and micturition was as often as every two or three hours during the day. The patient consulted a physician at this time on account of a progressive pallor. This was the first time that blood was noted in the urine. In August, 1910, the patient had a slight fever. Just how long this continued is not definitely known. However, the condition continued without much change until December, 1910, when the patient noticed a throbbing sensation in the left side which would last for a day or more and then subside. Three such attacks occurred in three weeks and during this time she lost eight pounds.

When brought into the Surgical clinic, January 9, 1911, an examination of the urine showed tubercle bacilli to be present. A cystoscopic examination of the bladder was attempted, but the bladder walls were in such a condition that no landmarks could be made out. The trigone was obscured by a covering of pus. The bladder held about five ounces. A variety of treatment was now instituted; antipyrin, ten grains to two quarts of sterile water to stop the hemorrhage from the bladder walls, as well as a two-per-cent solution of iodoform in olive oil for the cystitis. By these means the condition of the bladder was so improved that she became an out-patient about February 1 and returned daily for bladder treatment. But after twelve weeks of such treatment the cystitis still continued. At the end of this time cyctoscopic examination still failed to locate the ureters.

The patient was now referred to the Medical clinic for the tuberculin treatment, but three weeks' treatment failed to improve the bladder condition.

On May 9 a double kidney aspiration was made to see if one or both kidneys were involved. Both kidney pelves were aspirated, and the sealed samples were sent to Professor Aldred S. Warthin for diagnosis. Pus, blood, and cocci, but no tubercle bacilli were found in the urine from the left kidney. The urine from the right pelvis was negative.

On June 1 after both exploratory incisions had been allowed to close so as to guard against any infection of the right kidney, the left kidney was removed.

After the nephrectomy the patient continued to pass her urine every half to three quarters of an hour, so attention was directed to the tuberculous process in the bladder. The treatment consisted in two applications of fifty cubic centimeters of a six per cent solution of carbolic acid injected into the bladder and retained two or three minutes, then allowed to return through the catheter. These injections were three weeks apart. July 9, 1911: The patient now gets up once a night, and holds her urine over three hours during the day. The irrigating fluid returns clear from the bladder. The patient is able to walk around and feels very well. The incisions are completely healed...

Not more than one exploratory puncture is necessary to establish a diagnosis of tuberculous kidney, since in all cases where there is a tuberculous focus in the kidney, Koch's bacillus can be found in the urine from the kidney pelvis. Hence such a puncture should be made when the

diagnosis is doubtful, since there is practically no danger as far as the mere puncture of the kidney is concerned.

There was formerly considerable discussion over the disposal of the ureter almost always infected in tuberculous kidney. Therefore, to amputate close to the bladder leaves a stump which suppurates into the perivesical tissues and gives rise to deep seated abscess. If the ureter is not shortened but left as long as possible, it will surely drain through the wound, a much more convenient place to deal with suppuration.

It was also formerly thought that tuberculous cystitis might be primary in the bladder but it has been proven quite conclusively that in these cases there is always a primary focus in the kidney and that the bladder infection is always secondary to tuberculosis of the kidney.

DISCUSSION.

DOCTOR MARK MARSHALL: One phase of this case particularly interested me. It was interesting to notice that this girl was perfectly. healthy in appearance and actually gained weight while her disease progressed. I know that in the treatment of pulmonary tuberculosis, when a patient gains in weight, even though the gain be very slight, it is regarded as a favorable sign. I think that this often serves as a false guide in the treatment of pulmonary cases, for it often happens that when a patient has made a good gain in weight he is discharged as cured, whereas, a careful examination may reveal evidence to the contrary.

DOCTOR REUBEN PETERSON: Cases of tuberculosis of the kidney are apt to be of long standing and always are difficult to cure. Where it is difficult and often impossible to catheterize the ureters because of the condition of the bladder, it is usually possible to decide which kidney is affected through the presence of pain or tenderness in one or the other side.

We must decide whether to open and drain a tuberculous kidney, or to remove it. Fenger was Fenger was a great advocate of incision and drainage, claiming that nephrectomy was seldom necessary. I must confess that I have had very little success with the former treatment and have usually found it necessary not only to remove the tuberculous kidney but the ureter itself as far as the bladder.

While the process in the bladder is apt to continue after the removal of the diseased organ, after a time it clears up if the other ureter and kidney be not affected.

DOCTOR GEORGE KAMPERMAN: I remember hearing Doctor Loree read a paper a year or two ago in which he made the remark that tuberculous cystitis could be cured and the symptoms still persist. This was explained by the fact that although the infection could be gotten rid of, the excessive scar tissue in the bladder wall would still keep up the frequent micturition. Since this is the case, it would be difficult to tell whether a patient in such a case was ever cured. He would probably always have the symptoms even though the cystitis were cured, and since there is always the possibility that there may be some disease lurking there, it would be very hard to give any prognosis at all, especially for tuberculous patients.

AMERICAN PROCTOLOGIC SOCIETY.
STATED MEETING, JUNE 26 and 27, 1911.

THE PRESIDENT, GEORGE J. COOK, M. D., IN THE CHAIR.
REPORTED BY LEWIS H. ADLER, Jr., M. D., SECRETARY.
ABSTRACTS OF PAPERS.

[CONTINUED FROM PAGE 272.]

CANCER OF THE RECTUM.

J. RAWSON PENNINGTON, M. D., Chicago, Illinois.

I take it we are all agreed as to the increasing frequency of cancer. At least it seems no other conclusion can be drawn from the following figures: According to the Twelfth United States Census, cancer appears to have increased 12.1 deaths per 100,000 population in the previous decade. In Great Britain, so we learn from the work of Roger Williams, the deaths from cancer increased from 177 per million in 1840 to 885 per million living in 1905. Williams points out that while the population barely doubled from 1850 to 1905, the mortality from cancer increased more than six fold. Nor is the increase confined to the United States and Europe, it holds good for Japan, India and even for uncivilized countries. In short, cancer is one of the several diseases which is apparently increasing, by leaps and bounds, in spite of our boasted progress in medicine, surgery and hygiene. Apart from the increased prevalence, the present death rate from malignant diseases is something dreadful to contemplate. Our anxiety in regard to malignant disease of the rectum is pardonable when we reflect that a good proportion of cancers involve this region. Williams found that 9.6 per cent in males and 5.3 per cent in females were located in the rectum. Is there anything that can be done to check this foc? The writer believes there is, and that this society may be made a powerful factor for good in such a crusade. In Germany a similar crusade has been started against cancer of the uterus by Winter's agitating the subject both among the profession and the laity. It is estimated that the number of cases of inoperable cancer of this organ has been reduced over thirty per cent as a result of calling attention to the early symptoms. Of the 2914 cases of rectal cancer in the male referred to by Williams 2592 patients were over forty-five years of age and 2180 of the 2533 female patients. In the male sex again the average age, at which the onset was noted, was 49.7 years, the minimum being 16.75 and the maximum 74; while the female sex the average was 50.4 years with a minimum 21.8 and a maximum of eighty-eight years. This brings me to the crux of my argument, that every person who has reached the so-called "cancerous age" should be examined periodically for evidence of commencing carcinoma not necessarily of the rectum alone, but in the female for example, of the uterus also.

In one hundred and twenty resections of the rectum for malignant disease William J. Mayo observes: "It is an unfortunate fact that, in the majority, cancer of the rectum is not recognized in time to obtain a radical cure." I said a moment ago that cancer in the beginning is a

local disease. This granted, then early and thorough removal must lead to a cure. It has been shown that a large proportion of malignant growths originate in scar tissue. In cancer of the stomach, for example, the Mayos found that no less than sixty-two per cent showed evidence of a previous ulcer. In rectal cancer patients frequently give a history of previous operations on the part. Does the cancer occur in the scar left from an operation for hemorrhoids done by one of the commoner methods-ligature, clamp and cautery, or some other technic leaving much scar tissue and sometimes stricture? May it not be occasionally engrafted on the scar following the usual incision method of operating for fistula? Here is a suggestion for us in our own work, secure smooth healing by resorting only to such procedures as leave the minimum of cicatrical tissue, hence, the least possible nidus for possible mischief in the future. With the cooperation of the public it seems to me we should learn much about cancer in the early stages. To educate the public we must-as has been well said "organize, systematize, deputize, energize, supervise and economize." The field is broad and the opportunity is at hand. Shall we grasp it?

MALFORMATION OF RECTUM AND ANUS, WITH REPORT OF CASE. DONLY C. HAWLEY, M. D., Burlington, Vermont.

The facts of modern embryology explain a majority, but not all developmental defects of the rectum and anus.

1910.

M. B., female, aged four weeks, came under my observation in April, She had an imperforate anus, the rectum opening into vagina in the upper half of the rectovaginal septum. The opening, one-half by one-eighth inch in size, the longer diameter transverse, was evidently supplied with sphincter, as the child had three or four well controlled movements daily. Anal depression was present and the vulva and vagina were normal, except as noted. The presence of uterus was normal or otherwise not demonstrated. There was no distention of rectum, no impulse and no prominence in perineum. The child was well nourished and otherwise normal. Operative interference postponed. The child is at present well, and is thirteen months old and weighs twenty-two pounds. While this defect is sometimes seen, many cases reported, as atresia ani vaginalis are no doubt in reality imperforate anal canal with vulvar outlet, a malformation admittedly of common occurrence.

Cases in which intestine opens well up in vagina are not accounted for on embryologic grounds, the two structures being embryologically dissimilar and independent.

PRURITUS ANI, WITH REPORT OF CASES.

DONLY C. HAWLEY, M. D., Burlington, Vermont.

In this discussion I do not refer to cases due to intestinal parasites, errors in diet, et cetera, in which the pruritus is relieved by proper attention to the causative condition, nor so much to the symptoms as to the pathologic condition of the skin and nerve endings, which condition is pathognomonic. The nearly constant local cause of pruritus ani is

abrasion and ulceration of the anal canal, accompanied by blind sinuses underneath or fissures in the mucocutaneous lining. Further, some cases are associated with chronic proctitis, which may be a factor in producing or increasing the anal abrasions or ulcerations.

The treatment I have adopted is as follows: With the patient well anesthetized, the anal canal is dilated, and the ulceration, together with the sinuses and fissures, are thoroughly cauterized with the Paquelin cautery, and also the entire area of chronic dermal inflammation. My aim is to destroy ulcerated areas, the thickened and altered skin and the pathologic condition of the terminal nerve fibres.

Case I.-S. H. E., aged sixty-two, came under my observation June, 1908. He had suffered with rectal troubles for forty-five years. Twenty years ago he was operated on for fissure or fistula-was not certain which. He has had almost intolerable pruritus for eight years, and for the past year it has been so constant and unbearable, especially at night, that he has become a nervous wreck, and has lost forty pounds in flesh and has been unable to continue his business.

Diagnosis: Chronic pruritus ani. The skin was inflamed, soddened and thickened over a large arca about the anus, with many deep cracks, and four or five ulcerations and abrasions in anal canal.

Treatment as outlined. Result, cure and no return up to present time. Case II.-W. A., male, aged thirty-eight. History of pain in rectum. for twenty years, and of severe and intolerable pruritus.

Diagnosis: Chronic pruritus ani.

There was a large ulceration in anal canal and three or four blind sinuses, with an area of white brittle and infiltrated skin with large cracks about anus.

Operation, same as in Case I. Result, cure.

Other cases less severe have been operated upon during the past three years with satisfactory results. The treatment outlined is not new nor original, having been advocated by Mr. W. Mitchell Banks, and practiced by Mr. Fred C. Wallis. Ball's operation is designed to render anesthetic the skin over the undercut area. The operation described accomplishes the same end and also destroys lesions in anal canal. The former operation has resulted in extensive sloughing. To the latter no such danger attaches.

SYPHILIS OF THE ANORECTAL REGION.

LEWIS H. ADLER, Jr., M. D., Philadelphia, Pennsylvania.

I wish to relate the history of two cases of syphilis in which no outward visible effects of the patient's grave condition existed, except about the anus. In both instances, the anus was surrounded by syphilitic condylomata; the parts were bathed in a fetid seropurulent discharge and the patients' mouths were affected with mucous patches. In one case the patient was markedly improved by the use of salvarsan and the other one improved under the ordinary mercurial treatment, but disappeared from observation before a cure could be effected.

A consideration of the usual manifestations of the disease as affecting