119

While Dr. Strong and Dr. Teague believe that in similar

epidemics masks ought to be worn by all attending upon thesick, nevertheless the masks are not to be regarded asaffording absolute protection against the infection of pneu-monic plague. In the Manchurian epidemic the wearing ofmasks lent a false security to the wearers and led some ofthem to take unnecessary risks with fatal consequences.

APPENDICITIS AS A LOCAL MANIFESTATION OF

A GENERAL INFECTION.

THE current view that appendicitis is due to some local

cause, of which the most important is constipation, is no

doubt correct in the main, but the possibility that it may bea local manifestation of a general infection is not commonlyconsidered. That it may exceptionally be a manifestationof typhoid fever has long been known. Recently in ourcolumns Dr. F. J. Poynton and Dr. A. Paine reported a casein which appendicitis appeared to be due to streptococcalinvasion through the blood from follicular tonsillitis. 1 At a

meeting of the Académie de Medecine of Paris on Oct. 22ndM. F. Widal, in collaboration with M. P. Abrami, M. Et.Brissaud, and M. Weissenbach, made an important com-munication on the Hæmatogenous Origin of Certain AcuteAppendicites, which is worthy of further notice than the

brief note of our Paris correspondent. 2 They pointed outthat while the view had been maintained that appendicitismight be the localisation of a blood infection, no conclusivedemonstration of the fact had been given. This was furnishedby the following case. A woman, aged 45 years, was admittedinto the Cochin Hospital on May 17th, 1912, with the dia-gnosis of typhoid fever. She was in such a state of stupor thatshe could not answer questions. Previously in good health,she was suddenly attacked on May 3rd with fever, rigors,headache, and diarrhoea. On the following days she becameworse; there were four or five foetid stools daily, the tempera-ture rose to 1040 F., the headache increased, and deliriumoccurred. On admission she seemed to have a typicalattack of typhoid fever. The tongue was dry, the lipswere dusky, and the skin had a slightly icteric tint. On the

abdomen, flanks, and the sides of the chest was an abundant

eruption of rose spots. There were also tympanites andgurgling in the right iliac fossa, but no muscular rigidity.In the chest sonorous and sibilant rhonchi were heard. The

urine was dark coloured and contained albumin. On the

19th the general condition suddenly became worse, the

stupor increased, the temperature rose to 104.4°, there wasconstipation, the tympanites became intense, the abdomenpresented generalised "muscular defence," the hepaticdulness disappeared, and there was a peritoneal facies. The

pulse became small and uncountable, the extremities cold,greenish fluid was vomited, and the patient died comatose.At the necropsy 200 to 300 c. c. of turbid liquid were foundin the pelvis. In the small intestine the lesions of typhoidfever could not be found ; Peyer’s patches were not

swollen. Near the end of the vermiform appendix apatch of gangrene could be seen through the trans-

parent peritoneum. In its centre was a fine openingfrom which exuded on pressure a drop of turbid fluid. On

opening the appendix the typical lesions of gangrenous

appendicitis were found. On the mucous membrane of thecaecum was a number of ecchymotic patches. In the

appendicular pus and in the peritoneal fluid the paratyphoidbacillus B was found in almost pure culture. During life,on May 17th and 19th, this bacillus was found in the blood.The illness ran a course of two stages. For 15 days therewas the typical picture of severe typhoid fever, then the

1 THE LANCET, August 17th, 1912, p. 439.2 THE LANCET, Nov. 9th, 1912, p. 1328.

symptoms of acute appendicitis suddenly supervened. The-

appendicitis was evidently the final result of the generalinfection. M. Widal suggested that microbial emboli. dueto the septicaemia, entered the appendical and caecal

branches of the inferior mesenteric artery. The ecchy-motic patches in the cæcum showed a nodular and peri-vascular infiltration traversed by numerous dilated capillaries.obstructed by colonies of the paratyphoid bacillus. Thview that appendicitis may be of hæmatogenous originhas been sustained by clinicians for some years. In

1896 Jalaguier insisted that measles was a cause of appenm-dicitis, and in the following year Merklen and Faisans drewattention to influenza as a cause. After this several writers-

reported cases in which the portal of entry of the infectionwas furnished by a premonitory angina. Other cases were.

recorded in which the cause appeared to be pneumonia,scarlet fever, mumps, and even subcutaneous inflammation,Later pathological evidence was brought forward. In fatal’

cases of post-anginal appendicitis the streptococcus wa?found in the tonsil, submaxillary glands, and in the vessels,and coats of the appendix. More recently appendicitis hasbeen experimentally produced by infection of the blood, andthe view has been brought forward that the inoculated’

microbes may be eliminated by the appendix. All that was

wanting to complete the evidence was the cultivation of thecausal organism from the blood, and this has been furnished’by the case reported above. In cases of appendicitis which)early show severe general symptoms a septicsemic origin,should be suspected.

-

ONTJan. 22nd and 24th, at 5 P.m., the first two lectures.under the Semon Lecture Trust will be delivered at Univer-

sity College, London, by Dr. Peter McBride. The subjectwill be ’’ Sir Felix Semon, his Work, and its Influence onLaryngology."

THE HEALTH OF THE ARMY IN 1911.

I.

Improved Health of the Army.THE improvement in the health of the British army both

at home and abroad that has been so noticeable during-recent years continues to progress, the statistics for 1911that have just been issued showing that the ratios for-admission to hospital, average number of men constantlysick, and invalids discharged, are, the lowest hitherto-

recorded, while the death ratio is practically the same as.last year. The following figures are the ratios per 1000 :-

Admissions. Constantly Deaths. Invalids.-. sick. Invalids.

1889-98 ... 997-3 ... 59-85 ... 9’03 ... 15-361906-10... 534-0 0 ... 30-90 ... 4-59 ... 10-361910...... 443-1 ... 25-38 ... 3-44 ... 9-111911 ...... 421-1 ... 24-28 ... 3-47 ... 8-09

Not only is there great improvement since the decennium’immediately preceding the South African war, but on com-parison with the five-year period 1906-10 there is seen tobe a notable diminution in all ratios ; and in every item.but one there is an improvement as compared with 1910.Even if the number of men suffering from slight disabilities,and under treatment in barracks, be added to those con-stantly sick in hospital, the total ratio only amounts to-31 - 83 per 1000.The total force, amounting to 216,628 warrant and non-

commissioned officers and men, may be divided into three-groups from a medico-statistical point of view; about onehalf the number (109,399) are serving in the United.

Kingdom ; the remainder are either stationed in India

(72,371) or in the various colonies and dependencies of theEmpire (34,858). As compared with 1910, there is a

fractional increase in the admission and death-rates for-

1 Report on the Health of the Army for 1911. H.M. Stationery Office1912. Price ls. 8d.