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AN UNUSUAL CASE OF APPENDICITIS.

BY W. ALFORD TAYLOR, M.B. LOND.,HON. SURGEON, ROYAL BUCKS HOSPITAL, AYLESBURY.

THE following case came under my care at thehospital on Feb. 14th of this year.A farm labourer, aged 26, complained of generalised

abdominal pain. He had not felt well since Christmasand had had three attacks of colicky pain across lowerabdomen at intervals of a few days, each lasting for threedays, but not -severe -enough to stop him working. Threedays before admission he had vomited once. The bowelshad been open regularly except on the day of admission.On examination the temperature was 1022° F., the pulse-

rate 106, and the respiration-rate 28. The tongue wascoated and dry. He had generalised abdominal tenderness,more marked in the right iliac fossa. There was rigidityof the right rectus, and hyperesthesia over Poupart’sligament. Per rectum nothing abnormal was detected.Under an anaesthetic a small, hard, movable lump was

palpated 1 in. mesial to the anterior superior iliac spine.The abdomen was opened by Battle’s incision, and theappendix was found completely enveloped in a sheath ofomentum, which bled freely, but was returned to theabdomen after the insertion of haemostatic sutures. Theappendix was acutely inflamed and presented a drumstickappearance caused by a spherical swelling in. from theceecal end. The appendix was removed by the usualmethod, the stump being buried and the abdomen closedwithout drainage. The patient made an uninterruptedrecovery.

The appendix was found to contain an intactbarcelona nut, of full size, and showing indentationscaused by teeth. The patient denied having eatenany nuts sinoe Christmas. I

Medical Societies.

HARVEIAN SOCIETY OF LONDON.

THE TREATMENT OF ULCERATIVE COLITIS.A MEETING of this Society was held on April 19th,

with the President, Dr. HERBERT FRENCH, in thechair.A discussion on the Treatment of Ulcerative

Colitis was opened by Dr. H. LETHEBY TiDY from

Th6 Medical Aspect.He said that colitis was a condition in which there

was diarrhoea and the stools contained blood andmucus. This might occur without ulceration, as inbacillary dysentery, or ulceration might supervenewithout any change in the symptoms. It was,however, practically certain to be present in a patientwho had suffered from these symptoms for any lengthof time. The onset might be dramatically sudden,but more often, in civil practice, the doctor saw thepatient after his condition had drifted on for a fewmonths or, occasionally, for a few days or weeks.The chronic case might have acute exacerbations.

Certain general principles of treatment must beaccepted whatever other methods were adopted.First and foremost, the patient must be kept warm.Warmth checked peristalsis and had certain generaleffects which made it of the utmost importance.In Dr. Tidy’s experience the patient with the warmmoist skin would recover ; it had rightly been said,"the dysenteric who sweats never dies." There wasforty to fifty times the difference in mortality betweenthe warm and the cold patient. Mere confinementto bed was not enough; the extremities must bewrapped in wool to wrists and ankles, even ina tropical climate. The second cardinal principlewas that the patient must be given fluid-not inlarge draughts, but as a medicine. During the acutestage he should take 1 or 2 oz. every 20 minutes whileawake, with a total of 4 or 5 pints in the 24 hours.

The alternatives of treatment were by injection,by the mouth, by vaccines, and by serum. Dr.Tidy had found drugs by the mouth of little value,with the exception of aromatic sulphuric acid andcharcoal. It was utterly wrong to give morphiain any circumstances whatsoever. An injectionwould check the diarrhoea and was therefore veryhard to resist, but it must not be given. It wasdoubtful, too, whether the drug was ever justified bythe mouth,. even in the form of such preparations aschlorodyne. Cases that would clear up like an

ordinary diarrhoea would clear up just as well withoutmorphia, and severe cases ought not to have it. Dr.Tidy could not persuade himself that any valuableresults had followed the use of vaccines. Serum wasof enormous value for a very short time after theonset of bacillary dysentery, but not in the laterstages. It was therefore not indicated in the ordinarychronic colitis of civilian practice. There were threeways of treating the rectum-by starch and opiumenemas, by colonic washes, and by medicated enemas.The mortality would be halved at once if medicatedenemas could be abolished ; they could do verygrave injury and must be withheld to the very endof the treatment.The first measure should be the starch and opium

enema, with a maximum volume of 4 oz..-3 oz.

for the average man and 2 oz. for a woman-andwith a dose of -!If to 2 drachms of the tincture ofopium. The fluid should be administered througha soft rubber No. 10 catheter and funnel, with 6 to8 in. of pressure. Its effect lasted about 12 hours,and the enema should therefore first be given atnight, to ensure rest. It must not be given morethan five times a week and never on more than threeconsecutive days. If the anus and rectum were onceallowed to get irritated they would reject the enemaand the whole treatment would be put back for afortnight. If after three weeks of this treatmentthe number of stools had been reduced to half, thepractitioner might count himself lucky, and mightthen pass to the second stage of colonic washes. Thesemight consist of any bland fluid-for instance, a

drachm to the pint of sodium chloride or 2 drachmsto the pint of sodium bicarbonate. The wash shouldbe given in the same way as the enema with a pressureof 12 to 18 in.-never more than 2 ft. Two pintsof fluid should be used and should never take lessthan half an hour to administer. The patient shouldlie on alternate sides during the administration.There was no doubt that the fluid reached the csecumwhen given in this way. Very few patients wouldstand more than three washes a week, and they shouldnever be given them on more than two consecutivedays, with a maximum of four one week and threethe next. It would often be necessary to return fora time to the starch and opium enema to keep downthe number of stools. In contradiction to the adviceof the text-books. these two forms of treatmentmust be continued for six or eight months beforemedicated enemas were started. The medicamentsirritated the colon and must be the final curativestage of treatment, which was not reached until therewere consistently fewer than five motions a day.For a medicated enema albargin was the best prepara-tion in a dose of j,,L drachm to 30 oz. of saline ortap-water ; 25 oz. should be given very slowly aftera colonic wash, of which at least half must have beenreturned. The best routine was to give a washbetween 6 and 9 A.M. and the enema about 10 A.M.The absolute maximum was six in a fortnight, followedby a week’s rest. Any attempt to rush the treatmentdefeated its own object, and practitioner and patientalike must realise that the whole treatment was amatter of many months, usually eight or twelve.No colon which had been through this trouble wasgoing to be " cured," any more than an amputatedleg could be " cured," but most patients at the endof the course passed no more than two or threemotions a day and could live active lives. " Cure "might be interpreted as not more than three or fourfairly formed motions daily. There was no justification

858

whatever for the appalling mortalities recorded.Errors were due to reliance on medicated enemas anddrugs by the mouth and to haste.

aetiology and Pathology.Mr. LIONEL NORBURY said that the dysentery bacillus

had been incriminated as the cause of ulcerativecolitis, but against this was the absence of historyof infection, of infectivity, and of the bacillus in thestools, as well as the fact that the serum of patientsdid not agglutinate the Shiga bacillus, nor did thepatient benefit from antidysenteric serum. Manydifferent organisms had been isolated. Constitutionaldiseases, such as chronic nephritis, might be compli-cated by ulcerative colitis. In several cases achlor-hydria has been a feature, and these patients hadimproved on a course of hydrochloric acid. Shortageof calcium in the blood and of vitamins might bepredisposing causes. The pathology varied fromcedematous areas with vascular granular patches inthe colon to small punclied-out ulcers, which mightrun together and form large areas. CEdematous

masses of mucous membrane might be isolated andsimulate polypi. The ulcers were not underminedand were usually superficial, so that little scar tissueresulted. Nevertheless, they might spread to theperitoneum, producing nstulae and perforations.In many cases there was no characteristic ulceration,but only raw bleeding areas denuded of epithelium.The disease was one of early adult life and the sexeswere about equally affected, though at St. Mark’sfemales had seemed to preponderate. Death resulted

from haemorrhage, exhaustion, perforation, or periton-itis. The diagnosis was made on the symptoms andon the appearances seen through the sigmoidoscope.

The Surgicul Treatment.The treatment, after rest and warmth and suitable

measures directed to the cause, if this could be ascer-tained, consisted of removal of septic foci and aliberal diet, including vitamins, fats, and fruits.Drugs for alleviation of symptoms included zincoxide pills, 3 grains thrice daily; 15 minims ofcastor oil in gelatin capsules, kaolin, bismuth,opium, kerol, dimol, and animal charcoal. Vaccinesmight be made from organisms taken from thegranular surfaces (Dr. Cuthbert Dukes had deviseda special sucker for this purpose) or from the urine.Lavage should be administered in the knee-elbowposition, or with the patient on alternate sides and thepelvis raised. Hypertonic saline, silver, albargin,sanitas, or kaolin could be used. Blood transfusionwas useful for severe cases. Zinc ionisation gavegood results with some patients, although the

sigmoidoscope showed that no real cure had beenbrought about. If the case did not readily respondto ordinary methods appendicostomy should be Iperformed, as it was obvious that better irrigationcould be obtained from above than from below. Iffor any reason appendicostomy was unsuitable a

valvular ceecostomy might replace it. Two to fourquarts of fluid should be washed through the openingtwice daily, and very acute cases might be treatedwith continuous irrigation. To rest the colon a rightcolostomy or caecostomy was necessary, but the fluidfaeces at this level made the nursing difficult andstenosis was very likely to follow. In these respectsa right lumbar colostomy was better. Excision wasusually impracticable because of the debilitatedcondition of the patient. u’hile the symptomsmight improve considerably, the sigmoidoscopeusually showed that the condition was little altered.Ulcerative colitis was one of the most serious con-ditions of intestinal disorder and one of the mostdifficult to cure, requiring several years of regularirrigation through an appendicostomy.

Bacillary aetiology.Dr. BELL.lN&HAM SMITH argued that the condition

was an endemic dysentery, of which we had not yetrecognised the causative organism. In a number ofhis cases an unknown non-lactose-fermenting bacillushad been isolated. It was well known that the

Shiga bacillus was obtainable from all cases ofdysentery in the first 72 hours, but the number ofpositive results rapidly fell. Since few cases ofulcerative colitis were seen early, the organism wasnot likely to be found often. He agreed with previousspeakers about drug and local treatment, but thoughtthat sodium sulphate had value in the early stages,combined with spirit of aromatic ammonia and ginger.Adrenalin added to the opium enema was useful.The condition was practically incurable and couldonly be relieved. Of his 46 cases 24 had died, 13 undermedical and 11 under surgical treatment ; 16 hadimproved, and three had much improved.

Mr. C. P. G. WAKELEY pointed out that perforationwas nearly always in the csecum or right colon.Treatment should be based on sigmoidoscopic exam-ination. If the ulcers were shallow and the mucousmembrane cedematous, medical treatment would give-the best results, but it could do no good if the ulcerswere deep and going into the wall of the bowel. Then-caecostomy or right colostomy would give greatbenefit. After six months of medicated enemas thepatient was a miserable creature with tenesmus anda patulous anus, and would get great relief fromcaecostomy. Appendicostomy did not give verygood results. He preferred hypertonic saline at100° F. for irrigation from above. The conditionwas not so incurable as was made out if earlydiagnosis and treatment were instituted by the useof the sigmoidoscope.

Sir JOHN BROADBENT supported the bacillaryaetiology, quoting recent work at the Mayo Clinic,where a Gram-positive lancet-shaped diplococcus hadbeen isolated and had given satisfactory experimentalresults. Vaccines of this organism had given 60 per cent.of recoveries. He had seen cases which had improvedremarkably and thought the claim worth investigation.The PRESIDENT described two cases which he had

hoped to show. Both had been in an appalling stateafter years of medical treatment ; both had recoveredafter colectomy and resumed active life. The onlygood results he had known had been from colectomy,.but surgeons were loth to perform it and patientsto undergo it. There were probably many differentcauses of the condition, and in the later stages it-could not matter what the original cause had been.Cure meant getting the patient into such a state-that he no longer needed medical attention. He hadnever seen cure after any kind of treatment in a.

case of more than six months’ standing. Any treat-ment might give relief, but relapse followed. It wasremarkable that the condition never appeared any-where but in the colon.

Sir WILLIAM WrLLCox said that many cases werehopeless from the first. Post-mortem examination-showed that the condition was very like bacillary

dysentery, and that it might spread up the first fewinches of the small intestine. He agreed that theoriginal cause was a bacillus, but this was swampedby secondary infections in a few days. Treatmentmust depend on the stage of the disease. Hypertonic-intravenous saline was useful for those cases wherethe diarrhoea was choleraic.

Dr. Tii)y, in reply, said that the vast bulk of caseswere no doubt due to some organism, and he wassure that the Mayo coccus was the " enterococcus

"

of Sir Thomas Houston. Nevertheless ulcerativecolitis might be due to many different things.

Mr. NORBURY also briefly replied.

SOCIETY OF MEDICAL OFFICERS OFHEALTH.

AT a meeting of this Society held at the Guildhall,.Bath. on April 20th, the acting President, Dr. E. H.SNELL being in the chair, a discussion took placeon theCAUSES OF THE DECLINE IN TUBERCULOSIS MORTALITY.

’ Sir ROBERT PHILIP (Professor of Tuberculosis,.Edinburgh University), in the opening paper, traced-