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for all time, that the operation should be efficiently done,and that the lymph used should be of the necessary qualityto ensure the desired protection. So far as I know, no ex-periment has as yet been made for the purpose of ascertain-ing the comparative value of the two kinds of lymph underconsideration, though such an inquiry could, and most cer-tainly should, be made in the present unsettled state ofthe question. A few cases have come under my observationlately, which, so far as they go, seem to show the inade-quacy of lymph taken from a secondary vaccination to pro-tect from small-pox ; and though the cases are few, theyare in themselves none the less valuable, and they areoffered as a contribution to the subject with the hopethat their publication may be the means of stimulatinginquiry and observation in the same direction and elicit-ing further evidence on the point. It may be stated at theoutset that the following cases have all been vaccinated bythe same medical man, and suffered from small-pox withinthe past two months.The first case observed was a woman, Agnes P-, aged

thirty-eight, admitted with small-pox of a hsemorrbagictype, of which she died. Three large distinct marks wereobserved on the left arm, the result of a revaccination per-formed three months previously with lymph taken from thearm of an adult person who had been successfully vaccinatedwhen young. Her mind was perfectly clear on admission, andthe history of the family, voluntarily made, was so strikingthat it was carefully noted at the time. One child, whowas vaccinated successfully from the same arm as the motherherself, had just recovered from a bad attack of small-pox.Two other children had been taken to another doctor, andsuccessfully revaccinated from the arm of an infant fiveweeks before the mother’s attack; they had not takensmall-pox, though they slept in the same room with themother and sister already referred to.Kate R-, aged sixteen, admitted with a severe attack

of variola. There were three good old and three recentcicatrices on the left arm. This patient had been revac-cinated two months before admission from an adult person,and the operation was so successful that the medical mantook lymph from the resulting vesicles. Two children livingin the same house were revaccinated, and one vaccinatedat the same time from the arm of an infant living nextdoor. Not one of these has taken small-pox, although, asalready stated, they lived, together with Kate R-, in thesame infected house.Thomas M——, aged nineteen, had been revaccinated

five weeks before admission, and presented four good marksfrom his primary and two from his secondary vaccination.The doctor took lymph from the vesicles, remarking that° it was a very good arm, and had taken very well." Patientdescribed the " blisters " as being large. He had a mildattack of small-pox.Agnes T-, aged fourteen, admitted with a mild attack

of variola. She had five good old cicatrices on one arm andthree good recent ones on the other; the latter the result- of vaccination, a month previous to this illness, by lymphtaken from a person who had been successfully vaccinatedwhen young. Matter was taken from the arm.

Eliza C-, aged seventeen, admitted with a mild attackof small-pox. There were three large old cicatrices, and threesmaller but perfectly distinct ones on the same arm theresult of vaccination three years before. It cannot now beascertained from whom the lymph was taken with which thispatient had been vaccinated, but it occurred in the practiceof the medical man already referred to; and he took lymphboth from her arm and that of her sister, who had also beenvaccinated from the same source. The presumption is,therefore, that in this case, as in the others, secondarylymph had been used. The sister has since been in thecountry out of the way of small-pox.Thomas and George H-, aged respectively thirteen

and seven, had been vaccinated two months prior to admis-sion. The former, whose arm showed three good old cica-trices and a good recent one, had a very mild attack ofsmall-pox; while the latter, who had not been previously’vaccinated, but had two good recent marks, suffered from avery severe attack of a confluent character.

Charles R-, aged three years and a half, was vacci-nated " successfully," according to the opinion of the medi-cal man in attendance, two months previous to the present-attack. "One large" vesicle resulted. The rash was so

abundant that the cicatrix was not visible at the time ofadmission.While writing, in addition to the above, Frank G-, aged

twenty-five, has been admitted suffering from a smart at-tack of variola. This patient states that he was revacci-nated by the same medical man about March last, and that11 three out of the four places took welL" Only two smallrecent cicatrices can be distinguished, the variolous erup-tion perhaps obscuring the third; and there is one verylarge old cicatrix, the result of primary vaccination.These facts speak for themselves. It is true that in one

or two of the cases I have not had an opportunity of provingthat secondary lymph had actually been used. But whenit is considered that the same man vaccinated the series;that no single case of small-pox following a successful recentvaccination by any other medical man has been admittedinto this hospital during the present epidemic, and fur-ther, that in almost every case lymph was taken from thevesicles produced and known to be secondary,-I hold thatit is in the highest degree probable that the lymph used ineach case narrated was secondary and of the same kind;and that they may all therefore be taken as affording unim-peachable evidence that successful vaccination by secondarylymph does not protect from small-pox. Another equallrimportant conclusion can be drawn from the history cfthe first two families-namely, that successful vacoinatioo.by primary lymph does protect from small-pox.

It is worthy of remark that a number of these patients,who had been undoubtedly well vaccinated, were compara-tively young. In five of the cases the average age was 15’8years, the lowest being 13 and the highest 19; and each ofthese five bore decided evidence of successful primary vac.cination, the smallest number of good old cicatrices in anyone case being three, and the largest five. The protectiveinfluence of vaccination has thus worn out in a period ex-tending from thirteen to nineteen years. Of these fivecases only one is noted as

*’ severe," the others being" mild" attacks.In no case was the cicatrix following the secondary vac-

cination equal to that resulting from the primary. Insome it amounted to nothing more than a deep-red mark;and in others, where a cicatrix had been formed, it wassuperficial; but in all, the evidence of successful revac-cination was conclusive.

July. 1871.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

LONDON HOSPITAL.

FRACTURE OF OLECRANON IN BOTH ARMS; ONE TRICEPSWASTED AND PARALYSED, THE OTHER OF GOOD

STRENGTH; PARTIAL RUPTURE OFTENDO ACHILLIS.

(Under the care of Mr. HUTCHINSON.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborumet dissectionurn historias, tum aliorum, turn proprias collect as habere, etinter se comparare.-MORGAGNI De Sed. et CauB. Morb., lib. iv. Proœmium.

WM. B-, aged twenty-seven, was admitted on accountof suppurative inflammation of a subcutaneous bursa overthe right elbow following a fall on that part. There wasat first some doubt as to whether or not the abscess com-municated with the elbow-joint. The fluid was unmis-

takably synovial; but, as the movements of the elbow re-mained perfect and could be effected without pain, and theswelling was confined to the back of the joint, Mr. Hutchin-son concluded that the synovial fluid came only from a sub-cutaneous bursa. The case was interesting from the factthat the patient had fractured the olecranon process oneach side, and (as he stated) ruptured the tendon of hiscalf ; these accidents had all happened several years before.

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Ten years before admission he fractured the right olecranonby falling on his elbow from the rigging of a ship, a heightof about ten feet. He says that the

11 bones were separated"immediately after the accident. He went to a doctor andhad the arm put up in splints in a straight position. He

kept it so for three weeks and then took the splints off, nothaving seen the doctor again. Since that time he has hadno power to lift the arm straight into the air above hishead; the forearm falls into extreme flexion as soon asits centre of gravity gets to the proximal side of theelbow.The triceps of the right arm was found to be wasted and

quite flabby; when he tried to straighten the arm thatmuscle did not act in the least. The upper fragment of theolecranon was separated by at least an inch from the lowerone.

Five years later he fractured his left olecranon by a some-what similar accident, falling about four feet. He thoughtthat the bones were separated as widely in this instance asin the first accident. It was kept straight in splints for sixweeks, after which time he soon regained perfect use of thearm. The upper fragment was found to be movable onfirm pressure, but he had perfect use of his triceps, andthis muscle was apparently quite strong. The fracture ap-peared to have been oblique, and there was strong fibrousunion.He met with a third accident, in which he probably rup-

tured the tendo Achillis on the right side, about eighteenmonths ago. He jumped off a table, and on alighting feltas if something had struck his right calf. On examining ithe found a little " dent," into which he could put his finger.He could not walk by himself, but could limp along with help.He rested in bed for a fortnight, and had the leg bandaged,but no pains were taken to extend the foot. After thistreatment the 11 dent " had disappeared, and he found him-self able to walk as well as on admission. There was found, oncareful examination, a slight swelling at the junction of thelower and middle thirds of the calf, or perhaps ratherhigher than that point. On this swelling being pressed,the patient complained of pain. No such swelling could befelt in the opposite calf at the corresponding part.The right calf measured about half an inch less in cir- I

cumference than the left. The wasting was quite per-ceptible to the touch, and seemed to involve chiefly theinner part of the gastrocnemius, for when he put the calfmuscles into action it was that part which remained flabby,while apparently the soleus could be felt to act beneath it.Possibly the rupture had involved only the tendon of thegastrocnemius before its junction with the soleus. Thecalf of this leg was considerably weaker than that of theother, so that he could not stand on tip-toe on the corre-sponding foot. He always limped with the left foot.In commenting on this case, Mr. Hutchinson observed

that no cause was assignable for the occurrence of theseinjuries. The man appeared to be in robust health in everyrespect. He had never had fracture of other bones. Thecase illustrated the common result after fracture of theolecranon - non-union of the bone. In one instance theuniting medium was strong, close, and fibrous; in the otherit allowed of wide separation, the end of the bone beingpulled up behind the joint. No doubt this difference of re-sult was in large measure due to the too early use of theright limb, and to neglect of proper precautions in thetreatment. It was not, he thought, usually difficult to se-

cure close union after these fractures, although very diffi-cult to get actual bone. In the left arm, the close, fibrousunion had rendered the bone almost perfect as regards itsuses; the triceps had not atrophied, and the man could useit well. Probably the fracture was oblique, for in the ex-tended position the fragment became fixed, and no motioncould be detected.

It was also of interest to notice that absolute atrophy ofthe triceps on the right side by no means disabled the arm.In this respect the case was parallel to what happens afteratrophy of the quadriceps extensor of the thigh. The manasserted that he could use his arm well for everything thatdid not require him to lift it straight up in the extendedposition, and he followed a laborious occupation withoutdiscomfort. The reason why a muscle should atrophy inconsequence of non-union of the bone into which it is in-serted, was, Mr. Hutchinson observed, not quite obvious;but he had repeatedly noticed this result to follow badly-

united fractures of the patella, and sometimes very gooones. He had never before noticed it after ununited frac.ture of the olecranon.

WEST LONDON HOSPITAL.

ACUTE LARYNGITIS; TRACHEOTOMY; RECOVERY.

(Under the care of Dr. ROGERS.)FOR the notes of the two cases subjoined we are indebted

to Mr. Harrison, the house-surgeon.Although in the following case it was stated that one of

the patient’s children was liable to a rash on the nates whichcame and went, Dr. Rogers was of opinion that the laryngealaffection was not due to syphilitic poison; on the contrary,he attributed it to the fact of her being subject to greatand frequent atmospheric changes in the course of her

occupation as a laundress. He thinks that the laryngealmucous membrane was thickened, that a proportion of thethickening was due to a condition which had become per-manently established, and that the cartilages and mem-brane were quite free from specific ulceration. He there-fore discouraged the use of iodide of potassium, and confinedhis plan of treatment to careful attention to the conditionof the tube, and the administr tion of good food.The patient was a married woman, twenty-three years of

age, the mother of two healthy children. Her family ap-peared to be healthy. She had caught cold twelve monthssince, and attended for three months with aphonia at St.George’s Hospital. Her general health improved; but hervoice did not return. She continued at work until two daysbefore her admission, which occurred about 2 P.M. on the10th of June.On admission she was suffering from spasmodic dyspncea.

Her features were pale and drawn, and the face was coveredwith perspiration. She complained of pain and constric-tion over the larynx, and could only speak in a whisper.There was a husky, convulsive cough, with expectoration ofoffensive mucus. The pulse was 134 and weak ; the tonguefurred. She was ordered a grain of opium and one-sixthof a grain of tartarated antimony every four hours, andwarm flannels to the throat. In about half an hour shederived some relief from vomiting nearly two ounces ofmuco-purulent matter.Five hours after admission she was ordered an emetic of

sulphate of zinc; to be repeated if necessary. Two hourslater there was more dyspncea, with convulsive cough andinability to swallow ; the pulse 140, and very feeble. Aboutten hours after admission she was found to be in a semi-recumbent posture, with livid face and lips, anxious counte-nance, suffused eyes, and oedematous throat. On the tracheabeing opened, under chloroform, by Mr. Harrison, a largequantity of stringy and most offensive mucus was ejected.The relief was immediate, but for four hours there wasgreat difficulty in keeping the tube pervious, and the

breathing was carried on by jerks, which followed eachother at long intervals. At the end of this time it becametranquil. Though at first spasms occurred occasionally,and large quantities of the same offensive mucus pouredfrom the tube, the patient passed good nights, and steadilyimproved. The voice remained somewhat husky ; but onthe twenty-first day the wound had almost entirely closed,and the patient went into the country for change of air.

PERFORATING ULCER OF THE DUODENUM.

The following case may be advantageously compared withtwo cases recorded in these columns as occurring at St.George’s Hospital-the one in THE LANCET of Feb. 8th, theother in that of March 18th. The latter resembles the pre-sent case in the suddenness of the onset of gastric agonyafter comparatively mild premonitory symptoms; but allthree agree in the essential pathological features. It is nota little remarkable that each of the three patients wasseized with the disease at the age of fifty-six.

Dr. Rogers points out that the patient had not sufferedconstant pain for more than fourteen days, and that theamount of dyspepsia could have afforded no early indicationof the existence of ulceration. He suggests that in allsimilar cases, on the first appearance of coffee-groundejecta, or on the occurrence of great reluctance to takefood, it would be well to administer frequent nutrient