655CLINICAL NOTES.-PATHOLOGICAL SOCIETY OF LONDON.

abdominal wall might be a calculus lodged in a bladderdiverticulum near the fundus. But the sound struck nohard substance. Lateral lithotomy was out of the questionand accordingly I opened above the pubes and removeda calculus which Mr. W. H. Clayton-Greene, the surgicalregistrar, has thus described : "The mass was about thesize of a large walnut and consisted of some 10 to 12 layersof laminated tough material in appearance like wash-leatherand like the decolourised blood clot from an aneurysmal sac.The layers could be separated without difficulty. In thecentre of the mass was found a soft friable nucleus of mixedorates and phosphates about as large as a kidney-bean.This was doubtless the origin of the trouble and roundit blood had been deposited in laminæ which had graduallybeen decolourised." " No bladder pouch was discovered andit is not easy to account for the deposition of laminatedblood clot round a nucleus subjected, as it must have been,to the perpetual wash of urine. I have never seen anythinglike it before. After the operation the child was kept in awarm bath and recovery was uninterrupted. He very soonlost his pain and began to take as much interest in his

surroundings as his idiot state would allow. He was dis-

charged well on Feb. 10th.

THE MICROSCOPICAL OBSERVATION OF THEGLYCOGEN REACTION.

BY DR. G. SPEZIA,

THE microscopical reaction with iodine showing the

presence of glycogen in the white corpuscles may occurunder both physiological and pathological conditions.

Physiologically, I have observed it in the human subjectduring the digestive leucocytosis following hearty meals.

Studying this phenomenon in guinea-pigs which did notshow this reaction in their blood I succeeded in producing itvery distinctly, not only with injections of peptone into theperitoneal cavity, as Gabrietschewsky did, but I obtained iteven with subcutaneous injections of fats (olive oil), albu-minoids (peptone), and carbohydrates (glucose). Physio-logically, I have observed it also in pregnant guinea-pigs. Itherefore place on record this reaction with the formation ofglycogen by the action of various diastases from variousnutritive materials which exert a positive chemiotaxic action.

Pathologically, I have observed that it is always accom-panied by hyperleucocytosis in excess of that which has longbeen known to occur in suppuration and that it is mani-fested in the polynuclear neutrophile cells ; it is found in

inflammatory foci and also in the blood. In the blood it isthe more evident in proportion to the closeness of therelations between the blood and the organs affected (as incroupous pneumonia, for instance).The glycogenic reaction of the anasmias is found also in

the haemopoietic organs. This reaction is very evident inthe sputa in inflammatory diseases of the lungs ; in thesecases I have observed it, not only in the white corpuscles,but also (and I believe that I was the first to do so) inthe large phagocytes in which karyokinetic figures weredisplayed.

This reaction is the expression of a resistance of theorganism to toxic agents, whatever be their origin, whetherbacterial or not, a resistance which places in a circle (il qualemette in cercolo) a substance (glycogen) which must serve toarouse an increased degree of defensive activity, as is provedby the following facts. 1. This reaction is manifested after theinjection of various nutritive substances. 2. In pathologicalcases it attains its highest point in the inflammatory centre,as, for instance, in the foci of pneumonia or broncho-pneumonia, in which I have observed droplets of glycogen ofa size from 0.5 µ to 20µ (from 0 - 00002 to 0 - 0008 of aninch). 3. It is greater in severe toxic affections than inmild ones. 4. It is accompanied by hyperleucocytosis. 5.It is accompanied by evidences of cellular division (forexample, in tumours).Turin.

NOTE ON A CASE OF HYDATID CYST OF THESPLEEN.

BY FRANK R. SEAGER, L.R.C.P., L.R.C.S. EDIN.,L.F.P.S. GLASG.,

HOUSE SURGEON, SALOP INFIRMARY, SHREWSBURY.

A BOY, aged 11 years, was admitted into the SalopInfirmary on Jan. llth, 1903, under the care of Mr. A. I

Jackson, the senior surgeon, complaining of " a lump in thestomach on the left side." The history of the case was thatfour months previously he had first noticed a swelling belowthe ribs on the left side. The size of this swelling was not atfirst definitely noticed and there was no pain, but it graduallyincreased and the lad began to experience slight pain whichhe likened to " stitch." " It was now noticed that the swell-ing varied in size, being larger after a meal and at night.There was no sickness and the pain was not aggravated bytaking food. The bowels acted regularly. The familyhistory was very good. As regards the habits of the boyit was elicited that he was fond of accompanying keepersin beating for game and that he used to drink freelyof the water in brooks and to eat watercress whichwas plentiful in his neighbourhood. Physically he was

robust and well nourished. In the abdomen a swellingof the size of a small orange was distinctly noticeablein the left hypochondrium, projecting from below the costalmargin, with its centre just internal to the nipple line.Palpation of the tumour, beyond giving the sense of a cysticswelling, revealed nothing to suggest its nature or as towhich was the organ affected. The percussion note wasresonant over the tumour. There were no increase in

splenic or renal dulness, no pain or tenderness on manipula-tion, and no appreciable movement with inspiration. I’heurine showed a trace of albumin. The diagnosis was thoughtto lie between a hydro-nephrosis or a hydatid cyst of somepart. t.

Two days after admission an incision was made under ananæsthetic over the tumour and on opening the peritonealcavity the spleen at once presented in the wound, with two-thirds of its anterior surface occupied by a tense, shining,yellow-coloured tumour which fluctuated on palpation. Thiswas tapped and fully half a pint of clear limpid fluid wasdrawn off. The wound made by the tapping was then en-larged and a thick cyst-wall was shelled out in the ordinaryway. The wall of the cavity was then stitched to the

skin, a tube was inserted, and the rest of the wound wasswitched. The boy made an uninterrupted recovery. The

cyst was single with no daughter cysts.For permission to publish this note, which I hope may

prove of interest from the diagnostic point of view, I amindebted to Mr. Jackson.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.

The Excretion of Alkalies in certain Conditions of RenalDisease. -Ehrlich,’s Dimethyl (p) Amido-benzaldehydeReaction. - The Relation existing between Uric AcidExcretion and the Breaking -Dogvn of White BloodCorpucscles.A MEETING of this society was held on March 3rd,

Dr. W. D. HALLIBURTON, the Vice-President, being in thechair.

Dr. W. P. HERRINGHAM read a paper on the Excretion ofSodium and Potassium in cases of Renal Disease. In experi-ments cn the toxicity of urine when injected into the bloodof animals, an account of which was given to the society threeyears ago, he had been led to disbelieve Bouchard’s explana-tion and to conclude, with Feltz and Ritter, Astachensky,and others, that all the symptoms seen in rabbits might beaccounted for by the potassium salts held in solution. Therewas no necessary connexion between the toxicity of urine andurasmia. Indeed, it seemed to him probable that urasmiawas not due to the retention of any normal product bv’to something abnormal. Nevertheless, he had thought,it advisable to examine the excretion of sodium and

potassium in renal disease to see if it varied fromthe standard of health. The standard of health was not,however, very certain, it varied within considerable limits.He had expected that if any marked change occurredin cases of nephritis it would be in the excretion of

potassium. He found, on the contrary, that the great varia.tion was on the side of sodium. In patients who died therewas found a great, in some cases a complete, retention ofsodium. He had made 16 analyses in 11 cases of chronicinterstitial nephritis and of these six were fatal. In everyone of them the sodium excretion was nil or very small. Itwas not so in any of the five cases which did not end fatally.

656 PATHOLOGICAL SOCIETY OF LONDON.

He had made 20 analyses in nine cases of diffuse or paren s

chymatous nephritis and of these two were fatal. Both showed t

complete absence of sodium from the urine on one or more t

days. None of the seven cases in which recovery resulted s

exhibited this. Thinking it might be due to diet or that the tsodium might be passed in the fseces he had in one case of tinterstitial and in one case of parenchymatous nephritisanalysed the diet, the urine, and the fasces for a series of (days. These were included in the numbers given above. (A man, aged 47 years, who died from chronic interstitial (nephritis, with a dilated, hypertrophied, and fibrous heart, i

took during the last four days of life food containing10’2 grammes of potassium and six grammes of sodium and texcreted over 13 grammes of potassium but no sodium at, all. jA girl, aged 17 years, the subject of severe parenchymatous 1

nephritis, took during eight days food containing 13 grammes (

of potassium and five grammes of sodium and excreted 13 grammes of potassium and 2’4 grammes of sodium. (This close approximation of ingesta and egesta was considered aaccidental. It was beyond what was possible in an investi- gation of this kind.) On three of these days she excreted (

no sodium at all by the urine. She did not die till 30 days iafter the end of the experiment. A man, aged 38 years, t

convalescent from pleurisy, was used as a control In 11 ‘

days he took food containing 23.9 grammes of potassium (

and 9’ 3 grammes of sodium, and excreted in urine and fseces :together 20.9 grammes of potassium and 10’1 grammes of 1sodium. The sodium was wholly excreted by the urine, the <

fseces containing none. That the excretion of urea and salts (

was uneven in renal disease had already been shown by tvan Noorden and his pupils. The diseased kidney did not accommodate itself to change so quickly as the healthy,but that did not apply to those patients who had been on the <

same diet for a long time. The results were very remarkable i

and if the absence of sodium was proved by further i

researches to be really an indication of fatal cases the

analysis would be of importance in prognosis. Retention of isodium was not, however, peculiar to Bright’s disease. iSalkowski had already shown it to occur in several acute i

fevers. Dr. Herringham had also found it in two cases of large ascites repeatedly tapped. In one of them there was no sign whatever of kidney disease, but the other was a doubtful J

case. The latter had left the hospital and could not betraced ; the former was still an in-patient. The retention 1could not be supposed to be due to inability of the kidneysto excrete sodium while excreting potassium freely. It mustbe due, therefore, to some need of sodium within the

organism. In the case of a large ascitic effusion yieldingroughly 20 pints every fortnight of a fluid containing 0’3 percent. of sodium the need was obvious. But this did notseem to apply to the cases of interstitial nephritis whichhad little oedema. Dr. Herringham said that he owed specialthanks to Dr. Kennedy Orton and to Dr. Hurtley, who hadinvented and elaborated the analytic process used, and to Dr.Hurtley for his cooperation, without which the analyses, whichwere very long and laborious, could not have been performed.- Dr. G. C. GARRATT said that the retention of sodium in thebody in the form of sodium chloride might be for osmoticpurposes, or if not retained as sodium chloride the purposecould only be conjectured. This retention of sodiumchloride within the body had been observed by Prout inpersons about to die and it had been found that after deathfrom uraemia there was an excess of sodium chloride in thetissues. He suggested that the alteration in the osmotictension of the blood in ur&aelig;mia was in some way related tothe retention of the sodium salts. In fevers he had neverfound complete absence of sodium salts in the urine.If sodium citrate was given in fevers it was retaineduntil the fall of temperature and presumably for the

purpose of neutralising some acid condition. He wasof the opinion, however, that the sodium salts were

retained in renal disease for osmotic purposes.-Dr. R.HUTCHISON referred to the retention of chlorides in pneu-monia, which he said had been attributed to cloudy swellingof the renal epithelium which frequently accompanied thatdisease. He doubted the observation and had undertakensome investigations as to the excretions of chlorides in renaldisease and in all the cases examined (which were notadvanced cases of renal disease) he had always found a fairamount of chlorides. He considered that the absence ofsodium salts in the urine of the cases cited by Dr. Herringhamwas probably accounted for by the retention of the excess ofserous fluid in the tissues owing to the imperfect secretionof water from the body which might be present in the later

stages of renal disease.-Dr. HERRINGHAM, in reply, saidthat the amount of chlorides generally varied directly withthe sodium. The sodium was probably retained in the bodyas sodium chloride. He agreed with the last speaker thatthe sodium chloride was probably retained within the body inthe serum in the tissues.

Mr. H. W. ARMIT read a paper on Ehrlich’s Dimethyl(p) Amido-benzaldehyde Reaction. He said that dimethyl(p) amido-benzaldehyde had the formula of C6H4-COH-N(CH3)2 and was found by Ehrlich to unite with a constituent ofnormal and pathological urine, forming a red-coloured body.The chemistry of this combination was not exactly known,but Ehrlich believed that the methylene group of the reagentjoined with the unknown body in the urine, which hebelieved contained a pyrrol ring. Proescher had studied thechemistry of the red compound and gave as its approximateempirical formula C16H2406N2, which would give the formulaof the unknown body as C7H1506N, after subtraction of 0and addition of water. After dealing with some points ofthe chemistry of the reagent Mr. Armit pointed out that otherobservers had employed a somewhat inexact method of test-ing in the cold but he had come to the conclusion that thetest could be more usefully applied by the following method.To one cubic centimetre of urine, heated to frothing, 0’01cubic centimetre of an acid solution (2 per cent.) was addedand if the urine was coloured cherry red the reaction waspositive, while if the drop was seen to fall through the columnof urine like a red worm, or when, on the addition of moredrops, the froth was tinted, and the colour only appeared onthe addition of two such drops he called it a colour-changeof the second degree, and when the colour appeared on theaddition of the third drop a colour-change of the third

degree. Clemens had tested a number of pathologicalurines, but his results were irregular. Koziczkowsky hadused another method and had obtained results more likethose which Mr. Armit had obtained. Among his cases ofgastro-enteric diseases he obtained good positive reactionsin two out of eight cases of typhoid fever during the acutestage, while five gave less good reactions. None of the 35cases convalescent from typhoid fever gave reactions. Of threecases of acute appendicitis, one, which was complicated withfaecal fistula and pneumonia, gave a positive reactionand the other two gave no reaction, the abscess havingbeen opened in both. Of the cases of gastritis,only three gave second and third degree colourchanges. A number of other diseases were mentionedwhich gave no reactions. In acute infective processes noreaction was obtained in rheumatic fever, rheumatic endo-carditis, variola, or erythema nodosum ; two cases of

. pneumonia gave positive reactions, while two gave colourchanges of the third degree. In both the cases where apositive reaction was obtained the patients were very acutelyill. One case of diphtheria during the acute stage gave a.

colour change of the second degree and was a moderatelybad case, while two others which had been treated withantitoxin with apparent success gave no reaction. Of sixcases of scarlet fever during the acute stage two gave colour

! changes of the second degree, one a colour change of thethird degree, and three no reaction. None of the con-

L valescing patients (fever) gave a reaction. One case ofL vaccinia, which was admitted into hospital with the dia-L gnosis of typhoid fever and in which the patient was acutely

ill, gave a positive reaction. 85 patients suffering from

pulmonary tuberculosis were examined in this way. 16 gavereaction up to the third degree and eight gave positive re-

’ action, including one case of acute phthisis in whose sputummany cocci as well as tubercle bacilli were found. A second

l case of acute phthisis, where tubercle bacilli were presentin the sputum in almost pure culture, showed no reaction.No reaction was met with in miliary tuberculosis. One case

of bronchitis gave a change of colour, probably of the second. degree ; all the others gave no reaction. In influenza the anti-- pyrin prescribed for the pains produced some colour changes.

In infective endocarditis all the cases gave a positive re-

b action. In early septicaemia and in the severer forms ofi saprasmia the reaction proved positive. In all he examined1 over 350 specimens of urine. The diazo test did not correspondt with this test. Since all the patients who gave positiver reactions were in fever and were sweating he sought to findf out if sweating could produce it. Injecting pilocarpin nitratei into himself only increased the reaction slightly, as did hardf exercise. Mr. Armit came to the conclusion that the un-a known body was either excreted in larger quantities or wasr manufactured in larger quantities under certain conditions of

657CLINICAL SOCIETY OF LONDON.

increased destructive metabolism, and he believed that theaction of certain toxins, especially some coccic toxins, pro-duced it. From a clinical point of view he regarded thepositive reaction as indicating a very grave prognosis and hepointed out that while a colour change of the second degreemight assist to a correct diagnosis in some circumstances a

. positive reaction when there was clinical evidence of endo-carditis pointed to the affection being infective. The colourcombination could be demonstrated in the tissues and he de-scribed some experiments on rabbits which showed that theunknown body was stored up in large quantities in the

perichondrium and in smaller quantities in the whitematter, kidney, liver, and mesentery in animals which haddied from diphtheria toxaemia. Papenheim suggested thatthe body was urobilin, but Mr. Armit was able to disprovethis. The urine of a horse suffering from tetanus gave thereaction well. Horse’s urine was supposed to be free fromurobilin, and in this case Jaff&eacute;’s and Gerhardt’s tests were

negative. The filtrate after precipitation with acetate oflead gave some colour change. Urobilin was increased inall cases of pyrexia, while the unknown body was not con-stantly increased. Several compounds were capable of

joining dimethyl-amido-benzaldehyde to form red colourbodies, but Mr. Armit came to the conclusion that the

pathological reaction was formed by the union of the reagentwith only one body, the chemical nature of which was notknown. It might contain either a pyrrol or a benzol ring.-Dr. A. E. GARROD criticised the correctness of the formula ofurobilin given by Mr. Armit.-Dr. P. HoRTON-SMITH askedwhether the presence of the reaction in patients with chronictuberculous disease was of grave prognostic significance.-Mr. ARMIT, in reply, said that the prognosis was bad in casesof chronic pulmonary tuberculosis in which the reaction waspresent.

Dr. 0. K. WILLIAMSON read a paper on the Relation exist-ing between Uric Acid Excretion and the Breaking Down ofthe White Blood Corpuscles. The conclusions arrived at byprevious workers at this subject:did not agree. Horbaczewski,however, demonstrated the relationship experimentally,whilst of the clinical observations those of Kuhnau alonecarried conviction. It was pointed out that isolated observa-tions of uric acid excretion and of the white blood count ata corresponding time were of less value than continuous obser-vations extending over a considerable period of time showingthe corresponding variations. The observations recorded,therefore, were carried out on the latter lines. The objectaimed at was to determine whether an increased destructionof the white corpuscles as opposed to a diminished productionwas followed by an increase in the excretion of uric acid.This increased destruction would seem to be taking place,firstly, whenever a fall in the number of white corpuscleswas followed by a rise in the amount of phosphoric acidexcreted ; secondly, a diminution in absolute number of theolder forms of the white corpuscles, whilst the young cellsdid not correspondingly diminish, would also point to anincrease in destruction. If, however, the young cells, as

distinguished from the older forms, diminished markedly innumber, this would indicate a diminished production. Inorder, then, to determine the times of increased destructiondaily estimations of the amount of phosphoric acid inthe urine were made and, corresponding to the dailywhite blood counts, differential counts from stained films. Eleven patients, most of them suffering from pulmonarytuberculosis, were chosen for the observations which were recorded in tables and curves. These showed (1) that innearly every case in which a rise of the phosphoric acidcurve followed a fall in the white corpuscle curve this irise corresponded with a rise in the uric acid curve ; (2) thatin the majority of cases confirmatory evidence of increased destruction could be obtained from a study of the differential counts ; (3) that in those cases in which there were sudden ]and marked variations in the white corpuscle curve therewere similar variations in the curves of uric and phosphoric 7acid ; and (4) that in the case of the children the amounts of phosphoric acid and uric acid excreted were relatively 1

greater than in the case of the adults and that the irises in the curves of phosphoric and uric acid followed more rapidly on the fall of the white corpuscle curve

than in the case of the adults.-Dr. HALLIBURTON said that he thought that it had been proved that uric acid voriginated from nuclein, either from the food or from the (

metabolism of the body. He considered that undue stress was often laid upon the conditions of the leucocytes and investigators forgot the small volume occupied by the white i

! corpuscles. If all the white blood corpuscles were destroyedevery day the products of destruction would only form a

! very small quantity of the uric acid often excreted. The: glandular cells of the liver, lymphatic gland, and other! tissue contributed the larger share of the uric acid.-Dr.. W. D’E. EMERY suggested that the phosphorus resulting

from the destruction of the white cells was often retainedwithin the body and was not excreted.-Dr. HUTCHISONasked if Dr. WILLIAMSON had made any observations withregard to the condition of the uric acid secretion in casesin which there was a diminution of white corpuscles.-Dr.WILLIAMSON replied.

CLINICAL SOCIETY OF LONDON.

, Exhibition of Cases.A MEETING of this society was held on Feb. 27th, Mr.

HOWARD MARSH, the President, being in the chair.Mr. LEONARD S. DUDGEON exhibited three cases of

Volkmann’s Contracture. The first case was that of a child,aged five years, who had fractured the right upper arm nearthe elbow-joint in December, 1900. When put in plaster thefingers had become swollen and cyanosed and a pressure sorehad formed on the flexor aspect of the forearm. In January,1903, the forearm was found to be shortened and stronglypronated, the position of the hand and fingers beingquite typical. Passive movement, massage, and faradismhad resulted in very slight improvement. The second casewas that of a boy, aged nine years, who had met withan injury to the left forearm two and a half years before.A pressure sore had also resulted in this case. In March,1901, the patient was taken to St. Thomas’s Hospital andthe electrical reactions showed partial reaction of degenera-tion. There was also partial motor and sensory paralysis inthe region of the forearm. In February, 1902, Mr. H. H.Clutton had performed resection of the radius and ulna.Under daily massage great improvement had taken place.The third case was that of a boy, aged eight years, who hadinjured the left forearm in December, 1901, after which thearm became shrunken, the fingers contracted, and there wassloughing on the forearm. In September, 1902, the childwas taken to St. Thomas’s Hospital, the hands and fingersthen being in the typical position. In October Mr. Cluttonexcised three quarters of an inch from the radius and ulna.Great improvement had resulted.

Mr. H. B. ROBINSON showed a case of Dislocation of the

Long Tendon of the Biceps Flexor Cubiti. The patient,who was aged 27 years, had had the head of the lefthumerus excised in St. Thomas’s Hospital on Sept. 19th,1900, by the late Mr. William Anderson for recurrent dis-location. Recurrence had occurred nine times in the precedingthree years The result had proved most satisfactory. Sixmonths previously he fractured the right clavicle whichunited rapidly. On Jan. 3rd last he fell from a van and sub.sequently noticed that the right arm could not be broughtproperly to the side. The position of the arm was charac-teristic. The humerus was abducted and inwardly rotatedto a slight extent ; the shoulder-joint being then fixed

attempted movement was attended by rotation of the

scapula. The malposition could be easily rectified, afterfixiog the scapula, by bringing the elbow forward, thus re-

laxing the biceps, and then rotating outwards. The conditionwas apparently associated with an abnormal laxity of thejoint capasule and an increased play of the tendon in its

groove.-Mr. A. PEARCE GOULD suggested that the

abnormality might be due to a hypertrophied synovialfringe.-The PRESIDENT was not convinced that it was

dislocation of the long tendon of the biceps. This dis-

placement generally took place inwards and not outwards.The case, he urged, should be thoroughly investigated.-Mr.ROBINSON, in reply, thought that the joint might be

explored but asked what ought to be done if it proved tobe a dislocation of the tendon. He did not think that it was

indispensable to remove the head of the bone as on the otherside.

Mr. T. H. KELLOCK showed a case of Varicose Internal

Saphena Vein in a child, aged seven years. The conditionwas first noticed accidentally about a year ago. The courseof the vein seemed to be slightly abnormal, passing towardsthe inner surface of the thigh. Varicosity was also notice-able at the inner side and front of the patella, behind theinternal malleolus, and over the inner side of the foot. No