870

of tightness across the chest, great dyspneea and cough.When admitted in October, 1872, there was extreme pallorand debility; orthopnce.t. and great dyspnoea, on movement.The heart was found to be enlarged, with diffused apex beat,and a thrill felt there; a double murmur was audible overthe lower part of the cardiac area and towards the apex.He became much better, and was able to work after hisdischarge. On readmission in October last, he was extremelyill, and presented the symptoms of left pleurisy; he wasunable to lie down; there was anasarcaof the legs, and alsoascites. There was a systolic murmur over the heart’s apex, Iwhich was displaced to the right. Four pints and a half of ifluid, at first clear, then blood-stained, were removed fromthe left pleura by paracentesis, but he rapidly sank. At the

autopsy, the left side of the diaphragm was pushed down-wards, and the left pleura contained four pints of fluid, withsome blood-clots. An aneurismal sac, the sizeof alarge cocoa-nut, was found in the wall of the heart, opening by an orifice,the size of a crowquill, into the left ventricle near the apex.The sac was globular, partly divided by a fibrinous septum,its wall somewhat thin below, but thicker towards its upperpart, and externally it was covered by the adherent peri-cardium. The cavity contained a quantity of blood-clotand disintegrated blood. The left ventricle was not

hypertrophied, but somewhat dilated; the aortic andmitral valves were healthy; the aorta not atheromatous.Dr. Southey pointed out that the diagnosis in all thesecases is uncertain, and that the largest aneurisms oftenhave small orifices. - Dr. WICKHAM LEGG thought thisaneurism unusually large, the largest on record beinga case of Friedrich’s, in which it equalled the heartin size. He referred also to a monograph by Pelvet on thesubject.-Dr. GREEN thought the case very important, fromits bearing on the etiology of the disease. He questionedwhether the term " aneurism " was strictly applicable, andinquired what relation pericardial adhesion bore to the sacin such cases. - Dr. SOUTHEY, in reply, reinarked thatwhen the aneurism is large, the pericardium becomes ad-herent and forms the outer wall of the sac; hence ruptureoccurs less frequently than in smaller aneurisms.-Thespecimen was referred to a committee consisting of Drs.Southey, Green, and Legg.

Dr. MURRAY showed a solid Ovarian Tumour of large size,from a lady forty-eight years old, who had been tapped fivetimes in six months, with removal of large quantities offluid, which was discovered after death to have been ascitic.The uterus contained numerous fibroids. The tumour wasreferred to the Morbid Growths Committee.

Dr. DowsE showed a case of Malignant and Cystic Dis-ease of the Right Kidney, with a secondary growth in theright lobe of the liver. The cystic disease in the kidney wasmultilocular, and possibly formed by dilatation of the pelvisand calyces. The urine was free from albumen or bloodduring life.The meeting then adjourned.

CLINICAL SOCIETY OF LONDON.

THE above Society met on December llth, when the chair Iwas taken by the President, Mr. Prescott Hewett. Therewas a small attendance of members, but it will be seen fromthe subjoined report that the cases brought forward wereof considerable interest; the debate on Mr. Rouse’s case

being much enriched by the citation of rare cases of aneu-rism by Mr. Barwell and the President.Mr. MORRANT BAKER exhibited a male child a year old,

who was the subject of a Rare Form of Skin Disease. The

child presented a copious eruption over the whole body ofslightly raised smooth 11 plaques," the majority varying insize from a pea to a kidney-bean, some nummular in shape,others oval and wheal-like, in parts confluent, formingwheal-like projections measuring from one to two inchesin their long diameter. The colour of these patches variedfrom yellow to yellowish-pink and dull red, the pink andred spots being rendered paler by pressure. The skin wasnot tender, and there was but little itching. When one ofthe patches was scratched or irritated, the surface appearedas if blistered. The eruption was most profuse on the back

of the trunk, rather less on the face and arms, and least onthe legs, while the palms and soles, as well as the neigh-bourhood of the anus and the buccal mucous membrane

were quite free. The eruption was said to have begun, whenthe child was six weeks old, as small red pimples, the facebeing the last region to be affected. During the last fourmonths no fresh spots have appeared. The child’s generalhealth is unaffected, it is still suckling, has not been vac-cinated, and has never presented any signs of syphilitictaint, the parents, indeed, being perfectly healthy. Mr.Baker remarked upon the doubtful nature of the affec-tion, which in some respects resembled the class of ery-themata. Dr. Tilbury Fox had recognised the case as

resembling in many respects one now under his care.-Dr.TILBURY Fox then exhibited the case referred to by Mr.Baker. The subject, a child two years and a half old, wasbrought to him in May, 1873, with an eruption strikinglylike that in Mr. Baker’s case. The eruption had com-menced when the child (which was born at full term, andhad been healthy from birth) was six weeks old, in two smallred patches on the inner side of the left leg and thigh, theappearances being as if it had been scorched or scalded.Then the eruption somewhat rapidly extended over thewhole body, the patches, which were slightly raised, beingat first of a dull red or dusky copper tint, becoming palerand changing to a fawn colour. The whole body was mostthickly covered when the child was first seen, the onlychange that has taken place being that some of the patcheshave become paler. At the present time the eruption ismost thickly distributed over the skin of the trunk, espe-cially at the back of the neck, the limbs, genitals, and leaston the face. The patches vary in size from a split pea to analmond ; they are mostly of a fawn colour, are slightlyraised, the skin feeling a little tougher than natural wherethey are seated ; in fact, there seems to be distinct infiltra-tion. Close inspection shows them to be apparently due toa uniform infiltration of the true skin, generally massed inthe region of the hair-follicles. A few patches also existon the mucous membrane of the mouth and palate. Onirritation the deep copper-coloured patches take on asemi-urticarial character. The child’s health is in no

way affected, the eruption was not attended by any sym-ptoms, and there has never been jaundice. The mother is

healthy, has two healthy children, but is subject to biliousattacks. There is not the least history of syphilis. Thefirst case that Dr. Fox had seen was one in a child ninemonths old, which he saw in consultation with Dr. Greamabout two years ago. In this case, also a male, the eruptionhad commenced at the age of six weeks, and had been un-attended by any symptoms ; the patches, dull and red atfirst, did not begin to fade for a considerable time. Dr. Foxhad also seen a third case, which was at first supposed to besyphilitic. The mother of this child was weakly, andsubject to severe flooding, but there was nothing to favoura syphilitic hypothesis, and anti-syphilitic treatment had noeffed in curing the disease. Here, as in the other cases,the patches were fading in colour. Dr. Fox remarked uponthe close resemblance which the patches presented toxanthelasma, which was very well seen on the penis in his firstcase. But there was no evidence of any antecedent jaundiceor hepatic disorder in any of the cases, and xanthelasma wasvery exceptional in children. Mr. Hutchinson had nevermet with it in such young subjects. It certainly was noturticaria, which is essentially a hypersemic condition ofskin unattended with the deposition of new material, as inthese cases. He was inclined then to regard these cases asexamples of a very rare and hitherto undescribed form of £general xanthelasma, or, if objection be made to the use ofthat term, he might suggest the somewhat barbarous name-" xanthelasmoidea."Mr. RousE then read the notes of a Case of Popliteal

Aneurism. The patient was a man forty years of age, whohad contracted syphilis twenty years before, and whosemother had died of cancer. Two years before admission asmall swelling appeared in the right ham ; this swellinghad gradually increased, the leg becoming stiff and painful.Pulsation was noticed in the tumour six months before

admission, and the pain became more paroxysmal, being

871

most severe at night. On admission the right poplitealspace was occupied by a large pulsating tumour, measuringtwenty inches and one-third in circumference; there wasno lateral expansion, but a purring bruit could be heardwhich followed the pulse. The skin was tense and red-dened, the knee-joint the seat of effusion, while the end ofthe femur seamed enlarged. The inguinal glands on bothsides were enlarged. The patient had emaciated veryrapidly. While under observation the bruit at times dis-

appeared and then reappeared, while the effusion in theknee-joint diminished. Mr. Rouse ligatured the femoralartery, and for a few days the tumour decreased in size, pul-sation ceasing. A few days after the operation the tumouragain enlarged, and became painful, the leg becoming cede-matous. Then followed sloughing of a patch of skin overthe tumour, displaying layers of fibrin; the rumour thenfully suppurated, while the codema of the leg increased, fol-lowed by gangrene of the foot. Amputation of the thighwas performed. Examination of the limb after removalshowed a large aneurism of the popliteal artery, the outerand inner walls of which had sloughed away, so that aoavity had been formed filled with clot partly disintegrated,the popliteal trunk entering the sac above and the tibialarteries leaving it below. The popliteal vein was pluggedby adherent clot. The patient made a good recovery. Mr.Rouse remarked upon the difficulties in diagnosis of thiscase : the bruit and pulsation were unlike those of aneurism;while the rapid wasting, the effusion into the joint and en-largement of the femur, together with the family history ofcancer, pointed strongly to pulsating tumour of that bone.As illustrating this difficulty, he quoted the case of a manwho was admitted into St. George’s Hospital in 1865,with a large pulsating tumour in the right ham, the skinover the tumour being white and tense, while the knee-jointwas enlarged by effusion and thickening; there was adistinct bruit, and the tumour diminished in size on

applying pressure over the femoral artery. The patientbeing unable to bear the continued pressure of a

tourniquet, the femoral was tied. Two days after theoperation pulsation recurred. Secondary haemorrhage setin, and the patient died sixteen days after the operation.The tumour proved to be a large irregular encephaloid massarising from the lower end of the femur. There is also a

preparation in the museum of St. George’s Hospital of anenormous popliteal aneurism, in which, from the absenceof pulsation during life, it had been mistaken for malignantdisease. A second feature of interest in the case was theoccurrence of a slough over the tumour. Mr. Rouse had

only met with one case on record-viz., in the Gaz. Heb-domadaire, 1868, p. 109-where sloughing of the skin withseparation of layers of clot followed upon the cure of apopliteal aneurism which had become diffuse. The poplitealnerve was also paralysed. Lastly, the supervention of

gangrene was of interest, following upon the obstructionin the vein, due to pressure of the inflamed and suppuratingsac.-Mr. BARWELL referred to a case of a large aneurismof the popliteal which had burst and become diffuse, inwhich amputation was performed under the impressionthat the tumour was malignant. There was no pulsationin the tumour, which occupied the whole ham overlappingthe femur. The superjacent skin was of a blue colour. Inthis case it appeared that the man, having rested for a fewdays after the -rupture of the sac, had been enabled toresume his work for three weeks before applying for ad-mission to the hospital, a new sac for the false aneurismbeing formed from the greatly thickened and condensedtissues. Preparations of this case are preserved in themuseums of the Royal College of Surgeons and Charing-cross Hospital. lilr. Barwell inquired whether the gangrenein Mr. Rouse’s case did not result from thrombosis of thefemoral vein following the ligature of the artery, for he hadseen cases where this operation had been followed bythrombosis in the companion vein. He thought this tohave been more likely than that the pressure of the sac onthe popliteal vein should have given rise to thrombosis inthis vessel, for from the free discharge from the sac itspressure would be lessened.-The PRESIDENT, in drawingattention to the absence of pulsation, which occasionallyoccurred, in Mr. Rouse’s case, related the particulars oftwo very interesting cases in which the absence of pulsa-tion nearly led to a very great error. One, a man underthe care of Dr. Fuller, was admitted for great and persistent

pain in the lumbar region. The abdomen was carefullyexamined, but without result, and Dr. Fuller at first re-garded the case as one of rheumatism of the lumbar muscles.By and by a swelling appeared in the lower part of the bellyon the left side; there was no pulsation, and it was gene-rally agreed that the case was one of psoas abscess. The

swelling increased much in size, and extended below Pou-part’s ligament. Mr. Hewett frequently pointed out thecase to his pupils as a typical one of psoas abscess, butwhich he would let alone, as he was not in the habit oflaying open large abscesses. The skin then became red,and the abscess appeared on the point of rupture. Instead,however, of bursting, it forthwith diminished in size, untilit could hardly be felt. During the whole time the painfrom which the patient was suffering was very intense, andit even became more so as the tumour subsided. The mandied suddenly with symptoms of collapse very soon afterhe had been asking to be injected with morphia in the dayas well as at night, on account of the increased severityof the pain. Mr. Hewett had previously remarked that itwas rare to have such prolonged and persistent pain in theback, save in cases of aneurism or cancer. At the autopsythere was found a large aneurism of the descending aorta,which had ruptured into the belly. At no time had pulsa-tion existed, and there had been a narrow escape of openingit. The second case was one of femoral aneurism, for whichSir Benjamin Brodie had tied the external iliac; the manleft the hospital cured, but returned a few months laterwith recurrence of pulsation in the tumour; this wasarrested by pressure from a leather splint applied over thelimb. The tumour, however, again increased, and sixmonths later it had attained the size of a cricket-ball. Itwas then thought to be malignant, but the patient survivedfor five years, eventually dying of phthisis, the pulsationhaving ceased after continuing for eighteen months. The

original diagnosis of aneurism was then confirmed, and thecase showed that an aneurism might continue to enlargewithout pulsation being present. Mr. Hewett also relateda case of rapid gangrene of the whole lower limb, whichfollowed upon a gunshot wound in the ham of a boy; ampu-tation at the hip was: performed, and it was found thatof the two shots that had entered the limb, one was lodgedin the popliteal artery, the other in the vein. Here signsof gangrene set in within twenty-four hours of the injury.-Mr. MORRANT BAKER related the particulars of a case inwhich a large fluctuating, non-pulsating, but very painfultumour had appeared in the gluteal region. The diagnosiswas abscess, but only blood flowed on exploratory puncture;still it was thought possible that a vessel might have beenwounded, and Mr. Baker, after consultation with one of hissenior colleagues, enlarged the opening, and finally laid thesac freely open. A large blood cavity between the muscleand bone was thus exposed, blood welling up from the greatsciatic notch. The common iliac was tied, the patient sur-viving two days. At the post-mortem there was foundcaries of the sacro-iliac synchondrosis with ulcerationof one of the branches of the gluteal artery.-Dr. SOUTHEYrelated a case in which the prominent symptom wasextreme pain in the lumbar region, greatly increasedby movement. There was more dulness in the left lointhan normal ; the man was very pallid; heart’s impulseforcible, but free from murmur. The dulness in the loinincreased, and some fulness appeared, and then a decidedtumour, but no pulsation. In a few days, however, a dis-tinct thrill was perceived over the tumour, the pain in-creased, and oedema of both lower limbs occurred from

pressure on the iliac veins. Sudden death took place withinten days, and an aneurism was found springing from thedescending aorta close to its bifurcation; it had becomediffuse, and extended to Poupart’s ligament.-Mr. WAR-RINGTON HAWARD also related a case of abdominal aneurismin which pain in the back was positively the only symptom.Mr. Holmes had repeatedly examined the case for aneurismwith negative result. At one time the patient was thoughtto be malingering. Death occurred from rupture of thesac.-Mr. RousE, replying to Mr. Barwell, stated that thepopliteal vein in his case was entirely occluded by a firmpartially decolourised clot, softening in the centre.

Mr. VENNING then read notes of a Case of Syphilis in whichsecondary symptoms appeared twenty-three years afterinfection. The patient, forty-one years of age, had beentwenty-three years in the Life Guards. Twenty-three yea,is

872

ago he contracted an indurated chancre, for which he wastreated with mercury until the gums were sore. No consti.tutional symptoms then followed. Eighteen years ago hecontracted another chancre, followed by suppurating bubo.He subsequently married, and his wife and four childrenare perfectly healthy. Three months ago a scanty rupialeruption appeared on the left leg; there were enlargedglands in the groin. The eruption was cured by iodide ofpotassium. Mr. Venning thought that great stress shouldbe laid upon the enlargement of the inguinal glands at thetime of syphilitic infection, the condition being that ofCC multiple indolent bubo," or the 11 amygdaloid gland " ofMr. Henry Lee. Out of forty-eight cases of infectingchancres, all but two being treated with mercury, and thesetwo with iodide of potassium, all, with one exception, pre-sented these " amygdaloid" glands ; in nearly one-halfthey were present on both sides. Secondary symptoms hadoccurred in the majority of these cases. He would ask thenfirst-Do these 11 amygdaloid " glands, when once formed,ever disappear ? 2nd. Is their presence a sure sign of

syphilis ? 3rd. Do they ever exist apart from syphilis ? Thefirst question he would answer affirmatively, but he held thatwhen they disappeared the system was quit of the disease ;and the subjects would then be open to re-infection, whichMr. Gascoyen had recently shown to occur. To the second

question he also supplied an affirmative answer, and said Ithat in no case in which there was evidence of syphilitic Itaint were these glands absent. He would like to know Iwhat was the condition of the inguinal glands in cases of Jre-infection. Lastly, he had not met with their presence in iother affections. In his opinion, then, the "amygdaloid" Icondition of gland was a valuable aid in diagnosis.-Mr.PicK related a case in which the " amygdaloid " glands in Iboth groins had appeared after enlargement of the cervicalglands more than a year ago; the subject of them had re-cently contracted a soft chancre, but there was no evidenceof syphilis, and the glandular enlargement was thought tobe strumous. Mr. Pick also referred to his own and others’experience to the effect that after rowing exercise theinguinal glands frequently become" amygdaloid," subsidingafter the cause was withheld. He had met with a case of sy-philis in which there were still traces of eruption, but in whichthere was no enlargement of the inguinal glands remaining.- mar. MORRANT BAKER asked for more precise informationas to the characters of the rupial sores, upon which theirsyphilitic nature was founded. -Mr. BRUDENELL CARTERmentioned a case which bore upon the question recentlyraised by Mr. Gascoyen, as to the possibility of a father in-fecting his children but not his wife. A patient had cometo him with paralysis of the third nerve. He had contractedsyphilis twenty-four years ago. After his marriage his wifehad three or four miscarriages; the fifth child was bornalive, but was puny. Dr. Addison recognised the child tobe the subject of congenital syphilis, and put both it andthe father on anti-syphilitic treatment. The subsequentchildren were all healthy.-Dr. WHIPHAM also related a caseof congenital syphilis, in which the father alone was thesubject of the disease.-Mr. T. SMITH inquired what wasthe exact definition of Mr. Henry Lee’s 11 amygdaloid "

glands. Was it simply chronic enlargement ? If so, therewas nothing specific about them at all, for all the glands inthe body might be enlarged apart from syphilis, and chronicenlargement of the inguinal glands followed on many non-specific causes-e.g., leucorrhoea. He also thought that itwas not very unusual, in the upper classes of society at anyrate, to get secondary symptoms delayed in their appearance.He had met with cases of ulceration of the tongue and ofthe penis in old subjects which were said to be cancer,"but which were cured by iodide of potassium, and in thesecases recent infection was out of the question, although inmost there was a history of syphilis contracted in early life.In the present case, however, there was more possibility ofan infection subsequent to the time stated.-Mr. VENNING,in reply, stated that not only was the syphilitic gland cha-racterised by its persistence, but it was peculiar in formingone of a group of

11 multiple buboes " generally in the courseof the vessels. It felt pulpy, and its condition was wellexpressed by the term " amygdaloid." The rupial sores inhis case were marked by characters of psoriasis at theirmargins, and this, together with their appearance on heal-ing, was, he thought, ample evidence of their syphiliticnature.

Reviews and Notices of Books.Autobiography of A. B. Granville, M.D., F.R.S. Edited by

his youngest daughter, PAULINA B. GRANVILLE. Twovolumes. London: H. S. King and Co. 1874.IMPROVING on the Horatian advice to defer the publication

of your drama till the ninth year, Dr. Granville put off thepublication of his till wellnigh his ninetieth, with theresult, indeed, of multiplying the dramatis personce, but alsoof greatly deteriorating the style. And yet there is a certaincongruity between the matter and the expression of thesevolumes. Ulysses-like in the variety of his adventures, Dr.Granville is Homeric in the garrulity of his descriptions,and though never reaching the level of the " old man elo-quent," he never falls below that of the old man amusing.Besides its intrinsic value, his autobiography has an interestof another kind, showing as it does how physicians rose toeminence and honour in the times of the Regency, and re-vealing to us a state of society, professional and lay, gone,never, we hope, to return. Dr. Granville was the product of thateighteenth century which, French in its " civilisation," wasjust beginning to feel the nineteenth century reaction whichwas led by Germany. He carried far on into the presentday the traditions and the ideals of a generation much lessserious, much less sound, much less scientific than our own.

These volumes may be classed with Sir Henry Holland’s"Recollections," though Sir Henry’s, inferior in variety ofinterest, have greatly the advantage in intellectual weightand in dignity of tone. Dr. Granville, indeed, seems to haveaspired to be little more than a medical " Gil Blas," while,to give him his due, he not only sustained, but improvedupon the character. Born of Italian parents in Milan, hisearly manhood was thrown among the men and manners ofthe Revolution, and Republicanism, the ideal of governmentwith the giovent6 d’Italia, marked his mobile and ardentnature for her own. When a mere lad he got into troubleand prison for his politics, and on getting out again simplytransferred the scene of his revolutionary eccentricities toPavia, whither he had gone to study medicine. The severe

and elevating teaching of Rasori, Volta, Spallanzani, Scarpa,and Frank, was not without its sobering effect upon him. ForVolta in particular he entertained a reverence and an admira-tion which never abated; but after graduating, the 11 wandermadness"-the mania errabunda of medico-psychologists-drew him away from a promising academic career; carriedhimin company with strolling players from Genoa to Venice, andthence to Cephalonia and Corfu, where he added to his ex-cellent knowledge of Latin a fluent command of Romaic,which, in his case, did duty for Attic, Greek; till, after

residing with Ali Pacha, and studying the archasology of theHellenic foretime, he finally settled in Constantinople asbody-physician to a Greek merchant, in whose house he

stayed. This 11 situation," however, he threw up with cha-racteristic abruptness; passed some weary months on boarda Turkish man-of-war, and visited the Holy Land. In this

way his knowledge of the Mediterranean and its northernand southern shores became exhaustive in its minuteness,and he might have continued to move among its " floating"and polyglot communities for years but for an appointmentas assistant-surgeon on board H.M.S. Raven, which finallybrought him to England, where he married. On leavingthe navy he settled in practice at Manchester; but his resi-dence there, in spite of the society of Dalton, was brief.Launching on the "great world of London," and qualifyingas a member of the Royal College of Surgeons, he rapidlywormed himself into practice, got elected a Fellow of theRoyal Society, and through serving as interpreter to theForeign Office, obtained the entrée of the beau monde. His