1042 HOSPITAL MEDICINE AND SURGERY. -MEDICAL SOCIETY OF LONDON.

Vater. As is well known, the common bile-duct usuallyjoins the pancreatic duct (duct of Wirsung) a short distancefrom the duodenum, and the two channels form a slightlydilated ampulla before opening on the surface of the secondportion of the duodenum. This orifice, Hyrtl states,is narrower than the lumen of the gall-duct at anypoint, or is at least less distensible, so that gall-stonesoften remain impacted at this point.The conditions necessary for the production of acute

hasmorrhagic pancreatitis by a calculus are set forth byHalsted as follows. 1. In order that bile may be retrojectedinto the pancreatic duct the stone must be (a) too small toocclude the pancreatic duct or to interfere with the force ofthe jet and at the same time (b) too large to pass the

ampulla. 2. One calculus would be more likely to cause thepancreatitis than several, for other stones in the duct, unlessvery small, would weaken the force of the bile-spurt whichdrives the ball-valve against the papillary orifice. 3. The

gall-bladder must be normal or nearly so-not thickened,shrunken, or weakened by inflammation. Thus a smallcalculus in the ampulla of Vater converts the two ductsinto a continuous channel, while a large stone mightsimultaneously obstruct the duodenal orifice of the diver-ticulum and the orifices of the ducts which enter it,thus damming back bile and pancreatic juice upon theirrespective glands. Opie, who performed the necropsy onHalsted’s case, made the following experiments on dogs : infive instances the duodenum was opened and the duct wasinjected with bile, varying from 2’5 to five cubic centimetres.In two other cases the duct was opened, injected with bile,and ligated. In all hsemorrhagic pancreatitis and fatnecrosis were produced and verified by examination postmortem. If the theory set forth above is correct, and it

certainly seems probable from Opie’s experiments, theobvious treatment is to cut down on the duodenum andto remove the calculus from the ampulla of Vater. In thecase I have described no calculus was found, but it must

always be so exceedingly small that unless special pre-cautions are taken it may very readily be overlooked orwashed away. I am indebted to Mr. Allingham for per-mission to record the case.

SCARBOROUGH HOSPITAL.A CASE OF ACUTE HÆMORRHAGIC PANCREATITIS.

(Under the care of Dr. G. B. HUNT. )For the notes of the case we are indebted to Dr. C. H.

Brodribb.A man, aged 51 years, had been quite well until the

morning of August 15th, when shortly after eating hisbreakfast he went to his work feeling ’’ unwell" ; soon hebecame worse, with severe abdominal pain and vomiting, andwas taken home. A medical man was sent for, who saw himfor the first time at 3 P.m. and again at 8 P.M., when findingthat the vomiting was more frequent, that the patient wasbecoming collapsed, and that there was some slight dulnessin the left flank he asked another practitioner to see him. A

suggestion of perforated duodenal ulcer was made and theman was advised to go into hospital. His bowels had been

opened during the afternoon. The previous history was good,the patient never having had any illness that he knew of.The patient was admitted into the Scarborough Hospital

about 10 P.m. The temperature was 960 F., with a clammyskin and small, feeble, regular pulse of 88. He was quiteconscious ; indeed, he was very bright mentally consideringhis collapsed condition. He was vomiting ill-smelling bile-stained fluid and complaining of pain in his abdomen,chiefly in the umbilical region. Examination of the abdo-men showed it to move well with respiration and to beregular in contour. There was but little tenderness and no

rigidity, tumour, or enlargement of any organ could be madeout. Percussion showed dulness in both flanks which wasmoveable with position. There was no tympanites or dis-placement of liver dulness. A catheter passed beforeadmission drew off normal urine. He was watched for some50 minutes, when the dulness in the flanks becomingobviously increased and his pulse smaller-at 95-Dr.Brodribb telephoned his condition to Dr. Hunt who, afterseeing him, suggested an acute pancreatitis.An operation was at once performed, the abdomen being

opened in the middle line from the ensiform cartilage to the2 Handbuch der Topographischen Anatomie, Vienna, 1882.

umbilicus. A very large quantity of deeply brown-stainedfluid at once escaped. The omentum was examined and wasfound to show particles of necrosed fat all over it ; also theappendices epiploicse were found to be necrosed. A largehard mass could be felt in the region of the pancreas. The

stomach, duodenum, and other organs were apparentlynormal. The patient’s condition being bad the abdomenwas rapidly washed out with hot normal saline solution andsewn up. He was put back to bed very collapsed and livedabout three hours.

Neeropsy.-The post-mortem examination was confined tothe abdomen. The fat throughout the abdomen showednecrosis in patches, also small patches were found on theparietal peritoneum. These patches varied in size from thatof a pin’s head to that of a thumbnail and were firm andof a glistening, dark greyish colour. The pancreas wasmuch enlarged, the head being as much as two and halfinches thick and dark red from the extravasated blood. Thehead was the part chiefly affected, the process becoming lesssevere towards the tail which at the tip was of its naturalcolour. There was no peritonitis. The spleen, liver,duodenum, and other organs seemed to be normal.Remarks by Dr. BRODRms.-The extreme rapidity of the

onset and collapse, the rapid increase of dulness in theflanks with the absence of tympanites, signs of peritonitis,or localising symptoms seemed to me to be inconsistent withthe diagnosis of any one of the more common acuteabdominal conditions calling for laparotomy, while on open-ing the abdomen the condition of the omentum at once

pointed to pancreatic disease, which was confirmed by feel-ing the swollen pancreas. The great quantity of brown-stained fluid effused was very striking. I find in some

cases previously recorded in THE LANCET that the colour ofthe fluid is said to be due to bile. I thought when I saw itthat it was due to blood in which the pigment was changedto methaemoglobin, but unfortunately I was unable to test it.The pancreas and omentum were preserved by the formalinand glycerine method, which, it is interesting to note, turnedall the patches of fat necrosis coal black. I have to thankDr. Hunt for his kind permission to publish the case.

Medical Societies.MEDICAL SOCIETY OF LONDON.

General Meeting.-Presidential Address.A MEETING of this society was held on Oct. 14th, the

chair being occupied at first by Mr. J. H. MORGAN and

subsequently by Dr. W. H. ALLCHIN, the outgoing andincoming presidents respectively.At the general meeting of the society which immediately

preceded the ordinary meeting the Treasurer’s report andbalance-sheet were presented and adopted.-A vote of thanksto the Treasurer, to the retiring President, and to theSecretaries was proposed, and Mr. J. H. MORGAN and theretiring Secretary, Mr. F. C. WALLIS, replied.The incoming President, Dr. W. H. ALLCHIN, then took

the chair, and after some preliminary remarks on the pastand future work of the society, read the Presidential Addresson the Responsibility of the Organism in Disease. He saidthat among the widest spread inclinations of the human mind,however uncultivated or unlearned, was the desire toascertain the cause of such phenomena as came underobservation. That this was the case in respect to disease,so far as the laity were concerned, was well knownto most of them, and their patients were generally fullysatisfied by ascribing the malady to I I a chill" or in find-ing some ancestor supposed to have been similarly affected.This subject was chosen, for there were indications thatin the far-reaching and all-important extension of their

knowledge by the discovery of the part played by microbesin the production of morbid states the personal factorwas running the risk of being somewhat lost sight of.The President then dealt with the present conception ofthe nature of life, and he pointed out how the earliestrecorded Hippocratic teaching was strangely similar to thatof the present day. In considering the environment he saidthat although the main purpose of his remarks dealt withthe share taken by the individual in the causation andmanifestation of disease, yet it was necessary to say a few

1043PATHOLOGICAL SOCIETY OF LONDON.

words upon the external conditions to which every livingbeing was subject. For the present purpose the environmentfactors might be grouped as follows. 1. Violent contact,

represented by blows, injuries, and laceration of internalstructures by foreign bodies, such as calculi and the like.2. Another group of external conditions was representedby such natural agents as heat, light, electricity, and asbarometric pressure and gravity, and such subsidiary con-ditions as relative humidity or dryness of the atmosphere.3. The third set of conditions were those which producedtheir effects in virtue of the chemical changes which theyset up, and these included modifications of the ingesta andperversion of the alterations which they might undergo in theprocess of digestion and absorption-in fact the whole classof substances denominated poisons. As causes of diseasethese bodies were well known, and the recent developmentof bacteriology and a knowledge of the toxins elaborated bymicro-organisms had widely extended their acquaintancewith the agents of this group. Very striking as showing thevariable composition and constitution of bioplasm were theeffects of poisons, some of which were quite innocuous tosome cells whilst violently toxic to others. In attempting tocomprehend, therefore, the effects of external agencies, how-ever simple or however complicated they might be, they hadalso to reckon with the responsive capacity of the livingorganism. How was it, for instance, that the exposure tocold and wet would in several persons under similar circum-stances bring about very different forms of disease ? Whilstone developed acute nephritis another was attacked withacute pneumonia ; another had a rheumatic attack, andthe fourth might not suffer at all. Great and importantas was the discovery of the microbic cause of tuber-culosis it would be long before those who had had anyextensive experience of the ravages of that disease wouldadmit that the bacillus tuberculosis was the only thingto be kept in view either in the causation, the prevention, orthe treatment of the malady ; and at the present day, withthe vast impetus that had been given to the investigation ofexternal conditions by the discovery of the bacterial originof many diseases, there was a fear that the pendulumwould swing too far in that direction with the result that toolittle attention would be paid to the individual and the sharehe took in the origination of the disease, or what was moreimportant the part he should be made to play whether in theprevention of disease or in the treatment of it when existent.If now they turned to consider what bodily states wereto be regarded as heritable they would find that thenumber was very considerably less than was formerlysupposed and that the transmissibility even in those caseswhich were accepted was not so potent as was thought.In other words, it was less the disease itself than a pre-disposition or tendency towards it, often requiring for thedevelopment of the malady a suitable conjunction of externalconditions, in the absence of which the individual escaped,though this could not always be so, for the tendency mightbe so strong as to assert itself in spite of the most favourableenvironment. Prominent among those conditions whichtended to recur in successive generations were longevity andthe reverse. States which insensibly departed from thehealthy type, reaching to a degree in which the well-being wasinterfered with, were represented by an undue formation offat, obesity, or an exceptional leanness, and such stateswere notoriously prone to characterise the members offamilies over many generations. A third group comprisedsuch essentially nutritive disturbances as gout and diabetes.Possibly even the more marked illustrations of diseases

appearing in the offspring similar to those from which theparents suffered were to be found among nervous maladies.As further illustrating the responsibility of the organismitself in the occurrence and manifestation of disease might bementioned the undoubted influences exerted by age and sex.It was much to be desired that that society should prosecutesome collective inquiry into the incidence of disease insuccessive generations. But in endeavouring to form someestimate of the share taken by the individual in the deter-mination and manifestation of disease they were dealingwith a subject that was essentially practical in all its bear-ings, however speculative might be the basis which sub-tended the application. The correct estimation of the valueof the facts ascertained when inquiring into the family historyand life-history of patients depended upon some knowledge ofthe workings of the organism in response to external stimuli,and of such inherent qualities and capabilities as the patientmight possess. Whilst it might seem but little toward the

framing of a diagnosis in the use of that term which wasrestricted to the mere naming of the disease, in a wider senseof comprehending the real nature of the case it was all

important, and underlying as it did prognosis, the estimateof the individual resistance to the disease and furnishingtherein the only rational plan of treatment, its study couldnot be too sedulously cultivated. He would claim, therefore,that he had not, after all, wandered far afield from theirlegitimate occupation and whilst dulec est desipere in loco heventured to hope that his dissipation in generalities had notbeen out of place.A vote of thanks, proposed by Dr. MITCHELL BRUCE and

seconded by Mr. EDMUND OWEN, was accorded to thePresident for his address.

PATHOLOGICAL SOCIETY OF LONDON.

Sylvian Anclt’l’J/sm.-llae7n01’’I’hagic M.1fositis in L’ntcrie Fever.- Plenro- (J;,’sophageal FistlÛa.-Intperforate Pharynx.-General Dilatation of the Aorta .7vit7b Dissecting andSacculated Ane1trysms. -Hydatid o,f t7ae {tall-bladder.-Exhibition of Specirnens.A MEETING of this society was held on Oct. 15th, Mr.

W. WATSON CHEYNE, the President, being in the chair.Dr. WAKELIK BARRATT and Dr. RICHARD M. RALPH

exhibited a Right Sylvian Aneurysm lying upon the island ofReil and situated on the main trunk opposite the origin ofthe ascending parietal branch, the lumen of which wasnarrowed. The aneurysm, which was of the size of a pea,was met with in a female patient, aged 38 years. Left-sided weakness was noted during life, but no cortical

softening was present, nor did the aneurysm rupture, deathoccurring from an intercurrent condition. No cause couldbe assigned for the aneurysm, the arteries at the base of thebrain being elsewhere healthy. Endocarditis was absent andno evidence of syphilis was obtainable.

Dr. F. W. ANDREwES described a case of Muscular

Haemorrhage in Typhoid Fever dependent upon secondaryinfection with streptococcus pyogenes. The patient was aman, aged 18 years, admitted to hospital during the thirdweek of a severe and typical attack of typhoid fever. Hehad chronic double otitis media. He died during a relapseon the fifty-second day of his illness. Two days beforedeath there was pain in the left thigh, followed by a con-siderable swelling, suggesting deeply-seated fluid. Thelesions found post mortem were those characteristic of

typhoid fever. There was no endocarditis, and the vessels,including those of the affected limb, were natural. The

swelling in the left thigh was due to diffuse extravasation ofblood into the substance of the quadriceps extensor cruris,especially the vastus externus. There was no ruptureof the muscular fibres. No other muscles were foundaffected. The affected muscle showed a moderate

degree of Zenker’s waxy, or hyaline, degeneration, with

profuse extravasation of blood. It contained enormous

numbers of streptococci and no other organisms. Strepto-coccus pyogenes was isolated from it in pure culture, andthe same organism was found in the heart’s blood and spleen,mingled with other bacteria. There was, therefore, goodreason to believe that the haemorrhage was associated withthis secondary infection rather than with the primary typhoidfever. The affected muscle was exhibited, together with ateased preparation and microscopic sections showing thedistribution of the streptococci and the characters of thedegenerative changes in the muscle-fibres. Whether or notthe lesion was a true myositis was open to discussion,though this was probably the case. Zenker, Trousseau, andothers regarded such cases, which seemed to have beencommoner then than now, as due to rupture of the muscledue to a primary waxy degeneration, which Zenker showedto be common in typhoid fever apart from muscular haemor-rhage. More recently it had been held by Arnold, Weihl,and others that waxy degeneration was more often a sequelthan a cause of rupture and hoemorrhage, and this seemed tobe the more reasonable explanation in the present case, inwhich the haemorrhage was evidently septicsemic in character.- Dr. W. CAYLEY said that the present case supported theview that the haemorrhage was due to streptococcic infectionand not directly to the typhoid bacillus. He had seen morecases of haemorrhage into muscles in typhus fever than intyphoid fever. He did not consider that waxy degenerationof the muscle was peculiar to typhoid fever, for it was often

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