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and tube, having advanced further than on theright. The point of arrest in the metamorphosis ofthe Mullerian ducts was presumably antecedent tothat which gives rise to a uterus didelphys, and thecase was not one of true duplication of the uterus,due to dichotomy of the embryonic cauda, as

described by Gemmell and Patterson.

I am indebted to the Director of the Institute forMedical Research, F.M.S., for permission to publishthis case, and to Dr. Raymond Lewthwaite, seniorpathologist, for the preparation of, and advice upon,the sections.

MEDICAL SOCIETIES

OPHTHALMOLOGICAL CONGRESS

THE annual congress of the OphthalmologicalSociety of the United Kingdom was held in Londonfrom April 28th-30th under the presidency of Dr.GORDON HOLMES, F.R.S. At the first session Mr. R.FOSTER MOORE opened a discussion on

Differential Diagnosis of the Causes ofExophthalmos

He said he had estimated proptosis by standing behindthe patient, making him look a little upwards, andtilting the head backwards until the summit of thecornea first appeared in view in front of the eyebrow.In diagnosis bilaterality and the direction of proptosiswere important. Deep palpation of the orbitalcontents with the little finger enabled the front edgeof the orbital mass sometimes to be felt, revealingits existence, consistency, and position ; tenderness

might suggest an inflammatory origin. At times,although the tumour could not be felt, the orbitalfat was pushed forward and could be made to slipbetween the skin and the orbital margin. On palpa-tion too proptosis might be found to be reducible,if due for instance to cavernous nsevus ; or pulsationfrom an arteriovenous aneurysm might be detected.Limitation of movements was more likely to be

general in inflammatory than in neoplastic condi-tions, although a single muscle might be picked outby a local focus. Certainly there could be a highdegree of proptosis from a neoplasm with but littlelimitation of movement. The immobility in inflam-mation was probably due to the action of toxinson the muscles, but paralysis was sometimes due toinvolvement of a nerve, for instance the sixth incavernous sinus thrombosis. The speaker thoughtthat the ocular palsies accompanying the proptosisin thyrotoxicosis were due to persistent changes inthe muscles. Chemosis had relatively little diagnosticvalue.Among specific causes of proptosis, it was easy

to overlook the presence of an intraorbital foreignbody such as a bit of stick in a child. Callus forma-tion had been held responsible, he thought erroneously,for proptosis, for it was not usually formed bymembranous bones. Haemorrhage into the orbital

cavity, frequently due to trauma, occurred spon-taneously sometimes in haemophilia and scurvy orfrom physical causes as in whooping-cough or birth.Inflammatory causes provided the largest group,accounting for 35 out of 117 consecutive cases withoutGraves’s disease. Among them the average agehad been 16 in females and 23 in males, mostlyoriginating in the frontal and ethmoid sinuses and

hardly ever in the sphenoid or maxillary antrum.In Graves’s disease a retracted upper lid might givea false appearance of exophthalmos or of the othereye becoming smaller, or per contra a patient with adrooping lid might complain of the prominence ofthe other eye. The speaker believed that theapparent enophthalmos of sympathetic paralysiswas due to the drooping of the lid which was notaccompanied by any misplacement of the eye.

Considering tumours of the orbit, Mr. Foster Mooresaid that although metastases were rare in the orbithe thought they should be first excluded in all casesof unilateral proptosis in an adult. Arteriovenous

aneurysm, one of the rarer causes of proptosis, waseasily diagnosed. He had seen one case, a cookwho had heard a noise in her head like a pistol shotwhile she sat peeling potatoes ; she had afterwardsall the signs of an arteriovenous aneurysm. Althoughtrauma and post-embolic aneurysm were importantcauses of the condition, he believed that some casesmight arise idiopathically from congenital weaknessof the arterial wall.

EAR, NOSE, AND THROAT ASPECTS

Mr. TERENCE CAWTHORNE classified the patho-logical conditions of the ear, nose, and throat underfour headings : foreign matter being forced into theorbit; interference with the venous return from theorbit; extension of inflammation to the orbit; andinvasion by new growth. Under the first heading theconditions were traumatic and rare. Air had beenknown to have been forced into the orbit by blowingthe nose through a communication between the orbitand nose due either to trauma or a congenitaldehiscence. Cases were recorded of water gainingentrance through accidental perforation of the orbitfloor during antrum puncture. Cracking of theethmoidal plate during intranasal surgery mightcause bleeding into the orbit. Obstruction to thevenous outflow might be caused by growth from thesphenoid or nasopharynx or by thrombosis of thecavernous sinus. Clinically the routes by whichthrombophlebitis might reach the sinus fell into threegroups : anterior, via the superior ophthalmic veinfrom a primary focus on the face, nose, front teeth,frontal sinus, or ethmoid cells ; intermediate from theantrum or back teeth via the pterygoid plexus ofveins, foramen ovale, deep facial and inferiorophthalmic veins ; posterior, this (third) route leadingmostly from the ear. Inflammation, the commonestcause of proptosis from the laryngologist’s point ofview, came often from the frontal and ethmoidalsinuses ; in children rupture of infected ethmoidcells was sometimes seen, characterised by swellinground the inner canthus, a nasal discharge, pus in thenose, and definite X ray changes. Mucocele, osteoma,carcinoma, and sarcoma constituted the types of largeswellings of slow growth that encroached upon theorbit from the sinus. The diagnosis was made on thehistory of onset, distribution, and the presence orabsence of constitutional disturbance and of tender-ness. Because of the great strides made during thepast decade in the technique of sinus radiography,more and more reliance was being placed on thatpart of the investigation.

NERVOUS AND GENERAL MEDICAL ASPECTS

Dr. W. RussELL BRAIN spoke of the neurologicaland general medical causes of exophthalmos. Twodiseases of the bones of the skull might cause

exophthalmos by altering the shape of the orbits and

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so diminishing their capacity. In craniostenosis

premature union of some of the cranial sutures madethe skull too small for the growing brain, but expansiontook place where the sutures remained ununited.The disorder was hereditary and the deformity mightdevelop before birth, during infancy, or later child-hood. The orbits were abnormally shallow, theiraxes deviated outwards, and the exophthalmos mightbe slight or extreme. Ferrer had reported a casewho had acquired the power of voluntarily dislocatinghis eyes either singly or together by which meanshe eked out a precarious existence among the saloonsof South America. Diabetic-exophthalmic-dysostosiswas a rare disease in which softening of the orbitalwalls caused exophthalmos. A general rise of intra-

_

cranial pressure might cause a slight degree of

exophthalmos but much greater degrees were seen asa result of local presure of a tumour arising in theneighbourhood of the orbit. Meningiomas, slowlygrowing extracerebral tumours of adult life, formedthe most important group. In such cases ptosis dueto involvement of the third nerve or of the ocular

sympathetic was common and helped to distinguishthe exophthalmos from that of endocrine originwhich usually had lid retraction. Intracranial

aneurysms might also cause exophthalmos by localpressure. They were not syphilitic, but originatedin a congenital defect in the muscular coat of thevessel. Most intracranial aneurysms were too smallto cause symptoms except those arising from theintracranial portion of the carotid.

Venous obstruction might cause exophthalmos, themost striking condition being due to carotid-cavernoussinus aneurysm. The effect of raising the bloodpressure in the venous tributaries to the arterialsystolic pressure was a pulsating exophthalmos witha systolic bruit audible to patient and observer andsuppressible by digital compression of the carotid.The conjunctival veins were dilated and tortuous, andpapilloedema and more or less complete ophthalmo-plegia were present. The clinical picture of cavernoussinus thrombosis was similar except for the absenceof bruit and the presence of symptoms of acuteinfection. Impaired venous return from the head

resulting from aortic aneurysm, intrathoracic neoplasm,and even severe chronic emphysema might cause

exophthalmos which might be associated with markedcyanosis and tortuosity of the retinal veins.The study of the syndrome of exophthalmic ophthal-

moplegia had considerably illuminated the natureof the exophthalmos associated with goitre. The

syndrome affected middle-aged individuals and malesmuch more than did exophthalmic goitre ; progressiveexophthalmos of one or both eyes was associated withexternal ophthalmoplegia, unilateral or bilateral.The exophthalmos was of the florid type, sometimescalled in the United States malignant, with muchoedema of the lids and of the conjunctiva which mightprotrude beyond the anterior border of the cornea.Hyperthyroidism was rarely severe ; the conditionwas even progressive sometimes in patients withsubnormal B.M.R. after thyroidectomy. These find-

ings and recent experimental work on the thyrotropichormone of the pituitary suggested that the exoph-thalmos might be due to over-production of thathormone.

PROPTOSIS IN CHILDREN

Mr. J. H. DOGGART dealt with the differential

diagnosis of proptosis in children. The eye at birth,he said, was about three-quarters of its full grownsize so that the infant’s orbital cavity was relativelyfar smaller than that of an adult. Proptosis therefore

began earlier and attained more serious proportionsin childhood. The eye was also more distensiblethen. Many of the causes of proptosis were peculiarto children, and Graves’s disease was exceedingly rarein them. Myopia and buphthalmia could cause

undue prominence by increased size of the eye. Thefluid contents of the orbit might be increased bycystic tumours, inflammatory effusions, or by extra-vasated blood (from wounds, birth injury, haemo-philia, or scurvy). Meningitis sometimes obstructedthe orbital fluid by posterior adhesions. Inflammatorypseudo-tumour was a name given to deep infiltrations,often gummatous or tuberculous, displaying the

diagnostic features of orbital tumour. Sarcomawas the commonest of the primary neoplasms andmight grow so rapidly that it simulated inflammation.Growths arising from the optic nerve, chloroma,Hutchison’s tumour, Schuller-Christian xanthoma,dermoid cysts, and cavernous lymphangiomatamight also be responsible.The eyeball was retained in the orbit chiefly

by the optic nerve ; total ophthalmoplegia led to

slight proptosis which might be masked by droopingof the upper lid. Forward dislocation of an infant’seye was occasionally seen from spasm of the orbicularisin a bout of crying. In oxycephaly and in hereditarycleido-cranial dysostosis diminution of the orbitalvolume might occur.

OPHTHAI.MOLOGICAL SIGNS IN GRAVES’S DISEASE

Dr. E. E. PociiiN said that an appearance of

exophthalmos in Graves’s disease might be producedby two different phenomena : an actual proptosis anda widening of the palpebral fissure by retraction of theupper lid, giving the illusion of exophthalmos. Hehad investigated this lid retraction in a group of casesin which it was unilateral and uncomplicated byexophthalmos. In retraction, he was able to showby films, the eye had a characteristic staring expression,the lower lid was slightly higher on the affected side,and on closing the upper lid was wrinkled as if it werehitched up. He thought the raising of the lower lidwas mechanical, being due either to raising of thecanthus or to depression of the eyeball.

DISCUSSION

Mr. A. D. GRIFFITH described two cases of arterio-venous aneurysm with exophthalmos.

Mr. J. ELLISON recommended that in such condi-tions the patient should not be kept recumbent.He thought the common and internal carotid shouldbe tied.

Mr. WILLOUGHBY CASHELL described a case ofextreme proptosis following carcinoma of the antrum.

Mr. A’. F. MACCALLAN classified the causes of orbitalinflammation under the headings simple orbital oedema,orbital subperiosteal abscess, and orbital cellulitis.

Mr. F. W. LAw described a case of proptosis dueto spontaneous orbital haemorrhage in a man imme-diately before he rowed in the University boat race.

Mr. H. B. STALLARD mentioned that a varicoceleof the tributaries of the ophthalmic veins at the apexof the orbit could produce transient exophthalmos ;in one case this had led to forward dislocation ofthe eye on stooping.

Mr. HARRIS ON BUTLER had been called to a pekinesewhose eye had proptosed completely in a moment ofexcitement. This was apparently a common failingamong pekineses ; the condition kept recurring inthis dog after he had eventually reduced it under ananaesthetic.

Mr. D. V. GIRI reported ultimate good results ina patient who had had a severe initial reaction to a

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radium bomb. He thought the surgeon should notbe impatient of the damage produced at first inorbital conditions.

Mr. LINDSAY REA described a case of glioma in achild.

Mr. T. K. LYLE inquired the prognosis in womenof fifty with exophthalmos after affection of theethmoid cells.

Mr. W. C. SouTER said he had noticed retractionof the upper lid in cases of encephalitis and cerebralsyphilis. He had found that photographs to showproptosis were best taken from above the head.

The PRESIDENT emphasised Mr. Foster Moore’sremarks about the value of palpation in diagnosis ofexophthalmos ; the eye could be displaced in Graves’sdisease with less resistance than in inflammatory orneoplastic conditions. Venous engorgement shouldbe looked for. He had been much interested byDr. Pochin’s communication ; an illusion of exoph-thalmos given by retraction was often seen by neuro-logists for example in supranuclear ocular palsies andencephalitis. Ligature of the carotid for relief ofarteriovenous aneurysm involved the risk of hemi-

plegia. A follow-up undertaken for Sir Victor Horsleymany years ago had showed this complication to occurin one-third of the cases and in the war among youngand healthy men ligation had led to hemiplegiain more than half. He thought Mr. Rock Carling’smethod of temporary ligature an important one.

ST. JOHN’S HOSPITAL

DERMATOLOGICAL SOCIETY

AT a meeting of this society held on April 26th,with Dr. W. N. GOLDSMITH, the president, in the

chair, a paper onMinor Surgery of the Skin

with special reference to biopsy, was read by Dr.J. H. T. DAVIES (Hove). He explained that, in aprovincial hospital, methods of treatment must be

developed with a view to saving time. For manyyears he had seen few cases of plantar warts exceptin private practice, and had always treated them withX rays. He had never had a mishap, and the propor-tion of failure had been very small. When, however,he had curetted his failed cases, he had noticed thathealing was slow and that a woody induration hadformed in the underlying dermis. He had thereforewondered whether subsequent injury to the scar

might not have undesirable consequences. Radiumwas unpractical and difficult to control. Whensurface X ray therapy came into common use, itshould be possible to develop a safe and satisfactorytechnique. The chief disadvantage of curettage wasthe pain of introducing the local anaesthetic. Thiscould be much diminished by inserting the needlefrom the dorsum of the foot instead of parallel withthe sole.Some patients had an exceptionally thin dermis,

and care had to be taken to avoid penetrating it.Minute warts situated deep in the skin could hardlybe treated with X rays on account of the difficulty ofshielding the surrounding skin. He first made a

small hole with a galvano-cautery, then gave a localanaesthetic, and then enlarged the hole with a Vidalcurette or a double-bladed spoon. He packed withwool soaked in trichloracetic acid to stop bleeding,and trimmed the edge with scissors. Freezing with-ethyl chloride was effective, but the sole of the foot

was resistant, and two sprays should be usedsimultaneously.Radon seeds could be quickly and easily inserted

into the skin for rodent ulcer by attaching themto the end of a suture, which was drawn throughthe skin by a No. 4 cutting needle. When the seedwas in position it was held by a stitch. In takingskin for a graft, a convenient method was to make along wheal with local anaesthetic and transfix thesite with a row of hypodermic needles through whichsutures were threaded ; the skin was then clampedand the slip was cut off; the wound was closed bytying the sutures. The slip was cut into small pieces,each of which was stitched into place in the ulcerwhich it was desired to cover with epithelium.The first question in biopsy was : Who will

interpret the appearances ? Perhaps every derma-tologist should be his own histologist, but this was acounsel of perfection. There were at least two expertcutaneous histologists in London who were availablefor consultation, but they should not be expected togive an opinion without a full clinical descriptionand differential diagnosis. The chief inducements to

carry out a biopsy were the hope of making a diag-nosis of a puzzling condition, curiosity about whatlay beneath the surface, and the passion of thecollector. Even if all these aims were frustrated,the specimen would provide a record of the case

which would last long after the notes had been lost.Of the last 200 consecutive biopsies which Dr. Davieshad carried out, in 41 a completely new and sur-prising diagnosis had been suggested and in 63 a

doubtful diagnosis had been confirmed. Biopsy hadtherefore been positively helpful in half the cases.

In 51 cases the slide had shown features of interestunconnected with the problem for which it was made,and in 19 cases a slide illustrating a rare disease hadbeen added to the collection. In only a fifth of thecases had the biopsy given no help at all. Perhaps noother auxiliary method in medicine gave such fruitfulresults. He had never thought it possible to takedermatology seriously without the aid of biopsy.During the last ten years he had cut more than 800blocks, and he would have cut twice as many if hehad been able to.He showed his outfit, which could be carried in a

small tray, and included a dental-type hypodermicsyringe, a scalpel, sutures, a bottle of fixative withidentifying label; and a Kilner hook, which he declaredto be indispensable to the dermatologist for extractingsmall pieces of tissue. The outfit, he said, should bealways ready for instant use. The ordinary skindepartment did not possess suitable appliances, nor

L were any of the personnel trained, either in theL biopsy or in the preparation and examination of slides., If some institute would undertake the work ofr dermatological section-cutting, more biopsies would

. probably be undertaken. In selecting a lesion for biopsy one should be chosen which appeared to be in a ripe s-cage, but it might occasionally be morei profitable to take a lesion which suggested a diag-

nosis which it was desired to exclude. The lower, third of the leg and the dorsum of the foot should. be avoided, because they healed slowly, and ther connective tissue of the abdominal wall was difficultE to cut. The best place was the face, because even a clumsy wound would heal without permanent scarring.1 The direction of the incision should follow Lange’s1 lines. In sectioning an ulcer care should be taken toi go deep enough, for a piece taken out of the edge, might give a completely misleading picture. Somei of the subcutaneous tissue should be taken. Thet slip need only be long enough to make a good show