1195MEDICAL SOCIETY OF LONDON.

peritonitis rapidly supervened and the patient died onNov. 10th. At the post-mortem examination it was foundthat there was well-marked general septic peritonitis. The

appendix was in a sloughing condition, lying deeply over thepelvic brim, with no pus in its immediate neighbourhood.There was some blood-clot in the right lumbar region of theperitoneal cavity which appeared to have come from a per-forated ulcer on the anterior surface of the second part ofthe duodenum. Some blood-clot was also present in theduodenum. There was no other ulceration in the duodenum,stomach, or intestines. There had been no history of

previous gastric trouble.In the case at the Royal Halifax Infirmary and in

the first of the two cases at the Leicester Infirmary thepatients were young women, whereas duodenal ulcer ismore frequently met with in men. In both cases there was a

septic condition in the peritoneal cavity which appeared tobe doing well when the fatal complication occurred, and inboth the duodenal perforation was situated in exactly thesame position. In neither case was the perforation diagnosed,extension from the original seat of trouble being suspected,although in the first case it might have been ; the cause ofthe haemorrhage from the wound, however, was by no meansobvious.

In Case 2 at the Leicester Infirmary it is difficult toconnect the renal trouble for which this patient was firstadmitted in any way with the peritonitis causing his death.Was it possible that the abdominal mischief was due to anacute appendicitis, the ulceration in the duodenum andstomach being secondary to the septic peritoneal condition,as probable in the other two cases ? It appears to me more

likely that the duodenal perforation was the primary lesionand the inflamed condition of the appendix was due to thegeneral peritonitis, the inflamed gut allowing organisms toescape through the walls and giving rise to the frccal odourof the pus. Another interesting point is the long dura-tion, eight days, and the fact that the patient with hisabdomen full of stinking pus walked into the surgery. Thepresence of the large quantity of fluid in the abdomen wascompletely masked by the great distension of the intestines.The complete absence of all tenderness and the definitemovement of the abdomen during respiration are in myexperience uncommon. The fact that no trace of calculiwas found post mortem in the right kidney and that twowere found in the left kidney makes one wonder whetherthe wrong kidney was explored at the first operation, andwhether the pain on the right side was due to duodenalulceration at that time. The man seemed quite positive thattie had never had any pain after food, or other symptoms,at any time, although it is difficult to imagine that so muchulceration in the duodenum and stomach could have existedfor any length of time without giving rise to symptoms.’This appears to me rather in favour of the view that some,at all events, of the ulcers followed the septic condition ofthe peritoneum.After looking through some of the literature on the subject

I have been able to collect 59 published cases of perforatedduodenal ulcer. In these cases 27 of the patients diedwithout operation, the lesion being found post mortem.The remaining 32 cases were operated upon and 11 of thepatients recovered. With the above three cases this givesa mortality of about 823 per cent.

Medical Societies.MEDICAL SOCIETY OF LONDON.

’Typhoid Fever in South Africa.A MEETING of this society was held on Oct. 28th, Dr.

W. H, ALLCHIN. the President, being in the chair.Dr. A. ELLIOT and Dr. J. W. WASHBOURN communicated

a paper upon Typhoid Fever in South Africa. They analysedthe records of 262 cases which were admitted into theImperial Yeomanry Hospital at Deelfontein and then com-pared these with Dr. T. B. Poole’s cases at the EmergencyHospital at Maidstone during the epidemic of 1897 and withother statistics at the Metropolitan Asylums Board hospitalsand the Johns Hopkins Hospital. Their object was toascertain whether the type of fever in South Africa was thesame as that occurring in England and America. Themortality of their cases was 13’7 per cent.-practically thesame as that at the Metropolitan Asylums Board hospitals

during the year 1900, and that of the Worthing epidemic,but almost double that of the Maidstone epidemic and theJohns Hopkins Hospital cases. The incidence of relapsewas 11 per cent.-practically the same as that of otherstatistics in England and America. They pointed out thatearly removal of the patients and improper feeding on thejourney predisposed to relapse. The average intervalbetween the end of the primary attack and the commence-ment of the relapse was 10-8 days, which appeared to besimilar to that of other statistics. The longest intervalbetween the end of the attack and relapse was

31 days. None of their cases which relapsed died.In 12 of their cases there was a history of a pre-vious attack of enteric fever, an incidence of 4’5 per cent.Dr. Crombie had recorded an incidence of 6 per cent.amongst 150 officers who had been invalided from SouthAfrica. The frequency of second attacks they attributed tothe constant exposure to infection and to privationexperienced by the patients. The mortality was 10’7 percent. in 186 patients who had not been inoculated, while themortality was 16 per cent. among 25 patients who had beeninoculated. Adding together cases recorded at other hos-pitals the mortality among 120 cases inoculated was 7 4 percent., and among 556 cases not inoculated 10’9 per cent.They did not consider that this difference pointed to anymarked beneficial influence of inoculation. With regard tothe influence of the inoculation upon the incidence of thedisease, 59 of their staff were inoculated, of whom four con-tracted enteric fever. 25 were not inoculated, and of thesefour also contracted enteric fever. The four cases among thenon-inoculated who contracted the disease came from amongthe dressers who were younger than the rest of the staff.Adding together various other statistics they foundthat of 224 persons inoculated the incidence of attackwas 114 per cent. ; and of 157 persons not in-oculated the incidence was 14’6 per cent. From these

figures they drew the conclusion that inoculation was

not of any practical value in preventing the disease.

They drew attention to the considerable risk of contractingenteric fever incurred by persons engaged in attending tothe sick, the incidence of attack among them being 12-7 percent. Haemorrhage amounting to several ounces of bloodoccurred in 6’1 per cent. of their cases ; the incidence corre-sponding about to the average. Half of their cases ofhaemorrhage died, a much higher percentage than occurredin England or America. Phlebitis occurred in 5 6 per cent.,the incidence at Maidstone being 3 ’8 per cent., in Caiger andGoodall’s statistics 3 4 per cent., and in Osler’s 1’9 per cent.The latest date of the appearance of phlebitis after the endof the attack was 30 days. Pneumonia occurred in 3’05 percent. of the cases, the mortality being 50 per cent. Peri-ostitis, perforation, and parotitis occurred in about the usualproportion. There was constipation in 42’7 per cent. ofcases. At Maidstone it occurred in 50 per cent. of the cases,at the Johns Hopkins Hospital in 34 per cent., and atthe Edinburgh and East of Scotland Hospital in 37 percent. It thus followed that constipation was more

common both in South Africa and in England andAmerica than was usually imagined. Rapid pulse wasfrequently observed in patients who had been previouslyexposed to fatigue, and there was often cardiac collapsequite out of proportion to the severity of the attack.In two cases of convulsions one was attributed to theadministration of strychnine. Abdominal pain, sometimesso acute as to suggest perforation, occurred in several cases.In several cases there was difficulty in micturition at anearly stage of the disease. Cases of appendicitis immediatelypreceding and immediately following enteric fever wererecorded. A case of hepatitis was also described. Twenty-me cases associated with dysentery were recorded as arisingluring the attack or during convalescence and it was a

symptom of serious signification, the mortality being 33’3per cent. Rigors were observed in 11 cases ; in two of thesehey were due to malaria, the parasite having been discoveredn the blood. Arthritis was not uncommon during early con-valescence. In a limited number of cases it was due toheumatism. In the others it appeared to be allied to thearthritis occurring in scarlet fever. Other complications,uch as tender toes, epistaxis, pericarditis, and eruptions oflifferent kinds, were considered. The conclusions drawn by)r. Elliot and Dr. Washbourn were that the type of diseasen South Africa was practically the same as that met with inEngland and America, and that inoculation was of littlepractical value.Dr. WILLIAM CAYLEY, referring to the causation of the

1196 CLINICAL SOCIETY OF LONDON.

disease, said that although in this country almost all theepidemics were due to contamination of the water-supply itwas clear that the means of infection in the tropics was fre-quently by other agents, such as dust and flies. It would beof interest to know if the clinical type of the disease variedwith the different modes of infection. He congratulated Dr.Elliot.and Dr. Washbourn on the low mortality. He con-sidered that the evidence in favour of the immunity conferredby inoculation was sufficiently strong to make it desirablethat it should continue to be used.

Professor A. E. WRIGHT (Netley), referring to the questionof inoculation, said that although the general circumstancesin South Africa were such that the results were not so favour-able as those obtained from India, yet he was of opinion thatsome benefit was obtained from inoculation, however bad thegeneral surroundings. He certainly considered that inocula,-tion was advisable for India. In judging of the statisticsthere were several points to be taken into consideration. Oneof the most important of these was as to how long the patienthad been inoculated. There was a negative phase whichoften followed an excessive dose, and he quoted the case ofa man who had been inoculated three times and yet gottyphoid fever. He himself had had three injections againstMalta fever and yet he got the disease. It was certain alsothat the injection would only protect for a short time and hequoted statistics proving the value of being inoculatedtwice. He said that it was becoming evident that thedose had to be carefully adjusted and he now gave a smalldose and repeated it, and in this way he avoided the negativephase. It was certain, also, that in some cases the injectionafforded no protection, as was shown by the bactericidalproperty of the blood. He did not consider that age made

any essential difference to the incidence of the disease.

Surgeon-General HENRY CAYLEY quoted statistics fromthe Scottish National Hospital, South Africa. He said that itwas often difficult to obtain evidence from the soldiers as towhether they had been vaccinated or inoculated. Of the 54persons who composed the first section of the hospital all butthree were inoculated twice, two were inoculated once, andone not at all. Not one of the 54 got enteric fever thoughexposed to infection, and of these 25 were medical studentsbetween 19 and 24 years, the most susceptible age. In thesecond section, out of 102 persons 74 had been inoculated(some twice, some only once) ; of these five had entericfever. Of these five, three had not been inoculated and twohad been inoculated. Of 35 nurses 32 were inoculatedtwice, two were not inoculated, for they had recentlyhad enteric fever, and one refused to be inoculated and shebecame infected with enteric fever. He certainly thoughtthis evidence proved the value of inoculation for a certaintime, possibly from five to six months. He believed also thatinoculation made the attacks less severe. The cases ofarthritis met with arose (he believed) rather in associationwith Malta fever than with enteric fever, and he thoughtthe former fever occurred more frequently than was generallyrecognised. He said that the blood examination of themembers of the first section of the hospital some monthsafter they had been in South Africa still gave a highreaction, nearly all these having been inoculated twice ; inthe second section, however, which came out later, thereaction was poor, seeming to point to the fact that theinoculation had not been so efficiently carried out.

Dr. HOWARD TOOTH said that his iigures, though small,were favourable to inoculation. He thought that the moreseverely the person reacted to the inoculation the less likelywas he to be immune, and in Bloemfontein oflicers who hadhad severe reaction did not seem to be protected. With

regard to immunity he classed individuals under three heads :(1) persons who were naturally immune ; (2) persons whocould be rendered immune by inoculation ; and (3) personson whom no immunity could be conferred. He believed thatmost individuals belonged to the second group.

Dr. H. D. RoLLESTON said that with regard to inoculationit was clear that it did not absolutely protect, but thestatistics seemed to show that fatal results did not occur sofrequently in the inoculated as in the uninoculated. It was

important to take into consideration the interval elapsingbetween the inoculation and the attack of typhoid fever, andthis had been on the average 38 weeks. Relapses and secondattacks had been of common occurrence. He believed thatthere were several different strains of the typhoid bacillusand that an individual infected with two or more strains wasmot proof against other strains. He thought that the serumfor inoculation should be prepared with mixed strains from

as many different sources as possible. He pointed out that,although thrombosis was common yet there had been no case-of pulmonary embolism.I Surgeon-General MUIR said that before accepting inocula-tion as of value far more statistics were needed. He thoughtthat the source of enteric fever, though commonly water,was often conveyed by other means.

Dr. E. W. GooDALL said that with regard to causationtoo much stress had been laid upon the water-supply, and he-was convinced that this .was erroneous, for many cases arosein those attending the sick. All the complications whichhad been mentioned as occurring in South Africa afterenteric fever he had seen in England, and he had also seenulcerative colitis follow on an attack of typhoid fever.

Dr. WASHBOURN, in reply, said that although enteric fevercould be contracted in different ways he could not saythat the clinical type of the disease was different. The.test to which inoculation had been put in South Africa hadbeen severe, but it was in those cases where persons were-

frequently exposed to infection that it should be of greatestservice ; he did not consider that it should be resorted to inEngland where the sources of infection were comparativelyfew. Neither did he think that the inoculation should be.lightly undertaken, for he had seen an officer laid up forthree weeks with pyrexia after injection. He did not con-sider that the immunity of an individual could be estimatedby the bactericidal capacity of his blood. He regarded thearthritis which occurred in the same light as the arthritiswhich occurred after scarlet fever. He suggested that the.

thrombosis which was of frequent occurrence might be due.to the deficiency of salts in the food.

CLINICAL SOCIETY OF LONDON.

Exhibition of Cases.A MEETING of this society was held on Oct. 25th, Mr.

HOWARD MARSH, the President, being in the chair.Dr. RAYNER BATTEN and Dr. LEONARD GUTHRIE showed a

boy, aged 12 years, with Right-sided Hemiparesis and

Atrophy of the Left Optic Disc. He had fractured his leftfemur in October, 1900, and whilst laid up had had a,

doubtful attack of acute rheumatism. In February, 1901,he noticed weakness (gradual) of the right arm and of the.legs, with difficulty in writing and in walking. When seenon April 30th, weakness, ataxy, and intention tremors were’noted in the right arm. The right leg was wasted, the-

knee-jerk was exaggerated, ankle clonus was marked, and atypical Babinski’s plantar reflex was present. Sensation wasnormal. A faint presystolic bruit was present. The veins ofleft optic disc were engorged, but there was no swelling ofthe disc. On June 28th the condition of the discs was asfollows. The left optic disc was pale and excavated. The-cribriform plate was exposed at the bottom of the excavation.The disc was not filled in or opaque. There was no blurring-of vessels or of the margins of the optic disc. There was a,well-marked central scotoma for white (no colour perception).The retina in the macular area and up to the optic discshowed signs of disturbance and a number of fine white dots.The veins were somewhat large, dark, and tense. The right,optic disc was normal. No hemianopsia was present. OnOct. lst the paresis was much improved and the vision ofthe left eye was very slightly impaired. It was suggestedthat the patient might have had thrombosis in the neighbour-hood of the left motor tract with retro-bulbar neuritis.of the left optic nerve, or the condition might be-due to early disseminated sclerosis.-Dr. F. E. BATTEKsaid that he did not think the condition was due-to disseminated sclerosis. He had seen a similar casein a female, aged 25 years, who suddenly became hemi-plegic on the right side with aphasia and complete blind-ness in the left eye. The patient died some two years laterand at the necropsy it was found that there was softening’in the distribution of the left middle cerebral artery andthe left optic nerve was completely degenerated owing to-thrombosis of the vessel supplying this region.-Dr. BATTEN,.in reply, said that he thought the presence of a centralscotoma pointed to a vascular lesion.-Dr. GUTHRIE said thatthe remarkable recovery which the boy had made seemed’to him to be in favour of a disseminated sclerosis rather than.a vascular lesion.

Dr. J. P. PARKINSON showed a case of Glenard’s Disease,.