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INTUSSUSCEPTION OF THE APPENDIX
691
CLINICAL NOTES
For the
of
resting or atrophic by mouth or 15 mg. injected intramuscularly is required. (3) With stilboestrol 50-60 mg. given by mouth a glandular cystic hyperplasia can be produced. (4) The stage of transformation and the menstruation following proliferation can be produced with anhydro-oxyprogesterone 220-300 mg. given by (2)
proliferation
a
endometrium stilbcestrol 25 mg.
mouth.
(5) Only in 2 cases were slight secondary symptoms observed after the administration of stilboestrol, but these rapidly disappeared. No secondary symptoms appeared after the administration of anhydrooxyprogesterone in doses of 25 mg. (five tablets) daily. (6) Lactation was either prevented or inhibited in 20 women by the administration of stilbobstrol 5-15 mg. by mouth. In most cases 5 mg. was sufficient. We are indebted to Prof. Werthemann and Dr. Scheidegger, of the Pathological Anatomical Institute
of Basle, for making the histological preparations, and to the Society of Chemical Industry in Basle (Ciba) and to the firm of Merck in Darmstadt for supplying us with their preparations. REFERENCES
Bishop, P.
M.
F., Boycott, M., and Zuckerman, S. (1939) Lancet
1, 5. Buschbeck, H., and Hausknecht, K. (1939) Klin. W schr. 18, 160. Clauberg, C., and Uestün, Z. (1938) Zbl. Gynäk. 62, 1745. Cook, J. W., Dodds, E. C., Hewett, C. L., and Lawson, W. (1934) Proc. roy. Soc. B, 114, 272. Dodds, E. C., Golberg, L. Lawson, W., and Robinson, R. (1938) Nature, Lond. 142, 211. — and Lawson, W. (1937) Nature, Lond. 139, 627. Ehrhardt, K., Kramman, H., and Schäfer, H. (1939) Münch. med. W schr. 86, 261. Engelhart, E. (1938) Wien. klin. Wschr. 51, 1356. Fierz-David, H. E., Jadassohn, W., Uehlinger, E., and Monnier, R. (1938) Nature, Lond. 141, 974. Guldberg, E. (1938) Ugeskr. Laeg. 100, 854. Kreitmaier, H., and Sieckmann, W. (1939) Klin. Wschr. 18, 56. Lindemann, W. (1939) Zbl. Gynäk. 63, 719. Loeser, A. (1939a) Klin. Wschr. 18, 346. (1939b) Brit. med. J. 1, 13. Winterton, W. R., and MacGregor, T. N. (1939) Ibid, p. 10. Zondek, B. (1929) Klin. Wschr. 8, 2229. (1935) Hormone des Ovariums und des Hypophysenvorderlappens, Vienna. —
—
CLINICAL NOTES INTUSSUSCEPTION OF THE APPENDIX A REPORT OF TWO CASES
BY CECIL P. G.
WAKELEY, D.Sc. Lond., F.R.C.S., F.R.S.E., F.A.C.S., F.R.A.C.S.
SENIOR SURGEON TO KING’S COLLEGE HOSPITAL ; SURGEON TO THE BELGRAVE HOSPITAL FOR CHILDREN
ALTHOUGH
of the appendix is well hundred cases have been reported ; but probably the incidence is greater than this would lead us to believe, for there must be many that come to operation and are not reported. My first case was in 1919 and my second in 1938, an interval of twenty ’years. Both patients were children, and it is interesting to note that most of the recorded cases have been in young children. It seems probable that the same factors may be at work in the causation of intussusception of the appendix as are responsible for the enterocolic intussusception in infants. The most constant feature in these cases is the presence of enlarged glands in the root of the mesentery and in the ileocaecal angle. Also, there is a preponderance of lymphoid tissue in the terminal ileum and in the appendix. This increased lymphoid tissue acts as a foreign body and causes increased and irregular peristalsis of the bowel and appendix, which at times culminates in an intussusception. But this cannot always be the cause, for the condition has been seen in children up to the age of 10 and even in adults; Huddy (1927) records a case in a man aged 39. Sometimes a stercolith may be an exciting cause of the intussusception, and worms may play a
intussusception
known, less than
a
part. The histories of my two
cases were as
follows :
CASE I.-A boy, aged 10 months, was admitted to hospital in June, 1919, because of screaming attacks and diarrhoea of some two days’ duration. The child was well nourished and appeared contented. He allowed his abdomen to be palpated. A definite lump was felt in the right iliac fossa, and manipulation of it caused him to scream. The temperature was 100° F. and the pulse-rate 120. Acute appendicitis was diagnosed and the abdomen opened under gas-and-oxygen anaesthesia through a muscle-split incision in the right iliac fossa. When the peritoneal cavity was opened, the caecum was found to be hard, and, when this was delivered into
the wound, only the tip of the appendix could be seen, the rest of it being invaginated into the caecum (see figure). The terminal ileum was pulled downwards towards the tip of the appendix by the oedematous meso-appendix. An attempt to reduce the intussusception of the appendix was unsuccessful, for the peritoneal coat of the caecum gave way in two places. An incision was therefore made into the caput cseci, and the intussuscepted appendix, together with a cuff of csecum, was excised. The ceecal opening was then closed with a double layer of Lembert sutures. The child made an uninterrupted recovery and left hospital ten days after the operation. The excised specimen consisted of an appendix completely intussuscepted except for its tip. The
(A)
(B)
of the appendix : (A) external aspect ; section. The terminal ileum is pulled down by the cedematous meso-appendix.
Intussusception (B)
on
coats of the appendix were oedematous and infiltrated with blood, and the vessels in the meso-appendix were thrombosed. CASE 2.-A boy, aged 5 years, was admitted to in December, 1938, with diarrhoea and vomiting of four days’ duration. The day before operation the doctor who was attending him noticed some blood and mucus in the stools and therefore suspected intussusception and recommended hospital treatment. On examination the boy appeared anxious and was considerably dehydrated, having vomited several times the night before admission. On abdominal palpation a tender swelling could be felt in the right iliac fossa. Notwithstanding its tenderness it could be moved about the iliac fossa, and the question of
hospital
692
CLINICAL NOTES
appendix abscess was therefore dismissed and colic intussusception diagnosed. Rectal examination gave a negative result. The pulse-rate was 100 and the temperature 1006° F. Operation was performed through a right paramedian incision, and the csecum and terminal ileum An intussuscepwere delivered through the wound. tion of the appendix was discovered and was with difficulty reduced and the appendix excised, the stump being buried in the caecum. The boy made an uninterrupted recovery and was discharged twelve days after the operation. The appendix was oedematous and its wall in places necrotic, and the vessels in the meso-appendix were thrombosed. It is nearly a hundred years ago that McKidd reported a case, and it seems difficult to believe that fewer than a hundred have been reported since. BIBLIOGRAPHY
Christopher, F. (1938) Ann. Surg. 108, 1111. Evans, A. (1922) Brit. J. Surg. 9, 565. Hamilton, T. (1931) Med. J. Aust. 9, 408. Hipsley, P. L. (1922) Ibid, 2, 65. Huddy, G. P. B. (1927) Brit. J. Surg. 14, 580. Johnson, G. (1915-16) Ibid, 3, 564. McKidd, J. (1858-59) Edin. med. J. 4, 793.
DIFFUSE SCLERODERMA AND RAYNAUD’S PHENOMENON FROM THE USE OF A PNEUMATIC HAMMER
BY DUNCAN
LEYS, D.M. Oxfd, M.R.C.P.
PHYSICIAN, ROYAL NORTHERN INFIRMARY, INVERNESS
IN 1924, when he
was
42, the patient,
foreman fingers of both He was then working a
arteries in the legs (dorsalis pedis and posterior tibial) could not be felt. The tendon jerks were present in the arms and legs and there was no evidence of any sensory disturbance, nor of muscle weakness. The serum Wassermann reaction was negative. Radio" " grams of the hands showed slight tufting of the terminal phalanges only. DISCUSSION
Scleroderma
.E’.;MM6M)K.—Now 57 years of age, he was a man of middle size with a high colour. The face was expressionless and immobile and the mouth small. The skin over the forehead and cheekbones and round about the mouth was tense, thin, and inelastic. With the utmost effort to open his mouth, the vertical aperture was not more than 1in. The palpebral fissures of both eyes were small. There was diffuse thickening of the subcutaneous tissues in both hands, extending down the fingers, across the palm, and over th3 dorsum of the hand, which prevented closure of the fist and full extension of the hand. All the fingers of both hands were pale. Lewis’s hyperaemia test showed an abrupt cessation of flushing at the base of the palm and at the base of all five fingers on the dorsal aspect in both hands. Radialartery pulsation was easily felt at the wrist in both hands. The blood-pressure in the right arm was 130/70 ; in the left arm the systolic pressure was 140, but no diastolic end-point could be obtained. All the fingernails and the toenails to a less degree showed a convexity in a longitudinal direction ; there was moderate clubbing of all the fingers. The peripheral
Raynaud’s phenomenon
are
commonly associated, and Raynaud’s phenomenon is an occasional sequel to the use of pneumatic tools; but I can find no previous record of the two conditions developing together in a pneumatic-tool worker. The incidence of Raynaud’s phenomenon in these trades is so high that individual susceptibility can play little part in its causation. To the vibration itself (aided by cold) one must ascribe the permanent changes produced in the vessels. Loriga (1929) says that permanent changes in the vessels resulting from the use of compressed-air tools are unknown, but this is not generally agreed, and Hunt (1936) finds no complete recovery from the Raynaud condition even when work is stopped for considerable periods. In the present case the question arises whether vibrations caused the scleroderma as well as the partial ischsemia of the fingers ; or would the patient have developed these if he had never worked vibratory machines Whatever the answer to this particular question, legislation to regulate the use of vibrating tools now seems to be overdue. For most trades tools have been devised which minimise the vibratory effects, and no others should be permitted.
mason, first,noticed numbness of the
hands during cold weather. in the United States, and had begun to use a compressed-air hammer the previous year. The instrument was held in the right hand and a chisel in the left. He continued to use the tool until 1930. Many of his mates had noticed similar symptoms and were annoyed by them, but nobody regarded the condition very seriously. When he returned to Scotland in 1934 he went on working as a mason, but not with a compressed-air tool. His hands still worried him in cold weather, but he noticed no other disability, except that the skin of the hands appeared to be getting thick, and there was some stiffness of the hands, which made flexion and extension of the fingers difficult. In January, 1939, he had a fall on the ice when he was watching some curling, and about a week later he found that the numbness of the fingers in the left hand was worse, and that the grip seemed weak.
and
REFERENCES
Hunt, J. H. (1936) Proc. R. Soc. Med. 30, 171. Loriga, G. (1929) Occupation and Health. International Labour Office, p. 162.
New Inventions COMBINED SPONGE AND GAS-DELIVERY TUBE I HAVE been using for the past few years the attachment illustrated here for prolonged administration of nasal gas for dental purposes. With this
device gas is administered both through the throat sponge which is normally used by the dentist and through the nose by the orthodox nose-piece.
The figure is self-explanatory. The sponge (c) is held between the collar on the male tube (A) and that on the female tube (B). The rubber junction tube (E)
fits over tube (A) jamming tube (B) into place. Induction is carried out in the ordinary way with a nose-piece. As soon as the patient is adequately anaesthetised, the damped sponge, ready mounted on the fitting and connected by rubber tubing to the gas. apparatus, is pushed over the tongue and into the pharynx. It is then immaterial whether the patient breathes through the nose or mouth. Since I have used this method I have had no difficulty in keeping any patient quiet for an indefinite time once I have succeeded in getting him really aneesthetised. The fitting was made for me by Messrs. A. Charles. Kino,
4. TtvrtrtOiT tT’’’þt
T,nnrlnn
W1
W. H. MARSHALL, M.B. Camb.
CLINICAL NOTES
For the
of
resting or atrophic by mouth or 15 mg. injected intramuscularly is required. (3) With stilboestrol 50-60 mg. given by mouth a glandular cystic hyperplasia can be produced. (4) The stage of transformation and the menstruation following proliferation can be produced with anhydro-oxyprogesterone 220-300 mg. given by (2)
proliferation
a
endometrium stilbcestrol 25 mg.
mouth.
(5) Only in 2 cases were slight secondary symptoms observed after the administration of stilboestrol, but these rapidly disappeared. No secondary symptoms appeared after the administration of anhydrooxyprogesterone in doses of 25 mg. (five tablets) daily. (6) Lactation was either prevented or inhibited in 20 women by the administration of stilbobstrol 5-15 mg. by mouth. In most cases 5 mg. was sufficient. We are indebted to Prof. Werthemann and Dr. Scheidegger, of the Pathological Anatomical Institute
of Basle, for making the histological preparations, and to the Society of Chemical Industry in Basle (Ciba) and to the firm of Merck in Darmstadt for supplying us with their preparations. REFERENCES
Bishop, P.
M.
F., Boycott, M., and Zuckerman, S. (1939) Lancet
1, 5. Buschbeck, H., and Hausknecht, K. (1939) Klin. W schr. 18, 160. Clauberg, C., and Uestün, Z. (1938) Zbl. Gynäk. 62, 1745. Cook, J. W., Dodds, E. C., Hewett, C. L., and Lawson, W. (1934) Proc. roy. Soc. B, 114, 272. Dodds, E. C., Golberg, L. Lawson, W., and Robinson, R. (1938) Nature, Lond. 142, 211. — and Lawson, W. (1937) Nature, Lond. 139, 627. Ehrhardt, K., Kramman, H., and Schäfer, H. (1939) Münch. med. W schr. 86, 261. Engelhart, E. (1938) Wien. klin. Wschr. 51, 1356. Fierz-David, H. E., Jadassohn, W., Uehlinger, E., and Monnier, R. (1938) Nature, Lond. 141, 974. Guldberg, E. (1938) Ugeskr. Laeg. 100, 854. Kreitmaier, H., and Sieckmann, W. (1939) Klin. Wschr. 18, 56. Lindemann, W. (1939) Zbl. Gynäk. 63, 719. Loeser, A. (1939a) Klin. Wschr. 18, 346. (1939b) Brit. med. J. 1, 13. Winterton, W. R., and MacGregor, T. N. (1939) Ibid, p. 10. Zondek, B. (1929) Klin. Wschr. 8, 2229. (1935) Hormone des Ovariums und des Hypophysenvorderlappens, Vienna. —
—
CLINICAL NOTES INTUSSUSCEPTION OF THE APPENDIX A REPORT OF TWO CASES
BY CECIL P. G.
WAKELEY, D.Sc. Lond., F.R.C.S., F.R.S.E., F.A.C.S., F.R.A.C.S.
SENIOR SURGEON TO KING’S COLLEGE HOSPITAL ; SURGEON TO THE BELGRAVE HOSPITAL FOR CHILDREN
ALTHOUGH
of the appendix is well hundred cases have been reported ; but probably the incidence is greater than this would lead us to believe, for there must be many that come to operation and are not reported. My first case was in 1919 and my second in 1938, an interval of twenty ’years. Both patients were children, and it is interesting to note that most of the recorded cases have been in young children. It seems probable that the same factors may be at work in the causation of intussusception of the appendix as are responsible for the enterocolic intussusception in infants. The most constant feature in these cases is the presence of enlarged glands in the root of the mesentery and in the ileocaecal angle. Also, there is a preponderance of lymphoid tissue in the terminal ileum and in the appendix. This increased lymphoid tissue acts as a foreign body and causes increased and irregular peristalsis of the bowel and appendix, which at times culminates in an intussusception. But this cannot always be the cause, for the condition has been seen in children up to the age of 10 and even in adults; Huddy (1927) records a case in a man aged 39. Sometimes a stercolith may be an exciting cause of the intussusception, and worms may play a
intussusception
known, less than
a
part. The histories of my two
cases were as
follows :
CASE I.-A boy, aged 10 months, was admitted to hospital in June, 1919, because of screaming attacks and diarrhoea of some two days’ duration. The child was well nourished and appeared contented. He allowed his abdomen to be palpated. A definite lump was felt in the right iliac fossa, and manipulation of it caused him to scream. The temperature was 100° F. and the pulse-rate 120. Acute appendicitis was diagnosed and the abdomen opened under gas-and-oxygen anaesthesia through a muscle-split incision in the right iliac fossa. When the peritoneal cavity was opened, the caecum was found to be hard, and, when this was delivered into
the wound, only the tip of the appendix could be seen, the rest of it being invaginated into the caecum (see figure). The terminal ileum was pulled downwards towards the tip of the appendix by the oedematous meso-appendix. An attempt to reduce the intussusception of the appendix was unsuccessful, for the peritoneal coat of the caecum gave way in two places. An incision was therefore made into the caput cseci, and the intussuscepted appendix, together with a cuff of csecum, was excised. The ceecal opening was then closed with a double layer of Lembert sutures. The child made an uninterrupted recovery and left hospital ten days after the operation. The excised specimen consisted of an appendix completely intussuscepted except for its tip. The
(A)
(B)
of the appendix : (A) external aspect ; section. The terminal ileum is pulled down by the cedematous meso-appendix.
Intussusception (B)
on
coats of the appendix were oedematous and infiltrated with blood, and the vessels in the meso-appendix were thrombosed. CASE 2.-A boy, aged 5 years, was admitted to in December, 1938, with diarrhoea and vomiting of four days’ duration. The day before operation the doctor who was attending him noticed some blood and mucus in the stools and therefore suspected intussusception and recommended hospital treatment. On examination the boy appeared anxious and was considerably dehydrated, having vomited several times the night before admission. On abdominal palpation a tender swelling could be felt in the right iliac fossa. Notwithstanding its tenderness it could be moved about the iliac fossa, and the question of
hospital
692
CLINICAL NOTES
appendix abscess was therefore dismissed and colic intussusception diagnosed. Rectal examination gave a negative result. The pulse-rate was 100 and the temperature 1006° F. Operation was performed through a right paramedian incision, and the csecum and terminal ileum An intussuscepwere delivered through the wound. tion of the appendix was discovered and was with difficulty reduced and the appendix excised, the stump being buried in the caecum. The boy made an uninterrupted recovery and was discharged twelve days after the operation. The appendix was oedematous and its wall in places necrotic, and the vessels in the meso-appendix were thrombosed. It is nearly a hundred years ago that McKidd reported a case, and it seems difficult to believe that fewer than a hundred have been reported since. BIBLIOGRAPHY
Christopher, F. (1938) Ann. Surg. 108, 1111. Evans, A. (1922) Brit. J. Surg. 9, 565. Hamilton, T. (1931) Med. J. Aust. 9, 408. Hipsley, P. L. (1922) Ibid, 2, 65. Huddy, G. P. B. (1927) Brit. J. Surg. 14, 580. Johnson, G. (1915-16) Ibid, 3, 564. McKidd, J. (1858-59) Edin. med. J. 4, 793.
DIFFUSE SCLERODERMA AND RAYNAUD’S PHENOMENON FROM THE USE OF A PNEUMATIC HAMMER
BY DUNCAN
LEYS, D.M. Oxfd, M.R.C.P.
PHYSICIAN, ROYAL NORTHERN INFIRMARY, INVERNESS
IN 1924, when he
was
42, the patient,
foreman fingers of both He was then working a
arteries in the legs (dorsalis pedis and posterior tibial) could not be felt. The tendon jerks were present in the arms and legs and there was no evidence of any sensory disturbance, nor of muscle weakness. The serum Wassermann reaction was negative. Radio" " grams of the hands showed slight tufting of the terminal phalanges only. DISCUSSION
Scleroderma
.E’.;MM6M)K.—Now 57 years of age, he was a man of middle size with a high colour. The face was expressionless and immobile and the mouth small. The skin over the forehead and cheekbones and round about the mouth was tense, thin, and inelastic. With the utmost effort to open his mouth, the vertical aperture was not more than 1in. The palpebral fissures of both eyes were small. There was diffuse thickening of the subcutaneous tissues in both hands, extending down the fingers, across the palm, and over th3 dorsum of the hand, which prevented closure of the fist and full extension of the hand. All the fingers of both hands were pale. Lewis’s hyperaemia test showed an abrupt cessation of flushing at the base of the palm and at the base of all five fingers on the dorsal aspect in both hands. Radialartery pulsation was easily felt at the wrist in both hands. The blood-pressure in the right arm was 130/70 ; in the left arm the systolic pressure was 140, but no diastolic end-point could be obtained. All the fingernails and the toenails to a less degree showed a convexity in a longitudinal direction ; there was moderate clubbing of all the fingers. The peripheral
Raynaud’s phenomenon
are
commonly associated, and Raynaud’s phenomenon is an occasional sequel to the use of pneumatic tools; but I can find no previous record of the two conditions developing together in a pneumatic-tool worker. The incidence of Raynaud’s phenomenon in these trades is so high that individual susceptibility can play little part in its causation. To the vibration itself (aided by cold) one must ascribe the permanent changes produced in the vessels. Loriga (1929) says that permanent changes in the vessels resulting from the use of compressed-air tools are unknown, but this is not generally agreed, and Hunt (1936) finds no complete recovery from the Raynaud condition even when work is stopped for considerable periods. In the present case the question arises whether vibrations caused the scleroderma as well as the partial ischsemia of the fingers ; or would the patient have developed these if he had never worked vibratory machines Whatever the answer to this particular question, legislation to regulate the use of vibrating tools now seems to be overdue. For most trades tools have been devised which minimise the vibratory effects, and no others should be permitted.
mason, first,noticed numbness of the
hands during cold weather. in the United States, and had begun to use a compressed-air hammer the previous year. The instrument was held in the right hand and a chisel in the left. He continued to use the tool until 1930. Many of his mates had noticed similar symptoms and were annoyed by them, but nobody regarded the condition very seriously. When he returned to Scotland in 1934 he went on working as a mason, but not with a compressed-air tool. His hands still worried him in cold weather, but he noticed no other disability, except that the skin of the hands appeared to be getting thick, and there was some stiffness of the hands, which made flexion and extension of the fingers difficult. In January, 1939, he had a fall on the ice when he was watching some curling, and about a week later he found that the numbness of the fingers in the left hand was worse, and that the grip seemed weak.
and
REFERENCES
Hunt, J. H. (1936) Proc. R. Soc. Med. 30, 171. Loriga, G. (1929) Occupation and Health. International Labour Office, p. 162.
New Inventions COMBINED SPONGE AND GAS-DELIVERY TUBE I HAVE been using for the past few years the attachment illustrated here for prolonged administration of nasal gas for dental purposes. With this
device gas is administered both through the throat sponge which is normally used by the dentist and through the nose by the orthodox nose-piece.
The figure is self-explanatory. The sponge (c) is held between the collar on the male tube (A) and that on the female tube (B). The rubber junction tube (E)
fits over tube (A) jamming tube (B) into place. Induction is carried out in the ordinary way with a nose-piece. As soon as the patient is adequately anaesthetised, the damped sponge, ready mounted on the fitting and connected by rubber tubing to the gas. apparatus, is pushed over the tongue and into the pharynx. It is then immaterial whether the patient breathes through the nose or mouth. Since I have used this method I have had no difficulty in keeping any patient quiet for an indefinite time once I have succeeded in getting him really aneesthetised. The fitting was made for me by Messrs. A. Charles. Kino,
4. TtvrtrtOiT tT’’’þt
T,nnrlnn
W1
W. H. MARSHALL, M.B. Camb.