1792 THE ANNUS MEDICUS 1903.

opened three days after the inception of the illness the

gall-bladder was found to be distended and its fundus of adark-purple colour. The gall-bladder was incised and thewall was found to be gangrenous in its whole thickness.

Cholecystectomy was performed and an uneventful recoveryfollowed.

Mr. FREDERIC S. EVE has published three cases of

cholecystectomy. In the first case the gall-bladder con-tained purulent fluid and was at first drained. Later, tocure the biliary fistula which remained, the gall-bladderwas excised. In the second case the gall-bladder was dis-tended and contained many stones but the fluid was sterile ;cholecystectomy was performed. In the third case there wasa little pus in the gall-bladder and the mucous membranewas ulcerated. The gall-bladder was removed. In all three

cases rapid recovery took place. Mr. EVE considers that the

gall-bladder is a structure which can be dispensed with with-out inconvenience and therefore he thinks that in the future

cholecystectomy will be more often performed instead ofdrainage in cases in which the gall-bladder is thickened andcontracted.

Dr. H. A. LEDIARD has described a case of perforation ofthe gall-bladder occurring in a woman, aged 47 years. Manycalculi were present and were removed and then the openinginto the gall-bladder was closed by invaginating the edgesand stitching with Lembert sutures, as was suggestedby Mr. G. H. MAKINS. The operation was completelysuccessful.

Mr. LEONARD A. BIDWELL has published notes of fourcases of empyema of the gall-bladder, in all of which he em-ployed drainage. Of the four cases three patients recoveredand one died.

Hypertrophy of the Prostate.The treatment of hypertrophy of the prostate when it

leads to difficulty of micturition has excited much attentionand given rise to no small amount of discussion. On thewhole it may be said that most of those surgeons who have

devoted special attention to this department prefer to

enucleate the prostate and the results which have up tothe present been obtained fully justify this opinion. Mr.

P. J. FREYER’S statistics give a total mortality of less

than 10 per cent., even when all deaths after the opera-tion are included, though some of the fatal cases mightnot unreasonably ’be removed from the deaths. Dr.W. PRIOR PURVIS has reported a case in which heenucleated a mass from the prostate weighing six and a

half ounces. The best treatment for this condition wasdiscussed at the Swansea meeting of the British MedicalAssociation and it was also a subject of discussion at a

meeting of the Harveian Society where the debate was

opened by a paper by Mr. C. W. MANSELL MOULLIN whoentered somewhat fully into the whole question. There isno doubt that the more modern methods of treatment of

hypertrophied prostate are superseding habitual catheterism Iwhich is full of septic dangers for the patient with enlargedprostate. The temporary favour which was accorded to

vasectomy and castration for prostatic hypertrophy has beenfollowed by almost complete neglect.

AnetlrYS1n.Traumatic aneurysms of large arteries are nct common

but two cases of this condition have been recorded in

THE LANCET during the year. Dr. ALAN H. MulR narratesa case under the care of Mr. W. F. BROOK of trau-

matic aneurysm of the gluteal artery resulting from a

fall on the buttock. The internal iliac artery was com-pressed digitally through an opening made in the abdo-

minal wall. Then the sac of the gluteal aneurysm wasopened by an incision six inches long in the line of the

gluteal artery, the blood clot was turned out, and the arterywas tied. The fissured fracture of the hip-bone which hadwounded the vessel was seen. Complete recovery followed.

Dr. J. CROPPER has described a case of traumatic femoral

aneurysm which was under his care. It arose from a

punctured wound inflicted four months before. The vesselwas tied above and below the sac which was excised. Thevein was wounded during the operation and the haemorrhagewas controlled by firm packing. The patient soon recovered.The introduction of wire into the interior of an aneurysm is

now rarely employed. Mr. D’ARCY POWER and Mr. G. H.COLT have published a case in which this was done. The

aneurysm was situated on the abdominal aorta and was

exposed by an incision over it and 80 inches of silver wire

were introduced into the aneurysm and the opening wasclosed by a few Lembert sutures. The patient died 50 hoursafter the operation. At the necropsy a loop of wire wasfound projecting into the aorta. The instrument devised for

the introduction of the wire is ingenious and is likely to,

be used in future whenever this operation seems to be

indicated.

OBSTETRICS AND GYNÆCOLOGY.

The Anatomy of the Pregnant Uterus.

During the past year two valuable contributions have beenmade to our knowledge of the anatomy of the pregnantuterus. J. CLARENCE WEBSTER has published a paper on.the cadaver of a woman who died in the sixth month of

pregnancy which he studied by means of frozen sections.The specimen is principally of interest in showing the extentto which the uterus may be displaced upwards by the dis.tended bladder. The highest point of the fundus uteri is

opposite the first lumbar vertebra, while at full term thenormal level of the fundus is the disc between the first andsecond lumbar vertebrm.The second case, published jointly by PINARD, SECOND,

and COUVELAIRE, is that of a patient delivered by Csesareansection at full term whose uterus was bound down by peri-toneal adhesions on its posterior and left lateral surface tothe posterior wall of the pelvis and of the abdomen and tothe intestines. After the delivery of the child the uteruswas removed by hysterectomy. This interesting specimendemonstrates the fact that the fixation by adhesions of

practically the whole of the posterior surface of the uterus isnot incompatible with the development of pregnancy to fullterm. As a result of the presence of the adhesions the

anterior wall of the uterus had developed to a very markedextent while the posterior wall remained almost entirelyundeveloped. At the same time the lower uterine segmenthad undergone marked over-distension over an area on

the left side corresponding to the position of the fœtal head.The case affords an interesting anatomical proof of the

manner in which the so-called incomplete retroflexion de-scribed by ROBERT BARNES in cases of incarceration of theretroverted gravid uterus may occur.

T7ie Nutrition of the Mother and its Relation to the Size ofthe Child.

The view of PROCHOWNICK that it is possible to in- fluence the size of the child by modification of the mother’sdiet is confirmed to a considerable extent by the obser-vations of NOEL PATON in the case of guinea-pigs. Byregulating the food of the mothers he was able to showthat the weight of young per gramme of mother could bedefinitely altered. The average weight per litter in theunderfed animals was no less than 28 per cent. below the

weight per litter in normal well-fed animals. Physiologicallythe point of interest in these experiments is the demon-stration of the limitations in the extent to which the tissuesof the mother can be utilised for the construction of the

embryo.Ectnpic Gestation.

Extra-uterine gestation has been the subject of numerous ‘

publications during the past year. Our knowledge of thechanges that occur in the wall of the pregnant tube and

1793THE ANNUS MEDICUS 1903.

also of the manner in which rupture of the tube is pro-duced is much more complete than it was. The anatomyof the pregnant tube was fully considered in a paper pub-lished by J. R. ANDREWS, and the whole question formedone of the subjects of discussion at the meeting of the

German Gynæcological Society in June of this year.It is becoming more and more evident that the ovum in

cases of tubal pregnancy is imbedded beneath the mucousmembrane of the tube and is not simply attached to its sur-

face. The free pole of the ovum, that is to say, the part pro-jecting towards the lumen of the tube, is covered by a truedecidua reflexa, or by organised clot, or by some of the folds iof the mucous membrane representing such a decidua. The

development of the tubal decidua is a constant condition,although the amount of its development varies considerablyin different cases. In cases of tubal rupture the wall of thetube gives way, while in cases of early tubal abortion thecovering of the free pole of the ovum becomes torn through.The part played by the epithelium of the villi in causing thedestruction of the muscular tissue of the wall of the tube isnot yet completely determined but no doubt it plays animportant part. The occurrence of a primary abdominalgestation cannot yet be said to have been demonstrated

beyond doubt but the existence of ovarian gestation is nowaccepted by all observers. With regard to the question oftreatment in accordance with the conservative tendency ofrecent gynaecological surgery, it is becoming more and morethe custom with many obstetricians to adopt expectant treat-ment in the case of a limited peritubal hæmatocele due totubal abortion and to operate in practically all other casesof this kind, while the abdominal route is more generallyapplicable and more often employed than the vaginal.A work of much interest has been published by F. VON

WINCKEL on the deformities of the foetus in cases of

ectopic gestation. He draws the conclusion that mal-

developments of the foetus are much more common than isusually believed and occur in some 50 per cent. of the cases.He thinks that the contractions of the foetal sac, which are

often well marked, play an important part in producingthese deformities and diseases of the ectopically developedfoetus. It is interesting to notice that such deformities oftendisappear spontaneously if the foetus continues to live.

Deciduoma Malignum.Two of the meetings of the Obstetrical Society of London

were devoted to a discussion upon this most importantdisease. The subject was introduced by TEACHER of

Glasgow who in an exhaustive and interesting paper dealtvery fully vvith the whole matter. In connexion with the

paper a large number of pathological specimens and micro-scopical sections were shown. The most interesting problemyet unsolved in connexion with this disease is its relationshipto the tumours of apparently the same nature met with inthe male.TEACHER came to the following conclusions :-1. That the

so-called deciduoma malignum is a tumour arising in con-nexion with a pregnancy and originating from the epitheliumof the chorionic villi (or its forerunner, the trophoblast),which is of fœtal ectoblastic origin. The malignant bydatidi-form moles may be regarded as a variety of chorion epi-thelioma. 2. That the chorion- epitheliomata and malignanthydatidiform moles form a quite characteristic group of

tumours clinically and pathologically and that they shouldbe classified neither as sarcomata nor as carcinomata but as

a distinct class lJui generis. The most appropriate name ischorion-epithelioma malignum. 3. That, in addition to thecommon tumours developing from a pregnancy, there aretumours containing precisely similar structures which arenot connected with a pregnancy and which may occur inother parts of the body than the uterus and in either sex.The most probable explanation of these is that they are

teratomata originating from some structure which has themorphological value of an included matured and fertilisedovum, and the chorion-epitheliomatous tissues represent theactual trophoblast (chorionic epithelium) of the included

ovum.

Tuberculous Disease of the Genital Tract.The importance of tuberculosis in the etiology of diseases

of the genital tract is becoming more and more evident.This subject was discussed at- the International Congress ofObstetrics at Rome last year and was also considered at the

meeting of the British Medical Association at Swansea thissummer. Papers were read and specimens were demonstratedby TARGETT, KYNOCH, and ARNOLD LEA.

In the diagnosis of the condition TARGETT laid stress

upon the freedom from pain, the frequency of dysmenorrhcea,and the absence of repeated attacks of peritonitis such aspatients with the more common forms of pyosalpinx usuallysuffer from. The old view that amenorrhoea is usuallypresent can no longer be held, as further experience hasshown that the menstrual function is often not at all dis-turbed. The microscopical examination of the scrapingsfrom the utefus is of little value in making a diagnosis astuberculous endometritis is of very rare occurrence. AsTARGETT pointed out, the tuberculous pyosalpinx has

characters which often enable it to be recognised—viz., thepersistence of the fimbriated extremity, the absence ofadhesions on the serous surface, and the comparative thin-ness of the sac wall. Its contents are usually sterile andthe uterine end of the tube alone exhibits the characteristicstructure of tuberculous salpingitis.X Rays and Iiolet Light Rays in the Treatment of Caneer.Evidence is accumulating as to the value of these light

rays in the treatment of rodent ulcers and of true carci-nomata. A considerable number of cases have now been

recorded by CLEAVES, GRUBBE, and others in which verymarked benefit apparently has followed the use of the

violet and x rays in cases of inoperable cancer of the

uterus. It is to be hoped that we may soon have beforeus the results of a sufficient number of cases to enable usto form a definite conclusion as to the value of this methodof treatment. The possible effects of the emanations fromradium upon similar cases is a problem for the future todecide.

Pregnancy complicated with Uterine Fibroids.A discussion was opened by AMAND ROUTH at the meeting

of the British Medical Association on the Management of Preg-nancy complicated with Uterine Fibroids. He thought thatexpectant treatment was indicated in all cases unless therewere urgent symptoms. Owing to spontaneous elevation ofpelvic fibroids during the last few weeks or days of pregnancythreatened obstruction to labour did not, as a rule, persist.Sepsis with secondary infection of the fibroid was a seriousdanger in the puerperium. Induction of abortion should beabandoned. If urgent pressure symptoms supervened myo-mectomy was the ideal operation for subserous growths,failing that hysterectomy. After the child was viable

reposition might be tried, leaving radical measures for alater date. A cervical fibroid might be enucleated from thevagina as an alternative to panhysterectomy. In all othercases of fibroids obstructing labour as a first step the childmust be delivered by Caesarean section followed by myo-mectomy, supravaginal hysterectomy with retroperitonealtreatment of the stump, or panhysterectomy. If duringchildbed fibroids became infected a prompt extirpation ofthe uterus might save the patient’s life.

The Treatment of Frolapse of the Ut6rUS.An important discussion upon this very common condition

was held at the Congress of the German GynaecologicalSociety in Wiirzburg in June. It cannot be said that cur

1794 THE ANNUS MEDICUS 1903.

knowledge was much increased by the contributions read.The difference of opinion was most marked in regard to theetiology of prolapse of the uterus. Is it to be regardedas a purely local affection or is it merely the result of

general debility of the patient, and can prophylacticmeasures directed towards the correction of such errors

an the general health prevent its occurrence ? MARTIN

thought that they could and laid much stress uponthe importance of the patient’s general condition, of

-physiological involution in childbed and at the climacteric,and of the disturbed nutrition that occurred in severe

diseases, conditions in all of which there was extensive

’wasting of connective tissues and in which prophylacticmeasures were likely to be of much assistance. With the

improvement of the general condition the local affectionwould improve also and bad cases would become much lesscommon. Some of the other speakers dissented from thisview and held that prolapse of the uterus was entirely a localcondition and had no relationship at all to the generalhealth. The infrequency of this distressing complaintamongst better-class patients seems to show that the

importance of prophylaxis can hardly be overestimated andthat the condition can be, and is, preventable except in asmall number of cases in which infantilism, congenitalbackward displacements of the uterus, and imperfectdevelopment of the perineum play an important part in

the production of the displacement. There was a generalconsensus of opinion that one or other of the forms of

fixation of the uterus was indicated when operative treat-ment was required but that supplementary vaginal opera-tions were always necessary. The results as to cure from all

the various operations were about the same, while total

extirpation of the uterus gave no better results than anyother operation.

Obituary.The list of deaths amongst obstetric physicians has been

exceptionally heavy this year and includes such well-known names as MAX SANGER, HENRI VARNIER, GAILLARDTHOMAS, WILLIAM PLAYFAIR, and JOSEPH GRIFFITHS

SWAYNE.

OPHTHALMOLOGY.

The numerous points of contact that ophthalmology has with all other departments of medicine insure a full

attendance at the meetings of the various ophthalmologicalsocieties in this and other countries and occasion the exhibi-tion of numerous cases and the reading of many papers thatawake interest, give rise to discussion, and lead to fuller andmore exact knowledge of the different forms of disease thatthey illustrate. But this wealth and diversity of materialrender it difficult in a brief record of progress to do morethan to allude to the chief events of the year, to indicatethe principal topics that have attracted attention, and tomention a few of the more striking cases that have beenseen and described. The Ophthalmological Society of theUnited Kingdom has elected as its president Mr. JOHNTWEEDY who also occupies the high position of Presidentof the Royal College of Surgeons of England, an un-

precedented combination of honours.

Congresses.The meeting of the Egyptian Medical Congress was

held at the close of last year at Cairo and the vexed

questions of the nature, origin, and treatment of tra-

choma, which is there an endemic disease, were dealt with.It is said that partly as a result of this congress Sir

ERNEST CASSEL was induced to place the sum of$200,000at the disposal of the Khedive to institute a peripateticophthalmic dispensary with the object of relieving the

appalling amount of remediable disease in Egypt. It is to

be hoped that some permanent good may result from

this kind gift if only by showing the people how much

benefit may be effected by cleanliness and the adoptionof very simple antiseptic measures. The President of the

Ophthalmological Section of the British Medical Associationat Swansea was Mr. HENRY E. JULER. Interesting paperswere read by Mr. E. NETTLESHIP on Ocular Changes inRenal Disease ; by Mr. G. HAETRIDGE and by Mr.

CLAUD A. WORTH on Squint; and one on the Mechanism ofAccommodation in Man by Dr. K. A. GROSSMANN. A new

department of ophthalmology has been founded in the

University of Oxford and Mr. ROBERT W. DOYNE has beenelected as first reader. The post, which Mr. DOYNE is

thoroughly qualified to fill, will, in conjunction with the

ophthalmic hospital, afford many practitioners in and aroundOxford the opportunity of keeping up, and extending, theirknowledge of ophthalmic disease.

Uniformity of Notation.The multiplication of journals devoted to ophthalmology,

in which isolated cases are often reported in great detail,has led several observers to urge the necessity for greateruniformity being practised in such reports. Thus Dr.KNAPP of New York accepts and recommends the notationof the merididns of the eye originally proposed by Dr.

HARLAN, in which the numbering commences at the nasalend of the horizontal meridian, runs to 90°, which is thevertical meridian, and then outwards to the opposite or

temporal end of the horizontal meridian which is 1800.The general adoption of this notation by refractionists wouldprevent much confusion. Mr. LucIEN HowE points out thatmore uniformity is required in the numbering and in the useof prisms and suggests not only that the prisms should beground with greater accuracy than is practised at present,but that the application of prisms to test the power ofadduction and abduction, or the dynamic conditions of theeyes, should be conducted in the same manner, and, lastly,that the terms "latent " convergence and divergence shouldbe replaced by those of esophoria, exophoria, and the likenow generally used in America. Dr. CHARLES H WILLIAMSinsists on the great importance for the safety of the publicof more uniformity in the examination of the vision,colour sense, and hearing of all those employed on railways.A very interesting series of recommendations of the Sectionon Ophthalmology of the American Medical Association hasbeen published and it would be well if all railway officialsin the United Kingdom were examined on the lines that arelaid down in this report, a condensed account of which willbe found in the recently published Transactions of the

American Ophthalmological Society for 1902.

Roentgen Rays.The use of the Roentgen or x rays has become common in

the treatment of various diseases of the eyes and the

adjoining region, but especially in cases of epithelioma.Some very striking instances of the improvement effected inthis affection have been placed on record (with illustrations)by Dr. W. SWEET of Philadelphia. The loss of the ciliaand of the hairs of the eyebrows that has been observed in

’

more than one instance suggests the advisability of pro-tecting all but the diseased part with sheets of lead whenthis method of treatment is practised. The tube employedby Dr. SWEET was of low vacuum and was placed from sixto ten inches distant from the part ; the exposures lastedfrom five to ten minutes and the number of sittings variedfrom ten to 30 or more.

Affections of the Cornea.The treatment of conical cornea has been the subject of

discussion. Mr. A. STANFORD MoRTOrr adopts the methodproposed originally by Mr. HIGGENS of excising an ellipticalportion from the apex of the cone and has had many suc-cessful cases. Others, as Dr. J. TATHAM THOMPSON and

.

Dr. KARL GROSSMANN, prefer the application of the actualcautery to the apex, a plan originally proposed by Dr. ANDREWS