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CLINICAL SOCIETY OF LONDON

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1250 Mr. A. W. NUTHALL and Dr. J. G. EMANUEL (Birmingham) read a paper on, and exhibited specimens from, four cases of New Growth affecting the Alimentary Tract and presenting unusual characters, occurring in patients aged 44, 27, 56, and 38 years respectively. In every case the mucous membrane was intact and the serous coat was unaffected, and Mr. Nuthall and Dr. Emanuel advanced reasons for con- cluding that the growths had not arisen from the mucosa of the bowel but that they were of an endotheliomatous type. Mr. E. M. CORNER and Mr. S. G. ScoTT showed sections of, and described, a Tumour of the Lip and another one of the Submaxillary Gland, both of long standing and benign. Both shelled out easily and had a fibrous capsule. The structure of the tumour from the lip, which contained islands of cartilage, was fully described. The submaxillary tumour was similar, only it had little or no cartilage. Mr. Corner and Mr. Scott concluded that these tumours had originated from blood-vessel endothelium from the following facts : the structure of the walls of the canals, their lining cells being continuous with those of the parenchyma, their containing blood, and the absence of ordinary blood-vessels in the tumours. Mr. S. G. SHATTOCK discussed the nature of a Mixed Tumour of Endotheliomatous Type which had occurred upon the lower lip. It was an encapsulated tumour consist- ing of cartilage, and blood-channels lined with layers of polymorphous epithelium, in place of marked columnar form. The specimen had long been in the museum of University College and he was able to show it through the kindness of Mr. Lawrence. It belonged to the same group as those of the parotid, submaxillary glands, and palate. The cartilage in these tumours he had once thought might indicate a reversion to a tissue found in the glands of the mouth in lower ancestral forms. For besides the atavism which concerned the grosser forms of organs an atavism of tissue-a teleplasia as it might be called-was theoretically possible. He had found no evidence of this ; his examination of the parotid gland of the echidna and ornitho- rhynchus, the most likely of mammalian forms to exhibit such modified structure, showed a stroma of common con- nective tissue only supporting the acino-tabular elements of the gland. There was no alternative except to connect the cartilage in this series of tumours with Meckel’s cartilage, in the proximity of which they occurred, near its exterior termination. The blood-channels of the tumour, lined in part with columnar cells, offered great difficulties. In no member of the whole animal series were the blood- or lymph- vessels furnished with columnar epithelium If the endo- thelium of the heart and great arteries was derived from the hypoblat or endoderm, the peripheral blood-system arose from vasifactive mesoblastic cells. One suggestion the speaker would make was that the channels might arise in connexion with remnants of certain extensions of the primitive ccelom. The pleuro-peritoneal or body cavity or coelom arose as a direct extension of the primitive alimentary canal-i. e., it was of hypoblastic or endodermal origin. In the dogfish tubular extensions of the ccelom, lined with columnar cells, lay in the substance of the branchial bars, the blood space, lined with flat cells, being alongside ; these coelomic ex- tensions in the dogfish disappeared. Was the system of channels in thee tumours related to remnants of coelomic extensions in the branchial bars, the blood capillaries afterwards coming to communicate with them ? or did blood-vessels become invaginated into such a system after the manner described by Professor Ray Lankester as "phleboedesis," the columnar cells of channels in the tumour being furnished by the endodermal cells answering to a lymphatic sheathe Or was it simpler to assume that the mesoblastic cells which gave rise to the capillaries were of endodermal descent and that in these tumours the columnar form was a reversion indicating their primary source ? Mr. G. E. GASK exhibited sections of a Complex Papillo- matous Growth consisting of a delicate fibrous stroma and lined by a layer of flattened cubical cells taken from the synovial sheath of the tibialis anticus tendon, subsequent to an injury to the ankle-joint and probably originating from the endothelial lining of the synovial sheath. Dr. J. F. PAYNE, in discussing the series of papers which had been brought before the society, thought that the subject was surrounded by a good deal of difficulty. As regards "parotid tumours" he inclined to the view that they originated in someway in embryonal "rests. "-Dr. H. MORLEY FLETGHER asked Dr. Rolleston how he accounted for the elastic fibres in the tumour which he had observed, and Dr. ROLLESTON replied that the elastic fibres had remained while the fibrous tissue around them had undergone degeneration.- Dr. ARTHUR WHITFIELD also remarked that this same survival occurred in the lesions of tuberculosis.-Mr. J. H. TARGETT regarded the specimens exhibited by Mr. Nuthall and Dr. Emanuel as examples of schirrhus such as occurred in the stomach. He did not see why these specimens should not be regarded as ordinary carcinomata of the scirrhus type. He had seen a great many tumours of the so-called "parotid’ kind occurring in many curious places-the tip of the nose, the lacrymal gland, the palate, parotid gland, and else. where-but he had never met with or heard of any occurring- away from the face. As regards their origin, he preferred the old-fashioned view-viz., that they were altered gland’ tissue. At any rate, he felt sure that he could produce- sections from them which could not be distinguished from, gland tissue.-Mr. J. H. PARSONS, Dr. F. J. POYNTON, and Mr. J. W. T. WAhKKR also took part in the discussion. and Mr. RAYMOND JOHNSON replied. Mr. GEORGE PERNET read a paper on a case of Congenital Multiple Sarcoma of the Skin occurring in the body of a, newly-born female child which was brought to University College Hospital after death. There were 70 growths dis- seminated over the skin and sections of some of these. revealed the structure of round-cell sarcoma. Mr. W. G. SPENCER exhibited card specimens of (1) Fibro- myoma in one Breast and Carcinoma in the other; (2) Hasmorrhagic Cyst of the Pancreas resulting from aseptic. haemorrhagic pancreatitis ; and (3) Lymphangioma Hyper- trophicum of Congenital Origin. Mr. W. WATKINS- PITCHFORD (Birmingham) exhibited card specimens of a large Multilocular Cyst of the Pancreas. from the body of a woman 29 years of age. CLINICAL SOCIETY OF LONDON. Clinical Evening : Exhibition of Cases. A MEETING of this society was held on April 25th, Mr. HOWARD MARSH, the President, being in the chair. Mr. H. L. BARNARD exhibited : 1. A case of Left Parietal Meningocele or Cephalhydrocele occurring in a male child, aged two weeks, who was brought to the London Hospital for a swelling on his head. The swelling was noticed two-. days after birth and had not increased in size. It was situated on the upper and posterior part of the left parietal bone and was distinct from the anterior and posterior fontanelles and the sagittal suture. An attempt to reduce it. had led to cessation of respiration and pallor. 2. A case of Multiple Chondromata or Oteomata with Synostosis of the- Lower Epiphyses of both Ulnae and Fibulas. The tumours. projected from the ribs, scapulae, clavicles, and femora, &c. The epiphyses were for the most part enlarged. The lower epiphysis of the ulna had undergone early synostosis on both sides, leading to ulnar displacement of the hand at the wrist-joint. The fibulae (the homologous bones in the leg) were- in the same condition. The patient suffered from severe rickets when a child. 3. A case of Tumour of the Abdominal Wall. Mr. HASTIXGS GILFORD (Reading) showed a case of Conspicuous Delay of Growth and Development. The patient was an instance of a disorder which had not, hitherto been systematically described. though some dozen or more cases had been recorded by French and German- writers. He was 28 years of age and came of a healthy family. At 23 years of age he was 1-078 metres (three- feet six inches) in height and had since grown 18 milli- metres. His height and proportions resembled those of a, boy between six and seven years of age. A radiogram of the hand showed that ossification was no farther advanced than was usual at the age of 10 years, while the dentition was like- that of a child of the same age. The contour of the body and the appearance of the head and face were childish. The- sexual organs were the most backward in development; the testes had not descended and the external genitals were infantile. The intelligence was good, but his behaviour and conversation were more like those of a child than of an adult. The thyroid gland could be felt. The dwarfism in this case was apparently not due to any of the known causes of that condition. Achondroplasia, rickets, and micro- cephaly could be definitely excluded. Mr. A. A. BOWLBY exhibited a case of Ethmoidal’ Mucocele occurring in a man, aged 26 years, a horsekeeper..
Transcript
Page 1: CLINICAL SOCIETY OF LONDON

1250

Mr. A. W. NUTHALL and Dr. J. G. EMANUEL (Birmingham)read a paper on, and exhibited specimens from, four cases ofNew Growth affecting the Alimentary Tract and presentingunusual characters, occurring in patients aged 44, 27, 56, and38 years respectively. In every case the mucous membranewas intact and the serous coat was unaffected, andMr. Nuthall and Dr. Emanuel advanced reasons for con-

cluding that the growths had not arisen from the mucosa ofthe bowel but that they were of an endotheliomatous type.

Mr. E. M. CORNER and Mr. S. G. ScoTT showed sections of,and described, a Tumour of the Lip and another one of theSubmaxillary Gland, both of long standing and benign.Both shelled out easily and had a fibrous capsule. Thestructure of the tumour from the lip, which contained islandsof cartilage, was fully described. The submaxillary tumourwas similar, only it had little or no cartilage. Mr. Cornerand Mr. Scott concluded that these tumours had originatedfrom blood-vessel endothelium from the following facts : thestructure of the walls of the canals, their lining cells beingcontinuous with those of the parenchyma, their containingblood, and the absence of ordinary blood-vessels in thetumours.

Mr. S. G. SHATTOCK discussed the nature of a MixedTumour of Endotheliomatous Type which had occurred

upon the lower lip. It was an encapsulated tumour consist-ing of cartilage, and blood-channels lined with layers of

polymorphous epithelium, in place of marked columnarform. The specimen had long been in the museum ofUniversity College and he was able to show it throughthe kindness of Mr. Lawrence. It belonged to the same

group as those of the parotid, submaxillary glands, andpalate. The cartilage in these tumours he had once thoughtmight indicate a reversion to a tissue found in the glandsof the mouth in lower ancestral forms. For besides theatavism which concerned the grosser forms of organs an

atavism of tissue-a teleplasia as it might be called-wastheoretically possible. He had found no evidence of this ; hisexamination of the parotid gland of the echidna and ornitho-rhynchus, the most likely of mammalian forms to exhibitsuch modified structure, showed a stroma of common con-nective tissue only supporting the acino-tabular elements ofthe gland. There was no alternative except to connect thecartilage in this series of tumours with Meckel’s cartilage,in the proximity of which they occurred, near its exteriortermination. The blood-channels of the tumour, lined inpart with columnar cells, offered great difficulties. In nomember of the whole animal series were the blood- or lymph-vessels furnished with columnar epithelium If the endo-thelium of the heart and great arteries was derived from thehypoblat or endoderm, the peripheral blood-system arose fromvasifactive mesoblastic cells. One suggestion the speakerwould make was that the channels might arise in connexionwith remnants of certain extensions of the primitive ccelom.The pleuro-peritoneal or body cavity or coelom arose as a

direct extension of the primitive alimentary canal-i. e., it wasof hypoblastic or endodermal origin. In the dogfish tubularextensions of the ccelom, lined with columnar cells, lay in thesubstance of the branchial bars, the blood space, linedwith flat cells, being alongside ; these coelomic ex-

tensions in the dogfish disappeared. Was the systemof channels in thee tumours related to remnants ofcoelomic extensions in the branchial bars, the blood

capillaries afterwards coming to communicate with them ?or did blood-vessels become invaginated into such a systemafter the manner described by Professor Ray Lankester as"phleboedesis," the columnar cells of channels in the tumourbeing furnished by the endodermal cells answering to a

lymphatic sheathe Or was it simpler to assume that themesoblastic cells which gave rise to the capillaries were ofendodermal descent and that in these tumours the columnarform was a reversion indicating their primary source ?

Mr. G. E. GASK exhibited sections of a Complex Papillo-matous Growth consisting of a delicate fibrous stroma andlined by a layer of flattened cubical cells taken from thesynovial sheath of the tibialis anticus tendon, subsequent toan injury to the ankle-joint and probably originating from theendothelial lining of the synovial sheath.

Dr. J. F. PAYNE, in discussing the series of papers whichhad been brought before the society, thought that the subjectwas surrounded by a good deal of difficulty. As regards"parotid tumours" he inclined to the view that theyoriginated in someway in embryonal "rests. "-Dr. H. MORLEYFLETGHER asked Dr. Rolleston how he accounted for theelastic fibres in the tumour which he had observed, and Dr.

ROLLESTON replied that the elastic fibres had remained whilethe fibrous tissue around them had undergone degeneration.-Dr. ARTHUR WHITFIELD also remarked that this same

survival occurred in the lesions of tuberculosis.-Mr. J. H.TARGETT regarded the specimens exhibited by Mr. Nuthalland Dr. Emanuel as examples of schirrhus such as occurredin the stomach. He did not see why these specimens shouldnot be regarded as ordinary carcinomata of the scirrhus type.He had seen a great many tumours of the so-called "parotid’kind occurring in many curious places-the tip of the nose,the lacrymal gland, the palate, parotid gland, and else.where-but he had never met with or heard of any occurring-away from the face. As regards their origin, he preferredthe old-fashioned view-viz., that they were altered gland’tissue. At any rate, he felt sure that he could produce-sections from them which could not be distinguished from,gland tissue.-Mr. J. H. PARSONS, Dr. F. J. POYNTON,and Mr. J. W. T. WAhKKR also took part in the discussion.and Mr. RAYMOND JOHNSON replied.

Mr. GEORGE PERNET read a paper on a case of CongenitalMultiple Sarcoma of the Skin occurring in the body of a,

newly-born female child which was brought to UniversityCollege Hospital after death. There were 70 growths dis-seminated over the skin and sections of some of these.revealed the structure of round-cell sarcoma.

Mr. W. G. SPENCER exhibited card specimens of (1) Fibro-myoma in one Breast and Carcinoma in the other; (2)Hasmorrhagic Cyst of the Pancreas resulting from aseptic.haemorrhagic pancreatitis ; and (3) Lymphangioma Hyper-trophicum of Congenital Origin.

Mr. W. WATKINS- PITCHFORD (Birmingham) exhibitedcard specimens of a large Multilocular Cyst of the Pancreas.from the body of a woman 29 years of age.

CLINICAL SOCIETY OF LONDON.

Clinical Evening : Exhibition of Cases.A MEETING of this society was held on April 25th, Mr.

HOWARD MARSH, the President, being in the chair.Mr. H. L. BARNARD exhibited : 1. A case of Left Parietal

Meningocele or Cephalhydrocele occurring in a male child,aged two weeks, who was brought to the London Hospitalfor a swelling on his head. The swelling was noticed two-.days after birth and had not increased in size. It wassituated on the upper and posterior part of the left parietalbone and was distinct from the anterior and posteriorfontanelles and the sagittal suture. An attempt to reduce it.had led to cessation of respiration and pallor. 2. A case of

Multiple Chondromata or Oteomata with Synostosis of the-Lower Epiphyses of both Ulnae and Fibulas. The tumours.

projected from the ribs, scapulae, clavicles, and femora, &c.

The epiphyses were for the most part enlarged. The lower

epiphysis of the ulna had undergone early synostosis on bothsides, leading to ulnar displacement of the hand at the

wrist-joint. The fibulae (the homologous bones in the leg) were-in the same condition. The patient suffered from severe

rickets when a child. 3. A case of Tumour of the AbdominalWall.

Mr. HASTIXGS GILFORD (Reading) showed a case of

Conspicuous Delay of Growth and Development. The

patient was an instance of a disorder which had not,hitherto been systematically described. though some dozenor more cases had been recorded by French and German-writers. He was 28 years of age and came of a healthyfamily. At 23 years of age he was 1-078 metres (three-feet six inches) in height and had since grown 18 milli-metres. His height and proportions resembled those of a,

boy between six and seven years of age. A radiogram of thehand showed that ossification was no farther advanced thanwas usual at the age of 10 years, while the dentition was like-that of a child of the same age. The contour of the body andthe appearance of the head and face were childish. The-sexual organs were the most backward in development; thetestes had not descended and the external genitals wereinfantile. The intelligence was good, but his behaviour andconversation were more like those of a child than of an

adult. The thyroid gland could be felt. The dwarfism inthis case was apparently not due to any of the known causesof that condition. Achondroplasia, rickets, and micro-cephaly could be definitely excluded.

Mr. A. A. BOWLBY exhibited a case of Ethmoidal’Mucocele occurring in a man, aged 26 years, a horsekeeper..

Page 2: CLINICAL SOCIETY OF LONDON

1251

When five years old he had suffered from " an abscess in theleft eye," presumably from the history referring to a swellingin the orbit above the inner canthus and closely adherent tcthe inner wall. This condition had lasted for 13 months andwas followed by a persistent painless swelling in the regionof the upper part of the nose on the left side. On March 10th,1902, he first noticed that he was unable to breathe throughhis left nostril and he experienced pain at the inner side ofthis left eye. Since then the swelling had increased, becomemore tender, and was accompanied by greater pain. He hadnever had headache, vomiting, or diplopia. Mr. Bowlbyexplained that the inferior and middle turbinate bones hadbeen removed. The patient’s temperature had been elevated.and he had had severe attacks of pain. The vision wa.

perfectly normal, although the eyeball was so displaced. It

might be necessary to remove the ethmoid.-Dr. HERBERTTILLEY thought that in view of the difficulties connected’With the rapid healing of the wound caused by an externaloperation it would be advisable to operate through the noseby means of sharp spoons ; if due caution were used thereshould be no danger of encroaching upon the cribriformplate. Failing relief by this means he would suggest thatthe ethmoid should be attached by way of a large opening inthe anterior wall of the corresponding antrum. By this routethe lateral masses of the ethmoid could be reached and- easily dealt with.

Dr. W. ESSEX WYNTER exhibited a case of CongenitalAbsence of the Nose and Anterior Nares, with Deficiency ofthe Hard and Soft Palate. The patient, a female, six weeksold, the first child of healthy parents, showed this very unusualdeformity without "-hare-lip " or deficiency of the premaxilla.The child suffered from difficulty in feeding and respiration.-The PRESIDENT remarked that the case was exceedinglyrare. He did not know of any recorded cases.-Dr. TILLEYsaid that on closely examining the case it would be found<that the hard palate was not cleft but that its central portionfor about one inch in the antero-posterior direction and halfan inch transversely was abruptly drawn upwards into asmooth concavity. No intra-nasal structures were visible

through the mouth and the soft palate was quite a normalone and continuous with the concavity afore-mentioned.

Sir HUGH BEEVOR exhibited a case of Probable CongenitalAtelectasis occurring in a single woman, aged 22 years.She had no symptoms. The heart was on the right side ; the.,apex was in the third interspace in the axilla. The lungappeared to have the upper lobe almost solid, but the bronchi’were not patent, the breath-sounds being almost absent.There was no history of previous illness. A high and narrowpalate, a double coloboma of the iris, and developmental’changes visible in the lens and retinae, suggested that the.case might be one of congenital atelectasis of the lung orapneumatosis.-Dr. PERCY KIDD concurred in the diagnosisof collapse of one lobe. He had met with such a case in the

post-mortem room. He agreed that this case was one of- congenital absence of development of the right upper lobe.-Sir H. BEEVOR, in reply, said that he had not been able tomeet with any precedent until that mentioned by Dr. Kidd,but he had met with early obliteration of the upperlobe.

Mr. W G. SPENCER exhibited a case in which Excision of’the Right Wrist by a Posterior Median Incision for Tuber-wenlous Disease had been done three years previously. In

March, 1900, some sinuses in the right forearm had beenscraped and arthrectomy of the left knee performed. Sincethat time the patient had remained in good health.

Dr. J. WALTER CARR exhibited a case of CongenitalMorbus Cordis with Extreme Clubbing of the Fingers andToes occurring in a female, aged 10 years. The child had

always suffered from cyanosis and much dyspncea on exertion.She was fairly well developed and well nourished but showed a high degree of cyanosis. Clubbing of the finger-ends wasmarked. The heart was enlarged transversely, mainly to theright, but the exact nature of the lesion was obscure, as theonly murmur heard was a very faint systolic one over the leftborder of the sternum, most distinct at the inner end of thesecond and third spaces. There was marked concentrationof the blood, showing 8,000,000 corpuscles per cubic milli-metre and 20 per cent. of haemoglobin.&mdash;Dr. C. H. FENNELLreferred to a similar case occurring in a child, aged eightyears, who died from haemoptysis. It resembled the caseexhibited in the almost complete absence of murmur.-Dr.H. A. CALEY regarded the case as one of deficient inter-ventricular septum, associated probably with pulmonary-stenosis.

Dr. PERCY KIDD exhibited a case of Arthropathy occur-ring in a case of bronchiectasis. The patient was a man, aged30 years, a compositor, with enlargement of both hands

(including wrist-joints and fingers), ankles, and to a lessextent the knees. The fingers and toes were clubbed. The

physical signs in the chest resembled those of tuberculosis ofthe right upper and lower lobes, but no tubercle bacilli couldbe found in the sputum. The paroxysmal character of thecough and profuse expectoration suggested bronchiectasis.The sputum was not offensive. The patient had sufferedfrom gout several times during the past six years and hadhad chronic cough with expectoration for three years.

Mr. A. BEVAN (introduced by Dr. ARCHIBALD GARROD)exhibited -a case of Urticaria Pigmentosa occurring in a-

child, five years old. The spots had appeared first upon thelegs when she was only two or three months old, at first pinkin colour, then gradually turning brown.

Dr. STCLAIR THOMSON exhibited a case of ChancriformUlcer of the Tonsil or "Vincent’s Angina."

" The patient,a boy, aged. 12 years, had only been complaining ofa little sore-throat for four days. The right tonsilwas seen to be occupied by an oblong greyish sloughmade up of a pulpy or chalky membrane which was

easily detached. The case was shown as illustrating anuncommon form of membranous ulceration of the tonsilwhich had been described on the continent under variousnames, such as " diphtheroid angina," " membranousamygdalitis," and "ulcerating lacunar tonsillitis." Thename angina of Vincent" was given to it in consequenceof the discovery by Vincent in the membrane of a spindle-shaped bacillus of 4 &micro; in length and 1 A in width. Hehad previously discovered the same bacillus in the dirt of

hospitals.1&mdash;Dr. HERBERT TILLEY suggested that a carefulexamination be made of the organisms associated with theulcer, for in a genuine case of I I ulcerative tonsillitis " theirform and arrangement were very characteristic. The affection

was usually found in anaemic females.

HARVEIAN SOCIETY OF LONDON.

-Ex7tibition of Cases. -Tuberculous Disease of tlte Knee-joint.-Idiopathic Hereditary and Family Haematuria.

A CLINICAL meeting of this society was held on April 24th,Mr. W. WATSON CHEYNE, the President, being in the chair.

Dr. T. D. SAVILL showed a woman, aged 39 years, whowas the subject of Erythromelalgia or Sclerodactylia. Shehad had a general eczema of the hands which started 15months ago. The skin was now cured of any eczematouselement, but there was left a sclerotic condition which forsome months had prevented proper movement of the fingers.The redness was almost limited to the digits. All her otherskin was healthy. There was a history of numb dead hands,much the same as in cases of Raynaud’s disease. She couldnot resume her occupation because she was unable to closeher hands. The fingers were tapered in the way usuallyobserved in circulatory disorders.-Dr. LEONARD G. GUTHRIEand Mr. F. JAFFREY took part in the discussion.

Dr. ALEXANDER MORISON showed an infant, seven monthsold, who exhibited a great Enlargement of Veins passingfrom the vertex of the head to the left ear. When the childwas quiet a venous pulsation could be detected. There wassome tension of the fontanelle. Nothing wrong was noticeduntil the child was three months old. It was the third childof the family, the first having aborted at five months and thesecond child was now four years of age. A French physicianhad published a description of the condition, recounting 50cases, and he stated that there was a specific history in allthe cases. The French author thought that such childreneventually got well. Dr. Morison thought that the specificcharacter of the condition was not made out. The presentpatient had been treated for syphilis and for rickets.-Dr.E. CAUTLEY had seen cases without such history wherethere was marked obstruction to the circulation. In one caseof great obstruction the child developed hydrocephalus andthe obstruction was found to be due to a tumour. Assumingthe syphilitic causation of the disease, what was the lesionwhich would produce such a dystrophy’? The unilateral con-dition sometimes met with might be due to the fact that the

1 Vincent : Annales de l’Institut Pasteur, 1895, p. 488.


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