1475CLINICAL SOCIETY OF LONDON.

no tuberculosis in his family history. On examination amoveable tumour of the size of an adult kidney was foundin the left loin. There was no resonance in frontof it. The diagnosis of tuberculous glands in themesentery was made. The patient was now quite well. Thesecond case was a boy, aged six years, who was admitted tothe Hospital for Sick Cnildren, Great Ormond-street, on

August 3rd, 19)3. On admission he was well nourishedand well developed but there was a bright yellow tingeof the skin on the front of the chest. A slight swellingcould be seen over the appendicular region, and on

palpation a well-defined, somewhat rounded mass couldbe felt in the region of the casoum, of about thesize of a cricket ball. The swelling was definitely move-able, much more so inwards, and small nodules couldbe felt on its anterior surface. The tumour was removedOil August llth and the patient made a good recovery.-Mr. CUTHBERT S. WALLACE referred to a case in which he

operated for hernia and discovered tuberculous glands. The

patient recovered. In another case operated on for inguinalhernia the peritoneum was studded with tubercle. The-ecases i’lustrated the latency of abdominal tubercle.-Dr.WYKTER referred to a case of tuberculosis of the peritoneumand glands. Three drachms of 1 in 1000 adrenalin solutionwere injected into the peritoneum with a successful issue.-Dr. POYNTON drew attention to the difficulty of diagnosis oftuberculous glands ia the abdomen. He had tried adrenalinfor ascites without success.

Dr. MORGAN DOCKRELL exhibited three cases : 1. CysticHyaline Degeneration of the Sweat Glands of the Face in agirl, aged 20 years, who presented discrete spherical cream-coloured papules varying in size from that of a pin’s head tothat of a peppercorn, firm and hard to the touch. Microscopicexamination revealed a cystic condition of the sweat duct s filledwith hyaline material. 2. A case of Cystic Colloid Degenera-tion of the Sebaceous Glands in a girl, aged 20 years, whopresented minute milium-like papules on the cheeks accom-panied with scars on the sites of previous papules. Micro-

scopic examination revealed a cystic colloid degeneration ofthe sebaceous glands. 3. A case of Cystic Fibro-cellulomaof the Hair Follicles and Sebaceous Glands in the face of awoman, aged 25 years. There were small dirty-white semi-transparent tumours ranging in size from that of a pin’shead to that of a pea, coalescing in places, which micro-scopically presented cystic degeneration, epithelial new

growth, epithelial giant cell degeneration, and fibroid tissue.Diagrams of these cases were also exhibited.

CLINICAL SOCIETY OF LONDON.

Cardiac Syphiloma.-Suppurative PylPPhleb;tis.-Splenectomy for Rupture.

A MEETING of this society was held on Nov. 10th, Mr.H. H. CLUTTON, the President, being in the chair.

Dr. CHARLES W. CHAPMAN read a paper on the After-history and Post-mortem Record of a case of CardiacSyphiloma showing Bradycardia and Obstruction of theInferior Vena Cava. The subject of this communicationwas a man, aged 48 years, who when first seen in 1897complained of palpitation and syncopal attacks. It wasnoticed that the veins of the abdomen were greatly dilated.The patient was shown at a clinical evening of the societyand a paper was read on the case during the followingsession. Both were reported in vols. xxxii. and xxxiii.of the Transactions of the society. The patient had hada small itching sore in 187’7 but no secondary symptoms ;treatment had been of short duration only. There was in 1897a tumour at the back of the neck of the size of half a walnut.A diagnosis of obstruction of the inferior vena cava fromgummatous deposit was made and mercurial treatment fol-lowed by iodide of sodium was adopted. Under these measuresthe tumour and the syncopal attacks disappeared in thecourse of a few weeks. During the last eight years the patientwas more or less con tantly under treatment as an out-patient,and it was noticed that suspension of the use of specificremedies for two or three weeks was always succeeded by afailure in the general health. He was last seen at thehospital in June last, shortly after which visit he hadsuppurative appendicitis and was admitted into the LondonHospital, where he died from peritonitis. At the necropsy theabdomen was covered with varicose veins. There was a smallpatch of obsolete calcareous tubercle at the apex of the rightlung. The root of this lung with the neighbouring largevessels, glands, and mediastinal tissues were firmly matted

. into a mass of fibro-calcareous material. In the base of the

. right lung the rings of the larger divisions of the bronchiwere calcified. The pericardium contained an excess of

! clear fluid. There was much epicardial fat over the right! ventricle. Over the left ventricle and auricle the visceral

pericardium was thick and opaque in places. The heart

weighed 15 ounces. The heart muscle was brown and tough,with visible strands of fibrous tissue running through it. Bothventricles were dilated. The right auricle was dilated andcontained a small black clot. The cavity of the left auriclewas greatly diminished and constricted in its middle to aring which just admitted the tip of an index finger. Thecause of the narrowing was a dense mass of calcificationaffecting the whole circumference of the left auricle, theinter-ventricular septum, and the first inch of the aorta. Thevalves were pliant but just above the mitral ring the leftauricle was narrowed by the calcareous mass alreadydescribed. The aorta had many patches of atheroma. Theleft testicle presented a typical diffuse fibrous gummatouscondition. The liver was enlarged and indurated ; the

kidneys were normal.Dr. FRANCI3 H. HAWKHS (Reading) read notes of a case of

Suppurative Pylephlebitis due to a Suppurating MesentericGland in a boy, aged 12 years. The patient, 15 days beforeadmission to the Royal Berkshire Hospital, had an attack ofvomiting, followed four days later by a sudden chill, withvomiting and subsequent diarrhoea, which it was statedlasted for ten days. On admission there were pain andtenderness on pressure one inch to the right of, and a littleabove, the umbilicus and some tenderness over the lefthalf of the epigastric region. There were no jaundice andno vomiting ; the bowels were constipated and relieved onlyby enemata. For six days after admission the case assumeda condition of pyasmia and nearly all organs except theliver could be excluded as being diseased. On the sixth daya definite swelling appeared apparently somewhat suddenlyin the epigastric region on the left side. The patient diedfour days later. At the necropsy the portal vein was foundto be thrombosed and suppurating, and multiple abscesseswere found in the liver. The mesenteric glands were en-larged, several were in a state of suppuration, and one wasof a brownish black colour and discharged extremely offensivepus. The spleen was enlarged but contained no abscess.The Clinical Research Association sent the following report:I Direct examination of this pus reveals the presence of aconsiderable mixture of organisms, but neither tuberclebacilli nor pyogenic cocci can be found, and the onlyorganism detected in cultures is the bacillus coli communis.There is nothing in the structures of this mesenteric glandto throw light on the suppuration in the liver. Its tissuesare much softened and the lymphatic channels are dilatedfrom recent absorption." Dr. Hawkins pointed out the rarity .of such cases and considered that the suppurative pyle-phlebitis was secondary to the necrotic mesenteric gland.-Dr. F. DE HAVILLAND HALL described a necropsy which hehad witnessed that afternoon on a si ni ar case, secondary,however, to appendicitis. He remarked on the absence ofjaundice in Dr. Hawkins’s case.-Mr. CHARTERS J. SYMONDSsaid that in his experience jaundice had been exceptional.He gave an account of a case which he had recently seen. Thepatient suffered from sleeplessness and had had a rigor atthe outset of her illness ; otherwise it was a mild case ofappendicitis and so was not operated on until the fifth day,when another rigor occurred. The local appearances at the

operation were such as to cause fear of venous infection, sothat the surrounding tissue was freely removed. The

appendix was situate near the median line and high up onthe mesentery of the ascending colon. The after-coursewas uneventful save for sleeplessness and mild pyrexiauntil the tenth day, when symptoms of pylephlebitissupervened and rapidly proved fatal. He drew specialattention to the fact that the appendix might cause

infective pylephlebitis and yet not attract attention atthe necropsy.-Mr. WALTER G. SPENCER described a

case which he had saved by draining the gall-bladderand he was of opinion that this might be not infre-quently possible in the early stage of the disease.-Mr.SYMONDS thought the term " pylephlebitis " should belimited to cases of venous suppuration, which were alwaysfatal, and should not include, as Mr. Spencer used it toinclude, cases of cholangitis, which were similarly accom-panied by rigors, enlarged liver, and septic temperature.-Dr. NORMAN DALTON remarked on the co-existence of infec-tions from the bile-duct and portal vein.-Dr. A. E. GARROD

) referred to a paper by Dr. W. Langdon Brown in the

1476 OpmH1LMOLOGIOAL SOCIETY.

St. Bartholomew’s Hospital Reports. Of 43 cases 43 per cent.only had jaundice.

Mr. GRAHAM S. TMPSON (Sheffield) showed a successfulcase of Splenectomy for Rupture in a man, aged 27 years.The patient had fallen 20 feet, striking his left side as hefell ; he was at once admitted to the Sheffield Royal Hospitalfor a fracture of the left femur; he did not show any signsof an intra-abdominal catastrophe till four hours after theaccident. A diagnosis of rupture of the intestine was then madeand the abdomen was opened at once ; the abdominal cavitycontained much blood and some difficulty was experienced infinding the source of the bleeding. On examining the spleenits lower third was found to be nearly torn off and as therupture involved the hilum, the organ was excised. The manmade a rapid recovery. The only points to note were a

temporary acsemia and leucocytosis, delayed union of thefracture of the femur (12 weeks), and slight enlargement ofsome of the lymph glands. Mr. Simpson made some re-marks on the diagnosis and treatment of this condition,basing his observations on 100 cases which he hadcollected. He suggested that the three points of import-ance in the diagnosis were-an accurate history of the

accident, the signs of internal haemorrhage, and thelocalising signs. Of these last he attached most import-ance to Mr. C. A. Ballance’s observation that on suitablychanging the position of the patient the dulness of the rightloin shifted but not that of the left. He divided the casesinto four groups : 1. Cases in which the patient died atonce or within a few minutes of the accident (spontaneousrupture). 2. Cases in which the onset of symptoms wasgreatly delayed-from 24 hours to 15 days. This delaymight be due to clothing or to the bleeding being at firstsubcapsular and subsequently bursting through the capsule.3. In the majority of cases the symptoms showed themselvesin from one to 24 hours. 4. In a few cases the symptoms ofa rupture of the spleen had shown themselves and had gradu-ally passed off without operation. He recommended thatall these cases should be operated on ; those of the fourth

group because in two cases the blood had later become in-fected. As regarded the operation he thought that splenectomywould usually be found necessary, as the ruptures were oftenvery extensive and frequently involved the vessels of thehilum. He concluded by discussing the causes of failure ofthe operation and the sequelae of removal of the spleen.-The PRESIDENT was in favour of tamponage wherever possibleinstead of splenectomy.-Mr. T. CRISP ENGLISH describeda similar case in which the symptoms were very equivocalfor three days after the accident, when extensive collapseappeared suddenly. Although the patient was pulseless heoperated and she made a good recovery. The blood count,total and differential, was quite normal three weeks after theoperation and continued so for 18 months.-Dr. ALFREDERNEST JONES asked for details of the differential count inthis case, in view of the great theoretical interest of theoperation as bearing on the question of the origin of thewhite corpuscles. He referred to experimental researchescarried out in Russia by Kurloff, which showed that duringthe first year a hyperlymphocytosis appeared and wasfollowed in the second year by eosinophilia.-Mr. SiMPSON,in reply, agreed with the President as to the value oftamponage whenever it was possible. It was not often

possible on account of the frequency of implication of thehilum by the tear and the extreme haste with which theprocedure had to be carried out. As to the blood count, thepost-operative leucocytosis which was due to suppuration andwhich reached 44,000 at one time soon subsided. 13 monthsafter the operation several careful counts were made andtheir average two hours after a meal was : red corpuscles,4,760,000 per cubic millimetre; white corpuscles, 6500 percubic millimetre, of which 57’ 6 per cent were poly-morphonuclears, 1’ 2 per cent. transitional cells, 15 ’ 32 percent. large hyaline cells, 21 14 per cent. small lymphocytes,and 3’ 89 per cent. eosinophiles. No mast cells or normo-blasts were present.

OPHTHALMOLOGICAL SOCIETY.

The Value of the Opsonic Index for Tubercle in Phlyetenitla.-Some Varieties of Albinism in Man.-Congenital ColourBlindness in Females.-A Case of Metastatic Sarcoma of Ithe Optio Aerve and Retina.-&bgr;aehibitiOn of Cases andSpecimens.AN ordinary ’meeting of this society was held on Nov. 9tb,

Mr. J. PRI:&bgr;STIaeY SMITH, the President, being in the chair. I

Dr. L. B. Nus and Mr. LESLIE J. PATON contributed apaper on the Value of the Opsonic Index for Tubercle in1’hlyctenulse. This research was suggested by an observationof Dr. A. E. Wright that frequently a crop of phlyctenu’s de-veloped in patients undergoing inoculations with tuberculin.It occurred to Dr. Nias and Mr. Paton that an investigationof the opsonic indices for tubercle in the early stages ofphlyctenular conjunctivitis might throw some light on thequestion of the tuberculous nature of this disease and as towhether it was exogenous or endogenous in origin. Thedetermination of the opsonic index was done by Dr. Niasin the laboratory of St. Mary’s Hospital. 20 cases of

phlyctenular conjunctivitis were examined. Five cases ofother forms of conjunctivitis were examined as controls andseven out of the 25 cases were simultaneously tested todetermine their opsonic index for staphylococcus. The resultsshowed in most striking form variations from the normal inthe tubercle index of the cases of phlyctenular conjunctivitis,practically normal indices in the other forms of con-

junctivitis, and practically normal staphylococcus indices inthe majority of cases tested. In one case where there wasfairly advanced pulmonary tuberculosis both tubercle andstaphylococcus indices were lowered.

Mr. E. NETTLESHIP, in a note on Some Varieties ofAlbinism in Man, thanked those gentlemen who had re-

sponded to a circular lately issued by Piofessor Karl Pearson,Dr. E. Stainer, and himself asking for cases showing theheredity of albinism and said that additional cases wouldbe gladly received. He then mentioned the followingvarieties : (1) albinism of hair and skin with normaleyes ; (2) albinism of eyes with hair that, originallywhite, became ellow or even red or quite brown about theage of puberty ; (3) albinism of choroid only, as shown byophthalmoscopic appearances together with nystagmus anddefective sight; (4) progressive pigmentation of the albinoticeye corresponding to that above referred to in the hair andusually, but not always, occurring too long after birth topermit of improvement of sight; and (5) pied albinism-i.e., congenital absence of pigment from areas of £the skin ; any such cases in which the eyes were

albinotic would be specially valuable. In incompletehuman albinism the whole uveal tract was entirely free frompigment, whilst the retinal epithelium (including thatcovering the ciliary body and iris) was more or less pig-mented. Manz proved this in 1878 and Mr. C. H. Usher hadconfirmed it in some beautiful sections (shown on the screenat the meeting) from the eyes of two different individualsquite recently. In sections of the iris of a completelyalbinotic man Mr. Nettleship had found the posteriorepithelium as well as the iris itself devoid of any trace ofpigment.

Mr. NETTLESHIP also mentioned five families in which oneor more females were Congenitally Colour Blind. In fourof the families some of the males were also affected ; 7in the fifth the family history was not obtained.He pleaded for a systematic search for colour blindnessin females, especially in families where it was knownto exist amongst the males, in order to test the validityof the current doctrines: (1) that congenital colourblindness is very rare in females (about 1 female to40 males according to summarised statistics) ; and (2) thatcolour-blindness almost invariably passed from affected fatherthrough unaffected daughter to grandson, as in h2emophiliaand some other family diseases. It was pointed out thatslight degrees of colour blindness, especially if intentionallyconcealed, would be more difficult of detection in womenthan men.

Dr. ARTHUR J. BALLANTYNE described a case of MetastaticSarcoma of the Optic Nerve and Retina by means of lanternslides. The patient was a woman, 58 years of age, sufferingfrom paresis of the limbs and face on the right side, paresisof the left internal rectus, and blindness of the left eye.These symptoms, including the blindness, were said tohave come on rather suddenly a week before. The oph-thalmoscope showed a yellowish mass, horizontally, ovalin shape and rounded on its anterior surface, project-ing above the level of the fundus and concealingthe disc. Its diameter was about three times that ofthe normal disc. There were a number of large Same-shaped haemorrhages in the retina. The necropsy revealed,in addition to patches of softening in the left side-of the pons in its upper part and in the posteriorextremity of the corpus striatum on each side, a aat-

comatous tumour in the mediastinum and root of theleft lung, both supracemals, an abdominal lymphatic