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CARCINOMA IN A DIVERTICULUM OF THE BLADDER.
860 artificial pneumothorax. Dr. Maendl questionnaire to 180 specialists and hospitals in Germany, Austria, Czecho-Slovakia, and Switzerland, and he obtained answers and statistically suitable information from 29 doctors. He was thus able to add more than 1000 cases to his own not inconsiderable material of 300 cases, and of the total thus obtained there were 1330 cases in which the treatment had been completed, the pneumothorax having been started 2 to 12 years earlier. With regard to the permanent successes achieved, there were 784 cases in which information on this point was obtained, and among them there were 524, or 66 per cent., in which the improvement effected had been lasting. It was so in 49 per cent. of 172 of With regard to the Dr. Maendl’s own cases.
country
on
addressed
a
significance of a pleural effusion complicating an artificial pneumothorax, he shares with Muralt and Koeniger the opinion that such an effusion may be a sign of good prognosis. Of 70 patients who were still alive from 2 to 12 years after the induction of a pneumothorax, 38, or 54 per cent., had developed a pleural effusion, whereas of 76 patients who had died only 28, or 37 per cent., had developed such an effusion while the pneumothorax still existed. Of 15 patients who had achieved clinical recovery, maintained for 2 to 10 years, as many as 11. or 73 per cent., had developed a pleural effusion. If a pleural effusion is really as beneficial as these statistics suggest, it would be natural to provoke such effusions artificially-and nothing would be easier with the help of a little tincture of iodine or other irritant-in the course of lung collapse treatment. But the case for such a procedure would have to be made out much more convincingly than it has been at present. It is satisfactorv to note that there were onlv 15 cases of gas embolism, none ’, of which terminated fatally, among the cases collected by Dr. Maendl. ____
MEDICAL PRACTICE BY FOREIGNERS IN BERLIN. THE financial circumstances of medical practitioners within the German Republic are not at present so happy that free competition by foreigners is regarded with equanimity. As it stands, German law does not prevent foreign medical men from settling in Germany nor prohibit them from practising there; but the stipulation is made that they should not use any title identical with that of a duly registered
owing to the nearly total loss of Russian patients. Before the war these patients, flocking home from the western spas and health resorts, were wont to sojourn in Berlin to consult specialists there, whereas now
they
are
permanently settled, they prefer to position is one
consult their own countrymen. The which demands sympathetic handling.
INQUIRY INTO NITROUS OXIDE GAS. IN view of the need for more accurate knowledge of the modes of action of various anaesthetic agents. and of the impurities that may be associated with them, the Medical Research Council and the Anæsthetics Section of the Royal Society of Medicine have appointed an Anaesthetics Committee to initiate and dhect investigations. The following havealready undertaken to serve in this way : Dr. J. Blomfield (chairman). Dr. H. H. Dale, F.R.S., Prof. F. G. Donnan, F.R.S., Dr. C. F. Hadfield (secretary), Prof. M. S. Pembrey, F.R.S.. Dr. F. E. Shipway. Among other subjects of study an immediate investigation is to be made into the nature and frequency of impurities that may occur in nitrous oxide gas. Nitrous oxide is now used for operations of considerable duration, so that impurities likely to have small effect during brief inhalation might be seriously toxic after prolonged use. At present there is no generally recognised standard of purity for nitrous oxide ; it is not included in the British Pharmacopœia and is not subject to official tests. The nitrous oxide manufactured bv the various British firms that supply it is of the highest quality. but from time to time reports of somewhat indefinite nature appear to show that toxic effects have been caused by the administration of what is generally briefly known as 9. gas." The suggestion that this toxicity may be due to some impurity in the nitrous oxide calls for examination. and the Committee are seeking any relevantinformation. It is requested that anæsthetists who can supply evidence of this kind in detail, and if possible the cylinder to which it relates containing any remaining gas, will communicate wi-th the hon. secretary of the committee. Dr. Charles F. Hadfield, 47, Queen Anne-street, W’. 1. ’
CARCINOMA IN A DIVERTICULUM OF THE BLADDER. AT a recent meeting of the Brooklyn Urological practitioner or closely resembling it. Before the war Society, Dr. Augustus Harris, who reported an illustrathe actual number of foreign practitioners in Germany tive case,l remarked that the occurrence of carcinoma not possessing German qualifications was insignificant, in a diverticulum of the bladder was extremely rare. the foreign colonies in the country being of modest from about six cases in which the condition Apart size and apt to consult the German practitioner. This was not discovered until the autopsy, he had been condition was totally changed after the Russian unable to find a record of a single case. His own revolution, when Germany-and Berlin in particular patient was a man aged 63, who had had gonorrhoea -was overcrowded with Russians who preferred to 25 years previously, and at the age of 62 had had an live outside their national jurisdiction. In certain attack of hæmaturia for a few days, accompanied quarters of Berlin at the present time more Russian by retention for one day. Nine months later he began than German may be heard spoken, and Russian shops, to suffer from intermittent haematuria, slowness in theatres, libraries, restaurants, and journals have starting the act, and increased frequency of micturi sprung up in large numbers. It is stated that about tion. There was no pain, dribbling, or nocturia. He 100 Russian medical men have settled in Berlin and was rather pale and had lost weight. Vesical practise among the large Russian colony there. A malignancy was suspected, and examination showed recent letter addressed to the Berliner Aerzteblatt, the presence of a dense filiform stricture in the the official organ of the Berlin Medical Chamber, bulbous urethra. There were 5 oz. of residual called attention to the fact that several Russian urine. The stricture was gradually dilated until, after medical men in Berlin had private clinics of their own weeks’ time, full-sized sounds could be passed. eight and were operating there with the assistance of regisCystoscopy then showed a considerably inflamed and tered German medical men. The writer suggested that trabeculated bladder, and 1inches above the right Russian doctors were obtaining permission from the ureteric orifice the puckered opening of a divertiauthorities to reside in Berlin on the plea of being culum. The bladder was injected with sodium bromide political refugees. The Chamber, having approached solution and a cystogram taken, which revealed the Government, was informed that no special resi- a large sac with a capacity about half that of the dential facilities had been granted to foreign medical bladder. On opening the bladder the tumour was men, but that in several cases German doctors found to be inoperable, and cystostomy was perhad let off part of their flats to Russian medical formed. Death took place seven months after the Further investigation was men as consulting-rooms. operation. There was no autopsy. After the account promised. In the meantime the Berlin medical 1 Urological and Cutaneous Review. March, 1924. profession is losing a great part of its pre-war income
861 wise similar
of this case had been written an article appeared in the January number of Surgery, Gynecology, and Obstetrics by Judd and Scholl, who, in a series of 133 cases of diverticulum of the bladder, reported four with carcinoma, all of which were diagnosed cystoscopically by the appearance of part of the growth at the orifice of the sac. In three the tumour and sac were resected completely, while in the fourth radium Three died shortly after the operawas employed. tion, and one lived for two years. In six other cases carcinoma of the bladder was associated with a diverticulum.
cysts occurring in various sites upon the pelvic peritoneum. Histological examination showed that both the ovarian blood cysts and those occurring elsewhere possessed an epithelial lining closely resembling the uterine endometrium. Observation of the uterus during operations convinced Dr. Sampson that it was no unusual thing for menstrual blood to regurgitate through the Fallopian tubes into the peritoneal cavity, and actual experiment showed that very little manipulation of the uterus sufficed to bring about the same result after operations
upon the endometrium. These observations led Dr. Sampson to believe that blood cysts both of the ovary BROADCASTING HEART SOUNDS. and elsewhere within the pelvis may arise by AT a meeting of the Bristol Medico-Chirurgical implantation of fragments of endometrium escaping the Fallopian tubes. He was able, moreSociety held on April 9th a paper was read by Dr. through to obtain evidence for belief that what holds over, Carey F. Coombs and Dr. C. K. Herapath on auricular failure. This was followed by a discussion, and during for normal holds also for malignant uterine epithelium, the evening an experiment in " broadcasting " heart and on the strength of this he advises certain obvious sounds was made, which if not new to this country, modifications, such as a preliminary ligation of the Fallopian tubes, in the performance of hysterectomy was at least sufficiently unusual to be of more than Apart, local interest. The experiment was carried out by Mr. for malignant conditions of the uterus. Arthur Mitchell, of Clifton, who was introduced to however, from immediate practical considerations, the meeting by Prof. F. H. Edgeworth. The apparatus Dr. Sampson’s observations possess a wide general He believes on good evidence that the used was a sensitive microphone applied over the interest. endometrial implants grow more readily upon the ovary than elsewhere, and that the implants on the peritoneum are usually secondary to primary ovarian grafts. In the light of the work of Drew2 on growtli-producing substances, recently reported in THE LANCET, this indication of the presence of such a substance in the ovary is of particular interest ; the invasiveness of some of these implants, even while clinically benign, gives food for thought. Even more intriguing is the suggestion-it is no more than a suggestion, for the evidence on this point is by no means conclusive-that implants originally benign may undergo malignant change in the presence of such a change in the parent uterine endometrium. Experimental evidence strongly in support of Dr. Sampson’s views on the ætiology of the blood cysts has been produced by Dr. Victor C. Jacobson,3 of the Albany Medical College, working upon rabbits. ____
I
pelvic
THE OPHTHALMIC HOSPITALS OF EGYPT. THE publication of the usual annual report on the Ophthalmic Hospitals of Egypt for 1922 having been heart of a person in an adjoining room, and con- delayed, an abstract of it has been printed privately nected to a suitable transformer. This was then by Mr. A. F. MacCallan, C.B.E., F.R.C.S., who recently amplified by four wireless valves and reproduced vacated the post of Director of the Ophthalmic Section through a loud speaker to the audience at, the meeting. of the Department of Public Health. Mr. MacCallan The first case was that of a normal heart, and the held this post for 20 years, during which the organisasecond, one with total arrhythmia. In both instances tion of a system of special hospitals proceeded hand sounds corresponding to heart beats could be heard in hand with that of a definite school of ophthalmology clearly all over the room, the irregularity in the based on the administrativescheme of the Royal second case being strikingly demonstrated. The London Ophthalmic Hospital. The 23 existing improvement and perfection of such a method as this ophthalmic hospital units situated in the capital offers infinite possibilities for teaching in the future. towns of the 14 provinces are staffed by Egyptian The accompanying illustration, for which we are who, after obtaining their diplomas indebted to the Sport and General Press Agency, was at the Government Medical School, go through taken at the clinic of Dr. Leo Jacobsohn, of Charlotten- a course of instruction at the Giza Hospital and burg, who has also succeeded in amplifying the beats Ophthalmic Laboratory in the suburbs of Cairo, of the human heart so that they are audible in a lasting for a minimum period of two years. For some six years all Mr. MacCallan’s assistants have been large hall. Egyptians, but it must not be forgotten that in the THE NATURE OF "BLOOD" CYSTS. early years the help of other British surgeons was THE so-called blood cyst of the ovary has long been utilised in the initiation of hospital and laboratory recognised by gynaecologists the world over ; it is courses of instruction. These were Dr. L. S. Miller, of usually regarded as being produced by failure to Hobart, Tasmania, Dr. G. H. McLaren, of Montreal, rupture on the part of a Graafian follicle. Probably Canada, Dr. E. V. Oulton, of Brighton, Dr. R. G. many such cysts do originate in this way, but recent Waddy, now Professor of Ophthalmology at Sydney, work by Dr. John A. Sampson,1 of Albany, N.Y., and Dr. J. B. Horgan, of Cork. The origin of the ophthalmic campaign in Egypt suggests that many haveanother and much more interesting mode of development. These cysts was the liberality of Sir Ernest Cassel in placing attain to their greatest size on the ovary, but Dr. under the trusteeship of Lord Cromer, and thereafter Sampson, in the course of a long series of major under that of the High Commissioner for the time being, gynaecological operations, observed smaller but other- a sum of 40,000, the interest of which was to be used
surgeons,
___
2 On the Cultivation of Tissues and Tumours in Vitro, by 1 Benign and Malignant Endometrial Implants in the Peritoneal Cavity and their Relation to Certain Ovarian Tumours, A. H. Drew, THE LANCET, 1923, i., 785, 833. by John A. Sampson, M.D., F.A.C.S., Surg., Gyn., and Obst., 3 Autotransplantation of Endometrial Tissue in Rabbit, xxxviii., 3, 287. by V. C. Jacobson, Arch. Surg., 1922, v., 281.
country
on
addressed
a
significance of a pleural effusion complicating an artificial pneumothorax, he shares with Muralt and Koeniger the opinion that such an effusion may be a sign of good prognosis. Of 70 patients who were still alive from 2 to 12 years after the induction of a pneumothorax, 38, or 54 per cent., had developed a pleural effusion, whereas of 76 patients who had died only 28, or 37 per cent., had developed such an effusion while the pneumothorax still existed. Of 15 patients who had achieved clinical recovery, maintained for 2 to 10 years, as many as 11. or 73 per cent., had developed a pleural effusion. If a pleural effusion is really as beneficial as these statistics suggest, it would be natural to provoke such effusions artificially-and nothing would be easier with the help of a little tincture of iodine or other irritant-in the course of lung collapse treatment. But the case for such a procedure would have to be made out much more convincingly than it has been at present. It is satisfactorv to note that there were onlv 15 cases of gas embolism, none ’, of which terminated fatally, among the cases collected by Dr. Maendl. ____
MEDICAL PRACTICE BY FOREIGNERS IN BERLIN. THE financial circumstances of medical practitioners within the German Republic are not at present so happy that free competition by foreigners is regarded with equanimity. As it stands, German law does not prevent foreign medical men from settling in Germany nor prohibit them from practising there; but the stipulation is made that they should not use any title identical with that of a duly registered
owing to the nearly total loss of Russian patients. Before the war these patients, flocking home from the western spas and health resorts, were wont to sojourn in Berlin to consult specialists there, whereas now
they
are
permanently settled, they prefer to position is one
consult their own countrymen. The which demands sympathetic handling.
INQUIRY INTO NITROUS OXIDE GAS. IN view of the need for more accurate knowledge of the modes of action of various anaesthetic agents. and of the impurities that may be associated with them, the Medical Research Council and the Anæsthetics Section of the Royal Society of Medicine have appointed an Anaesthetics Committee to initiate and dhect investigations. The following havealready undertaken to serve in this way : Dr. J. Blomfield (chairman). Dr. H. H. Dale, F.R.S., Prof. F. G. Donnan, F.R.S., Dr. C. F. Hadfield (secretary), Prof. M. S. Pembrey, F.R.S.. Dr. F. E. Shipway. Among other subjects of study an immediate investigation is to be made into the nature and frequency of impurities that may occur in nitrous oxide gas. Nitrous oxide is now used for operations of considerable duration, so that impurities likely to have small effect during brief inhalation might be seriously toxic after prolonged use. At present there is no generally recognised standard of purity for nitrous oxide ; it is not included in the British Pharmacopœia and is not subject to official tests. The nitrous oxide manufactured bv the various British firms that supply it is of the highest quality. but from time to time reports of somewhat indefinite nature appear to show that toxic effects have been caused by the administration of what is generally briefly known as 9. gas." The suggestion that this toxicity may be due to some impurity in the nitrous oxide calls for examination. and the Committee are seeking any relevantinformation. It is requested that anæsthetists who can supply evidence of this kind in detail, and if possible the cylinder to which it relates containing any remaining gas, will communicate wi-th the hon. secretary of the committee. Dr. Charles F. Hadfield, 47, Queen Anne-street, W’. 1. ’
CARCINOMA IN A DIVERTICULUM OF THE BLADDER. AT a recent meeting of the Brooklyn Urological practitioner or closely resembling it. Before the war Society, Dr. Augustus Harris, who reported an illustrathe actual number of foreign practitioners in Germany tive case,l remarked that the occurrence of carcinoma not possessing German qualifications was insignificant, in a diverticulum of the bladder was extremely rare. the foreign colonies in the country being of modest from about six cases in which the condition Apart size and apt to consult the German practitioner. This was not discovered until the autopsy, he had been condition was totally changed after the Russian unable to find a record of a single case. His own revolution, when Germany-and Berlin in particular patient was a man aged 63, who had had gonorrhoea -was overcrowded with Russians who preferred to 25 years previously, and at the age of 62 had had an live outside their national jurisdiction. In certain attack of hæmaturia for a few days, accompanied quarters of Berlin at the present time more Russian by retention for one day. Nine months later he began than German may be heard spoken, and Russian shops, to suffer from intermittent haematuria, slowness in theatres, libraries, restaurants, and journals have starting the act, and increased frequency of micturi sprung up in large numbers. It is stated that about tion. There was no pain, dribbling, or nocturia. He 100 Russian medical men have settled in Berlin and was rather pale and had lost weight. Vesical practise among the large Russian colony there. A malignancy was suspected, and examination showed recent letter addressed to the Berliner Aerzteblatt, the presence of a dense filiform stricture in the the official organ of the Berlin Medical Chamber, bulbous urethra. There were 5 oz. of residual called attention to the fact that several Russian urine. The stricture was gradually dilated until, after medical men in Berlin had private clinics of their own weeks’ time, full-sized sounds could be passed. eight and were operating there with the assistance of regisCystoscopy then showed a considerably inflamed and tered German medical men. The writer suggested that trabeculated bladder, and 1inches above the right Russian doctors were obtaining permission from the ureteric orifice the puckered opening of a divertiauthorities to reside in Berlin on the plea of being culum. The bladder was injected with sodium bromide political refugees. The Chamber, having approached solution and a cystogram taken, which revealed the Government, was informed that no special resi- a large sac with a capacity about half that of the dential facilities had been granted to foreign medical bladder. On opening the bladder the tumour was men, but that in several cases German doctors found to be inoperable, and cystostomy was perhad let off part of their flats to Russian medical formed. Death took place seven months after the Further investigation was men as consulting-rooms. operation. There was no autopsy. After the account promised. In the meantime the Berlin medical 1 Urological and Cutaneous Review. March, 1924. profession is losing a great part of its pre-war income
861 wise similar
of this case had been written an article appeared in the January number of Surgery, Gynecology, and Obstetrics by Judd and Scholl, who, in a series of 133 cases of diverticulum of the bladder, reported four with carcinoma, all of which were diagnosed cystoscopically by the appearance of part of the growth at the orifice of the sac. In three the tumour and sac were resected completely, while in the fourth radium Three died shortly after the operawas employed. tion, and one lived for two years. In six other cases carcinoma of the bladder was associated with a diverticulum.
cysts occurring in various sites upon the pelvic peritoneum. Histological examination showed that both the ovarian blood cysts and those occurring elsewhere possessed an epithelial lining closely resembling the uterine endometrium. Observation of the uterus during operations convinced Dr. Sampson that it was no unusual thing for menstrual blood to regurgitate through the Fallopian tubes into the peritoneal cavity, and actual experiment showed that very little manipulation of the uterus sufficed to bring about the same result after operations
upon the endometrium. These observations led Dr. Sampson to believe that blood cysts both of the ovary BROADCASTING HEART SOUNDS. and elsewhere within the pelvis may arise by AT a meeting of the Bristol Medico-Chirurgical implantation of fragments of endometrium escaping the Fallopian tubes. He was able, moreSociety held on April 9th a paper was read by Dr. through to obtain evidence for belief that what holds over, Carey F. Coombs and Dr. C. K. Herapath on auricular failure. This was followed by a discussion, and during for normal holds also for malignant uterine epithelium, the evening an experiment in " broadcasting " heart and on the strength of this he advises certain obvious sounds was made, which if not new to this country, modifications, such as a preliminary ligation of the Fallopian tubes, in the performance of hysterectomy was at least sufficiently unusual to be of more than Apart, local interest. The experiment was carried out by Mr. for malignant conditions of the uterus. Arthur Mitchell, of Clifton, who was introduced to however, from immediate practical considerations, the meeting by Prof. F. H. Edgeworth. The apparatus Dr. Sampson’s observations possess a wide general He believes on good evidence that the used was a sensitive microphone applied over the interest. endometrial implants grow more readily upon the ovary than elsewhere, and that the implants on the peritoneum are usually secondary to primary ovarian grafts. In the light of the work of Drew2 on growtli-producing substances, recently reported in THE LANCET, this indication of the presence of such a substance in the ovary is of particular interest ; the invasiveness of some of these implants, even while clinically benign, gives food for thought. Even more intriguing is the suggestion-it is no more than a suggestion, for the evidence on this point is by no means conclusive-that implants originally benign may undergo malignant change in the presence of such a change in the parent uterine endometrium. Experimental evidence strongly in support of Dr. Sampson’s views on the ætiology of the blood cysts has been produced by Dr. Victor C. Jacobson,3 of the Albany Medical College, working upon rabbits. ____
I
pelvic
THE OPHTHALMIC HOSPITALS OF EGYPT. THE publication of the usual annual report on the Ophthalmic Hospitals of Egypt for 1922 having been heart of a person in an adjoining room, and con- delayed, an abstract of it has been printed privately nected to a suitable transformer. This was then by Mr. A. F. MacCallan, C.B.E., F.R.C.S., who recently amplified by four wireless valves and reproduced vacated the post of Director of the Ophthalmic Section through a loud speaker to the audience at, the meeting. of the Department of Public Health. Mr. MacCallan The first case was that of a normal heart, and the held this post for 20 years, during which the organisasecond, one with total arrhythmia. In both instances tion of a system of special hospitals proceeded hand sounds corresponding to heart beats could be heard in hand with that of a definite school of ophthalmology clearly all over the room, the irregularity in the based on the administrativescheme of the Royal second case being strikingly demonstrated. The London Ophthalmic Hospital. The 23 existing improvement and perfection of such a method as this ophthalmic hospital units situated in the capital offers infinite possibilities for teaching in the future. towns of the 14 provinces are staffed by Egyptian The accompanying illustration, for which we are who, after obtaining their diplomas indebted to the Sport and General Press Agency, was at the Government Medical School, go through taken at the clinic of Dr. Leo Jacobsohn, of Charlotten- a course of instruction at the Giza Hospital and burg, who has also succeeded in amplifying the beats Ophthalmic Laboratory in the suburbs of Cairo, of the human heart so that they are audible in a lasting for a minimum period of two years. For some six years all Mr. MacCallan’s assistants have been large hall. Egyptians, but it must not be forgotten that in the THE NATURE OF "BLOOD" CYSTS. early years the help of other British surgeons was THE so-called blood cyst of the ovary has long been utilised in the initiation of hospital and laboratory recognised by gynaecologists the world over ; it is courses of instruction. These were Dr. L. S. Miller, of usually regarded as being produced by failure to Hobart, Tasmania, Dr. G. H. McLaren, of Montreal, rupture on the part of a Graafian follicle. Probably Canada, Dr. E. V. Oulton, of Brighton, Dr. R. G. many such cysts do originate in this way, but recent Waddy, now Professor of Ophthalmology at Sydney, work by Dr. John A. Sampson,1 of Albany, N.Y., and Dr. J. B. Horgan, of Cork. The origin of the ophthalmic campaign in Egypt suggests that many haveanother and much more interesting mode of development. These cysts was the liberality of Sir Ernest Cassel in placing attain to their greatest size on the ovary, but Dr. under the trusteeship of Lord Cromer, and thereafter Sampson, in the course of a long series of major under that of the High Commissioner for the time being, gynaecological operations, observed smaller but other- a sum of 40,000, the interest of which was to be used
surgeons,
___
2 On the Cultivation of Tissues and Tumours in Vitro, by 1 Benign and Malignant Endometrial Implants in the Peritoneal Cavity and their Relation to Certain Ovarian Tumours, A. H. Drew, THE LANCET, 1923, i., 785, 833. by John A. Sampson, M.D., F.A.C.S., Surg., Gyn., and Obst., 3 Autotransplantation of Endometrial Tissue in Rabbit, xxxviii., 3, 287. by V. C. Jacobson, Arch. Surg., 1922, v., 281.