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is mure gradual and the surgeon may wait until the primaryshock has passed away. It is in these cases that the gauzetamponade is :-o useful, or actual suture of splenic substancewith catgut. I know of no evidence that minor ruptures ofthe spleen may be recovered from without operation, thoughI think it extremely likely. We are all familiar with casesof abdominal injuries associated with intra-peritoneal extra-vasations of blood which are recovered from spontaneously.In some of these huge pancreatic cysts afterwards arise,indicating that so safely placed an organ as the pancreas has actually been injured. I tear that no statistics, no rules, canbe laid down as to when to operate and when not to operatein abdominal injuries without external wound. These casesmust each be judged on its own merits. As a general truthit may be stated that exploration when signs of graveinternal lesions are evident and persistent is becoming moreand more the practice of the day in English hospitals.

Medical Societies.

PATHOLOGICAL SOCIETY OF LONDON.

Presidential Address.—Macroglossia Neuro-fibromatosa.—Diffuse Thickening of the Skull of a Child.—A Case ofPolio-encephalitis Inferior.A MEETING of this society was held on Oct. 21st, Sir J.

BURDON SANDERSON, Bart., the President, being in thechair.The PRESIDENT delivered an introductory address on New

Discoveries relating to Immunity (which will be publishedin rxtenso in a future issue). He said that his aim would benot to attempt to offer to the society an exposition ofnew discoveries relating to immunity such as that whichhad been given a few weeks ago in Professor W. H.Welch’s admirable Huxley Lecture. The task which hehad set before him was the much humbler one of trans-

lating into language which would have been intelligibleto the student of 20 years ago the technical, languagewhich was unavoidable in dealing with complicated experi-mental data. He began by sketching the progress of

investigations relating to the etiology of inflammation and of tubercle during the 10. or 12 years preceding Ithe discovery by Koch of the bacteriological method. He then passed on to the discovery by Nuttall andBuchner of the anti-infective properties of the liquorsanguinis and by Behring of antitoxins. The second part ofthe address was devoted to the discussion of certain pro-minent results of recent investigations relating either to themode of action of the soluble products which, like the toxinof diphtheria, acted as powerfully as the microbes from whichthey were derived, or to the more "natural" process of infec-tion by the penetration of living bacteria. With referenceto the former the evidence of the distinctness of the toxicaction from the protective reaction was chiefly dwelt on.

The second form of infection, as representing the naturalprocess as it presented itself in disease. was more fully dis-cussed. Towards the conclusion of the address the remarkable

analogy discovered and investigated by Ehrlich and Bordetre,pectively between the action of alien blood discs and of

disease-producing bacteria was commented on. The con-

sideration of haemolysis led on to a brief notice of the

important re-earches now being carried on in the new seruminstitute at Copenhagen. Finally. the President drew atten-tion to the recent investigations of Pro’fet-sor R Muir of

G-lasgow, of Dr. Roger in Paris, of Dr JMaIlojy in America,and others as to the participation of the bone marrow, of thespleen, and of the lymphatic system in protective reactionagainsb various disease.; and recommended this subject topathological inquirers as a fruitful field of research.

Mr. F. C. ABBOTT and Mr. S. G. SHATTOCK recordedin detail a hitherto undescribed form of Macroglos"ia forwhich the term "macroglossia neuro-fibromatosa" was sug-gested. The condition was met with in a female child, agedtour years, who was admitted to St. Thomas’s Hospital inAugust, 1900. She was the youngest of seven children, inwhom and in the family history there were no abnormalities.The deformity of the ear was noticed at birth and the

enlargememt of the tongue shortly afterwards. The tonguebegan to protrude from the mouth at, the age of one and a

halt years and latterly was nearly always kept protructed even3 in sleep. She began to talk at the usual age, but speechhad been much interfered with by the size of the tongue.f On admission the greatly enlarged tongue was usually pro-i truded from the mouth but could be withdrawn within it. The increase belonged entirely to the left side, the other- being stretched along the raphe, so bending the tip to the, right. In addition to the general enlargement there was a, fairly circumscribed tumour in the posterior part of the left

half. The consistence was tough and the mucous coveringt was dry, thickened, and coarsely granular. This granular’ appearance was due to marked enlargement of the fungi-3form papilla and was most noticeable posteriorly. Novesicles were present on any part of the surface. The! whole left side of the face showed a vague puffy fulness

which interfered with the child’s expression on this side andthis area was also subject to unilateral flushings when thechild was excited. This fulness became more marked in theneck and formed a large swelling below the jaw from themid-line back to the sterno-mastoid muscle. Here the

swelling consisted of lumps and knotted cords plainly tobe felt through the skin. The left ear was larger andthicker than its fellow and the fore part of the helixextended as a broad smooth swelling across the concha,the cavity of which it largely occupied. In speakingthe words were thick and badly formed and salivadribbled from the mouth. No sweating accompanied

the unilateral flushings nor was there any overgrowthof hair on this side. Mentally the child was very bright.At the operation on Sept. 5th the anterior two-thirds of theleft side of the tongue were removed by V-shaped incisions,the posterior one being designed to match the cut raphe.The diseased condition obviously extended beyond theposterior limit reached and a portion of the circumscribedgrowth had to be left behind. The child did well and on athe 26th a second operation on the neck was undertaken.Through a long curved incision two large masses wereremoved, consisting of worm-like coils of semi-transparentwhite cords. All the anatomical structures of the part wereinvolved and their recognition was difficult. The portionremoved included the superficial part of the submaxillarysalivary gland and also extended high behind the jaw.Left facial paralysis, complete below but not above,followed this operation. The child left the hospital on

Nov. 9th. The tongue lay entirely in the mouth and wasnearly symmetrical and the appearance of the neck wasmuch improved. The facial paralysis and an increasedfulness of the side of the face left her still much distorted.Mr. Abbott and Mr. Shattock did not see the child again tillthe present summer. The tongue now lay entirely in themouth which was kept -hut naturally and was fairly sym-metrical. The clearness of articulation had improved.There was, however, a ecurrence of the abnormal tissue,of the size of a small alrnond, which had arisen from thepart left behind at the operation. Attempts to test the tastefailed owing to the youth of the patient. The face was inthe .ame state of slight general fulness as when first seenand the unilateral flushings still took place. The facial

paralysis had much diminbhed and the left eye could beshut and was clos,.d Hormany during sleep. The musclesof the mouth also reacted to electrical timulus. The earwas much the same as when last seen. No recurrence ofthe cords could be felt beneath the site of the opera-tion on the neck, but similar structures could be feltaround this area and extended in various directions

following the nerves of the cervical plexu’—viz., to themid-line in front, to the second pieee of the sternum,over the whole area of the posterior triangle and across theclavicle, and beneath the skin over the mastoid process. Inno instance did the-e cross the mid-line of the body.The condition of the tongue formed clinically so prominent afeature in the case that Mr. Abbott and Mr. Shattock thoughtthe name of "macroglossia neuro-fibromatosa" suitableto it, although it took no account of the other parts involved.In ordinary macroglossia, however, it was not unusual forthe condition to extend beyond the limits of the tongue.Clinically the appearance of the tongue closely resembledthat met with in tough fibrous macroglossia of lymphaticorigin and the true condition was not diagnosed till afteroperation. The unusual feature of the case on examinationwas the cord-like masses in the neck. These resembledthose met with in plexiform neuro-nbroma of other regionsand might make a correct diagnosis possible. Mr. Abbottand Mr. Shattock believed the diffuse thickening of the face

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and eialargemunt ot the ear tu be uue to diffuse iorma-tion of soft fibrous tissue, as met with over neuro-

fibroma elsewhere, and akin to the soft fibromata ofRecklinghausen’s disease. Another explanation, that theywere of trophic origin, secondary to involvement ofthe sympathetic, of which the unilateral flushings gaveevidence, was discussed and rejected. The facial

paralysis was no doubt due to a large part of the

plexiform growth in the neck having been on the facialnerve, and in their tortuous course branches even of the

temporo-facial had been excised in the upper part of theincision. The nerves involved included the facial, the

hypoglossal, and the motor root of the third division ofthe fifth nerve ; the lingual and probably the auriculo-temporal branches of the third division of the fifth nerve,and possibly the first and second division were impli-cated ; also the glosso-pharyngeal, the transverse cervicaland descending supra-sternal and supra-clavicular sensorybranches of the cervical plexus, with probably the

ascending branches in addition. The unilateral flushings ’,pointed i;o some change in the cervical sympathetic butno other evidence in support of this was obtained. Thedissection of the tongue showed that all the nerves were en-larged and increased in length so as to be in serpentine orshort transverse folds, with the result that in many situa-tions a compact plexus had been produced ; in the divided

posterior surface the muscular substance was hardly re-

cognisable in consequence of the universal enlargement of thenerves lying in it. Microscopic sections made through thebase of the removed portion showed that the enlarged nervesconstituted by far the chief part of the sectional area, thebundles of muscle fibre being widely separated betweenthem. The enlargement of the tongue was due solely to thelesion of the nerves, the intervening muscular and connectivetissues being compressed without trace of oedema or of

lymph or haemangeiectasis The nerves were enlarged even inthe conical and fungiform papillae. The increase was due toa diffuse formatiun of loose connective tissue in connexionwith the endoneurium, and each nerve was circumscribed bya lamellar sheath. In certain of the enlarged nerves nerve-cells occurred, indicating the involvement of the glosso-pharyngeal (in addition to the lingual and hypoglossal).Unna’s acid orcein stain showed a complete absence ofelastic tissue in the new formation. The enlarged nerveplexus removed from the neck presented similar changes,and the condition affected the nerves penetrating the por-tion of submaxillary salivary gland removed at the same time.Mr. Abbott and Mr. Shattock described a case ot neuro-

fibromatosis of the thigh in which masses of fibromatousnerves were associated with some thickening of the skin andits elevation into folds-neuro-fibromatous elephantiasis orneuro-.’ibromatous pachydermatocele-and pointed out theessential likeness between this condition and that of the

tongue. In Robert Smith’s work on Neuroma (Dublin,1849) one case was given of multiple fibroma of the nervesin which a certain number of tumours grew in connexionwith the branches of the hypoglossal, but there was nothingcoming within the category of macroglossia. The only casewhich seemed to approach the present was one referredto by Alexis Thomson in a boy, in whom Robsonobserved a plexiform tumour of the left side of thehead and occiput, associated with left-sided macro-

glossia ; here Mr. Abbott and Mr. Shattock thought it

probable that the macroglossia was neuro-fibromatous,although it was taken to be of the common type. Theonly lesions with which plexiform neuro-fibroma mightpossibly be confused were certain intra-vascular tumours,which in rare cases occurred in the neck, though morecommonly in connexion with the testicle. Not only mightsuch intra-vascular extensions contract adhesions with theintima of the containing vessel, but conversely in the caseof plexiform fibroma the lamellar sheath might evince somarked a readiness to cleave through the lymph spacesbetween its component lamellae as to suggest the occupa-tion of a vessel by a growth contained within it.-Dr.J. H. THURSFIELD narrated a case of what appeared tobe a similar condition which had recently been under thecare of Mr. H. T. Butlin. The patient was a child, agedthree years, who was the subject of swelling of the tongue,the face, and the neck, all of which was confined to theright side. In several other respects it resembled the caserecorded by Mr. Abbott and Mr. Shattock. The child wasstill living. The microscopical appearances of the portionof the tongue which had been removed were identical withthose which had been shown on the screen. Dr. Thursfield

suggested that the disease had started in the deeper tissuesof the neck and had spread secondarily to the tongue.

Dr. F. W. ANDREWES showed the Skull of a male child,aged four and a half years, which presented great thicken-ing of the entire vault and, to a lesser degree, of the jawbones. The child was imbecile. No other bones wereknown to have been affected. The skull was markedlyasymmetrical. The bones affected were all membranebones-viz., in the vault, the frontal, parietal, and inter-parietal region of the occipital; and in the face the lowerjaw and to a slight extent the upper jaw and malars.The temporal bone was unaffected. There was completesynostosis of all the sutures of the vault, but those of thebasis cranii were natural. The thickening of the vault wassharply defined and greater over the frontal and parietalbosses than elsewhere. The greatest thickness was of aninch. The distinction between the diploe and the tables ofthe skull was lost. All was uniform’dene cancellou-; boneshowing a normal microscopic structure with widenedHaversian canals. The nature and causation of the condi-tion were obscure. There was no history indicating con-genital syphilis nor were any evidences of syphilis or

rickets found during life or post mortem. Osteitis de-formans was a disease of later life. The term I I hy I ey-ostosis cranii" had been used for the condition whichseemed more allied to leontiasis ossea than to any other

affection, though in this instance the calvaria and notthe bones of the face took the chief share in the disease.-Dr. A. F. VOELCKER recalled the case of a child on whomhe had made a post-mortem examination 12 or 13 years agoat the Hospital for Sick Children, Great Ormond-street. Thechild had been an idiot ; the skull after death resembled theone exhibited. There was atrophy of one cerebral hemi-

sphere and of the cerebellar hemisphere of the other side.The bones of the skull were very thickened and softenedOther bones in the skeleton were similarly affected. Therewas marked beading of the ribs. There were well-markedevidences of rickets ; syphilis had been considered butexcluded. -Dr. W. F. ARMOUR remarked that the middle

meningeal arteries had been markedly enlarged, as evidencedby the grooves in the skull.

Dr. F. E. BATTEN showed macroscopical and microscopicalspecimens of a case of Polio-encephalitis Inferior affectingthe nucleus of the seventh nerve on the right side. The

patient was a child, aged five years, who was taken ill withfever, and two days later suddenly developed right facialparalysis with difficulty in swallowing due to weakness of theright side of the palate. There was no paralysis of the limbsor ocular muscles. Vomiting was present. There was no lossof consciousness. The child died from respiratory failurethree days later. The specimen showed an acute congestionmost marked in the region of the seventh nucleus of the rightside, with thrombosis of the finer vessels, haemorrhage andexudation of small round cells, with complete destruction ofthe cells of the nucleus. The lesion could be seen both

macroscopically and microscopically. In the seventh nucleusof the left side and in the sixth nucleus of either side therewas but little change apart from some slight engorgementof the vessels. There were considerable peri-vascularengorgement and some exudation of round cells in themedulla in the region of the ninth, tenth, eleventh, andtwelfth nuclei, rather more marked on the right side thanon the left, but at no point was there the marked destructionwhich was present in the region of the cells of the seventhnucleus. The lesion was of vascular origin and exactlycorresponded in appearance with that found in an acuteanterior polio-myelitis and an acute polio-encephalitissuperior. The frequency of acute anterior polio-myelitisduring the month of August of the present year was alludedto and the present case was considered to be of the samenature.-Dr. J. BATTY SHAW asked whether the paralysis ofthe facial muscles was quite complete. The facial nerve wassupposed to be composite in its origin and this case

suggested that the nucleus of origin of the facial nervewas really a single one.-Dr. BATTEN, in reply, remarkedthat the congestive lesion was not absolutely limited to onenucleus and they could not be quite certain that there wasnot partial involvement of other nuclei.

HARVEIAN SOCIETY OF LONDON.

Exhibition of Cases.A MEETING of this society was held on Oct. 16th, Mr.

W. WATSON CHEYNE, C.B., the President, being in the chair.