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previously. He was not struck but in his haste to get awayfrom the police he was knocked down in the rush andtrampled on. He was arrested as a gambler, conveyed to thepolice station, and as he complained of some abdominal pain9e was taken to hospital after a two hours’ journey from theNew Territory. He was a badly nourished narrow-chestedyouth, about 90 pounds in weight.On admission his temperature was normal ; the pulse was

MO and good. The abdomen was slightly tympanitic in frontand in the flanks; some gurgling was felt on pressure. The

patient was put to bed and spent a good night. Lead and

opium fomentations were applied to the abdomen. On the

’following morning his bowels were opened twice with an.enema. The temperature was 98’2°F., the pulse was 120and improved, and as he had not passed urine during themorning ten ounces were drawn off with a catheter. Theabdomen still remained tympanitic all over ; change of

,position made no difference.It was decided to watch the case. There was no shock ;

othe patient was chatting with his neighbours and would have-sat up in bed if allowed. Fomentations to the abdomen

were continued and the diet consisted of milk, beef-tea, andrrice-water. At 8 P.M. the temperature reached 100°, theabdomen was more distended, and the pulse was not im-proving, so it was decided to make an exploratory incisionas it was suspected that the spleen was ruptured. At 9 P. M.Dr. W. V. M. Koch kindly administered chloroform and withthe assistance of Mr. J. Bell the abdomen was opened with atwo-inch incision midway between the pubes and the um-’bilicus. A gush of blood followed the opening of the peri-toneum and distended coils of small intestine filled the wound.The incision was rapidly prolonged upwards to the left of theumbilicus and the spleen was examined. It was a large oneof the malarial type and a rupture was easily felt at theposterior border. The pedicle was ligatured with strong silk.and a spleen weighing 2 pounds 3 ounces was removed.The peritoneal cavity was quickly cleansed of blood, filledwith saline solution, and the abdominal wound was closed.An injection of 15 minims of strychnine was given hypo-dermically after the operation. The patient passed a good,night and appeared to be recovering from shock. Morphine,strychnine, and camphor were given hypodermically atintervals. The temperature was 970 and the pulse was 130.He felt inclined to vomit. At 9 30 P M. he vomited once,bringing up some brownish "coffee-ground" vomit. The

pulse was then 142 and thready and the temperature was100°. Nutrient enemata were given every six hours andIretained. Champagne only was given by the mouth.On Jan. 24th the temperature was normal and the pulse

was 120. The patient conversed with the Chinese ward boys.He vomited frequently during the night, "coffee ground

"

,vomit on each occasion. Towards evening he seemed to beimproving rapidly; he only vomited once during the day.He took a little milk by the mouth and retained it. Thenutrient enemata were partially returned. The vomit- examined microscopically showed altered blood corpuscles- and blood pigment. The patient, in spite of steady improve-ment during the day, gradually sank during the night and-died at 10.45 A.M. on the 25th.Necropsy.--Post-mortem examination showed that the

pedicle ligature had held well ; there was no sign of evencommencing peritonitis. The stomach was much distendedand full of brown fluid and its mucous membrane was- dotted with minute petechiæ, like flea-bites. The contents,of the stomach consisted of altered blood and gastricsecretion. The intestines and their contents were normal.All the other organs were healthy.Remarks by Mr. LAING.-My reason for recording this case

is that it is of interest from both a surgical and medico-legalpoint of view. Undoubtedly the patient’s death was due topersistent hæmatemesis following abdominal section. Suchcases are undoubtedly rare and a few have, I believe, beenrecorded, but I am not able just now to quote them in detail.Why petechial haemorrhage should begin after abdominalsection in an otherwise healthy stomach I am unable todetermine. No injury was done to that organ when re-

moving the spleen as it was easily displaced upwards for thepurpose. The patient recovered well from the shook of the- operation and it was naturally a disappointment to lose sucha case from such a caue.

That a man can live with little or no discomfort for 26’hours with a ruptured spleen is of considerable medico-legalinterest. Had the police not arrested the patient I daresaye would not have had any medical or surgical attention

whatever but would have bolted for his native village andhave died in due course. The rupture was one of threeinches long, just through the capsule, so that the hmmor-rhage was slow but sure. The accompanying tympanitesmade the diagnosis difficult even here where ruptured spleensare fairly common and have been removed successfully.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.

On the Yalue of a Comparative Examination of the Blood andUrine.-The Bacteriological Findings in a Case ofClimatic Bubo.-A Case of Bacillus Pyoeyaneus Pyæmiafollowing Ear Disease.A MEETING of this society was held on April 19tb, Dr.

E. KLEIN, Vice-President, being in the chair.Dr. A. E. WRIGHT read a paper on the Comparative

Examination of the Blood and Urine. He said thathis communication was to illustrate the practical use

of a method which he and Dr. J. Newport Kilcerhad recently described and published in THE LANCETfor estimating the amount of salt in the blood andthe amount of salt in the urine. He first describedthe method by which he estimated the quantity of saltin the blood and in the urine. He said that in judgingof the efficiency of the kidney there were two points to con-sider : (1) the capacity of the kidney to eliminate salt fromthe blood ; and (2) the capacity of the kidney to eliminatewater from the blood. He had found in a case of urticaria inwhich there was a considerable quantity of albumin in theurine that the excretory efficiency of the kidney for salt waspractically normal and at the same time he found that thecoagulation period of the blood was prolonged to five minutesand that the lime salts were diminished. He therefore con-cluded that the albumin in the urine was due to a serous

haemorrhage into the kidney and not to structural disease ofthe organ. He pointed out that a diminished quantity oflime salts in the blood produced a diminished coagulabilityand such a diminution of lime salts was brought about bythe introduction of soaps, sour alcohol, sour fruit, and goose.berries, and this accounted for the production of urticariaafter the ingestion of these articles. Dr. Wright mentionedthe case of a boy with physiological albuminuria in whomthe excretory quotient for salt was normal, and he statedthat in all cases of renal disease he had found the excretoryquotient of salt to be less than normal.

Mr. J. CANTLIE and Dr. R. T. HEWLETT described theBacteriological Findings in a case of Climatic Bubo. Mr.Cantlie said that the climatic bubo was probably a foimof plague or pestis minor. He had seen numerous cases in1893 and the disease usually appeared before plague andcontinued during and after that disease had stopped. Itattacked the white race in particular. It was a definitedisease which ran its course with fever in from three tofour weeks. The glands enlarged and had to be excised.They contained several foci of necrosis with but little pus.The disease could not be arrested by early Excision of theglands ; in fact, it was best to wait for two or threeweeks before excising them. - Mr. Cantlie distinguishedbetween pestis minor and pestis ambulans, for in the latterthe definite plague bacillus could be found. Mr. Cantlieand Dr. Hewlett then described the results of a bacterio-logical examination of the case of climatic bubo. The

patient, who had come from Kolar Goldfields, had a con-dition of the inguinal glands which was seen by several

acquainted with the disease who all agreed that it was oneof climatic bubo. A gland was excised and examined. Two

species of cocci were obtained (prcbably micrococcus pyo-genes albus and micrococcus cereus albus) and also a minutebacillus. This was somewhat like the plague bacillus butperhaps rather more pointed and about half the size. Itstained well by Gram’s method but indifferently with theordinary aniline dyes, with a tendency to polar staining. Itwab probably feebly motile and did not form spores. On

agar it formed an extremely delicate growth, resembling thatof the pneumococcus. It grew en gelatin very slowly,forming a white growth without liquefaction. On serum at37° C. the growth was much more luxuriant, forming colonieslike those of the diphtheria bacillus but whiter in colour.

1 THE LANCET, April 2nd, 1904, p. 921.

1124

Milk was curdled in three or four days. Glucose was feeblyattacked with the formation of a little acid and gas butlactose did not appear to be attacked. Broth became slightlyturbid but the major part of the growth sank to thebottom. The bacillus was without action on mice andguinea-pigs and was not agglutinated by the patient’s blood.Whether this bacillus had anything to do with the disease ornot must be left an open question. The chief interest inconnexion with it was that it agreed in its charactersvery closely with the description of a bacillus isolatedby Kitasato in plague.2-Dr. KLEIN said that he hoped onthe next occasion that Mr. Cantlie had an opportunity hewould examine the glands so as to show how the organismwas distributed within them. He said that there was con-siderable variation in the organism described by Kita-sato and it was difficult to conceive how two organismsso essentially different as the plague bacillus and theKitasato bacillus could be varieties of the plague bacillus.-Dr. W. J. R. SIMPSON said that he had met with a bacillussimilar to that described in certain cases and had not infre-quently seen the disease in Cape Town. In a cat infectedwith plague this bacillus was found and the man to whomthe cat belonged was also affected with plague but to a milddegree. Exactly the same organism was found in the glandsremoved. This form of bubo seemed always to occur sometime before the onset of true plague.-Dr. WRIGHT saidthat he did not think that this bacillus should be con-sidered as a variety of the plague bacillus. 1 here was butone plague bacillus. In the present case Mr. Cantlie andDr. Hewlett had described two forms of micrococcusand this small (Kitasato) bacillus, and it was not proved thatthe enlargement of the glands was due to this organism. Hedid not think that there was any evidence that pestis minorcould develop into plague.-Dr. W. D’E. EMERY said that anorganism having similar characters had been obtained fromacne and skin lesions and suggested that in the present caseit might have had a similar origin.

Dr. T. J. HORDER described a case of Bacillus PyocyaneusPyæmia following Ear Disease. The bacillus pyocyaneus mightbe pathogenic to man as the partial or sole cause of abscesses,as setting up a form of dysentery, or as (rarely) causing ageneral infection. The case recorded was one of these last.

The patient was a man sufferirg from otitis media of longduration. He was admitted to hospital for fever, severe head-ache, and delirium. Diarrhoea set in a week later. Therewere no signs of cerebral disease. Widal’s test was twice

negative and there was a leucocytosis of 32,000. Emaciationwas very marked. The fever was not high but was continuedin type. During the fifth week of the patient’s illness para-plegia appeared. Death occurred at the end of this week.At the post mor’em examination the brain and the membraneswere natural. Green pus was found in both middle ears, inseveral abscesses in the lungs, and in a large abscess of thespinal meninges. From this pus the bacillus pyocyaneus was

grown in pure culture, pathogenic to animals and giving theusual cultural reactions of this organism.-Dr, W. BULLOCHsaid that it was possible that the general infection might havetaken place after death from the point of infection in theears. He had frequently seen spastic paraplegia come on in Ithe course of bacillus pyocyaneus poisoning but he had noexplanation of the disease. It was extraordinary that thebacillus pyocyaneus was not more pathogenic to ma.n as itwas so markedly pathogenic to animals.-Mr. L. S. DUDGEONsaid that he had seen two cases of bacillus pyocyaneusinfecticn; in one of the cases he had been able to find the

organism in the blood during life.

LIVERPOOL MEDICAL INSTITUTION.

Carcinoma of the Œsophagus : Gastronomy.-Excision of theGasserian Ganglion.-The Technique of Aseptic Surgery.A MEETING of this society was held cn April 14tb, Dr.

JAMES BARR, the President, being in the chair.Dr. PHIl IP NELSON related a case of Carcinoma of the

Œsophagus which occured in a woman 50 years of age.Difficulty in swallowirg had only existed for three months’but had rapidly increased. Her voice was hoarse and therehad been several attacks of laryngeal spasm. Upon examiDa-tion there were found to be complete paralysis of the leftvocal cord and abductor paralysis of the right cord. An

Ce3ophageal bougie became arrested at a point opposite thecricoid cartilage. Gastrostomy was performed by Mr. F T.

2 See Twentieth Century Practice of Medicine, vol. xv., p. 331.

Paul in June of last year. The patient obtained marked relieffrom the operation and all went well until January of thisyear when she died. Subsequent examination showed thatthe growth had opened into the trachea and the right lungwas the seat of a large abscess.

Mr. DAMER HARRISSON related two cases in which he hadremoved the Gasserian Ganglion for Paroxysmal Neuralgia.The first case was that of a man, 45 years of age, who foryears had suffered from severe neuralgia corresponding tothe distribution of the inferior dental and infra-orbitalnerves. The inferior dental nerve was exposed in the bonycarial and a portion of it was excised ; the infra-orbital nervewas exposed and stretched. The operation was followed bycomplete relief of the symptoms. Some months later, how-ever, there was a return of the neuralgia and Mr. Harrisson,after reflecting the zygoma, exposed and tore through themiddle and inferior divisions of the fifth nerve. Pain wasrelieved for ten months but then returned again. Finallythe Gasserian ganglion was excised by Rose’s method. Thisoperation was performed seven and a half years ago andsince then there had been no return of the neuralgia. Inthe second case the neuralgia was confined to the distribu.tion of the inferior dental nerve which Mr. Harrissonexposed near the base of the skull and tore through.Marked temporary relief followed, but some months later,owing to a return of the neuralgia, the Gasserian ganglionwas excised by the same method as in the previous case.This operation was performed in 1896 and the patient hadbeen entirely free from pain ever since.

Mr. PAUL, in opening a discussion on the Technique ofAseptic Surgery, said that the recent changes in the treat-ment of wounds did not constitute a revolution like theintroduction of Listerism but they were unquestionably veryimportant and he thought that there were many advantages indiscussing the details of their practice. He first dealt withthe preparation of the skin of the patient and said that therewas a strong tendency amongst surgeons to leave this im-portant matter too much to the discretion of the nurses. Thehands of the surgeon were next considered. For his own parthe Employed the permanganate method and was well satisfiedwi h it. Except in septic cases he did not wear rubbergloves but his assistants did. For ligatures and buriedsutures he much preferred catgut, prepared according to amethod he described, to silk and for skin sutures he usedsilkworm gut. He did not hesitate to employ drainage inthe form of a glass tube or gauze if there was anyreason to expect an accumulation of serum in the wound.For dressings he preferred plain sterilised gauze andabsorbent wool. In conclusion, he said that while theintroducticn of Listerism had been the means of savingmany lives the introduction of the aseptic method hadbeen the means of saving much time in the more perfecthealing of wounds.-Sir Wn LIAM M. BANKS said that he hadfollowed the whole course of antiseptic surgery from 1865,when he had learnt its tenets from Professor Lister, until to-day and had practised it in every phase of its development.More and more it was resolving itself into simple but

thorough surgical cleanliness. He deprecated the lavish

expenditm e upon modern operating theatres and said that hefound his operations done in private just as successful asthose done in the most elaborately built hospital theatres.He boiled everything that came in contact with the woundand for this reason preferred silk to catgut as a ligature. As-to skin cleansing, if the skin was well shaved a goodscrubbing with any mild antiseptic was all that was

necessary. He had a strong opinion that aseptic surgerywould soon resolve itself into belling everything that couldbe boiled and sbaving everything that could be shaved.-Mr.W. THELWALL THOMAS thought the term aseptic when usedas opposed to antiseptic unfortunate ; there was no suchthing as aseptic surgery in the strict sense of the term forevery surgeon used chemical antiseptics for the skin.He was convinced that the deeper parts of the skin werenever rendered sterile and was an ardent advocate for the-wearing of rubber gloves by the surgeon and his assistants.He considered the question of aerial infection to be a negli-gible quantity in private practice but in hospital theatres,where septic and clean cases were operated upon, it was amatter for serious consideration, and he strongly approvedof the principle of special theatres and wards for septiccases.-Mr. G. P. NEWBOLT compared the results of 126 con.secutive cases of hernia operated upon without and withrubber gloves, the conditions otherwise being the same. Inthe first series 1 case in 5 suppurated. In the second’