422

the process of immunisation points to more general changesthan a mere change of habit of the phagocyte alone.4. That changes occur in all the tissues has been shown byEmmerich, who succeeded in protecting animals by inocu-lating them with the tissue juices of such as had been im-mumsed. 5. Some of the methods of immunisation, as theinjection of so-called antitoxine, or of small repeated dosesof poison, &c., point strongly to general changes in the body,the phagocytes being altered with the rest of the body.6. Lastly, phagocytosis does by no means explain many ofthe phenomena mentioned in the first part of the discourse.

MEDICAL SOCIETY OF LONDON.

On the Cure or Subsidence of Ascites due to Hepatic Disease,—Hæmatemesis, with Special Reference to that Form medwith in Females in Early Adult Life.AN ordinary meeting of this Society was held on Feb. 15th,

the President, Dr. Douglas Powell, in the chair.Dr. J. S. BRISTOWE read- a paper on the Cure or Sub.

sidence of Ascites due to Hepatic Disease. He took as hiatext four cases which were under observation up to thepresent time. 1. A governess, aged forty-four, who cameto St. Thomas’s Hospital in the summer of 1886. She wasdepressed and lacrymose, and suffered from delirium andhallucinations. She had jaundice, ascites, oedema of thelegs, and diarrhoea ; also suffering from bronchitis and anattack of poly-arthritis during her stay of nine months anda half. There was no albuminuria and no enlargementof veins. Five, thirty two, and thirty-four pints of fluidwere removed by paracentesis abdominis on three severaloccasions, and she left greatly improved on May 24th, 1887.She was again admitted on Aug. 29th, 1889. Her com-plexion was sallow, she still had bronchitis, and eighteenand twenty pints of fluid were removed from theabdomen. She left on Jan. l2th, 1890, and has con-

tinued well since except for the bronchitis. Shewas seen last week. The case was a typical one

of chronic alcoholism, as was borne out by themental condition, and an attack of peripheral neuritison the second occasion, and it may be accepted that theascites was due to cirrhosis of the liver which still existed,and was liable to induce a recurrence of the ascites. 2. Agentleman aged thirty-five who had fallen into intemperateand immoral habits in 1878. He was lost sight of tillOct, 8bh, 1882; he was then weak and thin, suffered fromsickness, and for three weeks had had oedema of the feetand ascites. On Nov. 20th he was worse, was irritable andrambling, and had in addition some fluid in the left pleura.On Nov. 22nd he was admitted to Sb. Thomas’s Home, withjaundice and dyspnœa, the left pleural and the peritonealcavities being full of fluid. A month later he was improvedin all respects. Three pints of fluid had been removed fromthe pleura, and he left on Jan. 24th, 1883, for New Zealand,where he has remained in fairly good health. Here, a.gain,was a very clear alcoholic history; and though the ascitesgot well without tapping, there could be no doubt, from thefact of the development of this form of dropsy and ofjaundice, that his liver was at that time affected withearly cirrhosis. 3. A man in good circumstances, aged forty,who kept an eating-house. He was known to drink manyglasses of spirits daily, and was seen in consultation onOct. 24th, 1888. His complexion for some time had beensallow, and for six weeks there had been enlargement of theabdomen and oedema of the legs. In addition the liver wasenlarged and there was jaundice. He was enjoined to ab-stain from alcohol, to take a tonic and a pill of mercurydigitalis and squill. He was tapped five times; nine,thirteen and a half, nineteen and a half, nineteen, andfifteen pints being removed. On Dec. 28th the liver wassmaller, and he had gained flesh ; four tappings were per-formed since, the quantity of fluid removed being eight tosixteen pints, the last occasion being in August, 1889. Afterthat he went to Vichy, and on his return took cold and waslaid up with bronchitis and pleurisy. He was tapped againon Feb. 5th and March 3rd, and twice since, and has beentaking 1-16th of a grain of iodine off and on. On Feb. 8tb,1892, he was in excellent health and spirits, and carried onhis business with his old energy, going to market three timesa week, but he continued to take gin-and-water. In thiscase paracentesis was performed fourteen times in the

course of a year and ten months, the alcoholic his.tory was indisputable, and that the ascites dependedupon the hepatic disease is shown both by theenlargement of the liver and the temporary jaundice.4. A lady, aged twenty-four, belonging to a respectableand wealthy family, with small and delicate physique, andusually enjoying good health, was seen April 30th, 1890.At the end of the preceding year she had a sudden andprofuse attack of hsematemesis while abroad ; there was a.recurrence on arriving at a seaport in England, andsince reaching home there had been two more, the last on.the dav preceding the consultation. Latterly there hadbeen pain and uneasiness after focd, with loss of appetite.She was ansemic and weak, acd was treated for the ensuingtwelve days as a case of simple ulcer of the stomach, withgreat improvement. The abdomen then filled rapidly inthree days. Eleven pints were removed on May 15th,and by the 28th paracentesis had been performed threetimes, nine pints being withdrawn on each occasion. The1L ver was now found to be enlarged. The general healthhad improved, and the gastric symptoms had disappeared.After another tapping a small nodule could be felt, and theidea of cancer was entertained. In June she was tapped fourtimes, the quantity removed being from four to fifteen pints.Itwas then found out that a brother had been under treatmentfor a congenital syphilitic affection of the eye. This led to!the diagnosis of syphilis, and iodide of potassium was pre. ,

scribed in - ten-grain doses. Later the quantity was in.creased and mercury was added. In August she was tappedfour times, and in September thrice, the quantity being fromfour to seven pints. Altogether paracentesis was per.formed twenty-seven time?, the last occasion being Sept.22nd, 1890. She was now better than she had been foryears. The causes of obstruction were threefcld : 1. Truecirrhosis affecting the small vessels and capillaries. 2. Cancerous and syphilitic growths occupying the transversefissure compressing or involving the portal trunk, andocclusion by thrombi. 3. Obstructive disease of the heartor lungs causing " nutmeg " liver. The first three cases be-longed to the first and the fourth to the second class, With reagard to the mode of recovery in these cases, it was, in the firstplace, amply proved that there is a fairly free communicationbetween the portal vein and the systemic veins, and hencewhen portal obstruction exists there is a tendency for theblood of the portal circulation to be shunted into some ofthese other veins which gradually dilate, so that withoutany beneficial change in the liver itself the ascites may dis-appear. The oesophagus, as shown by Drs. Wilson andRadcliff, has a ring of veins which is largely concerned inthe process, and the consequent varicose condition of thesubmucous veins in this pare and their tendency to ruptureare the source of the profuse haemoptysis and melæria in thelate stages, though the vessels of the stomach and duodenumare the ones affected ab first. Sometimes, however, ther&is no evidence that the anastomosing veins have dilated,and on this supposition alone recurrence of ascites after re-newal of bad habits would be inexplicable. Moreover, in thecase of a chronic inflammatory process dependent on anirritant locally applied, cessation of the influence would belikely to be followed not only by arrest of the disease, butalso by some amelioration in so much of it as had recentlyoccurred and was amenable to treatment. In the nrft threecases there was jaundice, which implied a wider orprofounderchange than that producing ascites, and which subsided.Again, as in Case 4, there are causes of obstruction whichare removable. The tfficacy of treatment depends largelyon the accuracy of diagnosis. Doubtless there ale manycases of visceral syphilis which are misinterpreted to thedetriment of the patient. A simple and fairly successfultreatment is to promote the general health by suitable dietand tonice, to cut off alcohol, to tap from time to time with-out waiting for extreme distension, and to regulate thebowels. Bearing in mind the tendency to spontaneousdiarrhoea,, purgative measures were not to be recommended,and diaphoretics were of little use ; more was to be hopedfor fromdiuretics, especially copaiba in teo-graindosesandthepill of mercury, digitalis, and fquill. There was no objec.tion to the use of mercury and iofiide of potassium in the earlystages.—The PRESIDENT, referring to cedema of the legs, saidbe should be inclined to attribute it rather to the general con-dition of the heart and circulation, and he thought that restand deprivation of alcohol was to some extent answerable forthe improvement that took place under treatment, apartfrom local considerations.-Dr. HAVILAND HALL suggested

423

that repeated tapping was liable to produce peritonitis andadhesions, thus introducing fresh areas for absorptionand collateral circulation, and cited an illustrativecase. He referred to some of the drugs recommendedfor cirrhosis. - Dr. HADDEN mentioned a necropsyrecently made on a man who fourteen years before hadbeen a patient with cirrhosis hepatis and ascites underDr. Murchison, and was tapped. The cirrhosis was wellmarked, but there was no ascites, and death was due to othercauses.-Mr. MARMADUKE SHEILD, referring to paracen-tesis, said that great care was needed to ensure absolutecleanliness of the instruments, and that the fluid should beevacuated slowly through a fine trochar. He thought thevery rapid dropsy in the fourth case suggested thrombosis.The presence of retinitis or choroiditis afforded the best indi-cation of congenital syphilis.-Sir HUGH BEEVOR mentioneda case in which great cedemaof the legs occurred in an alcoholicsubject, there being nothing to explain it. In another caseof cirrhosis the gradual dilatation of veins on the rightaide of the abdomen was obvious to the sight.-Dr. SIDNEYPHILLIPS mentioned a case not syphilitic, which cleared upunder iodide of potassium, and he thought this a good drug togive in cirrhosis hepatis, in doses up to forty grains, threetimes a day.-Dr. PASTEUR, referring to the ascites ofyoung children, said that many of them were doubtlessdue to tubercle, and cleared up.-Dr. BRISTOWE, in reply,said he regarded oedema of the legs as due to the collectionof fluid in the pelvis and pressure on veins there. Hementioned other cases similar to those quoted, but of whichthe notes were less complete. He thought the examinationof the eyes was of great value in recognising syphilis, butsaid that the signs were so slight as to have been overlookedby skilled observers. In young children tubercle, alcoholiccirrhosis, and’congenital syphilis had to be considered in theproduction of ascites.

Dr. DONALD HOOD read a paper on the Haematemesis ofEarly Adult Life in Females. The author wished to drawattention to the clinical phenomena accompanying thisform of haemorrhage, stating that from his own experienceof the symptom he would feel inclined, in a large majorityof instances, to look upon it as but denoting a state ofpassive congestion, or stasis in the vessels of the stomach,and as being directly due t) the anæmic condition so

generally found accompanying this form of haemorrhage,and noo necessarily the result of ulceration. His personalexperience is confined to about forty cases, and as supple-mental to these he brought before the Society 155 casescollected for him by Dr. Goodall, late Medical Registrarto Guy’s Hospital, from the clinical and pathologicalrecords of that hospital during a period of twenty years.It was noted that during that period no case is recordedat Gay’s Hospital of a young girl succumbing to all

attack of hsematemesis due to gastric ulcer. Duringthe same period of twenty years sixteen patients wereadmitted suffering from a fatal peritonitis, the resultof a perforating ulcer. Eight were men and eightwere women. Ulcer of the stomach, regarded as

causal in producing fatal ’peritonitis, is equally fatal toboth sexes, and at much the same time of life. Itwas asked why it should not be equally causal withregard t) haemorrhage ; clinically severe haemorrhage,excepting as the result of incipient cirrhosis, beingmarkedly rare among males in early life. In dis-cussing the etiology of heamatemesis, cases would appearto fall into one of three fairly well-defined groups-the period of early adult life, largely composed of anaemicgirls, and comprising the cases referred to by the author ;the period of middle life, in which the haemorrhage is

usually due to cirrhosis or ulceration, haemorrhage fromcirrhosis being much more frequent among the female sexthan is supposed to be the case; and, lastly, the period ofadvanced life, in which malignant disease and ulceration areabout equally met with. In the course of the communicationreference was made to two cases published by the lateDr. Murchison, in which a minute pore-like orifice wasfound leading into a bloodvessel. In both of these re-peated attacks of haematemesis occurred before death.Haematemesis is so frequently found accompanying theanæmia of girl life that it would appear to be one of the Iresults of that profound blood change, and when the gastricsymptoms of anaemia are compared carefully with those dueto ulceration of the stomach, a marked difference willusually be found to exist, the stomach symptoms of anaemiabeing generally of less intensity. The author considered

the matter as one of importance, having special regard totreatment, for he maintained that in a very large majorityof cases of hæmatemesis occurring in early adult female lifeand complicated with ansemia, a treatment based on salineaperients combined with iron will give better results thanone which would be urgently demanded if an ulcer ofthe stomach were the source of hæmorrhage.—Dr.HABERSHON acknowledged that these cases did notaff,)rd proofs by post - mortem examination, and re-

ferred to the long experience of Dr. Brinton andof the late Dr. Habershon, which left the impressinnin their minds that actual ulceration did occur, though itwas often no doubb superficial. In many cases the hæmate-mesis appeared to occur at what would be the menstrualperiod in girls suffering from ansemia and amenorrhœa.—Dr. SIDNEY PHILLIPS pointed out that the two main pointswere (1) the occurrence of gastric ulcer without hæmate-mesis, and (2) (?) the occurrence of haematemesis withoutgastric ulcer. He mentioned cases in men and women inwhom sudden hæmatemesis had caused death, and nolesion had been discovered post mortem. Some cases ofhæmatemesis were associated with violent pulsation ofthe aorta, pain and vomiting, and hypochondriasis.-ThePRESIDENT alluded to cases which had proved fatal and inwhich no lesion had been discovered post mortem. He re-ferred to a specimen in the Middlesex Hospital museum inwhich a minute aneurysm had ruptured, and suggested thisas a possible cause. He noticed that patients usually gotwell rapidly after the occurrence of haemorrhage, possiblythrough the clot affording some protection to the site.-Dr. HooD, in reply, mentioned two patients in whom therehad been no haematemesis, but in whom a large number ofhealed ulcers were found in the stomach after death. Heremarked on the wonderful rapidity of recovery afterhaemorrhage. His plan of treatment was to give nothingby the mouth for two days, then small doses of opium,feeding by enemata.

CLINICAL SOCIETY OF LONDON.

Perforation of the Vermiform Appendix.-AeuteAppendicitis.—Relapsing Appendicitis.

AN ordinary meeting of the Society was held on Friday,Feb. 12tib, the President, Sir DyceDuckworth, in the chair.

Dr. D. B. LEES read notes ot four cases of Perforation ofthe Vermiform Appendix. Case 1 : A man aged twenty-seven was admitted into Sh. Mary’s Hospital on Oct. 17th,1890, with a history of having caught cold on the 15th, fol-lowed the next morning by pain in the right iliac fo3sa,which came on gradually. The bowels had been regular,but he had vomited. There was moderate distension of theabdomen, with some tenderness over the appendix. Hediagnosed a lesion of the appendix, but in view of the mild-ness of the symptoms did not deem it necessary to inteifere.In twenty-four hours, however, the man was in a hopelesscondition. At 9 P.M. he bEgm to vomit, the matter beingat first dark green and then black, and he died six hourslater—less than four days from the onset of the attack.Post mortem the appendix was seen to be perforated at thetip, and contained concretions. A section of one of thelarger concretions showed a white nucleus enveloped inwhite stratified layers. It was evident that the concretionshad formed within the appendix and had been there bornetime previously to the illness. Case 2 : A lad aged seven-teen was admitted on Nov. 22nd, 1890 He had beenseized with a sadden sharp pain in the right iliac region onthe 20t)h. It grew worse, and he vomited. The abdomenwas moderately distended, tympanitic all over, and tenderon pressure. No lump could be felt. Dr. Lees called inMr. Page, and some hours later the appendix was cutdown upon and found to be perforated, outside which aconcretion was seen. There was some local peritonitis. Aligature was placed round the appendix, and the distal partremoved. There was a direct communication between thepeIforated appendix and the peritoneal cavity. He madea perfect recovery. Case 3: A man aged twenty wasadmitted on Jan. 3rd, 1892, Early on that day he hadbeen seized with an acute pain, at first referred to theumbilicus, but ultimately settling down in the region ofthe vermiform appendix. Vomiting began two days later,and the bowels were so loose that he was sent into thehospital with a diagnosis of typhoid fever. He was