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ROYAL MEDICAL AND CHIRURGICAL SOCIETY.
1686 the patient still has a good pulse and where not too many days have elapsed since the strangulation, and particularly where youth is on his side. Under such conditions the surgeon may hope for a successful result. It might be noted that in cutting away the diseased bowel the incision was made obliquely (about 20° to the axis of the tube), on the principle that, in view of after contraction effects, an ellipse the minor axis of which is that of the bowel contains
more
square
area
than
a
transverse section.
Medical Societies. ROYAL MEDICAL AND CHIRURGICAL SOCIETY. The
Prognosis and Special Referenee
Treatment of Oirrhotie Ascites with: to the Treatment by Laparotomy.Metabolism in Phthisis. A MEETING of this society was held on June llth, Dr. F. W. PAVY, the President, being in the chair. A letter was read from His Majesty the King according his patronage to the Royal Medical and Chirurgical Society. The PRESIDENT referred to the reception by the King of a deputation from the Royal Medical and Chirurgical Society for the purpose of presenting an address of condolence on the death of Her late Majesty Queen Victoria. The President also reported that the roll of the Royal Medical and Chirurgical Society had been signed by the King. It had previously been signed also by Queen Victoria and William IV. Dr. H. CAMPBELL THOMSON made a communication on the Prognosis and Treatment of cases of Ascites occurring in the course of Alcoholic Cirrhosis of the Liver with special reference to the Treatment by Laparotomy. There was, he said, at the present time a considerable diversity of opinion regarding the prognosis of cirrhosis of the liver after the appearance of ascites. He had endeavoured to collect such information from the works of others and from his own experience, and this he believed would establish the following points-(l) That ascites arising during the course of a case of alcoholic cirrhosis of the liver might be due either (a) directly to the cirrhosis, or (b) it might depend upon some condition co-existing with the cirrhosis, such as chronic peritonitis or perihepatitis. (2) That ascites when directly dependent upon the cirrhosis was almost always a fatal condition, while, on the other hand, ascites associated with cirrhosis, but not directly dependent upon it, might often be temporarily relieved and occasionally permanently cured. (3) That, under these circumstances laparotomy performed on cases of cirrhosis of the liver with ascites was only likely to be successful in those cases in which the ascites was an associated condition of the cirrhosis and not directly dependent upon it, and that if this were so it would be misleading to look upon the operation as being one for the cure of cirrhosis of the liver. It should rather be looked upon as a means for the relief of cases of ascites, some of which, although occurring in the course of cirrhosis of the liver, were not directly dependent upon it and which were amenable to treatment. (4) That, taking a series of cases diagnosed during life as"cirrhosis of the liver with ascites," there was not sufficient evidence to show that the operation possessed any definite superiority over the more simple method of tapping. The observations of various authorities on the subject were quoted, and it was shown that whereas a patient suffering from ascites directly due to cirrhosis of the liver rarely lived long enough to survive more than one tapping (the average duration of life, according to Dr. Hale White, after the enlargement of the abdomen was first noticed being only eight weeks), patients suffering from ascites due to some associated condition might survive repeated tappings and even apparently recover. The clinical course of cirrhosis of the liver might, Dr. Thomson believed, be summed up in the following way. Cases might exist for years without any ascites, or, indeed, without any definite symptoms, but during this period ascites was liable to arise from some associated condition, the most common being chronic peritonitis and perihepatitis. Ascites
arising from this cause might be frequently relieved, and occasionally it eventually entirely disappeared, and the patient then returned to his former state of latent cirrhosis.
As time went on the cirrhosis until frequently the cirrhosis itself gave rise to. ascites, for which tapping was of no avail, and the patient succambed a few weeks after its onset. There need not be,. and frequently was not, any long interval between the first and last tapping, as the associated ascites often merged imperceptibly into that directly dependent upon the cirrhosis. Turning to the question of treatment directed to relieve the ascites, this could in most cases, Dr. Thomson believed, only be effectually done by tapping. Formerly it was advised to put off tapping as late possible, whereas now it was generally, advised as to tap early. The more radical operation recently introduced by Morison and Rutherford of opening the abdomen and promoting adhesions between the peritoneum, omentum, and parietes was then considered. A table of all the recorded If the operation were to. cases was submitted and analysed. survive it must be shown that it possessed some distinct
without any ascites.
progressed
over tapping since, notwithstanding the slight, risk of abdominal explorations, it was in every way The cases best suited more formidable than tapping. for operation were those in which the ascites was only an associated condition of the cirrhosis ; the presence of cirrhosis was not necessarily a contra-indication, but the further advanced the cirrhosis the less chance must there be of the operation being successful. If there believe that active symptoms of was good reason to cirrhosis had supervened and that the ascites was directly dependent upon the cirrhosis the operation should not be undertaken. There was, of course, often great difficulty in deciding whether the cirrhosis was still latent, and to this end the most careful attention must be given to the general condition of the patient. Errors would be further eliminated by only selecting such cases for operation which had been tapped several times.Dr. F. PARKES WEBER mentioned that the specific gravity of the fluid withdrawn by paracentesis of the abdomen was often notascertained, but that it ought always to be, and in regard to the point now under consideration it might furnisb very serviceable information. If the specific gravity were high (say, up to 1020 or nearly so) there was probably some inflammation present. In a case of cirrhosis which he (Dr. Weber) had observed the abdomen had been twice tapped and the specific gravity of the fluid withdrawn was noted as 1020. No further tapping was required. The post-mortem examination, six years later, proved that besides cirrhosis of the liver there had been perihepatitis and perisplenitis. In such cases, if a laparotomy were performed, the localised inflammation between the liver and diaphragm or about the spleen might have escaped notice and the cure of the ascites would then be set down as due to the operation. When peritoneal effusion occurred early in cases of cirrhosis the liver generally showed obvious enlargement, and the effusion was as often induced by a non-suppurative perisplenitis as by any peritonitis localised about the liver. Temporary cardiac weakness should likewise be mentioned as a possible cause of temporary ascites in cases of hepatic cirrhosis. Like Dr. Campbell Thomson and some others, Dr. Weber thought that laparotomy was not likely to give good results excepting in cases in which the liver was large, or at all events by clinical examination appeared to be large. In many of these cases an equally good result would be obtained by a few tappings, sometimes followed by the application of pressure to the abdomen, as recommended by Dr. Alexander Morison for ascites due to various causes.Dr. HALE WHITE referred to cases of cirrhosis of the liver with ascites which he had recorded 10 years before, and he was glad to find that Dr. Campbell Thomson had arrived at the same conclusions. All the cases he (Dr. White) had since seen tended to support these conclusions. Referring to the pathology of cirrhotic ascites, a little thought showed that it was not due merely to pressure on the venous radicals of the portal vein, and ligature of that vein did not produce ascites. Cirrhosis of the liver might be compared to granular kidney. Both lesions were only part of a general change, as witnessed by the onset of swelling of the feet in some cases before the ascites, and the termination by coma in both diseases. The ascites was probably due mostly to some associated peritonitis. When investigating a number of
’ superiority
1
Brit. Med. Jour., Sept. 19th, 1896.
1687 which proved, post mortem, to have cirrhosis of the per diem, while in cases with a considerable degree liver he had found that quite half of them had never had of arrest the excretion rose to 2’5 and 3 grammes. The any symptoms attributable to that condition during life. It rate of absorption of nitrogen was, on the whole, below cases
.
the normal, the more so the greatsr the severity of the was the same in granular kidney.-Dr. CAMPBELL THOMSON, in replying, dwelt on the early occurrence of swelling of the disease. On increasing the amount of proteid given there feet before the abdominal swelling as a valuable aid to the was a lessened absorption of nitrogen per cent., so that on large diets the waste of food was very considerable. The diagnosis of cirrhosis of the liver. Dr. FRANCIS W. GOODBODY, Dr. NOEL D. BARDSWELL, average rate of absorption of fats was extremely good in all and Mr. J. E. CHAPMAN made a communication on Meta- the cases, averaging about 98 per cent., thus confirming the bolism in Phthisis. Owing to the different opinions clinical observation that fat-containing foods were very well held by various observers as to the efficiency of treating borne in pulmonary tuberculosis. In the most advanced tuberculous diseases, and more especially pulmonary tubercu- cases of the disease under observation the most suitable losis, by over-feeding, it had occurred to them to carry out diet was found to consist of 129’87 grammes proteids, some researches as to the effect of increased feeding on the 135’05 grammes fats, and 225’56 grammes carbohydrates. metabolism of patients suffering from this disease. For this The conclusions arrived at were: 1. Both clinically and purpose cases of the disease of varying severity were selected, experimentally tuberculous patients showed very satisfactory and after their metabolism on the ordinary hospital diet had results on their diet being increased slightly above the been determined the diet was increased in various ways in original, and it was evident that the state of the appetite order to ascertain what was the maximum they could take gave too low an estimate of the requirements, as the original without causing too great a strain on the organism. Special diets were of their own selection as regards quantity. 2. attention was devoted to determining what number of calories Comparatively large diets were well borne by those who were per kilogramme body weight was the most suitable, as this much below their normal weights, but not so well supported was the easiest way of determining a. suitable diet. Having by-nor were such good results obtained in-patients up to ascertained the highest-known weight of, the patient a their normal weight and with arrested disease. 3. In all calculation was made as to what number of calories he cases very large diets gave unsatisfactory results, as the gain would require in a healthy condition. From this it was in weight was at the expense of the general health, as comparatively easy to order a diet containing a sufficient indicated by the failure of appetite, marked digestive number of calories to ensure that a system of over-feeding disturbanoe, and increased intestinal putrefaction. 4. was carried out. It was difficult to see what benefit a patient diets gave the best results, and could Moderately large could obtain from a system of " cramming," as the strain on probably have been continued for an indefinite period. 5. the organism must be very excessive. The researches The assimilation and absorption of nitrogen was good on the were made at the Brompton Hospital upon cases selected whole, even in cases with high pyrexia. The absorption of by Dr. Kingston Fowler. The estimations were made at the fats was excellent, although very large quantities were laboratory of University College. The first series of experi- given. 6. The patients complained least of discomfort on ments were designed to ascertain the normal metabolism the diets which gave the best results experimentally, and of certain healthy individuals who were placed on diets the onset of severe dyspeptic trouble coincided with detecontaining from 60 to 80 calories per kilogramme body rioration in the experimental results. 7. In cases in which weight. These excessive diets were taken with great the disease was becoming quiescent and the patient was difficulty, and the condition of the patients altered approaching his normal weight it was advisable to diminish considerably for the worse, although an increase in the quantity of food ; but even at this period a more subweight (from two to three kilogrammes) was noticed. stantial diet was necessary than when in health.For some days after the termination of the experiment Dr. BARDSWELL remarked that moderate quantities of food they suffered considerably from mucous colitis and did not gave the best results. The diet in any given case was regain their normal condition for from two to three weeks. best fixed by considering the amount of weight the patient In tuberculous diseases, in contra-distinction to the normal was below his maximum and the range of the pyrexia as individuals, patients suffering from pulmonary tuberculosis representing the activity of the disease. Further, if a stood a markedly increased diet very well and did not suffer patient put on one pound per week the lungs did better than a nearly so much from anorexia or dyspepsia. The number more rapid increase. He was much opposed to 11cramming." of calories per kilogramme body weight which gave the - Mr. CHAPMAN remarked that the diets as shown on the best results was between 50 and 70, any increase above charts exhibited had been calculated without certain extras. the latter number being quickly followed by symptoms The diets were worked out at 50 calories per kilogramme.of inability to take the diet, and in some cases vomit- The PRESIDENT complimented the authors on their coming occurred. When more than 70 calories per kilo- munication and remarked on the value of their researches in gramme body weight were taken there was a decided the sanatorium treatment of phthisis as being based upon a increase in weight during the period, but in no case was rational chemical foundation.-Dr. HALE WHITE had made some similar observatiuns on a patient under the Weir an adult patient so well at the termination of the period. In the cases suffering from the more advanced stages of the Mitchell treatment and in the main had come to the same disease more satisfactory results were obtained on diets conclusions. The patient had taken very large quantities containing about 70 calories per kilogramme, as on these of food. The fat had all been absorbed excepting about diets there was a considerable retention of nitrogen in 3 or 4 per cent. He had never succeeded in attaining a the body together with a comparatively small tax on the nitrogenous equilibrium and suggested, in order to account digestive organs. In cases which were not so advanced for the nitrogenous deficit, that possibly it was stored up in a diet containing about 60 calories per kilogramme gave the tissues in some form other than proteid. He remarked better results as regards the absorption and retention on the laborious nature of such investigations.-Dr. of nitrogen than larger ones. The average quantity of HORTON-SMITH asked if it was possible to give some urine excreted was low in comparison with the amount simpler rules for the construction of a dietary.-Professor of fluid taken, even when there were no noticeable night- VAUGHAN HARLEY remarked on the laborious nature of sweats, and the quantity did not increase proportionately such inquiries. They opened a new domain in medicine. to the increase in the quantity of fluids. In comparison The nitrogenous deficit was partly due, perhaps, to with the quantity of nitrogen given in the food the excre- Icheating" by the patient. A deficit of three grammes tion of total nitrogen in the urine was very low in the was well within experimental error. Too rapid an increase worst cases and increased markedly as the condition of caused considerable upset and what was to be aimed at was the lesions improved. The proportion of this substance a steady increase in weight. The number of calories per kiloexcreted in the form of urea was much below the normal in gramme could be based on the difference between the present bad cases ; it also fell when very large diets were given. and the highest weight of the individual.-Dr. GOODBODY, Notwithstanding the fact that a considerable quantity of in reply, referring to the difficulty of obtaining nitrogenous proteid was given in the diet the excretion of uric acid did equilibrium, said that the six patients under observation not increase markedly except in cases complicated by con- during four weeks gave 22 different periods for investigation, tinuous fever. On attempting to " cram" the quantity of and of these they had succeeded in obtaining nitrogenous ammonia increased considerably, pointing to diminished equilibrium in three instances. There was no easy means alkalinity of the blood. As had already been noted by of obtaining accurate information, though the estimation Russian observers, the authors of the paper found that the of urea gave a certain amount of information. The best quantity of phosphoric acid excreted in this disease was method was to estimate the total nitrogen in the urine and very small, in some cases being less than one gramme fsecea.
-
more
square
area
than
a
transverse section.
Medical Societies. ROYAL MEDICAL AND CHIRURGICAL SOCIETY. The
Prognosis and Special Referenee
Treatment of Oirrhotie Ascites with: to the Treatment by Laparotomy.Metabolism in Phthisis. A MEETING of this society was held on June llth, Dr. F. W. PAVY, the President, being in the chair. A letter was read from His Majesty the King according his patronage to the Royal Medical and Chirurgical Society. The PRESIDENT referred to the reception by the King of a deputation from the Royal Medical and Chirurgical Society for the purpose of presenting an address of condolence on the death of Her late Majesty Queen Victoria. The President also reported that the roll of the Royal Medical and Chirurgical Society had been signed by the King. It had previously been signed also by Queen Victoria and William IV. Dr. H. CAMPBELL THOMSON made a communication on the Prognosis and Treatment of cases of Ascites occurring in the course of Alcoholic Cirrhosis of the Liver with special reference to the Treatment by Laparotomy. There was, he said, at the present time a considerable diversity of opinion regarding the prognosis of cirrhosis of the liver after the appearance of ascites. He had endeavoured to collect such information from the works of others and from his own experience, and this he believed would establish the following points-(l) That ascites arising during the course of a case of alcoholic cirrhosis of the liver might be due either (a) directly to the cirrhosis, or (b) it might depend upon some condition co-existing with the cirrhosis, such as chronic peritonitis or perihepatitis. (2) That ascites when directly dependent upon the cirrhosis was almost always a fatal condition, while, on the other hand, ascites associated with cirrhosis, but not directly dependent upon it, might often be temporarily relieved and occasionally permanently cured. (3) That, under these circumstances laparotomy performed on cases of cirrhosis of the liver with ascites was only likely to be successful in those cases in which the ascites was an associated condition of the cirrhosis and not directly dependent upon it, and that if this were so it would be misleading to look upon the operation as being one for the cure of cirrhosis of the liver. It should rather be looked upon as a means for the relief of cases of ascites, some of which, although occurring in the course of cirrhosis of the liver, were not directly dependent upon it and which were amenable to treatment. (4) That, taking a series of cases diagnosed during life as"cirrhosis of the liver with ascites," there was not sufficient evidence to show that the operation possessed any definite superiority over the more simple method of tapping. The observations of various authorities on the subject were quoted, and it was shown that whereas a patient suffering from ascites directly due to cirrhosis of the liver rarely lived long enough to survive more than one tapping (the average duration of life, according to Dr. Hale White, after the enlargement of the abdomen was first noticed being only eight weeks), patients suffering from ascites due to some associated condition might survive repeated tappings and even apparently recover. The clinical course of cirrhosis of the liver might, Dr. Thomson believed, be summed up in the following way. Cases might exist for years without any ascites, or, indeed, without any definite symptoms, but during this period ascites was liable to arise from some associated condition, the most common being chronic peritonitis and perihepatitis. Ascites
arising from this cause might be frequently relieved, and occasionally it eventually entirely disappeared, and the patient then returned to his former state of latent cirrhosis.
As time went on the cirrhosis until frequently the cirrhosis itself gave rise to. ascites, for which tapping was of no avail, and the patient succambed a few weeks after its onset. There need not be,. and frequently was not, any long interval between the first and last tapping, as the associated ascites often merged imperceptibly into that directly dependent upon the cirrhosis. Turning to the question of treatment directed to relieve the ascites, this could in most cases, Dr. Thomson believed, only be effectually done by tapping. Formerly it was advised to put off tapping as late possible, whereas now it was generally, advised as to tap early. The more radical operation recently introduced by Morison and Rutherford of opening the abdomen and promoting adhesions between the peritoneum, omentum, and parietes was then considered. A table of all the recorded If the operation were to. cases was submitted and analysed. survive it must be shown that it possessed some distinct
without any ascites.
progressed
over tapping since, notwithstanding the slight, risk of abdominal explorations, it was in every way The cases best suited more formidable than tapping. for operation were those in which the ascites was only an associated condition of the cirrhosis ; the presence of cirrhosis was not necessarily a contra-indication, but the further advanced the cirrhosis the less chance must there be of the operation being successful. If there believe that active symptoms of was good reason to cirrhosis had supervened and that the ascites was directly dependent upon the cirrhosis the operation should not be undertaken. There was, of course, often great difficulty in deciding whether the cirrhosis was still latent, and to this end the most careful attention must be given to the general condition of the patient. Errors would be further eliminated by only selecting such cases for operation which had been tapped several times.Dr. F. PARKES WEBER mentioned that the specific gravity of the fluid withdrawn by paracentesis of the abdomen was often notascertained, but that it ought always to be, and in regard to the point now under consideration it might furnisb very serviceable information. If the specific gravity were high (say, up to 1020 or nearly so) there was probably some inflammation present. In a case of cirrhosis which he (Dr. Weber) had observed the abdomen had been twice tapped and the specific gravity of the fluid withdrawn was noted as 1020. No further tapping was required. The post-mortem examination, six years later, proved that besides cirrhosis of the liver there had been perihepatitis and perisplenitis. In such cases, if a laparotomy were performed, the localised inflammation between the liver and diaphragm or about the spleen might have escaped notice and the cure of the ascites would then be set down as due to the operation. When peritoneal effusion occurred early in cases of cirrhosis the liver generally showed obvious enlargement, and the effusion was as often induced by a non-suppurative perisplenitis as by any peritonitis localised about the liver. Temporary cardiac weakness should likewise be mentioned as a possible cause of temporary ascites in cases of hepatic cirrhosis. Like Dr. Campbell Thomson and some others, Dr. Weber thought that laparotomy was not likely to give good results excepting in cases in which the liver was large, or at all events by clinical examination appeared to be large. In many of these cases an equally good result would be obtained by a few tappings, sometimes followed by the application of pressure to the abdomen, as recommended by Dr. Alexander Morison for ascites due to various causes.Dr. HALE WHITE referred to cases of cirrhosis of the liver with ascites which he had recorded 10 years before, and he was glad to find that Dr. Campbell Thomson had arrived at the same conclusions. All the cases he (Dr. White) had since seen tended to support these conclusions. Referring to the pathology of cirrhotic ascites, a little thought showed that it was not due merely to pressure on the venous radicals of the portal vein, and ligature of that vein did not produce ascites. Cirrhosis of the liver might be compared to granular kidney. Both lesions were only part of a general change, as witnessed by the onset of swelling of the feet in some cases before the ascites, and the termination by coma in both diseases. The ascites was probably due mostly to some associated peritonitis. When investigating a number of
’ superiority
1
Brit. Med. Jour., Sept. 19th, 1896.
1687 which proved, post mortem, to have cirrhosis of the per diem, while in cases with a considerable degree liver he had found that quite half of them had never had of arrest the excretion rose to 2’5 and 3 grammes. The any symptoms attributable to that condition during life. It rate of absorption of nitrogen was, on the whole, below cases
.
the normal, the more so the greatsr the severity of the was the same in granular kidney.-Dr. CAMPBELL THOMSON, in replying, dwelt on the early occurrence of swelling of the disease. On increasing the amount of proteid given there feet before the abdominal swelling as a valuable aid to the was a lessened absorption of nitrogen per cent., so that on large diets the waste of food was very considerable. The diagnosis of cirrhosis of the liver. Dr. FRANCIS W. GOODBODY, Dr. NOEL D. BARDSWELL, average rate of absorption of fats was extremely good in all and Mr. J. E. CHAPMAN made a communication on Meta- the cases, averaging about 98 per cent., thus confirming the bolism in Phthisis. Owing to the different opinions clinical observation that fat-containing foods were very well held by various observers as to the efficiency of treating borne in pulmonary tuberculosis. In the most advanced tuberculous diseases, and more especially pulmonary tubercu- cases of the disease under observation the most suitable losis, by over-feeding, it had occurred to them to carry out diet was found to consist of 129’87 grammes proteids, some researches as to the effect of increased feeding on the 135’05 grammes fats, and 225’56 grammes carbohydrates. metabolism of patients suffering from this disease. For this The conclusions arrived at were: 1. Both clinically and purpose cases of the disease of varying severity were selected, experimentally tuberculous patients showed very satisfactory and after their metabolism on the ordinary hospital diet had results on their diet being increased slightly above the been determined the diet was increased in various ways in original, and it was evident that the state of the appetite order to ascertain what was the maximum they could take gave too low an estimate of the requirements, as the original without causing too great a strain on the organism. Special diets were of their own selection as regards quantity. 2. attention was devoted to determining what number of calories Comparatively large diets were well borne by those who were per kilogramme body weight was the most suitable, as this much below their normal weights, but not so well supported was the easiest way of determining a. suitable diet. Having by-nor were such good results obtained in-patients up to ascertained the highest-known weight of, the patient a their normal weight and with arrested disease. 3. In all calculation was made as to what number of calories he cases very large diets gave unsatisfactory results, as the gain would require in a healthy condition. From this it was in weight was at the expense of the general health, as comparatively easy to order a diet containing a sufficient indicated by the failure of appetite, marked digestive number of calories to ensure that a system of over-feeding disturbanoe, and increased intestinal putrefaction. 4. was carried out. It was difficult to see what benefit a patient diets gave the best results, and could Moderately large could obtain from a system of " cramming," as the strain on probably have been continued for an indefinite period. 5. the organism must be very excessive. The researches The assimilation and absorption of nitrogen was good on the were made at the Brompton Hospital upon cases selected whole, even in cases with high pyrexia. The absorption of by Dr. Kingston Fowler. The estimations were made at the fats was excellent, although very large quantities were laboratory of University College. The first series of experi- given. 6. The patients complained least of discomfort on ments were designed to ascertain the normal metabolism the diets which gave the best results experimentally, and of certain healthy individuals who were placed on diets the onset of severe dyspeptic trouble coincided with detecontaining from 60 to 80 calories per kilogramme body rioration in the experimental results. 7. In cases in which weight. These excessive diets were taken with great the disease was becoming quiescent and the patient was difficulty, and the condition of the patients altered approaching his normal weight it was advisable to diminish considerably for the worse, although an increase in the quantity of food ; but even at this period a more subweight (from two to three kilogrammes) was noticed. stantial diet was necessary than when in health.For some days after the termination of the experiment Dr. BARDSWELL remarked that moderate quantities of food they suffered considerably from mucous colitis and did not gave the best results. The diet in any given case was regain their normal condition for from two to three weeks. best fixed by considering the amount of weight the patient In tuberculous diseases, in contra-distinction to the normal was below his maximum and the range of the pyrexia as individuals, patients suffering from pulmonary tuberculosis representing the activity of the disease. Further, if a stood a markedly increased diet very well and did not suffer patient put on one pound per week the lungs did better than a nearly so much from anorexia or dyspepsia. The number more rapid increase. He was much opposed to 11cramming." of calories per kilogramme body weight which gave the - Mr. CHAPMAN remarked that the diets as shown on the best results was between 50 and 70, any increase above charts exhibited had been calculated without certain extras. the latter number being quickly followed by symptoms The diets were worked out at 50 calories per kilogramme.of inability to take the diet, and in some cases vomit- The PRESIDENT complimented the authors on their coming occurred. When more than 70 calories per kilo- munication and remarked on the value of their researches in gramme body weight were taken there was a decided the sanatorium treatment of phthisis as being based upon a increase in weight during the period, but in no case was rational chemical foundation.-Dr. HALE WHITE had made some similar observatiuns on a patient under the Weir an adult patient so well at the termination of the period. In the cases suffering from the more advanced stages of the Mitchell treatment and in the main had come to the same disease more satisfactory results were obtained on diets conclusions. The patient had taken very large quantities containing about 70 calories per kilogramme, as on these of food. The fat had all been absorbed excepting about diets there was a considerable retention of nitrogen in 3 or 4 per cent. He had never succeeded in attaining a the body together with a comparatively small tax on the nitrogenous equilibrium and suggested, in order to account digestive organs. In cases which were not so advanced for the nitrogenous deficit, that possibly it was stored up in a diet containing about 60 calories per kilogramme gave the tissues in some form other than proteid. He remarked better results as regards the absorption and retention on the laborious nature of such investigations.-Dr. of nitrogen than larger ones. The average quantity of HORTON-SMITH asked if it was possible to give some urine excreted was low in comparison with the amount simpler rules for the construction of a dietary.-Professor of fluid taken, even when there were no noticeable night- VAUGHAN HARLEY remarked on the laborious nature of sweats, and the quantity did not increase proportionately such inquiries. They opened a new domain in medicine. to the increase in the quantity of fluids. In comparison The nitrogenous deficit was partly due, perhaps, to with the quantity of nitrogen given in the food the excre- Icheating" by the patient. A deficit of three grammes tion of total nitrogen in the urine was very low in the was well within experimental error. Too rapid an increase worst cases and increased markedly as the condition of caused considerable upset and what was to be aimed at was the lesions improved. The proportion of this substance a steady increase in weight. The number of calories per kiloexcreted in the form of urea was much below the normal in gramme could be based on the difference between the present bad cases ; it also fell when very large diets were given. and the highest weight of the individual.-Dr. GOODBODY, Notwithstanding the fact that a considerable quantity of in reply, referring to the difficulty of obtaining nitrogenous proteid was given in the diet the excretion of uric acid did equilibrium, said that the six patients under observation not increase markedly except in cases complicated by con- during four weeks gave 22 different periods for investigation, tinuous fever. On attempting to " cram" the quantity of and of these they had succeeded in obtaining nitrogenous ammonia increased considerably, pointing to diminished equilibrium in three instances. There was no easy means alkalinity of the blood. As had already been noted by of obtaining accurate information, though the estimation Russian observers, the authors of the paper found that the of urea gave a certain amount of information. The best quantity of phosphoric acid excreted in this disease was method was to estimate the total nitrogen in the urine and very small, in some cases being less than one gramme fsecea.
-