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The patient’s condition did nor, however, admit of the stomach being explored and he died within an hour.

Necropsy.-At the post-mortem examination an ulcer ofthe size of a threepenny-bit was found at the apexof the lesser curvature, near the cardiac end, and ratheron the posterior surface. It was very high up and awkwardlyplaced, so that to introduce a tube would have proved a workof considerable difficulty. Except for the one ulcer thestomach was healthy.CASE 2.-A man, aged 49 years, called Mr. Rendle up at

midnight on account of severe abdominal pain. Aboutan hour after a dinner of pork and stewed rhubarb he hadbegun to feel abdominal pain which had gradually increasedtill now it was extreme. chiefly at the epigastrium. Morphiaand turpentine stupes relieved him and on the next dayhe seemed to be better, though still tender to the touch ;his bowels, which had not acted on the morning of hisattack, were confined, not even flatus passing. On the fol-

lowing day this condition continued in spite of purgatives ;- the pain had practically vanished and Mr. Rendle concludedthat he had an internal obstruction to deal with. A surgicalcolleague saw the patient with him, agreed in the diagnosis,and both advised removal to the hospital and an ex-

ploratory operation The patient and more particularly hisfriends all had a great horror of operation, and would onlyagree to his entering the hospital on condition that nothingshould be done until frequent enemata (which had been.administered at home, but not very effectively) had beentried; and most unfortunately these brought away a gooddeal of fascal matter and he was able to pass flatus, hisgeneral condition being at first much improved. The

improvement, however, was not maintained, and on the fifthday, as he was obviously losing ground, permission wasobtained to operate. A ruptured appendix was found,ligatured, and removed, but the patient never rallied and.died on the following day.CASE 3.-A married woman, aged 41 years, was admitted

into the South Devon and East Cornwall Hospital one

evening on account of severe abdominal pain. She hadsuffered for years from indigestion off and on, but had beenpretty well (for her) until two days previously. She then wasseized shortly after breakfast with griping pains whichlasted all day more or less ; on the next day they still con-tinued, but she was able to do her usual work and took herordinary food. The bowels not having acted for two daysshe took half an ounce of castor oil at night, after which thepain just below the sternum became exceedingly acute, andcontinued so all night in spite of a copious relief of thebowels. She tried to get up on the following morning but1-iad to return to bed. She was seen by a medical man,who put her on a diet of milk only, and sent her to the hos-pital in the evening. On admission she was obviously veryill; the temperature was 100 .6° F. and kept rising, the pulse- was 112, and the respirations were 24 and purely thoracic.The abdomen was distended and very tender, especiallyover the epigastrium ; liver dulness was nearly absent. Itseemed to all who saw her, looking at her symptoms andprevious history, that a gastric ulcer was probably thecause of her trouble, and accordingly Mr. Rendle openedthe abdomen in the middle line over that organ, but founcit, as also the small bowel, save for flakes of receni

lymph and free fluid in the peritoneal cavity, quite healthyHe then made a second opening through the right rectu!and came down on a mass of omentum which wa:

:adherent somewhere near the appendix. This wa!

transfixed and ligatured, when about an ounce of ver;fœtid pus was evacuated from deep down in the pclvisThe appendix could not be found for some time as i’was bound tightly down by adhesions. The right ovary an(tube, very swollen and oedematous, were removed, thus freeing the appendix and bringing it into full view. Th

patient’s condition was now exceedingly grave and shseemed to be practically moribund. Dr. W. L. Pethybridgkindly transfused her with three pints of saline solution, anDr. H. W. Webber sutured the incision over the stomac-while Mr. Rendle rapidly transfixed the appendix and mesc:appendix with silk, tied it, and cut the appendix away closto the cæcum. He did not think it safe to spend even thlittle time necessary to fold in the edges of peritoneum, beput a Keith’s glass tube deep down into the pelvis anclosed the wound as rapidly as possible. The patient madan uninterrupted recovery.Remarks by Mr. RENDLE.-The difficulties that attend th

correct diagnosis of grave abdominal injuries are alread

sufficiently well known, but the above cases that have

recently come under my care (during the illness of mysenior) may be of interest as showing how even themost carefully formed opinion may prove to be in error.

In each of these cases a wrong diagnosis was made asto the nature of the illness both by myself and by thecolleagues who saw them with me, but I do not thinkthat we were therefore to blame. Peritonitis was obviouslypresent in each case and only the cause had to be deter-mined. In Case 1 the onset seemed to be characteristic ofa ruptured appendix, especially as there was an absolutedenial of any previous indigestion or symptoms pointing tothe stomach, which also seemed to be contra-indicated bythe age and sex of the patient. In Case 3 the converseappeared to be probable, and, accordingly, I turned myattention to the stomach first of all. Case 2 is the one uponwhich I look back with much regret. The question of theappendix being at fault was considered very carefully, andwe both of us came to the conclusion that it was not; buteven here, had we been able to get leave to operate earlier,as we wanted to do, the result would probably have beenvery different. It was a case where an exploratory opera-tion seemed to be absolutely necessary, but, as so oftenhappens, the friends of the patient were dead against it andinfluenced him to refuse consent until it was too late. I

thought this group of cases, which followed close on oneanother, worthy of being recorded.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

Adjourned Disczcssion on Modern Methods of Vaccination andtheir Scientific Basis.

A MEETING of this society was held on Jan. 14th, Dr. F. W.PAvy, the President, being in the chair.

Dr. S. MONCKTON COPEMAN, in the first place, repeatedthat portion of his demonstration which was given at the lastmeeting of the society and which was fully reported inTHE LANCET of Dec. 14th, 1901 (p. 1670), dealing with thetransference of variola through monkeys and calves, andthe subsequent successful vaccination of the child with thelymph thereby obtained.

Professor SIMS WOODHEAD said that he had performed manyexperiments in order to test the effect of adding glycerine tocalf lymph and he could fully confirm the observations of Dr.Copeman. He said that the addition of 50 per cent. glycerineto lymph had a greater effect in eliminating the non-spore-bearing organisms than the spore-bearing organisms, butthat the staphylococcus pyogenes aureus was more resistantto the action of glycerine than other organisms, but that evenon this organism it had a considerable effect, since itdiminished all but a few-probably about 5 in 1000 beingleft. The spore-bearing organisms were almost entirelyunaffected by glycerine and this seemed to give some

indication of the nature of the organism of vaccine, whichmight be so small as to be invisible to the present power ofthe microscope. It had been pointed out by THE LANCETSpecial Commission on Glycerinated Calf Vaccine Lymphs 1that when the spore-bearing organisms were in excess inthe lymph, the collection of the vaccine lymph hadnot been carried out with all the care that could bedesired, and he considered that if a lymph showed manyspore-bearing organisms it was a proof that the vaccinehad not been properly collected. He then dealt with theeffects of glycerine on the activity of the lymph and said that

’ he did not believe that for three or four weeks it diminishedthe potency, but that after that time the lymph lost someof its activity. He believed that glycerination had most

’ effect on those organisms which grew at the body tempera-ture. It had been stated that worse" arms and morelocal inflammation were caused by glycerinated lymph.

’ This he did not believe to be the case, but he asked that theLocal Government Board should, if possible, prepare statistics

from their returns in order to decide this point.Dr. T. D. ACLAND said that he hoped that the time would

THE LANCET, April 28th, 1900, p. 1227.

161

not be far distant when the Government would take steps tosupply a standard lymph throughout the country. Hedivided the subject into three main headings : (1) the originof vaccine lymph ; (2) the preparation of vaccine lymph,especially in relation to its purification, standardisation, andstorage ; and (3) the use of the prepared lymph, especiallyin relation to methods of vaccination, dosage, efficiency ofvaccination, and the question as to the extent and dura-tion of after-effects or complications of vaccination. He

pointed out that although vaccination was in vogue morethan 100 years ago it had been outstripped in the scientificdetails of technique by many of its successors in the depart-ment of protective inoculation. He said that glycerine hadlong been used to dilute lymph, but that until the researchof Dr. Copeman it had not been used as a scientific means offreeing the lymph from extraneous organisms. He thenreferred to the standardisation of lymph by inoculatingrabbits and said that in this way the potency of any particularlymph might readily be tested before being sent out withouthaving resort to the necessity of vaccinating infants. Hesaid that this method had been carried out at Lille with greatsuccess for over two years. He considered that vaccinationas practised was open to two main objections, firstly, thenecessity for creating a local sore which proved a possiblestarting point for various inflammatory complications ; andsecondly, that in the homes of the poor the vaccinatedchild imposed an extra burden on the already over-

worked mother. He next dealt with the extent andnumber of vesicles produced and thought that thereought to be a fixed irreducible minimum below whichno certificate of successful vaccination should be given.Lastly, he referred to the treatment of variola by the anti-toxin of vaccinia and stated that cases had been thus treatedwith serum taken from a calf which had been vaccinatedfour weeks previously. The observations were, however, in-conclusive. He gave notice of the following motion :-That in the opinion of this meeting of Fellows of the Royal

Medical and Chtrurgical Society it is desirable that the Governmentshould without delay make such additions to the national vaccineestablishment as shall enable it to supply glycerinated calf-lymph to allmedical practitioners who may desire to use it; and that, in view ofthe national importance of the subject, steps should be taken to testand regulate the sale of all imported lymph and to inspect the manu-facture of all that is made in this country.

Professor HACCIUS (Geneva) said that in 1892 he experiencedconsiderable difficulty in obtaining good lymph in calvesand cow-pox could not be found. He therefore attempted totransmit variola to the calf ; in this he was successful, andafter passing the virus through seven calves he then inocu-lated a child with the result that typical vaccine vesicleswere formed. These results he published, but ProfessorChauveau of Paris held that the disease in the calves wasvaccinia and not modified variola, and further ProfessorChauveau inoculated a cow with variola and from the vesicle

produced inoculated a child who developed typical variola.He (Professor Haccius), however, explained the last result asbeing in reality due to the direct transference of the variolavirus, the cow being merely a stage in its transference. Hesaid that Dr. Stumph of Munich had carried out experimentssimilar to those of his and had confirmed his results. Itwas well known that all cases of variola could. not be thus ’,transmitted to the calf, but he believed that the identity of vaccinia and variola would be proved.The discussion was adjourned.A demonstration with the Epidiascope " was given after

the meeting.

MEDICAL SOCIETY OF LONDON.

Observations on the Surgical Treatment of ObstructiveJaundice, resulting from airt Experience of over 200

Operations.A MEETING of this society was held on Jan. 13th, Dr.

W. H. ALLCHIN, the President, being in the chair.Mr. A. W. MAYO ROBSON tleeds) read a paper upon

the above subject. He said that his recent operative ex-perience in cases of chronic obstructive jaundice, espe-cially in those associated with gall-stones and with chronicpancreatitis, had led him to take a more hopeful attitudein considering the treatment of deeply jaundiced patientsfrom a surgical standpoint. The first and often themost difficult question was that of diagnosis, and thefollowing causes of jaundice must be taken into con-

sideration : (1) common dact cholelithiasis ; (2) .chronic

pancreatitis ; (3) simple stricture of the common bile-duct ; (4) inflammatory adhesions causing pressure on, or

stenosis of, the hepatic duct or of the common bile duct ;.(5) hydatid disease of the liver pressing on or discharginginto the bile ducts ; (6) gummata implicating the ducts ;.(7) chronic catarrh of the bile ducts ; (8) cancer of thecommon bile-duct ; (9) cancer of the head of the pancreas ; T(10) cancer of the liver associated with jaundice either dueto catarrh or pressure ; (11) cirrhosis of the liver ; and

(12) other rare causes, such as aneurysm of the hepaticartery or of the aorta and other tumours of the liver, thegall-bladder, the pylorus, the kidney, or the intestine-

pressing on or occluding the common bile duct. Surgeryheld out good prospect of cure in the first five causes-

enumerated. Medical treatment alone was advisable for the-sixth and seventh causes and in the remainder with certain

exceptions relief could only be hoped for. Mr. Mayo,Robson then dealt with one or two points which he had foundof use in guiding him to a conclusion as to whether thecase was suitable for an exploratory operation or not.He said that a painless onset of chronic jaundice mustalways give rise to the suspicion either of chronic catarrhdependent on cancer of the liver, or of occlusion of the-hepatic or common bile duct by growth, and if this were-associated with distension of the gall-bladder and rapid loss.of weight and strength, cancer of the head of the pancreas.would probably be found. On the other hand, the history ofan attack of pain followed within from 24 to 36 hours byjaundice was strongly suggestive of cholelithiasis. Enlarge--ment of the liver was much more common in obstruction due’to cancer than it was in that from gall-stones. The pre--sence of ascites was suggestive of malignant disease. The.

jaundice of gall-stones was rarely continuous but it increasedand diminished from time to time, whereas the jaundice ofobstruction due to growth steadily increased. Fat in the-motions and glycosuria with very rapid wasting were sug-gestive symptoms of pancreatic trouble. A rigid right,rectus abdominis and tenderness one inch above and,to the right of the umbilicus were suggestive of gall-stone-trouble, as was McBurney’s tender spot of appendicitis..The question as to treatment depended on the diagnosis. 1.If the diagnosis was doubtful an exploratory operation was.advisable, providing that the general condition of the patientrendered it probable that such a procedure per se would nothasten death. 2. If malignant disease was positivelydiagnosed operation could, with some few exceptions where it.had been possible to completely remove it, do but little good.3. If gall-stones, or in fact any of the first five enumerated’.causes, were diagnosed, operation was decidedly advisable.,Mr. Mayo Robson then proceeded to consider these three-conditions, and he quoted five cases regarded as hopelesswhich had been operated on with good success ; these cases,,he said, supported his first proposition. With regard to the.second proposition he considered that there were two classes.of cases in which operation could do no good-(a) primary-cancer of the liver and (b) cancer of the head of the:

pancreas-but in young patients the question of operation,should always be considered, as malignant disease of the-pancreas was not common until middle age. Three caseswere quoted which showed that in forms of cancer other-than those mentioned relief or apparent cure had resultedfrom operation. With regard to the third propositionoperation was urgently demanded. 212 patients suffering-from obstructive jaundice dependent upon one or other ofthe causes above mentioned had been operated on. Ofthese 183 recovered, showing a mortality of 13’6 percent. A careful study of the causes of mortality showedthat the two greatest dangers were haemorrhage and shock:and the two next serious causes were exhaustion and sepsis.The employment of chloride of calcium in large doses hadbeen an efficient means in controlling the hæmorrhage, andthe administration of strychnine and large saline enemata,with or without brandy, half an hour before operation had’diminished shock. But of even greater importance was the-cultivation of the habit of operating expeditiously, and even,the most complicated cases should not occupy more than ar&

hour.Mr. J. H. MORGAN said that the success of the opera-

tion evidently depended on the accuracy of the diagnosiswhich had preceded operation and that that accuracy had,been derived from experience. He considered that rapidity-of operation was most important and that shock could be-largely avoided thereby.

Mr. F, S. EVE said that he thought it advisable to explore.