pure form there is at present no good scientific basis. Any good nurse or housewife in feeding a convalescent would naturally select a diet already rich in this substance. With the child, however, especially the newly-born the case is slightly different. The chemical study of lecithin above referred to already indicates its importance during growth, an observation which is directly confirmed by physiological experiment. Thus, Danielewsky, Desgrey and Zaky, Billon and Stassono, and, finally, S. Hatai, the latter using my preparations, have conclusively demonstrated that animals develop more and better on a diet containing lecithin. As the young child is altogether dependent on milk for its supply of lecithin this point becomes of especial importance in artificial feeding. Now, although bovine milk contains about the same amount of lecithin as human milk,' the dilution which is necessary in order to make bovine milk available for the child, reduces the comparatively small amount of lecithin from onethird to one-tenth. Indeed, following the method of dilution suggested by Holt, the dilution is greatest during earliest infancy when most growth takes place and lecithin is most needed. The addition of lecithin in this case seems, therefore, justified and should receive a thorough trial. The fact that infants have grown and grown well without this addition is no argument against its use. May it not be possible that the well-known difference in the result of feeding bovine instead of human milk is not altogether due to the difference in the proteids, as generally supposed, but partly due to the lack of the proper quantity of lecithin? Holt calls especial attention to the fact that improper feeding in infancy very often does not show its effect until later in life. The addition of lecithin in the form of yolk of egg has indeed been occasionally used in modifying bovine milk for infant feeding. On account of the undesirability, in this particular case, of the proteid present in the yolk it would be better to add pure lecithin in the form of an emulsion. Dr. John Zahorsky, of St. Louis, has kindly consented to undertake clinical observations with such an emulsion, especially in cases of rickets. The results we hope to report at a later date. 'The statement of Hammarsten that human milk contains more I have not been able to confirm. In conclusion, we see that a selection of foods rich in lecithin will undoubtedly prove a valuable dietetic measure in certain diseases. The use of the pure preparation recommended by manufacturers can be of only limited value, even if the present prohibitive price should be reduced. With regard to the use here suggested for the pure preparation to modify bovine milk for infant feeding only clinical experience can decide as to its usefulness. A Peculiar Cystoma. BY WILLIAM S. DEUTSCH, M.D., Senior Assistant Surgical Clinic, Medical Department, Washington University; TH HE case of Post Rectal Cystoma, which I report this evening, I had charge of in the Washington University Hospital for Professor Tuholske, before and after operation. Mrs. C. was sent to the Clinic by Dr. Wm. L. Mosby, of Bardwell, Ky. and gave the following history: Father died of heart disease at the age of 63 years; mother died of phthisis at the age of 44 years. Four brothers and one sister died in childhood of causes unknown to the patient. One sister living and healthy. One brother living and healthy, and one has phthisis. No history of tumor or cancer in the family. The patient was delicate during her early years, having had most of the diseases of childhood. She began menstruating at the age of 16 years and has continued to do so regularly and without trouble. At the age of 20 years, while walking on a log she fell astride of same and suffered for a few days with pain in the perineal region, but which apparently gave her no further trouble. She was married at the age of 31 years, and eleven months later her physician had to perform embryotomy to deliver the child on account of the obstructed canal. She passed through the puerperal state normally, and with the exception of a very painful and difficult defecation seemed no worse for her confinement. Read before the Medical Society of City Hospital Alumni, January 19, 1905. Physical Examination.—The patient is a brunette, height, 5 feet 8 inches; weight, 180 pounds, with normal chest and abdomen, quite an amount of adipose tissue. Temperature, pulse and respiration normal. Urine 1019, negative. Red blood cells 4,000,000, white cells 4000. Hemaglobin 75 per cent. A vaginal examination, made extremely difficult on account of the tumor crowding up the posterior wall of the vagina, revealed the uterus and adnexa normal, but the outlet of the pelvis encroached upon by a semi-solid mass about the size of a large cocoanut, springing, apparently from the rectal region. Rectal examination showed the mass to lie posteriorly to the rectum, and so pushing on the rectum as to bring it against the vaginal wall. Diagnosis. Post rectal cystic tumor. Operation was advised and the following method was carried out: A semicircular incision was made along the coccyx and、 sacrum. The coccyx was now removed and the parts widely retracted so as to see well the territory to be dealt with, when the dissection toward the tumor was attempted. In dissecting off the wall the cyst ruptured and a large quantity of a thick glue-like fluid escaped. No hair or bone was found. The cyst wall was dissected out as far as it could be reached, the epithelial lining membrane curetted out thoroughly, leaving a large open cavity extending back into the hollow of the sacrum which was packed with gauze and the skin wound sutured. The rectum was not interfered with in the least as was shown by digital examination and irrigation, as well as by the normal bowel movements which the patient had after the operation. The patient had a long process of wound healing, owing to the continuous drainage necessary, for which I found the glass drainage tube, with the patient in the Syms' position, everything to be desired. Sections of the cyst wall were given to Professor Tiedman, pathologist of Washington University, who reported cystoma, probably of rectal origin, with colloid carcinomatous degeneration. Some of these sections are under the microscope, which I will be glad to have the members examine. I report this case to you this evening because I consider this form of post rectal tumor a very rare one, especially one that grew to a large size in this region, sufficiently large to make its bulging anteriorly toward the vagina a hinderance to the passage of the fetal head. In this case the history tells us that the size of the tumor made the crushing of the child's head necessary to allow delivery. From the embryological standpoint there is every reason to believe that this class of tumors owes its origin to the postanal gut and should not be confounded with that form of rectal tumors which grow from the rectum, usually peduculated, and occasionally present as a projection from the rectum. While the patient leads us to think that the fall she had astride the log caused this growth, literature only too plainly shows us that this variety of tumors is of congenital origin. Bland Sutton, in his admirable work, "Tumors, Innocent and Malignant," says the following: "In order to appreciate the nature of cysts arising in the immediate neighborhood of the rectum, it will be necessary to consider a few points in connection with the embryology of this portion of the alimentary canal. In the early embryo, the central canal of the spinal cord and the alimentary canal are continuous around the caudal extremity of the notocord. This passage, which brings the developing cord and the gut into such intimate union, is known as the neurenteric canal. When the proctodem invaginates to form a part of the cloacal chamber it meets the gut at a point some distance anterior to the spot where the neurenteric canal opens into it; hence, there is for a time a segment of intestine extending behind the anus and termed in consequence the post-anal gut. Afterwards, this post-anal section of the embryonic intestine disappears, leaving merely a trace of its existence in the small structure at the top of the coccyx, known as the coccygeal body. There is good reason to regard the post-anal gut as the source of that variety of congenital tumors situated between the rectum and the hollow of the sacrum-congenital cystic sarcoma." Dr. Dewis C. Bosher, of Richmond, Va., reports operating on seven cases of sacrococcygeal fistulæ caused by the rupture of cysts spontaneously in the median line. He cured the fistulæ by dissecting out and destroying the cyst wall. In looking over the literature of these cases I find no mention of any malignant tendency in these tumors which makes the case I have reported one of especial interest, and I shall watch, with great concern, the future of the patient. [3135 WASHINGTON AVENUE.] The Protozoan-Like Bodies Described By R. L. THOMPSON, M.D., ST. LOUIS, MO. N the Journal of Medical Research for January, 1904, Dr. Mallory described in the skin of four subjects who had died from scarlet fever, certain bodies that in their morphology strongly suggested that they might be protozoa, and I am asked tonight to speak regarding the appearance and significance of these bodies. To all progress there is opposition and it is fitting that it is so. The establishment of any hypothesis is only possible by long and convincing labor. It was years after the discovery of bacteria that their relationship to disease was suggested and it was years after this suggestion that such relationship was established. But even after the discovery of the relationship of certain bacteria to certain diseases, a gap was left in our etiological knowledge of infectious disease that could not be filled in by bacteria on the one hand or neurasthenia on the other. And it is only recently that certain evidence has been brought forward to show that the protozoa may form a few cases at least in this desert of ignorance. In certain of the protozoan diseases the organism is of a type that puts discussion beyond question, e.g.. trichinosis and amebic dysentery. In others, e.g., malaria, no one questions the etiological significance of the parasite and its cycle can be well understood through the discovery of its development and transmission by an intermediary host. In yellow fever we suspect a parasite and in kala azar the discussion is not as to whether the organism found is a protozoan or not, but, how shall it be classified. In smallpox, bodies have been described by Wasalewski, Guaneario, Pfeiffer, Councilman, Howard, De Korte and many others, and more or less of a life cycle of the organism constructed, while one who has worked with these bodies can not help but believe in them. Their etiological significance as a factor in smallpox is still a moot question but Read before the Medical Society of City Hospital Alumni, January 19, 1905. |