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is generally somewhat plumper and less lanceolate than the other types of pneumococci. I ts capsule is larger, as shown by the His stain, and is usually stained pink with the counterstain of the Gram stain. The colonies on solid media are more moist, mucoid and larger than those of the other types. The peritoneal exud~te in the mouse is usually quite mucoid, and can be drawn out into strings with the platinum wire. I t occasionally happens, how- ever, that strains of pneumococci Type I I I are encoun- tered which do not show well-developed mucoid charac- teristics, and Type I I strains are found which show mucoid characteristics well developed. Therefore, the serological method of differentiation is the most reliable. I t should be remembered that Streptococcus mucosus (which pos- sesses a capsule) is not bile-soluble.

The type of infecting pneumococci should always be verified from a culture of the heart 's blood of the mouse or by the Avery method.

(To be contin~led.)

C O N G E N I T A L CYSTIC K I D N E Y S AND L I V E R , GASTRIC U L C E R , G A S T R O - E N T E R O S T O M Y : LATER., GASTRIC CARCINOMA; P E R F O R A - TION.

BY T. GILLMAN MOORHEAD, M.D:, F.R.C.P.I.

IN April, 1918, I received a letter from a patient asking for an appointment. He told me that he was a miller by trade, was 45 years of age, and had been quite well until twelve months ago, when he began to suffer from dyspepsia., with severe p~ins in the chest, and from vomiting. He had at first got complete relief from the consumption of bisurated magnesia, but of late this ha.d failed to alleviate his sufferings. On arrival, I saw a tall man, extremely emaciated; and on examining the abdomen, I was fortunate enough to see at once large

CONGI~NITAL CYSTIC LIVER AND KIDNEYS 288

peristaltia waves origir~ating obviously in the stomach. The diagnosis of pyloric obstruction was therefore easily made, and was confirmed by the discovery of an easily palpable, mobile lump in the epigastrium. Further examination, however, rather complicated matters, as, in addition, a large swelling was felt on the left side of the abdomen, in the kidney region, and extending down- wards from that region. As far as I could determine, this swelling was composed of an upper part, which felt like a somewhat enlarged kidney, and a lower part, also feeling rather like a kidney, and separable from the upper portion by a distinct groove. The mass was slightly moveable on deep respiration. As the urine Was absolutely normal, much doubt existed in my n~ind, and in that of Mr. Johnston, who later saw the case with me, as to the nature of this tumour, and at first we greatly feared that it might be a malignant retroperitoneal mass, in which case operation, even to relieve the stomach symptoms, seemed hardly justifiable, inasmuch as the patient was extremely weak and thin. However, a test meal ad- ministered a couple of days after the patient was first seen' by me showed the presence of abundant hydrochloric acid, and in consequence I decided to recommend opera- tion. The abdomen was opened, a pyloric stricture was found, presumably non-malignant, and a gastro-entero:s- tomy was performed. The patient was so ill that Mr. Johnston thought it inadvisable to do anything more than what was absolutely necessary, and in consequence he closed the abdomen without investigating the left-sided swelling. Rapid improvement followed: within ~ fort- night the patient insisted on returning home, and in October he wrote to inform me that he had gained nearly two stone in weight, and had long since been back at his work.

I heard nothing further till November 5th, 1919, i .e., about 18 months after the operation.

H e then again came to see me, and told me that he had remained perfectly well till five weeks previously, when he again began .to suffer from severe pain after his

q

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food, and from loss of weight and energy. He then looked extremely ill, and I urged him to come into hospital at once. He refused at the time, but subsequently entered hospital on December 16th. The pyloric lump was still very easily palpable, and was extremely tender to touch; the mass on the left side could also be made out, and I now thought that I could feel something also on the right side, but the abdomen in general w~s somewhat dis- tended, and in consequence palpation was a little diffi- cult. A test meal now showed practically no t tCl . , and

trace of lactic acid; while an x-ray report showed that tke stomach was small, and had a well-marked hour-glass constriction, which appeared to be present at the level of the gastro-enterostomy opening : there was slight irregu- larity in outline in the region of the stricture, suggesting the presence of a chronic perforating ulcer. Food was seen to pass through the pylorus in small quantity as well as through the new opening. On December 21st, just as our examination was completed, the patient announced his determination of returning home for Christmas. He came back again on January 1st, looking worse than ever.

My diagnosis now lay between malignant disease of the stomach and gastro-jejunat ulcer, but inasmuch as the probabilities were in favour of the former diagnosis, and also against the likelihood of being able to afford much relief by operation, I decided, with the approval of Mr. Johnston, to wait a few days and see what relief could be obtained by dieting and sedatives. On the morning of January 3rd he appeared much as before ; he still had pain, but on the whole felt much easier. That evening I was sent for urgently owing to the sudden occurrence of severe abdominal pain. I t was obvious that a perforatior~ had occurred, and at 7 o'clock the abdomen was opened. A perforation in the anterior stomach wall was stitched, and the usual surgical procedure was adopted. The patient survived till the morning of January 7th. During the interval between the operation and his death he com- plained only of increasing weakness, and was free of pain.

As no permission was obtained for a post-mortem ex-

CONGENITAL CYSTIC LIVER AND KIDNEYS 235

amination, it was only possible to remove the abdominal organs through the operation incision. The abdominal viscera were matted together to a considerable extent by evidently old-standing adhesions ; above the great omentum evidence of more or less diffused peritonitis was visible; the mesentery was studded over with small malignant nodules. On opening the stomach the old ga.stro-enteros- tomy opening was found to be quite healthy, though, even after the lapse of eighteen months, some chromicised catgut was present. This is the third occasion on which I have found such catgut present at a period months sub- sequent to the operation of gastro-enterostomy, and I therefore feel inclined to doubt the wisdom of employing i~ for this purpose. Just to the left of the new opening a large malignant ulcer was found, which had c~used the constriction and obstruction of the outlet of the stomach about an inch to the right of the pylorus. This ulcer had perforated anteriorly. Microscopically, it proved to be of ordinary scirrhus type. The mass in the left side proved to be a congenital cystic kidney, which was divided by a transverse depression into a well-defined upper and lower lobe, corresponding to the masses felt at the first examina- tion, and which had proved so puzzling. The right kidney was also cystic, but was smaller than the left; it was bound down so firmly by adhesions that even at the post- mortem examination it was palpated with some difficulty. The cysts of the kidneys when cut into were found to contain a fluid with a curious sheen. On microscopical examination, the cause of this was found to be the presence of many cholesterin and leucin crystals. The liver was also cystic, the cysts being fairly numerous, and varying in size from a pinhead to a hazel nut ; they were clustered, especially in the left lobe, and in the region of the trans- verse fissure. Microscopically, the cysts did not differ in any way from those described as so often found in associa- tion with congenital cystic disease of the kidney. They contained a perfectly clear fluid, were lined by flat. epithelium, and were surrounded by a thin, fibrous wall. No abnormalities were found in other organs.

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The points of interest in this case are as follows : - -

(1) The combination of gastric ulcer followed by gastric carcinoma,, with congenital cystic kidneys and cystic disease of the liver; a combination which, as already pointed out, rendered the diagnosis of the stomach condition rather doubtful at the first examination.

(2) The malignant change in the gastric ulcer in spite of the ga, stroenterostomy. The presence of abundant tIC1, and the great gain in weight after the first opera- tion, seem conclusive evidence in favour of the ulceT being non-malignant at the time the first operation was done.

(3) The cystic condition of the liver. Into the nature of these cyst, s it is quite unnecessary to enter, as the subject is fully dealt with in Rolleston's " Diseases of the Liver ." Clinically, they are of little importance, but inasmuch as they are rarely found except in association with cystic disease of the kidney, their occurrence is strongly in favour of the latter disea~se being of congenital origin