702 DR. FARQUHARSON, M.P., ON THE RESULTS OF SANITATION.

there are serious daggers connected with defects in our

complicated arrangements for drainage and sewage disposal.This is depressing, but it has its bright side. No doubt it isdangerous to be placed within easy reach of receptacles offoul air and sewer gas, as we all are, and necessarily mustbe, under the system of water-borne sewage common to ourgreat towns ; but the greater the risk the greater should bethe care exerted to keep it off. It would be a good thing ifworkmen, and more especially those who manufacture the’complicated structures which modern hygiene requires,should not only feel but carry into practice thefull sense of responsibility resting on them in connexionwith their tlaje; and that they should be taught how abit of scamped work-a leaking cesspool, or a badly placedor constructed drain, or a badly-socketed soil-pipe, or

any derangement in the mechanical contrivances designed tokeep out the sewer gas which is always trying to force itsway in.-may destroy human life just as effectually as poison,or the knife. This is why I have persistently supported thePlumbers’ Registration Bill in and out of Parliament, being- convinced, as I am, that without establishing a monopoly, or- doing any real harm to any vested interest, the establish-ment of a defined curriculum, followed by registration and- examination, will raise the status and character of theworkman, and by increasing his sense of responsibility and,his interest in his work will not only confer benefits on him,but also on those by whom he is employed.The next point I wish to refer to is the curious way invhich, when we have abolished one set of diseases, anotherband of successors sometimes springs up hydra-headed toplague poor humanity. I suppose it must be so, for we poormortals have not put on immortality, but must shuffle offour mortal coils, in some swift or lingering way, so

that if we are prevented from dying from one disease wemust of sad neoessity die from another, and diminution ofone death-rate involves increase somewhere else. Entericfever remains pretty stationary in the last ten years,but a drop from 309 in 1876 to 175 in 1895 does credit to.our sanitary administration, and phthisis has gone downfrom 26,443 in 1876 to 22,775 in 1894. Small-pox has takena satisfactory dip downward from 2405 in 1876 to 33 in 1895.Measles, a arlet fever, and whooping cough have killed fewerthan formerly, but, per contra, diphtheria has largelyincreased, and that is no doubt due, as Sir R. Thorne Thornesaya in a private communication which I have received fromjhim, " to the ever-growing facilities for personal infection,and other similar points have followed on the success inherding our child population into elementary schools at the’very age at which they are most susceptible to this disease."40 umber diseases have also increased, and the point I wish tomake is this, that they are mostly diseases connected with thenervous system, and that Crichton Browne was probably rightin hia opinion that not merely the nervous temperament, butthe neurotic diathesis is on the increase among us. To beginwith, it is a mournful but I fear an undoubted fact that morepeople go mad than formerly. I have not by me any.4r,atibtics to prove this beyond the report of the Registrar-general for 1895, but there I find under the heading ofinsanity and general paralysis-a disease which was seldom,heard of in former years-3620 deaths in 1895, against 933rin 1876.

Angina pectoris, a typically neurotic disorder, has increased’within the same period from 397 to 696; valvular disease ofthe heart, which has some practical sympathy with the,neurotic diathesis, has gone up from 274 to 10,072 ; whilstBright’s disease, the frequent causation of which by suddenmental shock has been demonstrated by Clifford Albutt,hows an alarming rate of increase from 4100 to 8351.Cancer has nearly doubled since 1876, and diabetes reachedits highest point in 1895, accounting for 2265 deaths over10 in 1876, whilst most of us know only too well thefirm grip taken by influenza on the British constitution, and ithe way in which in more recent years it has attacked the IImervous system. There seems no doubt, therefore, about’the fact that we are now in the midst of a neurotic age,.and, moreover, an age which is essentially anaemic. Howmany young girls in any rank of life escape passing through.a blocdleas stage, which suggests a strike or a lock-outamong their red corpuscles, and a consequent stagnationof their vital processes ? 7Let ua take another glance at the Registrar-General’s report,

where we will see that deaths from arivemia, chlorosis, andlC1JCocythaemia have advanced from 576 in 1876 to 1883 in1895, and this, together with a glance at the cheeks of the

rising generation, must convince you that this increase of

pallor is only too real.[Dr. Farquharson here remarked that he wished to say a

word in favour of sexual selection, commending the Vicar ofWakefield for choosing his wife as she chose her wedding-dress-" on account other wearing qualities." With respectto vaccination, he suggested that the age should be raised soas to avoid the teething and eruptive periods, and that everyinfant should have four good marks, the operator beingpreferably a public vaccinator. He then referred to schoollife and house accommodation, and concluded as follows :]Each of us is individually responsible to ourselves and to

others for our scheme of sanitation, and then we pass intothe hands of local authorities, who are doing good work, whogenerally give you value for your money, and whose beneficialoperations I hope you duly appreciate. But over them standsthe House of Commons, and I am glad of this opportunity ofsaying that I have a very poor opinion of that legislativeassembly in its dealings with public health. Both sides arebad, but that to which I belong is, I think; the worst, forsuspicion of scientific methods atld of progressive sanitationis deep-rooted in certain Radical quarters, and abstract viewsof personal liberty and distrust of the so-called tyranny ofmedical men sway a kind of plausible sentiment which is

usually irresistible in its paralysing effects on hygienic legis-lation. As a Member lately remarked with refreshingfrankness when we were considering the Public Health(Scotland) Bill, " When I see the doctors on both sidesof the House my instinct tells me that something is wrongand I will vote against the amendment." Under such con-ditions the private Member can do nothing, beyond beingusefully employed in stimulating public opinion in and out-side the House, until particular problems reach the acutestage and are taken under Government protection. Inconclusion, let me reiterate the strong wish I have alreadypublicly expressed in favour of a Ministry of Health, adepartment of the State which would collect into one

harmonious whole the scattered threads of sanitary legisla-tion, which would focus all health questions, and admissionto which would be an object of honourable ambition to thebest scientific talent of the day.

ABSTRACT OF A

Post-Graduate AddressON

THE MEDICAL ASPECTS OFAPPENDICITIS.

Delivered at the West London Hospital on Feb. 3rd, 1897,

BY DONALD W. C. HOOD, M.D.CANTAB.,F.R.C.P. LOND.,

SENIOR PHYSICIAN TO THE WEST LONDON HOSPITAL.

GENTLEMEN,-That form of local peritonitis so frequentlymet with in the right iliac fossa and known under the variousnames, typhlitis, perityphlitis, or appendicitis, presentsnumerous features of interest both to the physician and thesurgeon. I have thought that it might be useful on thepresent occasion to discuss the disease from its medical

aspects alone, for while fully acknowledging the brilliantachievements of surgery in connexion with abdominaldiseases, I have no hesitation in affirming that we are indanger of looking upon the treatment of appendicitis from atoo exclusive point of view, and I fear that many, by forget-fulness of the good results which follow a purely medicalcourse of treatment, lose the valuable opportunit:es whichonly come to those who see the disease at the earliestonset.

In considering the diagnosis of appendicitis we must firstglance at the forms or varieties under which the disease ismet with, and we must consider briefly those affections withwhich it is liable to be confounded. We meet with appen-dicitis in one of two principal forms-namely, (1) an acute

703DR. D. W. C. HOOD : THE MEDICAL ASPECTS OF APPENDICITIS.

peritonitis due to sudden perforation of the appendix, and(2) localised inflammation in connexion with the csecum orappendix.The first variety is happily rare, and I believe is in many

cases akin to that form of perforation met with in gastriculcer and latent typhoid fever. During twenty-five years’fairly active work I have never met with such a case eitherin private or hospital practice, and I doubt whether suchperforation ever occurs without some premonitory symptoms.These cases are usually met with in the post-mortem room,and they may come there without a correct diagnosis, butthis scarcely proves that symptoms were entirely absent.Some individuals, however, have an exceptional power ofwithstanding the constitutional disturbances of severe

diseases, this tolerance of disease being especially marked inlatent typhoid fever, and in acute perforating gastric ulcer.Hence it is possible for perforation of the appendix to takeplace even where those symptoms which we consider to bepathognomonic of the condition are latent, if not entirelyabsent. The following case proved to me that well-markedobjective symptoms may be present without producing muchconstitutional distress. A medical friend called upon meone afternoon, stating that he had not been feeling wellfor some days, and I was surprised to find the iliacfossa occupied by a large tumour. Within a few hoursof seeing me he was examined by a surgeon, who

subsequently informed me that he looked upon thetumour as being malignant. However, a few days’rest in bed and opium as a remedy restored my friendto perfect health, and there has been no recurrence ofabdominal trouble.The second or more ordinary form of appendicitis can be

subdivided into many clinical states, but I doubt if we gainmuch by such subdivision. We have clinically to considertwo main conditions of localised inflammatory mischiefwithin the right iliac fossa, one with tumour and onewithout. In other words, the inflammatory mischief may becircumscribed or more diffuse. The first and by far moreusual condition can only be overlooked or misinterpreted ’’,through carelessness or ignorance ; the other form, however,is much less common, and the symptoms are frequently liableto misinterpretation. A good instance of this variety cameunder my notice last year. The patient had gone to churchon a Sunday feeling well ; after the service she felt poorly,and it was thought that she had been chilled, the windhaving been specially keen and penetrating. That night shewas seized with sharp abdominal discomfort and diarrhoea,which continued during the following day, the temperaturerunning up to 101° F. She was given a "dose," but thepain, pyrexia, and diarrhoea continued for the next fourdays. It was on the evening of the fourth day, that I firstsaw the patient. She looked very ill, had a small, rapidpulse, raised temperature, dry red tongue, and frequentdiarrhoea. The abdomen was flat, and there were no rosespots. Extreme pain was felt on making light pressure onthe right iliac area. No tumour could be detected. It

appeared to me that the balance of clinical evidence was infavour of the attack being due to local trouble rather thanto specific fever. The following day a pultaceous blood-stained stool was passed. The patient was still in a verycritical state. The diarrhoea had ceased, there was pain inthe iliac fossa, but no tumour or thickening. The next

morning on making careful pressure over this area there wasdecided resistance, giving the sensation of infiltrated tissue.The condition of the patient then improved, and she made acomplete recovery, but from first to last there was no decidedtumefaction of the part.The ordinary form of appendicitis as met with in hos-

pital patients is unattended with much difficulty as regardsdiagnosis, because the disease is well developed and past theprimary stage of initial onset, but with private patients thecase is different, and more often than not we have the

opportunity of investigating the symptoms of the attackwithin a few hours of their commencement.The first symptom is pain, which may vary in amount

from extreme pain, almost agony, to mere abdominal dis-comfort. As far as my experience serves me, commencingappendicitis is invariably attended with some rise of tempera-ture. In the larger proportion of simple abdominal ailmentsattended by pain there is no rise of temperature; butabdominal discomfort with diarrhoea and raised temperaturehas been far from unusual with certain forms of influenza,and this fact must be kept in view. If, then, in any patientwho complains of aching in the abdomen we find a raised

temperature, it is necessary to carefully examine the part.This cannot be properly done unless the patient is undresaedand lying down. Even in the earliest stages inspection willoften give us assistance; aided by good light you will atonce be struck by the absence of movement over the affectedarea. The portion of the abdominal parietes lying betweenthe ribs and the pelvic crest moves but little if at allduring respiration. This want of muscular action is farmore evident later, but it will be present at first in some-degree. I have often been able to demonstrate the absenoeof movement when not easily detected by the eye by placingon the part a long lever such as a stethoscope. In the firsbfew hours of illness pain. with even but a slight rise oftemperature, should be sufficient to place us on our guard,and when, after baring the abdomen, immobility of the partis seen, it is almost pathognomonic of the specific nature ofthe attack, and scarcely renders necessary the putting to proofthe presence of the fourth symptom- tenderness on palpation.In recent years much stress has been laid upon the Jimitationof pain to one spot, the so-called" McBurney’s point,"’but I prefer to trust to the general conditions rather than toany one limited point of more decided pain than another.Far more help will be given by placing the palm of a warmhand upon the abdomen. Gentle pressure over the iliacfossa will in ninety nine cases out of a hundred give all theinformation required, and will be far less likely to lead toerror than if the tips of the fingers are pressed into a partwhich is even in many normal individuals exceedinglysensitive. As time measured by hours passes on we shallfind evidence of resistance, thickening of deep parts, andfinally tumour, which may in some cases encroach largelyupon the abdominal cavity. The whole abdomen may be-come swollen and tender. The early stage of fever plusabdominal tenderness is well shown in the following case..A girl, aged nine years, had suffered from a sharp attackof appendicitis in December, 1881. On Jan. 15th, 1882, hernurse found her crying in bed and complaining of stomachache. The child bad gone to bed apparently in perfect-health and had completely recovered from a previous attack.When seen by me within an hour of the first complaint Ffound tenderness of the iliac fossa and a temperature of100° F. The attack was a severe one, the temperature’’fluctuating between 101° and 103° for eight days. The-bowels acted on the ninth day. The patient made a perfectrecovery and since the illness has had no return of abdominaltrouble.

In addition to the four cardinal symptoms of appendicitis,the pain, fever, local tenderness, and immobility of abdominalwalls, there are other symptoms which attend the progress ofthe attack, the most common being vomiting. I find that in308 cases this symptom was specially noted in 208 patients-It is a symptom which forebodes neither good nor evil.Appendioitis may be complicated by either constipation or-diarrhoea ; the former occurred in 145 patients out of 308,the latter (diarrhoea) in 58 patients out of the same number.The presence of diarrhoea in the early stage frequently leads-to an erroneous diagnosis, so that it is well to bear in mindthis not unusual state of bowel. Of the 58 cases in whichlooseness of bowel was present, 43 made good uncoPJplicated’recoveries and 3 recovered with abscess. Nine patientsdied; of these 2 succumbed to general peritonitis and 7* ’suffered from abscesses.Some writers make a distinction between those attacks of

local peritonitis which are accompanied by exudation ofcoagulable material but in which the symptoms pass awaywith more or less rapidity, and that class of cases where the! -inflammatory mischief leads up to the formation of pus.Clinically I believe it to be absolutely impossible to die-tinguish between these two classes of case in their earlierstages, and I think it is equally impossible to say whether or-not they have the same pathological cause. On this points.our hospital cases afford us but little assistance. Thesepatients being admitted at every stage of their illness, anymortality-rate obtained from a series of cases is grosslyri-misleading as to the direct effect of treatment. Dr. Eyre-has very kindly and with great care and labour examined:";the medical records of Guy’s Hospital between the years.1867-1895, and has tabulated for me all the cases of

appendicitis admitted as such during that period. Thus -

among 308 cases admitted during twenty-nine years fifty-fivepatients died. But when these individual cases were

examined we found that in a large proportion the patient ..died within a few hours of admission, and many wereadmitted!after the formation of an abscess. Such statistics

704 MR.EVE: SURGICAL TUBERCULOSIS AND KOCH’S NEW TUBERCULIN.

are of almost no value as indicating the efficacy or thedisadvantages of any line of active treatment.

My experience of surgery in connexion with appendicitisis 7cil, every case that has come under my care has hithertomade a complete recovery, with the solitary exception of aman admitted into the North West London Hospital someyears ago suffering from a second attack. He was admittedwith symptoms of general peritonitis and an operation wasnot considered advisable. He had apparently quiterecovered from the primary attack. The treatment adoptedbefore admission had been that of purging.The onset of the affection varies much-it may be acutely

sudden or creep insidiously on for several days. The follow-,ing history is of value as it comes from the hand of amedical man who placed himself under my care in May, 1894.The patient stated: "On getting into bed I was suddenlyseized with shivering and vomiting; my temperature was,100 6° F. The abdomen generally was tender. I passed avery restless night, nausea and retching being continuous.Abdominal pain was acute, but so far not localised. The

temperature was 101.°. During the day symptoms were much,the same. During the second night the pain became localisedin the right iliac fossa and the diagnosis was clear." I sawthe patient on the third day of illness. The right iliac fossawas occupied by a large tender tumour. The case did well,the bowels being relieved on the tenth day. There has beenno return of the inflammatory mischief.

, The symptoms may begin in a most indefinite manner andrun a very slow course, in such cases being mostly gastricin character and liable to be treated as such.

(Dr. Hood here gave clinical descriptions of several othercases. He also quoted from Dr. Hawkins’s monograph onDiseases of the Vermiform Appendix, and remarked thatperitonitis occurring in connexion with the uterineppecdaes may sometimes create difficulties in thediagnosis. He continued :]

-

la the course of the last dfty years the treatment of theselocal inflammations occurring within the abdomen has passedthrough three stages. Daring the first period the maintreatment was that of opium combined with calomel.Gradually the calomel was omitted from the prescription andtreatment remained with opium alone. During later yearsopium with many has been dreaded, and early operationhas taken its place. For my own part I attach the utmostimportance to the making of an early diagnosis and to theearly use of opium; I scrupulously avoid all aperientremedies.

The cases which have been under my own care includetwelve private patients and twenty-three in hospital, all ofwhom, with the one exception above alluded to, made a goodrecovery, and in nc instance was there suppuration. The,cases seen in private have remained under observation andhave been free from any form of abdominal discomfort.Hospital cases do not afford evidence of the good results:which follow a simple medical treatment, in consequence ofthe fact that a large proportion of them do not apply untillong after the commencement of their symptoms. Mypatients, on the contrary, with scarcely an exception, cameunder treatment at a very early stage of illness, and are ofvalue as showing the results of a purely medical treatment.Practically a relapse is not of dangerous omen. Amongmy private cases in which the subsequent history has beenknown to me there were three instances of relapse. Onewas a child who sixtten years ago had two attacks within thesame year and has had no return. The second was a manwho suffered from a very severe form in 1879 and in 1881 hadanother, but since that date has had no return or any formof abdominal discomfort. The third was a young man whoduring 1888-9 had five attacks, in 1890 passed throughtyphoid fever and since the last attack of appendicitis hashad no trouble of any kind referable to the abdomen. Thesecases were all treated with opium. The patient should beconfined to bed and kept absolutely to slop diet-in fact,treated on the same lines as if suffering from typhoid fever.He should have hot applications to the abdomen, and fromfirst to last should be rigorously kept from any form ofaperient remedy. I have never seen any harm ensue fromthe bowels being confined for from seven to double thatnumber of days. My plan has been to wait till the fall oftemperature and then when scybalous masses are to be feltin the left iliac fossa to give a simple soap-and-water enema.Opium should be given from the first moment that diagnosisis possible. I prefer to administer it either in its solidform or as Dover’s powder, the amount varying with the

exigencies of the case, and I think that one is more likely toerr from giving too little than from giving too much, In anordinary case I give half a grain every four or six hours, andI have never seen harm ensue. It soothes the nervoussystem, renders the restraint of bed more endurable, relievesthe pain which if untreated is often very great, promotesphysiological rest of the part affected, and, in my opinion,promotes repair and restoration of the inflamed tissue.When I first commenced practice I used to combine bella-donna with the opium, but soon gave up the use of theformer drug, as I could find no material advantage in thecombination and it had the disadvantage of making thethroat dry and parched.

CASES OF SURGICAL TUBERCULOSISTREATED BY KOCH’S NEW

TUBERCULIN.BY FREDERIC EVE, F.R C.S. ENG.,

SURGEON TO THE LONDON HOSPITAL AND TO THE EVELINA HOSPITALFOR SICK CHILDREN.

THE following eight cases are examples of surgicaltuberculosis under my care at the Evelina Hospital in whichthe treatment by Koch’s new tuberculin 1 (tuberculin R)has been completed, or nearly so. The first three cases of

tuberculous disease of joints without sinuses or evidence ofsoftening of caseous material show the only favourableresults. Cases 2 and 3 were examples of early tuberculosisof the elbow and hip respectively. Of these it may fairlybe said that the same results might have been anticipatedfrom "surgical rest" and improved diet &c. In Case I-apatient with relapsing tuberculosis of the knee of four years’duration-it seems probable that the remedy exerciseda favourable influence. Case 5 was an instance oftuberculous peritonitis with ascites which was treatedimmediately after admission by laparotomy. Duringthe administration of the tuberculin there was no re-

accumulation of the fluid, but the child continuouslylost weight. It was necessary to give the tuberculinvery slowly and gradually owing to the weakly conditionof the child and to avoid pyrexia ; so that at the date ofwriting the treatment is only just completed. The remainingfour cases were all examples of tuberculosis with sinuses.These, with one possible exception, were absolutely uninfla-enced by treatment. The sinuses did not heal, and in threeinstances operation was ultimately required. Case 7, that ofa child with tuberculous teno-synovitis of the dorsum of thehand, seems clearly to show that no immunity to tuber-culo&is was established by the treatment. The tuberculousmaterial had become caseous and broken down with sinusformation, but was not, in the ordinary acceptance of theterm, septic. After the conclusion of the tuberculin courseall the tuberculous material was freely and carefully removedby operation, no bone disease being found. The woundhealed by first intention, but two or three weeks laterrecrudescence occurred in the scar and subjacent tissues.The exception mentioned above was a patient with tuber-culous epididymitis. A sinus remained after the opening ofan abscess at the London Hospital just previously toadmission to the Evelina Hospital. The sinus healed duringthe administration of tuberculin.My own personal impressions of the results of the new

remedy may be summed up as follows. Some slightalthough no markedly favourable influence may be exerted incases of early tuberculosis of joints or in those in which noevidence of softening of caseous material exists. Butthe effect where caseous material has broken down, andespecially if the disease has become septic, is negative. Thesubsequent course of the cases described below will be care-fully watched.

It cannot be said that the new remedy is altogether freefrom the drawbacks possessed by the old tuberculin ofproducing pyrexia and constitutional disturbance. In nearly

1 Professor Koch’s original article announcing the remedy appearedin the Deutsche Medicinische Wochenschrift, April 1st, 1897.

2 My experience is not confined to the cases here recorded, but I havewatched several other cases in which the treatment has not been com-pleted and some under the care of my colleagues in which the coursewas completed.