Dr. H. J. Boldt of Progress in Gynæcology New New York (New York Medical Journal, March 21, 1908) says in part that our knowledge of chorioepithelioma may be classed among the late achievements in gynæcology. The first description of this malignant disease was given by the late Martin Saenger. Since he called the attention of the profession to this occasional transformation of conception product structures many exhaustive and valuable articles on this comparatively new disease have appeared, and we have learned to recognize it sufficiently early to save many lives by immediate radical surgical intervention.

Very marked progress has been achieved in the treatment of purulent peritonitis. It has been proved by those who have tried the more modern method of extensive non-intervention that the rate of mortality is much lower. After the primary cause of the peritonitis has been removed no attempt should be made to rid the abdominal cavity of the purulent secretion by flushing and sponging, because to remove it all is impossible and the time consumed in flushing and sponging is too long and the traumatism too great. One should content himself with placing a drain in the cul-de-sac of Douglas, without any flushing or sponging. Rapid work is essential. When the patient is put to bed she should be placed in a semi-sitting position, the position suggested by the late Dr. George R. Fowler.

From that time on continuous instillation of saline solution should be used, a method advocated by Dr. J. B. Murphy.

It is certainly marvelous what a large quantity of fluid is absorbed. He has found that the best technique consists in taking an ice-water cooler of two or three gallons capacity, filled with hot saline. solution (0.9 per cent.). This is kept at a temperature of about 110° F. by adding more very hot solution as needed. The quantity so added should be noted, so that we may know how much the patient absorbs. The container is placed alongside the bed and the rubber tube, with a small-sized rectal point, is attached. The flow is regulated by the faucet, and should not be more rapid than a quick dropping. The nozzle is inserted into the rectum, and the instillation is continued steadily day and night. In one of my cases 14 quarts were absorbed in 24 hours.

We have also learned by experience that in instances of cystocele associated with descent of the anterior vaginal wall a simple operation on the vaginal mucosa, such as some form of anterior colporrhaphy, does not suffice to cure a patient of the cystocele, but that it is necessary to separate the bladder from its cervical attachment and displace it upward, and then attach the vagina to that part of the cervix to which the bladder had been previously attached.

It would take more time than that allotted on this occasion were he to consider also the strictly scientific progress made in gynæcology and to consider in detail all of the clinical advances. He, therefore, limited himself to those achievements which he considered most important and bears strictly on gynæcology.

Pelvic Diseases.

Relation of Appendi- Bandler (Medical citis to Gynecological Record, April 18, 1908) concludes that appendicitis in the form of an inflammation of the mucous membrane does not result from inflammatory diseases originating in the uterus or annexa. Involvement of the appendix viewed as a peritoneally covered organ may take place as part of a peritonitis, more or less localized or more or less extensive, which has its origin in inflammatory diseases of the annexa. Severe inflammations of the appendix, in so far as they cause a pelvic peritonitis or in so far as the accumulation of pus is located in the pelvis, naturally involve the uterus and annexa in adhesions, do not cause pyosalpinx, but may cause tubo-ovarian cysts. A distinctive diagnosis as to original site of the infection, when the appendix and right annexa are involved, is often impossible except from the operative clinical standpoint, and even then is not always certain. Mild attacks of appendicitis, without the production of well-defined peritonitis, may involve the annexa without adhesions, but especially by infection of the Graffian follicles, alterations of the stroma and the production of varicocele of the broad ligament. Such alterations in the annexa generally result from processes extending from the cervix and uterus into the broad ligaments, and a definite decision as to the source of the trouble may be often impossible.

Estimation of Date of George L. BroadConfinement. head (Post-Graduate, May), who has been studying this question in 500 cases, arrives at the following conclusion:

I. There can be no doubt that menstruation, when accurately known, is our best aid in estimation, as it is available at any period, and in a large proportion of cases

we can tell the date of confinement within two weeks, regardless of any further examination.

2. The height of the fundus is important during the first eight months, but is less so, generally speaking, from that time on, as the uterus reaches the same points at eight and nine months and eight and one-half and eight and one-third.

3. The engagement of the vertex in the pelvic brim is of great importance, especially in primiparæ, as in a large proportion of cases the vertex is found to be engaged during the last week of pregnancy, while comparatively few are engaged before that time, either in primiparæ or multiparæ.

In the valuation of the last two signs, large children, twins, deformity of the pelvis and excess of amniotic fluid must, of course, be taken into consideration.

4. In the condition of the cervix we have another valuable sign, chiefly, however, in primiparæ, for, while the internal os in nearly one-half of multiparæ admits one finger before the middle of the ninth month, in primiparæ only one-third admit one finger up to the beginning of the last week. During the last week the greater number of both admit one finger.

5. Quickening is very indefinite, as the sensations of women in respect to this cannot usually be depended upon with sufficient accuracy for a scientific estimation.

6. If the navel protrudes the chances are about even that the woman is at full term, but it must be remembered that a large number of women are at full term with a flat or depressed navel.

7. The sinking of the uterus during the last two weeks is a sign of considerable importance in intelligent women, but, of course, can be of service only late in pregnancy. The sign of very abundant secretion is of value, especially when it is

associated with softening and relaxation. of the entire vagina and vulvar orifice.

Ectopic Gestation As- Dr. Stephen E. sociated with Fibro- Tracy of Philadelmyomata. phia reports the following interesting case (New York Medical Journal, May 30, 1908):

The history of the case is as follows: Mrs. W., aged 37 years; nullipara; began to menstruate at the age of 17 years. The menstrual periods occurred every 29 to 34 days, lasted from 5 to 7 days, and were always painful. On two occasions the intramenstrual period was six weeks, and at these times she supposed she was pregnant. During the last 12 years she had been confined to bed many times with attacks of pelvic peritonitis. The last The last menstrual period prior to this illness was in September, 1907. The menstruation, beginning on October 20, was scanty, and the period lasted about half the usual time. On the evening of December 20, after being upon her feet a greater part of the day, she had discomfort in the pelvis and supposed she was about to develop another attack of peritonitis. She started to take a hot douche to relieve the discomfort, and almost immediately after the fluid began to run into the vagina she was seized with agonizing pain across the lower abdomen, became nauseated and vomited. Two days later I saw the patient in consultation. At that time the pain was dull in character, and there was decided tenderness over the lower abdomen. Upon vaginal examination the pelvis was found filled with a hard conglomerate mass, and nothing definite could be made out. Operation was recommended and refused. The following day the patient passed six or seven drops of blood from the vagina. The pain subsided gradually and the patient left her bed about three weeks after the beginning

of the attack. From then on, although suffering with some discomfort in the left. side of the pelvis, she was able to be up and about the house. In the early morning of March 1, 1908, she was seized with severe pain in the lower abdomen, after which she vomited and had diarrhoea. The following day the temperature was 101° F. and the pulse rate 120 per minute. After this attack of pain she consented to operation, and was admitted to the Stetson Hospital the afternoon of March 3.

Upon admission she had a temperature of 99° F. and a pulse rate of 80 per minute; the lower abdomen was tender and there was a mass on the left side. Upon vaginal examination a mass was found which filled the pelvis and extended up the left side of the abdomen above the anterior superior spine of the ilium. The pelvic portion of the mass was hard, while the abdominal portion was soft. With the exception of a few drops of blood passed after the beginning of the attack in December, there had been no bleeding from the vagina; at times there was a slight, pinkish, leucorrhoeal discharge.

Operation was performed under ether anesthesia. When the abdomen was opened it was found that the gestation sac filled the left side of the pelvis and the lower portion of the abdomen, and was almost completely surrounded by adhesions. After placing gauze pads to protect the general peritoneal cavity, the hand was passed gently behind the sac to determine the anatomical relations. Scarcely had the sac been touched when the pelvic and lower abdominal cavities were flooded with blood. The sac was quickly enucleated and brought to the surface, and the portion attached to the left broad ligament clamped, cut and removed. An attempt was made to temporarily control the bleeding by packing

with gauze, but this was not successful until a large vessel, fully as large as any uterine artery I have ever seen, at the fundus of the bladder was ligated. By careful manipulation it was found that the uterus contained many fibroid tumors, which were adherent in the bottom of the pelvis and could not be enucleated in the usual manner because the adhesions were very dense, and there was no room to work, as the pelvis was packed with gauze to control the bleeding. The bladder was then pushed down, the broad igaments were clamped, the uterus was am

putated at the internal os, and by making traction upwards on the uterus the fibroids were cut free by scissors and the bleeding points controlled by forceps from below upwards. After the uterus was removed ligatures were applied and the forceps removed, and the toilet of the pelvis completed as after the ordinary. hysterectomy. The bleeding from the omentum and along the edge of the bowel, which had been controlled by gauze pressure, was then controlled by ligatures. A few other bleeding points were then controlled, and the abdomen was closed without drainage.

The Treatment of Arthur
Chorea.

Francis Voelcker, M.D., F.R.C.P., contributes this article to Folia Therapeutica, April, 1908, and divides the treatment into three heads: (1) General, (2) Symptomatic and (3) Specific:

(1) General.—Directly a case of chorea is recognized the child should be taken from school, or if at home, should be kept apart from the other children in the house, at all events for the greater part of the day. So often the early stages of the disease go unrecognized because it is not appreciated that the little outbursts of temper, irritability, spitefulness, peevishness or emotional instability are the early evidences of the condition, even before there is any definite motor evidence of the disease. The recognition of this fact will often prevent the outbreak of a violent manifestation of choreic movements which may follow on the injudicious, though well-intentioned, correction of faults which are themselves only the re

sult of a disease in its earliest stages. In many of these cases, and especially if the child has already had one attack of chorea, an attack may be aborted by taking the child out of its usual surroundings and sending it away into quieter ones with a relative or nurse who is well known and congenial to the patient. Isolation in the early stages is undesirable, if by isolation we mean shutting a child up by itself. Rest is a very important requirement at this stage, but note must be taken of the temperament of the child, for in some cases the forcible detention of a child in bed all day long will do more harm than good. On the other hand, it is essential that the child should be made to lie down for at least part of the day, though there is no reason why this procedure should be made tedious or punitive by deprivation of toys, books or of mechanical work. Sewing or knitting should only be allowed when those arts have been already acquired, and new kinds of work should

not be attempted.

It is advisable that these children should have a light burning in their bedrooms at night, and a grownup person should sleep in the same room.

The question of exercise must be largely determined by the coexistence of other rheumatic manifestations, as indicated by the temperature, by the state of the heart and by the presence of pain. In the absence of these there is no harm in letting the child go out for short walks, but it must be remembered that any fright, overfatigue or excitement may have the result of causing a rapid development of symptoms.

By the adoption of these general hygienic precautions and by feeding the child well and securing sleep by means of a warm bath at night, and by the administration of sedatives, I think it is quite possible to avert an attack of chorea. For the purpose of securing sleep I have found nothing so useful as the administration of trional in 5-grain doses every six hours. It is rarely, however, that we are called on to treat the very early stages of the disease, as they are generally not recognized till the movements are quite. definite.

(2) Symptomatic. The symptomatic treatment of chorea will in the main resolve itself into the treatment of the movements, insomnia, the emotional upsets, the wasting, and of the paralytic phenomena which may constitute the great feature of an attack of chorea.

Movements. Directly these are marked the child should be put to bed and kept there. The bed should not be too large, and should be protected at the sides, so that there is no risk of the child falling out, and if the movements are at all severe it will be necessary to have the sides of the bed padded. When movements are marked, water-beds are not indicated, though in the paralytic form of chorea,

and when there is very marked wasting, they are of the greatest use. When the movements distress a child much, considerable relief can be obtained by wrapping the child up in a blanket and then tucking the child firmly into bed. It is important in such cases to avoid anything which would seem to the child to savor of punishment. Choreic movements should not be allowed to go on unrestrained. The measures we may employ to diminish the movements may be divided into (i) external applications and (ii) internal medication.

External Applications.-These include packs, baths, douches, sponging, massage and electricity. Of all the external agents there is none so satisfactory as the use of the hot-pack. The child is wrapped in a blanket, which is wrung out in hot water, covered over with a mackintosh sheet, and then with another dry blanket, and thus enveloped, is tucked up in bed. In such a warm pack a child may be left for several hours. In a case recently under my care, where, in spite of the internal administration of sedatives, the movements were becoming more marked and the insomnia increasing, the application of the hot-pack was followed by ten hours' continuous sleep, with a very marked diminution of the movements. This form of treatment is nearly always grateful to the patient.

Cold-packs are indicated when the case is complicated with severe pyrexia, but apart from that they do not offer any advantages over the hot-packs.

Cold douches and tepid sponging find their chief utility during the period of convalescence or in very chronic cases.

Blisters and counter-irritation along the spine need only to be mentioned to be condemned.

Massage is undoubtedly of great benefit when the movements are subsiding.