1235

artificiai tooth plate. It presented a more distinct rim Ithan in the case shown. The man, who was between 50 and60 years of age, had enlarged lymphatics in the submaxillarytriangle and an eruption similar to that in the case shown.

Mr. ALBAN H. G. DORAN read a paper entitled °’ LargeBile Cyst of the Liver ; Jaundice without Cholelithiasis ; In-cision and Drainage; Recovery." The patient was a woman,aged 42 years, who three years before admission to hospitalwhen in the second month of pregnancy fell against a wash-ing tub, striking the right hypochondrium ; abortion occurredwithin a few hours. The case will be found in full at p. 1218.- Mr. W. BRUCE CLARKE said that Mr. Alban Doranhad hardly made it clear to what pathological condition thepresence of the cyst was due. He considered that the

cyst was either congenital in origin or due to injury and hewas inclined to favour the view that it was due to injury.He mentioned the case of a patient who was the subject ofhydronephrosis and also had epilepsy. On getting out of bedone night he had an epileptic fit and fell and injured his side.He recovered from the immediate effects of the injury but itwas found that the kidney had become very much distendedand on examination it wa-< ascertained that a renal vesselhad ruptured into the hydronephrotic cyst. Similar cases

of traumatic hydrone phrosis had been recorded and he

thought there was no reason why a cyst should not be pro-duced in the liver in the same way. With regard to thecause of the jaundice he was of the opinion that it dependedon pressure on the duct and that the normal passage did notopen till some three weeks after the operation. Hedid not consider that it was possible in such a case

as this before operation to diagnose between a hydatid’cyst, a simple cyst of the liver, and malignant disease.-Mr. A. C. BUTLER-SMYTHE referred to the difficulty of

- diagnosis in the present case. He had seen the patientbefore operation and had formed the opinion that there wasprobably a large distension of the gall-bladder. With regardto the nature of the cyst he thought that the diagnosis mighthave been settled by cutting off a portion of the wall of the- cyst at the time of the operation The gall-bladder and theducts were greatly pressed upon by the cyst and he thoughtthat the jaundice was probably more due to mechanicil

obstruction than to actual obliteration of the ducts. With Iregard to the moveable kidney which was present on theTight side he was of opinion that the right kidney could in alarge majority of cases be felt in women who had had morethan one pregnancy. He did not consider that the adminis-tration of chloride of calcium had much effect in preventingthe occurrence of h&aelig;morrhage.-The PRESIDENT saidthat he did not think it necessary to explain the persistentflow of bile into the cyst after it had been opened as due toa catarrhal condition of the duct, for he regarded the opening into the cyst as the freer passage, and it was only whenthe cyst began to contract that the bile resumed its originalchannel.&mdash;Mr. ALBAN DORAN replied.

MEDICAL SOCIETY OF LONDON.

Discussion on Purpura in Childhood.A MEETING of this society was held on Oct. 26th, Dr.

F. DE HAVILLAND HALL, the President, being in the chair.Dr. A. BB VOELCEER opened a discussion on Purpura in

’Childhood. He found some difficulty in defining the termpurpura, for it might be a diease, essential or idiopathicpurpura, or only a symptom-symptomatic purpura. It wasa condition in which heamorrhages occurred in the skin andin and from the mucous membranes. He would limit thediscussion of it to the condition as met with in the first 12years of life. Essential purpura was by no means a commondisease. At the Middlesex Hospital in ten years (1891-1900)only 36 cases had been admitted and only five of these wereunder ten years of age. At the Hospital for Sick Ohildren,Great Ormond-street, out of 6465 cases admitted in six years.(1897 to 1902) there had been only 16 cases of purpura.The disease was more common in the female sex. Sym-ptomatic purpura, on the other hand, was, he believed,more common than essential purpura and more common in

early life than in adults. Season had no influence in itscausation. The toxic effects of certain drugs, such as

potassium iodide, quinine, and ergot, were well known to beoccasional causes ; and among the other causal factors were

whooping-cough, measles, and other acute specific fevers(when it indicated a severe toxaemia), septicaemia, andmalignant endocarditis. Cases of gastro-enteritis asso-

ciated with purpura were referred to and their connexion wasdiscussed. The condition might also be associated withchronic renal disease, cardiac valvular disease, malignantdisease (especially sarcoma), jaundice, leukaemia, Hodgkin’sdisease, haemophilia, and rheumatism. Purpura was not atall common in scurvy or scurvy rickets. There were four

recognised clinical varieties : (1) purpura simplex, where thepurpuric eruption was confined to the skin ; (2) purpurarheumatica, in which the joints were said to be affected ;(3) purpura h&aelig;morrhagica (morbus maculosus), in whichthere were haemorrhages from the mucous membranes andsevere constitutional symptoms ; and (4) Henoch’s purpurawhich wa common in children, had a tendency to relapse,and to the occurrence of joint symptoms, which might beushered in by diarrhoea, vomiting, and abdominal pain. Dr.Voelcker did not believe that there was any close or neces-sary relation between purpura and the rheumatic state. Theformer was only related to rheumatism in the same way asit was to the acute specific fevers. In regard to the treat-ment rest in bed was indicated. No drug appeared to haveany definite controlling influence. Opium was of value forthe pain and diarrhoea. Calcium chloride had been triedbut without effect. It was chiefly from epistaxis that thefatal issue resulted and pcssibly suprarenal extract might beapplicable for this

Dr. F. J. POYNTON regarded purpura as a symptomatic con-dition and said that in most cases it appeared to him to berelated to a rheumatic process. Purpura was not common inhis experience in the scurvy rickets of childhood. The rheu-matic poison seemed to have a very definite effect on theblood-vessels as seen in cases of purpuric pericarditis and inthe epistaxis which was apt to occur in rheumatic children.He believed that purpura was definitely associated withrheumatism and was dependent on the rheumatic micro-

organism.Dr. J. WALTER CARR agreed as to the rarity of so-called

essential or idiopathic purpura and quoted statistics in proof.Oat of six cases five were girls and one a boy. He believedthat purpura was closely related to rheumatism. The casesof rheumatic purpura which died were probably registeredunder rheumatism. Some cases of purpura were of h&aelig;mo-philic origin, as in a case which he had watched for threeyears. Uthers were undoubtedly idiopathic in the sense ofhaving no obvious causal agent. Rest was a valuableelement in treatment. Turpentine seemed to be of usesometimes.

Dr. A. E. WRIGHT regarded the pathology of purpura as aquestion of derangement of the balance between the bloodand the blood-vessels. There was certainly a nervous in-fluence in the process of effusion and he mentioned the caseof a man who could produce an attack of urticaria at willby fixing his mind upon the subject. There were, in hisview, three varieties or degrees of effusion-serous effusion,consisting of lymph, as in urticaria ; serous bsematomata

containing lymph and some blood cells, as in chilblains anderythema ; and purpuric effusions of all the blood elements.There were various causes of effusions. Hsemophilic bloodwas deficient in fibrin. He did not expect to find deficientcoagulation in every case of purpura but other elements ofthe blood might be found wanting such as serum globulinand serum albumin. Bacterial toxins broke down thealbumins into peptones which were much less viscid.Calcium chlOIide would only be of use when the effusiondepended on deficiency of lime in the blood, not in con-ditions such as those he had just mentioned.The PRESIDENT remarked on the rarity of essential

purpura In ten years out of 1000 in-patients at theWestminster Hospital there were only 15 cases of purpuraand only five of these were under ten years of age. At theLondon Hospital (according to Sir Stephen Mackenzie) in16 years out of 17,000 patients there were only 200 cases ofpurpura-49 under ten years of age. He (the President)had been particularly struck by the association of purpurawith ulcerative colitis. He agreed with Dr. Voelcker in notregarding purpura as neccssarily connected with rheumatism ;the joint pains of the former might be mistaken for rheu-matism. Sulphocarbolate of sodium in half-drachm dosesevery four hours had been useful in his experience but hedepended mainly on turpentine.

Dr. VOELCKER replied.