. She was very restless, however, and complained more than ever of pain in the back. The respirations became more rapid and gasping, and the expression more anxious. I could still feel no radial pulse. I gave her two drachms of brandy in a little water, had hot applications made to the feet and legs, withdrew the pillow from under the head, and gave four minims of liquor strychniæ by the mouth. I had no digitalis with me, nor any suitable needle for making an intravenous or hypodermic transfusion of saline solution, but I made preparations for giving_a copious hot rectal injection of the same. I informed the husband that I was much alarmed by the patient's condition, and made inquiries about her previous history, but could get no information, except that they "did not think" she had ever had rheumatism or scarlet fever, and that she had not been subject to fainting or other signs of heart trouble. I gave another two drachms of brandy in water, and continued the hot applications to the lower limbs. I was about to administer the enema of hot salt solution when the breathing became interrupted, and the patient ceased to toss the arms about. I called in her husband, but she was unable to speak to him before she expired. I was only by the bedside for something over half-an-hour, and lost no time in doing what I have described above. Perhaps more might have been done had the means been at hand.

I have ventured to record this case somewhat at length, because instances of sudden death in the puerperium, or immediately after labour, are fortunately not every-day occurrences, and the precise cause in many cases is not selfevident. Thrombosis of the pulmonary artery, air embolism, internal (or other) hæmorrhage, heart failure (syncope), cerebral hemorrhage, and shock after difficult labour, are the chief

causes.

In the case I have related I consider I had to deal with gradual (one might call it progressive) failure of the heart There was no evidence of serious hæmorrhage either before or after my arrival. The blood that escaped while I was there was of a venous character. There was no unconsciousness till the last few minutes. There was no rupture of the uterus. The finger-nails and lips were not blanched, but bluish in colour from an early period, for the attendants said they had noticed this ever since the child was born. No "inward examination" by the nurse was confessed to; I asked the patient, and she said none was made. All the symptoms were marked before I made a vaginal examination or gave a douche, hence air embolism may be excluded. Nothing suggested cerebral apoplexy. The difficulties of the labour were not apparently of a kind to cause shock. The child was alive and well.

The literature to which I have access says comparatively little about sudden death after labour. Herman, in "Difficult Labour," p. 308, says: "When a patient is very prostrate the effect of suddenly emptying the uterus may cause fatal syncope.' But here he is referring to "placenta prævia" with loss of much blood. He adds that a patient in whom loss of blood has been stopped may "pass gradually into collapse and die." Leishman (in the 1888 edition, p. 334) says thrombosis and embolism are predisposed to by exhausting hæmorrhage, but he mentions no cases of sudden death within a few hours of

delivery from these causes. Goltman (Medical Record, May 8, 1897) remarks on a case of thrombosis secondary to varix which caused sudden death during the puerperium, and says that pulmonary embolism is the cause of most such cases, but adds that prolonged labour or shock may directly cause sudden death (Braithwaite's Retrospect, Vol. CXV.). The most full and interesting account of the subject within my reach I found in "Churchhill's Theory and Practice of Midwifery," though the edition is very old (1872), and, significantly enough, the pages in that portion of the book were uncut. In chapter 22 he deals with sudden death, and details a number of cases. Amongst them is (p. 630) one described by

M. Chevallier thus :-" After the birth of the second child (twins) she appeared a good deal exhausted, and as the discharge of blood was very moderate the accoucheur thought it best to defer the extraction of the placenta. She recovered a little, but about two hours afterwards grew suddenly faint, breathed short, and died in about half an hour." On page 631 is also a quotation from Ramsbotham's "Practical Observations," which describes such cases under the heading of "Idiopathic Syncope," and a similar quotation from Christison on page 630. Either of these would serve to describe the case of A.M. almost precisely, and they appear to refer to a class of cases in which death is due to heart failure of more or less sudden occurrence, unassociated with thrombosis, embolism, hæmorrhage, or entrance of air into a vein, and in the absence of organic heart disease.

UNUSUAL TYPE AND LOCATION OF LUPUS ERYTHEMATOSIS.

By W. McMurray, M.D., Physician to the Department for Diseases of the Skin, Sydney Hospital.

IN New South Wales lupus erythematosis is much more common than lupus vulgaris. In 1,000 consequative cases in private practice the proportion was 13 to 4. It is rare to see it occur on mucous membranes. This is the reason of publishing the following case:

S.P., aged 21, farmer.

Family History.-Father, 62, suffers from rheumatism; mother, 63; five brothers, five sisters-all living, in good health. There is no history of phthisis.

Personal History.-At age of 10 suffered from sunstroke; was ill a fortnight. For some time afterwards was subject to headache and vomiting. In cold weather suffers from chilblains. With these exceptions he has always had good health.

History of Present Condition.-Six years ago the lower lip became swollen, painful, and cracked, "just like a cold." This seemed to get better for a time, and then relapsed. Three months afterwards the upper lip became similarly affected. A mucoid secretion forms during sleep, which causes glueing of both lips and great discomfort. When the lips become stretched, as in laughing, they crack, and blood crusts form over the fissures. They are constantly scaling. It is just as active in summer as during the cold season. The lesions on the left side of the nose and lobules of the ear appeared three years subsequently.