129

Complement-fixation in regard to tubercle should bedone, and a differential blood count, with a bloodcoagulation time. And there should certainly be asearch for focal infections, with radiography of teethand sinuses. Always the possibility of early Graves’sdisease must be considered, and an exploration shouldprecede a decision to extirpate the orbital contents.

Mr. LINDSAY REA related a case of similar kindwhich had been under his care recently. The patientwas a young man who was brought to hospital withhis left eye proptosed, and the conjunctiva swollen andchemosed, so that the lids did not meet over the cornea.He denied venereal disease. Exploratory puncture ,with division of the external rectus revealed nothing. ISubsequently the Wassermann was found positive.Vision in the eye concerned was reduced to bareperception of light. Three weeks later the other eyebegan to be proptosed. The man was put upon treat-ment by novarsenobillon, combined with iodide ofpotassium and mercury inunction. At the end of thethird week the improvement was definite, and inthe sixth week the eyes settled down, the lids againmet, and vision was 6/6 in each eye. Even if theWassermann had been negative, he would havepersevered with antisyphilitic treatment.

Bi-temporal Hemianopia due to Fracture of Skull.Mr. EnERTON GRAY showed a man who, in 1911,

fell 12 feet and sustained a depressed fracture in thefrontal region of the skull. There was severe epistaxis,and on recovering consciousness he complained ofdefective sight. There had been severe headache,and in certain positions there was double vision.He also lost the sense of smell. Pupils were equal andactive, and there were no colour scotomata. Therehad been no albuminuria or polyuria, and his sugartolerance was not increased. He had, however,peculiar nystagmoid movements of the head.-Mr.J. H. FiSHER regarded the case as a very unusual one.The fracture must, in order to cause the symptoms,have run across the roof of the orbit and involved thecribriform plate and olfactory lobes, as well as

implicating the optic chiasma.

Congenital Blindness 2cithout Obvious Ocular or CentralCause.

Mr. RAYNER BATTEN showed a sister (aged 6) andbrother (aged 3) who were born blind, without obviouscause. The children were otherwise healthy and wellformed. There were no evidences of congenitalsyphilis nor of central nervous disease. Wassermannwas negative in both the children and their mother.The boy had about +6 of astigmatism, and the girlhad hypermetropia in one eye, and hypermetropicastigmatism in the other. Whether the pupils reactedto light was doubtful. Both had slow nystagmus.- Mr. LESLIE PATON referred to two children in thesame category whom he had had under observation fora number of years. These at first had head-noddingand nystagmus. They showed fine macular changes.-Mr. FISHER thought that in Mr. Batten’s cases

there were pathological changes in the retina andoptic nerves. The boy had pallor of the disc, and thegirl had thread-like retinal vessels, and in the lowerpart of her fundus was a definite sheathing withpigment of some of the vessels.-Mr. M. S. MAYOUspoke of a girl, aged 18, who was born blind and whosediscs looked very similar to those of Mr. Batten’s.two cases. Two years after he saw her she died asthe result of an accident, and the post-mortemshowed she had large cysts occupying the occipitallobes, the cysts comprising a distansion of the posteriorhorns of the lateral ventricles.-Dr. FRANCHESCHETTI(Zurich) thought it probable that these two childrenhad a familial disease, and that it was likely theblindness might be due to colour-blindness. In thelatter there was also a fine nystagmus.

-Alr. P. G. DoYrTE showed a patient with micro-phthalmia, a retinal cyst, and pedimculated growthsalong the line of the orbito-nasal fold.

NORTH OF ENGLAND OBSTETRICAL ANDGYNÆCOLOGICAL SOCIETY.

A MEETING of this Society was held at Manchesteron Dec. 19th, 1924, Prof. A. DONALD, the President,in the chair, when Dr. KENNETH V. BAILFY reada paper on the

Pathology of Ectopic MÜllerianoma (Pelvic ’

Adenomyoma).Dr. Bailey said that since the work of von

Recklinghausen and Cullen towards the end of thenineteenth century-who first aroused full interestin the subject of " adenomyomatous " growthsaffecting the female pelvic organs-many authorshad written on tumours of this class. In recenttimes, however, the condition had become associatedpathologically with the name of Sampson, of Albany,U.S.A., and clinically with that of Donald, ofManchester. Hitherto, no attempt had been made to’classify this tumour from a pathological and aetio-logical standpoint ; its aetiology still remained indoubt and its life-history was, as yet, very imperfectlyexplained. However many instances of tumour

formation there might be in the pelvis at the onetime, they were all, aetiologically, part of the onepathological condition, and must, therefore, be lookedupon as part of the one tumour. They were, in fact,all brought about by the periodic or occasionalinvasion of the various pelvic organs or peritonealsurfaces by either endometrial tissue or Fallopian tubalepithelium.

Dr. Bailey classified the various tumour formations,which together constituted this pathological conditionof the pelvis, into two types : (a) endometrial type z(b) Fallopian tube type. These two types differedessentially in their gross pathology and even moredefinitely in their histological characteristics. Bothtypes, however, might create widespread lesionsthroughout the pelvis. It was the ovary, however,which exhibited the results of the growth andactivity of these tissues to the fullest extent. Arelatively insignificant reaction might be the onlyevidence of this growth in the uterine wall when,in the same case, the ovary had been transformedinto a distended sac containing dark, tarry blood,a product of the activity of the invading tissue.It was from the ovary, therefore, that the life-history of this condition could best be studied.

Dr. Bailey said that the chief differences in the grosspathology between the endometrial and Fallopiantube types of this condition were as follows :-

Endometrial Tye.-(1) An affected ovary may exhibitany stage from that of possessing small, diffuse haemor-rhagic areas on its surface to advanced excavation and dis-tension transforming it into a distended sac filled withchocolate-coloured fluid blood, and cellular debris. (2) Thelesions produced in the ovaries, uterine wall, pelvic ligament,rectum, &c., are obviously of an active local invasive nature.The impression of great activity on the part of the abnormallyplaced tissue is produced. Excavation may be extensive.(3) The pelvic adhesions are of a very dense character.The ovaries are fastened to the uterine wall or broad liga-ment by actual new growth in many instances and areoften very difficult to detach.

Fallopian Tube Type.-(l) Is evidenced by-small scatteredhaemorrhages on the ovarian surface, of varying colourfrom bright red to almost black according to their age ;advanced conditions exhibit erosion of the ovarian surface.A small depressed scar may mark- the site of an old deposit.(2) This type is characterised by the relatively light natureof the pelvic adhesions, differing markedly from the densecharacter of those produced by the endometrial type.(3) Blood cavities in the ovary are not produced. (4) Bothmacroscopically and microscopically there is the appearanceof only slight invasiveness on the part of the misplacedtissue, which only penetrates at most to a depth of about2 mm. below the surface of the organ in which it is growing.

The chief microscopical differences between thesetwo types, Dr. Bailey said, would be evident in abrief description of their life-history.

130

Life-history of the Endometrial Type.(a) As it Affected the Ovary.

Stage 1.-Not visible to the naked eye. It was seenmicroscopically to be of the nature of a deposit of typicalendometrial tissue on the ovarian surface. Perhaps oneor two typical gland spaces situated in fine fibrin networkwhich also contained endometrial stroma cells might besituated on the surface of the ovary or perhaps scatteredcolumnar cells identical with those which line the glandsof the endometrium might form this primary deposit.

Stage 2.-Invasion of the ovarian stroma by this abnor-mally placed endometrium. (a) If the primary endometrialdeposit occupied a relatively wide area on the ovariansurface, this stage was visible to the naked eye as a minutehaemorrhagic excavation thereon and microscopically theinvading endometrium could be seen to have commencedits penetration of the ovarian cortex. (b) If the primarysite were relatively small in area, this stage was markedby the production of a small, somewhat diffuse hsemor-rhagic bleb on the surface of the ovary. Microscopically,a pseudo-cyst was formed immediately beneath the ovariansurface (but connected with it) containing the activeendometrium and extravasated blood.

Stage 3.-(a) Misplaced endometrium invading over arelatively wide area penetrated the ovarian stroma in awedge-shaped formation. The actual glandular elementswere preceded by masses of stroma cells. This was the stageof intense activity on the part of the invading tissue, bothin penetration and proliferation. (b) Endometrium activelyinvading from a relatively small surface area might do soby a long, apparently quickly formed channel, at thetermination of which the most advanced endometriumwas situated in one or more actively proliferating clumps.

Stage 4.-Commencing degeneration of the invadingelements. At this stage the height of activity of the mis-placed tissue was reached or passed. It was visible to the ’,naked eye as a "seam" of chocolate fluid blood whichstretched for varying distances into the tissues of the ovaryand marked the track of invasion of the penetratingendometrium. The chocolate fluid blood was the long-retained product of the menstrual activity of the endo-metrium and was composed of blood corpuscles, bloodpigment, degenerated epithelial cells, phagocytes, andcellular debris. Microscopically, the invading endometriumwas always found in connexion with the deepest part ofthe " chocolate seam and was seen to be undergoingdegenerative change.

Stage 5.-Commencing cavity formation in the ovaryitself. Further extravasations of menstrual blood byendometrium situated in connexion with a " chocolateseam caused local distension of the seam by liquefactionof the surrounding ovarian stroma and an actual cavitywas formed in the substance of the ovary. Microscopically,endometrial tissue of vitality perhaps equal to that foundin association with Stage 4 was seen situated in close con-nexion with this cavity.

Stage 6.-Last stage. Here the ovary was transformedinto a distended " sac " the size of a tangerine orangeor even larger. The walls of this "sac " were composedof the thinned-out and compressed ovarian stroma itself,deeply and irregularly infiltrated by old blood. Theextensively excavated ovary was filled with chocolatefluid blood, the product of the activity of the invadingelements. Such an ovary was always densely adherentat the primary site of invasion to neighbouring structures-e.g., uterine body or the base of the broad ligament.Microscopically, the remains of degenerated endometrialtissue might possibly be found in the deepest parts of thelarge cavity.The stages in the life-history of the endometrial

type of this growth were thus brought about by aprocess of pure invasion of the affected organ-e.g.,ovary-by the misplaced endometrium. Excavationwas commenced with consequent cavity formation.The terms " chocolate cyst," " haemorrhagic cyst "used by other authors were erroneous. A " bloodcavity " was produced in the ovary by this processof excavation. There was no cyst wall producedby the activity of the foreign elements. Dr. Baileybelieved that the ovary became adherent to neighbour-ing structures during Stage 2, when slight hasmor-rhagic erosion or excavation had taken place on itssurface. It might escape adhesion for a time in thisstage when a small space was formed immediatelybeneath the surface, but would sooner or later becomeadherent as the area of primary deposit of the endo-metrial tissue became larger. The ovary was, there-fore, adherent at a very early stage in the life-history

of the tumour and remained so during the growth ofit. There was no " perforation " of the " cyst " asdescribed by Sampson and others. The mouthof the blood cavity was formed at the commencementof the growth inwards of the endometrial tissue, andthe site of " perforation

" mentioned in literature wasthe cavity mouth which was always found glued tosome neighbouring structure. Dr. Bailey was of theopinion that the tissue found in these blood cavitiesand excavations was endometrium because (1) itwas morphologically identical; (2) its function wasthe same-viz, menstruation-and this occurredconcurrently with menstruation in the uterineendometrium; and (3) eetiologically, as he hoped toprove, the glandular and stromal elements were

derived from the uterine cavity itself.(b) Endometrial Invasion of the Uterine Body

from Without.Stage .—Implantation on the uterine surface of a clump

of endometrial glands or epithelium and stroma cells. This,if extensive enough, might be visible to the naked eye asa minute haemorrhagic spot or bleb of a somewhat diffusenature.

Stage 2.-Active penetration and proliferation on thepart of the invading endometrium. The actual glandularelements were preceded by masses of typical stroma cellswhich pushed their way in between the muscle bundles ofthe uterine body. Menstrual blood was extravasated intothis " stromal bed " which in areas of intense extravasationbecame transformed into a highly hsemorrhagic, loose,spindle-celled matrix.

Stage 3.-Characterised by microscopical evidence ofretrogressive change in the misplaced endometrium. Theglands had become widely dilated and lined by cuboidalor low epithelium. They were either empty or containedold blood and were surrounded by a thin bed of stromacells which did not exhibit any invasive activity.

(c) Endometrial Inmsion as it Affects the FallopianTube from TVithout.

Dr. Bailey had seen only one case in which theFallopian tube was definitely invaded by endometrialtissue deposited on its serous surface from without. Inthis the fimbrial end of the tube exhibited two small,discrete chocolate-coloured areas on its surface andanother diffuse haemorrhagic area at some littledistance from these. Microscopically, the muscularwall of the tube could be seen to be invaded bytypical endometrial elements having no connexionwhatever with the epithelial elements of the tuballumen. This, he held, was the only case of the kindas yet reported.

Life-history of the Fallopian Tube Type.Stage l.-Like the endometrial type, this stage was not

visible to the naked eye. It consisted of a deposition onthe ovarian surface of a mass or strip of loose Fallopianepithelial cells, of the same morphological characteristicsas those which lined the tubal plicae. These cells were ofa high cylindric variety. Their sides were concave, themiddle of the cell body appearing constricted. Theirsurfaces were relatively broad and were ciliated. Theirnuclei were situated nearer the surface than the base.These cells were packed closely together in a somewhatdisorderly manner when observed in rows, and a constantfeature was that their surfaces presented a "dirty" "appearance due to adherent particles of blood debris (fibrin)which had apparently been attracted by, and becomeentangled in, the cilia attached to them.

Stage 2.-Commencing invasion of the ovarian stromaof these cells. This took the form of a minute indentationin the ovarian surface lined by the invading cells and avery slight rarefaction of the subjacent tissue. There wasno evidence of a " stromal bed " as in the endometrial type.This stage, also, was not visible to the naked eye.

Stage 3.-From this point penetration of the ovarianstroma continued until a stage was reached at which oneor more definite gland-like spaces were formed at shortdistances below the ovarian surface. Often only one spacewas formed, rarely more than three or four together. Thesespaces were widely dilated, atypical in shape, as comparedwith endometrial gland spaces, and lined by the highcolumnar ciliated cell of this type. They always resteddirectly on the ovarian stroma. They had no " bed " ofstroma cells. There was only a relatively slight rare-

faction of the surrounding ovarian tissue, brought aboutin many of the cases by the effect of extravasated blood inthe vicinity.

131

Stage 4.-From this point onwards the abnormallyplaced Fallopian elements began to degenerate. Very littlefurther penetration took place. The affected ovary wasnever deeply invaded. There was no excavation. Withdegeneration of the epithelial cells lining these gland-likespaces and extravasation of the contained blood into thesurrounding ovarian stroma, the life-history of Fallopianepithelial invasion of the ovary came to an end. Stages 3and 4 could be detected in the gross specimen by the presenceon the surface of the ovary of minute, discrete, haemor-rhagic spots, varying in colour from bright red to black,according to their age. A depressed scar might mark thesite of a very old deposit.

Dr. Bailey held that Fallopian tubal epitheliumwas unable to invade the musculature of the uterinebody. He had found evidence of it, however, in theovarian ligament and Fallopian tube wall.

E’Moy.Dr. Bailey believed the primary deposit on the

ovarian surface (or any other surface) to be broughtabout by the " shedding " on to it of endometrialor Fallopian tubal epithelium emanating from theuterine cavity or Fallopian tubal lumen respectively,as the result of a process of retrograde menstruationor back-flow through the tubes, by which elementsof this nature were eventually expelled via theabdominal ostium of the Fallopian tube and depositedon the surfaces of the various pelvic organs.To prove this assertion he had examined the uterine

cavity and the lumen of the interstitial, isthmic,ampullary, and fimbrial portions of the Fallopian tubein undamaged specimens of pelvic organs affectedby this tumour removed during menstruation. Inthese he could demonstrate the presence of free bloodand epithelial elements, the only possible source ofwhich could be from the uterine cavity itself. ThatStage 1 in each type was of the nature of a deposit onthe surface of the affected organ he believed on accountof the fact that its microscopical appearance couldin no way be accounted for by any of the numeroustheories hitherto advanced in the search for thesetiology of this condition.

’

N omenc7ature.

Many names had been ascribed to tumours ofthe female pelvic organs containing aberrant epithelialelements. Some were suggested on aetiological grounds--e.g.,

" salpingitis isthmica nodosa," " adenomyositistubae," and " adenomyo-salpingitis " ; others on a

pathological basis-e.g., " adenomyoma " as thecondition is called to-day, "endometrioma," as

Blair Bell named it, or "adenoma" as Sampsonlatterly called it. Dr. Bailey, however, consideredthat from its pathology and eetiology, as he haddescribed it, this tumour which was in itself (1)locally malignant, (2) did not tend to the formationof metastases, and (3) originated in whatever organit was growing " from without," was most compre-hensively described as

"

ectopic Mullerianoma."The discussion was adjourned.Specimens and cases were presented and dis-

cussed by the PRESIDENT and by Drs. BLAIR BELL,FOTHERGILL, IVENS, FLETCHER SHAW, and DOUGAL.

NURSING HOME FOR MIDDLE CLASSES AT LIVERPOOL.By the generosity of the late Mr. Robert Davies, shipowner,of Wallasey, and his executors, a committee of the StanleyHospital, Liverpool, has been able to purchase and equipthe beautiful mansion of " Kiln Hey," Sandford Park, WestDerby, as a nursing home intended exclusively for the useof middle-class patients of limited means. A sum of 610,000was presented to the committee and this with other generousdonations has enabled the committee to make this pioneereffort to meet the needs of that large section of the publicwhose case is not served by the hospitals or private nursinghome. The " Robert Davies " Nursing Home is managedby a committee distinct from that of the Stanley Hospital,but the chairman is common to both institutions. Thirtybeds are available, but there is no resident medical staff, aseach patient will be attended by his or her own surgeon orphysician, who will conform to the rules of the home. Patientswill be charged three guineas a week in addition to professionalfees. Maternity patients will be received only by specialpermission, and no infectious or mental cases will be admitted.

Reviews and Notices of Books.THE EVOLUTION OF MAN.

Essays by G. ELLIOT SMITH, M.A., M.D., Litt.D.,F.R.C.P., F.R.S. London : Humphrey Milford,Oxford University Press. 1924. Pp. 158. 8s. 6d.THE essential theme of this book, as the author says

in his preface, is the development of the view of theimportance of the cultivation of vision in the evolutionof man’s intellect. Such a theme calls for a generalreview of the course of human evolution, and this isprovided in the three main chapters of the work-on the Evolution of Man, Primitive Man, and TheHuman Brain. A " foreword " on Man’s Pedigreeleads up to the first chapter. The subject-matters ofthe chapters are derived from various addresses givenat different times before different audiences : theyhave been brought together to meet the wants ofanthropological students who desire information onthese more recent views. But for those also who areonly amateurs in the science this book will be afascinating study, for it is the work of an acknowledgedmaster of the subject, dealing lucidly and learnedlywith many of the wider problems contained within it.Moreover, there are no sterile references, nor collectionsof unrelated facts, to annoy and bore such an amateuranthropologist, while the serious student has an

authoritative work to which he can refer with confi-dence. We confess that when we had finished readingthis little book we turned back and read it throughagain, with increasing pleasure and profit. We hadhoped at first to come across some discussion of suchthings as the anatomical details of the Rhodesianskull, or of the reasons for refusing descendant rankto the Neanderthal man with reference to the originalowner of the Mauer jaw, or maybe some talk about thedentition of Propliopithecus and Eoanthropus, forProf. Elliot Smith’s remarks on these and many othersuch points would be of great interest and importance;but one recognises, of course, that such matters donot really come within the scheme of this book andwould be out of place. The fundamental difference ofoutlook between the " historical " and "evolutionary "schools of ethnological thought are dealt with vigorouslyby Prof. Elliot Smith, who is a-leading exponent of theformer school, and does not spare his opponents in histrenchant and reasonable criticism.The book is not only of great interest, but it is one

that will give some idea of the present trend of anthro-pological thought to those who are not concerned asexperts in the formation of it. It has some excellentillustrations and is well produced.

PRACTICAL SURGERY.

By VICTOR PAUCHET. Translated by F. R. B.ATKINSON, M.D., C.M. Edin. With a Preface bySir CHARLES GORDON-WATSON, C.M.G., F.R.C.S.London : Ernest Benn, Ltd. 1924. Vols. I.and II. Illustrated. Pp. 252 and 293. 18s. 6d.per vol.Tms is an original type of book in that it is

an atlas of drawings made from actual operations,accompanied not simply by a description of procedure,but by remarks on the advisability of employingthe different methods in the light of the author’sown experience. This is a commendable feature,especially so as the advice tendered is essentiallypractical and obviously well considered. Of the twovolumes, the second is the more valuable. In thefirst an indifferent and inadequate chapter on surgicaltechnique is followed by descriptions of operationsupon hernia, hydrocele, haemorrhoids, and a fewother matters which proceed upon generally acceptedlines. An interesting method of operating uponvesico-vaginal fistula is described, by which free accessto the site of operation is obtained. The results ofit are said to be exceptionally good. The authoradopts Sir Arbuthnot Lane’s views as to the far-