666 PATHOLOGICAL SOCIETY OF LONDON.

itself will probably destroy all the glands and block upthe lymph-channels. In cases of cancer and tuberculosisthe surgeon must of course remove the glands with thesurrounding tissues as thoroughly as possible ; the incon-venience of a chronic oedema weighs light against a possiblerecurrence.

STATION FAMILY HOSPITAL, RAWALPINDI.

A CASE OF CARCINOMA OF THE RECTUM; OPERATION. ((Under the care of Captain T. H. GOODWIN, R.A.M.C.) _THE choice between the perineal operation of proctectomy

and that introduced by Kraske must depend chiefly on thelocality and extent of the malignant growth. If the upperlimit of the tumour does not extend beyond three inches orso from the anus the perineal route is far preferable, forthe operation is distinctly less severe ; inasmuch as in sucha case the peritoneal pouch does not need to be opened andthe risk of peritonitis is greatly lessened. If, however, thegrowth involves a portion of the rectum covered by peri-toneum Kraske’s operation, or some modification of it, isneeded for the complete removal of the tumour. In the

following case the operation itself was a success, death

occurring apparently from a secondary deposit in the brain.A married woman, aged 59 years, was admitted to the

Station Family Hospital, Rawal Pindi, on August 29th, 1901,complaining of continuous pain in the region of the rectumand anus which was much increased by defecation. The

family history was unimportant. The patient had alwaysenjoyed good health until three and a half months previouslywhen she had an attack of dysentery accompanied by a gooddeal of tenesmus. Since that time she had experienced analmost constant desire to defecate, the resulting motionsbeing small and blood-stained. She had suffered fromconstant very severe pain which was much increased bydefecation. On examination per rectum a hard nodular masscould be felt within the anal margin ; the growth extendedcompletely around the rectal wall and was in the shape ofa signet ring, extending for about two and a quarterinches upwards posteriorly and for about half that distancein front. The sacral glands were apparently not enlarged.The general health was fair. No secondary growths couldbe discovered. The tip of the forefinger could reach abovethe mass in every direction and the growth was freely move-able. Excision of the growth was decided on, the patientherself being very anxious to undergo operation. On accountof her age and condition Kraske’s method of operation wasrejected as being too severe and lengthy in performance.She was placed on a nourishing diet and the bowels werekept opened with mild laxatives.On Sept. 9th, an enema having been previously admin-

istered, the patient was placed under chloroform and was putin the lithotomy position. - Captain Goodwin then removedthe lower three inches of the rectum by the perineal route,the tissues between the rectum and the coccyx being com-pletely divided. The gut was drawn down and was unitedto the margins of the incision by a few sutures. The hæmor-

rhage during the operation was extremely free and manyvessels required ligature. The vaginal wall was not invaded bythe growth. An iodoform and gauze dressing was applied.On examination of the excised growth it appeared to havebeen completely removed, with a surrounding margin of

healthy tissue. A stained section under the microscopeproved the growth to be a squamous carcinoma. On the

following day the wound was dressed and appeared to behealthy. From the date of operation to Sept. 30th the

patient improved steadily ; she was quite free from pain andgained in weight and strength considerably. The wound’healed well and rapidly around a rectal bougie and the gutshowed no tendency to retract. A fortnight after the opera-tion she was able to sit up for the greater part of the day.On Oct. 5th she had regained to a great extent control overthe lower bowel, the motions being no longer passed uncon-sciously. On the 9th the patient, who had been drowsy forsome hours, became delirious and the pupils were sluggish inreaction, dilated, and slightly unequal. This conditionbecame gradually worse until the 19th when the patientexpired, dyspnoea having existed for two days previously.The cause of death was evidently a secondary growth in thebrain, involving the respiratory centre. No necropsy wa:

permitted by the relatives. Examination per rectum re-

vealed no enlarged sacral glands, the wound had healed, and

there was no sign of local recurrence.Remarks by Captain GooDwIN.-The eventual terminationof the case was extremely disappointing, as, from theabsence of local recurrence, the rapid healing of the wound,and the early control over the fæces, there appeared to beevery prospect of a successful result. The chief point ofinterest in the case appears to me to be that, although noenlargement of the sacral glands could be felt per rectum,yet the probability is that they were involved to a slightdegree. Had circumstances permitted of an operation byKraske’s method, with complete extirpation of the glands,I believe that the eventual result of the case would havebeen successful.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.

Low Proteid Metabolism. - Proteolytic Enzymes in the

Spleen.-Chylous and Chyliform Ascites.-New UrinaryPigments.A MEETING of the Chemical Section of this society was

held on March 5th, Dr. W. D. HALLIBURTON, chairman ofthe section, being in the chair.

Dr. VAUGHAN HARLEY and Dr. FRANCIS GOODBODY madea communication on cases of Low Proteid Metabolism. Itwas popularly believed that when large eaters remained thinthey did so because a large proportion of the food taken bythem passed through the alimentary tract unaltered, andDr Harley and Dr. Goodbody brought forward these cases toshow that this was not always correct. As a matter offact, certain individuals had a remarkably low metabolism, sothat they actually needed less food than other people. Threecases were described in which the patients were kept undersimilar conditions-namely, in bed and having only massageas exercise. The diet in all cases was carefully analysedand the urine and faaces were examined, the faeces beingdivided into different periods by means of charcoal. Awoman, weighing 72 kilogrammes, was found to be able to

. live on a very small amount of food-in fact, on one pound! of mutton per diem. During the seven days of observation. she only lost two kilogrammes in weight and during the; first six days only one kilogramme. During this time thequantity of nitrogen taken in the diet was 12’16 grammesper diem, while the average output of nitrogen in the urine

was 13’51 grammes, so that she lost from the tissues in; the body generally one gramme of nitrogen per diem.

During this period of seven days she passed only five- motions and the charcoal showed that there was a markedtdelay in the passage of the fæces along the alimentary1 canal because the charcoal did not reappear till from

, 60 to 70 hours after having been given. The quantity of- nitrogen in the faeces was extremely small, being only 0 48gramme, while the fat was 1-09 grammes-amounts corre-- sponding, in fact, to those found in fasting individuals byy other observers. On comparing this woman with a man ony a diet of one pound of meat per diem it was found that when. he was taking 14 ’72 grammes of nitrogen per diem in hise food he excreted in the urine no less than 22-71 grammes, sof that whereas the woman lost only one gramme on an averagee per diem the man, on the other hand, lost no less than sevene grammes of nitrogen. During the four days of observatione the man lost two kilogrammes in weight ; the nitrogen in thee faeces was 0’66 gramme and the fat was 2-43 grammes perd diem. The woman was now put on a very small diet duringd two periods of five days each. In the second period of five daysit she took 6 ’08 grammes of nitrogen, the diet containing onlya- 4 ’16 calories per kilogramme. During this time she passedy. 7’32 grammes of nitrogen per diem in the urine, so thatsr during the five days there was a loss of one gramme ofn- nitrogen per diem from the tissues. During the two periods

in which she took this remarkably small diet her averagein weight was, for the first period 66’8 kilogrammes, and for)n the second 66’5 kilogrammes, so that the loss in weight wasnt very small indeed.-Dr. F. G. HOPKINS (Cambridge)y. referred to some experiments which were being madene by four or five healthy men at Cambridge weighingas from 60 to about 75 kilogrammes, whose daily excretion

667CLINICAL SOCIETY OF LONDON.

of nitrogen was only about six or seven grammes withoulloss of weight. There could be no question as to thE

possibility of these men doing work, yet they only metaboliseèbetween four and seven grammes (taking the extremE

limits) of nitrogen per diem. This ability to work on suchan extremely low diet was apparently due to slow and

thorough insalivation, which was one of the tenets of the. ‘ cult into which they had formed themselves.-Dr. E. H.STARLING remarked that in using the expression " calories tit must be remembered that fat was included which did not

play an active part in metabolism. In this sense fat simplyplayed the part of ballast.-Dr. HALLIBURTON referred tothe popular notion that Eastern .nations existed on a veryilow nitrogenous diet ; but recent .analysis of Chinese diet-aries showed a large aggregate of proteids in the fruits andgrains. This was especially true of nuts.

Dr. S. G. HEDIN made a communication on the ProteolyticEnzymes in the Spleen of the Ox. Spleen juice pressed fromthe disintegrated cells of the spleen contained a proteolyticenzyme which acted very strongly in an acid medium, whilstin a neutral or alkaline medium it acted very weakly ornot at all. The disintegrated and not pressed spleen-cells con-tained, in addition to this enzyme, another enzyme that actedupon proteids only in alkaline media. This enzyme seemed tobe present in the cells in the form of a zymogen which was not soluble in water, but when exposed to the action of weakalkali or weak acid it yielded an active enzyme soluble inwater. As to the purpose of the enzymes, it seemed probablethat they had to carry out digestion inside the leucocytes.Intracellulardigestion, according to researches mainly carriedout in Metchnikoff’s laboratory, appeared in most cases tobe performed in an acid media, although in some instances itcould be performed also in alkaline fluids.

Dr. ROBERT HUTCHISON read a paper on the conditionsknown respectively as Chylous Ascites and ChyliformAscites. He stated that in the former of these conditionsthe opacity of the fluid was due to the presence of fat andthe fluid became quite clear on agitation with potash and-ether. A specimen of fluid from a case of true chylousascites was exhibited which exactly resembled milk in appear-ance and contained 2’3 per cent. of fat. The patient, a man,aged 32 years, exhibited no other symptom and his bloodcontained no filariæ. The cause of the ascites in this casewas obscure. In chyliform ascites, which had only beenaccurately investigated within recent years, the fluid wastess opaque than in the chylous form and often had a

greenish tinge. Different observers had ascribed the

opalescence to (1) lecithin, (2) mucoid substances, and

(3) in a smaller group to a casein-like body. The fluidexhibited was obtained from a man, aged 46 years, whosuffered from chronic parenchymatous nephritis and chronicpurulent peritonitis. It contained neither lecithin nor

mucoid substances, but a proteid which yielded nuclein orparanuclein on digestion, and which was presumably derivedfrom cellular disintegration. The methods of analysisemployed were described in detail and a brief bibliographyof the conditions was added.

Dr. H. A. SCHOLBERG read a paper on a hitherto Un-described Purple Pigment in Urine. This pigment was metwith in a patient admitted to St. Bartholomew’s Hospitalsuffering from Peripheral Neuritis under the care of Dr.J. A. Ormerod. The condition was probably congenital andwas met with in the patient’s father and in another memberof the family. The pigment was not due to any drugs takenand it was differentiated from other purple pigments hithertorecognised. The means of its detection were described, andthe conclusion arrived at was that it was a purple pigmentallied to, though different from, the purple-coloured pigmentthat produced the deep colour in hsmatoporphyrinuria.When the urine was in large bulk the condition describedalight resemble alkaptonuria.Dr. F. H. THIELE read a paper on a Brown Urinary

Pigment. The pigment had been found in four patientsadmitted to University College Hospital. The first was amiddle-aged woman suffering from pyorrhcea alveolaris ; thesecond was a woman suffering from parotitis ; the third wasa child; and the fourth was a woman admitted for

sloughing ulceration of the vagina. The pigment wasprecipitated from solution by ammonium sulphate, leadacetate, and alkaline baryta mixture. It was soluble inalcohol, amylic alcohol, and chloroform, and to a less extentin water. It yielded no spectroscopic band and in con-centrated solutions it blotted out the spectrum from the redonwards. An alkaline solution of the pigment in caustic

soda did not yield on the addition of calomel the rose-redcolour obtained with urobilin. The pigment was very muchlike urobilin, but differed in several respects. In one caseit was worth noting that the patient subsequently had adistinct urobilin band in the urine and besides having ayellowish pigmentation of the skin she had a raw surfaceon the abdomen the edges of which were green.

Dr. A. E. GARROD remarked on the interest of both of these

papers, which bore eloquent testimony to the value of thespectroscope in the recognition of biliary derivatives in theurine. Dr. Schölberg’s case appeared to be an individual varia-tion in metabolism.-Dr. H. BATTY SHAW remarked on theinterest attaching to the second of Dr. Thiele’s cases inwhich the skin was certainly very yellow, but as there wasno bile pigment in the urine possibly the case belonged tothe condition which some writers had described as " urobilinjaundice."-Dr. HOPKINS and Dr. GARROD dissented tothe use of the term "urobilin jaundice," the latter remark-ing that there was no evidence that the colouration ofthe skin was due to urobilin.-Dr. J. R. BRADFORD hadseen cases at long and rare intervals in which there was

yellowness of the skin, and the urine, though containing nobile pigments, contained large quantities of urobilin.-Dr.HALLIBURTON remarked on the difficulty of the spectroscopicrecognition of urobilin.

CLINICAL SOCIETY OF LONDON.

Exhibition of Cases.A MEEfING of this society was held on Feb. 28th, Mr.

HOWARD MARSH, the President, being in the chair.The PRESIDENT showed a man who had sustained a Dis-

location of the Semilunar Bone, the displaced bone havingbeen removed by operation. Skiagrams of the case wereshown by Mr. Mackenzie Davidson.

Dr. GRAHAM BROWN (introduced by the PRESIDENT)exhibited a new form of Æsthesiometer for estimating thedegree of acuteness of tactile sense at different parts of theskin. The instrument consisted essentially of a smoothsurface which could be made rough to any desired degree bymeans of adjustable projections from this surface. It was

specially suitable for clinical work in cases in which tactilesensation was impaired and was designed to measure thedegree of loss in any given case.

Dr. WILLIAM EWART exhibited a case illustrating theTreatment of Bronchial Dilatation and Bronchial Catarrh byPosture and Respiratory Exercises. Dr. Ewart describedthe method, which consisted of keeping the foot of thebed raised, sometimes to a considerable height, whilstthe shoulders were kept low, only the head resting on thepillow. The first case in which it occurred to him to

carry out this indication’ had been published ; others,including some cases of phthisis, had been under treatment.The method, however, had been previously thought of anddescribed by Quincke. The patient exhibited was a man,aged 21 years, who was suffering from bronchiectasis.

Mr. JOHN R. LUNN exhibited cases of (1) Locomotor Ataxywith Disease of the Shoulder-joint in a man, aged about 65years ; (2) Polyarthritis in a man, aged 30 years ; and (3)Osteitis Deformans in a man, aged 72 years (with skiagram).-In the discussion which followed reference was made to casesof osteitis deformans in which fracture had occurred, thoughthis was thought to be unusual unless sarcoma was present.-Mr. ANTHONY A. BOWLBY, in discussing the case of poly-arthritis, thought that this resembled some cases exhibitedon a previous occasion by Dr. Percy Kidd in which bronchi-ectasis had existed. He (Mr. Bowlby) believed that therewas a great deal to learn about polyarthritis, and he sug-gested that Mr. Lunn’s case was due to some form of chronicseptic infection by reason of the number of joints involvedand the long duration.

Mr. CUTHBERT S. WALLACE exhibited a case of Excisionof the Lower End of the Ulna for an old Colles’s Fracture.The patient was a man, aged 55 years, who was admitted tohospital in August, 1899, for loss of power in the hand inconsequence of a Colles’s fracture which he had receivedsome time previously. There was much abduction of thehand and flexion was extremely limited owing to the lowerend of the ulna overlapping the carpus. About three-quarters of an inch of the ulna was removed through anincision on the inner side of the wrist. Skiagrams showedthe condition before and after operation. The patient couldnow follow his occupation.