ST. MARY'S INSTITUTE OF PATHOLOGY AND RESEARCH.

1245 There were very varying estimates as to the frequency of occurrence of diverticula. In the mortuary period of knowledge-when everything we knew was gleaned from post-mortem examinations-diverticula were said to be very rare ; certainly very few ST. MARY’S INSTITUTE OF PATHOLOGY cases indeed were recorded. Since the investigations of surgeons and radiologists had been going on it AND RESEARCH. became known that more than 1 per cent. of the total population had duodenal diverticulum. But to ensure a diagnosis by X rays it was necessary to have a DIVERTICULA OF THE ALIMENTARY TRACT. combination of expert radiologist and very incredulous ON June 15th Sir BERKELEY MOYNIHAN delivered physician or surgeon. When those two agreed their before a large audience at St. Mary’s Institute of diagnosis might be right in 50 per cent. of the cases. Pathology and Research a lecture on this subject. Their Results. Their Origin. As to the tendencies of diverticula, these " wayside The lecturer said that one of the ways in which he houses " took care of material passing along the lumen delighted to squander his time was by reading a of the tube, and it became the lodger there, and the dictionary, and it recently occurred to him that he accretion caused a progressive increase in its size. would like to know the exact meaning of the word One in the pharynx, for example, might become quite diverticulum." It was described as a wayside gigantic. Inflammation followed, and an ulcer might house of ill-fame." The development of diverticula in form ; and if this burrowed deeper and deeper, attachment to surrounding structures might occur, and perman might be essential to the formation of certain organs : the pancreas and the liver were formed by foration through the diverticulum, resulting in an diverticula budding out from the duodenum. Things external fistula. The commonest example of this was sometimes went awry, however, with a diverticulum, the fistula which formed between the bladder and the and then certain pathological consequences might large intestine, and this was practically always a fistula ensue. Among the sequelae were the following: between a chronic diverticulitis and the bladder, (1) The diverticulum might progress in normal fashion, brought about by simple inflammation, probably at the base of the diverticulum glandular tissue might never by a malignant condition. Occasionally, the be found which eventually became pancreas or liver process of perforation was so slow that the walls of the intestine all round the diverticulum became or thyroid gland, pancreas and liver retaining their ducts which open into the intestine ; the thyroid enormously thickened, and then, in the large intestine gland losing its duct, and having only a small part of especially, there would take place such an exact the foramen caecum, and a structure like an appendix mimicry of malignant disease that no one was expert might result. (2) The diverticulum might be present enough to distinguish one from the other by naked-eye at a certain period of foetal development and thereafter examination alone. All surgeons would admit having wither. Twelve years ago Lewis and Thing investigated excised supposed carcinoma of the sigmoid to find the condition in the foetus of the duodenum and the later that it was typical chronic diverticulitis. So far rest of the small intestine, and they found that, as a as the large intestine was concerned, he thought the normal condition, small diverticula were developed commonest of the after-results was the formation of almost through the whole length of the intestine, and cancer. He thought it true to say that not less than that occasionally diverticula were found budding out i 25 per cent. of cases of carcinoma of the large intestine from the stomach. The rule was for these diverticula on the left side were due to chronic diverticulitis, to disappear at the fourth month, but when they another of the groups, therefore, in which longremained they formed diverticula such as he would continued minimal irritation gave rise eventually to show numerous photographs of. (3) A diverticulum carcinoma. Sir Berkeley Moynihan then showed slides of a might be present as a normal process during development, and might fulfil its function, but its distal part large series of specimens. On dissecting the pharynx might be cut off altogether from the lumen of the from behind there would be found, between the two alimentary canal, and certain remnants were left portions of the inferior constrictor, an area almost behind, forming such structures as the pouch of Rafke devoid of muscular tissue. In the upper part the funcand Meckel’s diverticulum. The foregoing were all tion was to grasp the bolus of food so as to drive it congenital, and in them all the coats of the intestine down into the oesophagus, and the lower part of the were represented, hence they were known as true constrictor acted as a sphincter. For some reason diverticula. There were also acquired diverticula, there was a lack of coordination between the two parts which appeared during later life ; these were false of the inferior constrictor, so that the sphincter would diverticula, in that they did not contain all the coats of not relax at the exact moment it should. Pressure the intestine. Acquired diverticula were of two types : was brought on the Langerman-Ackerman area, and either pulsion diverticula-occurring by herniation of a little bulb of mucosa occurred, which gradually the mucosa through the remaining walls of the enlarged until there was produced a large pouch in the intestine-or traction diverticula-an adhesion on the neck. The condition could be diagnosed by pressing outer side of the intestine pulling out a small angle- on the left side of the neck, when a bubble of gas like process from the mucosa through the other walls passed into the mouth, or even food. If a bismuth of the intestine. The occurrence of pulsion diverticula meal were given, a black shadow could be seen remainmight be due to a variety of reasons. There might be ing in the diverticulum three or four weeks afterwards. a congenitally weak spot in the intestine through Indeed, a pharyngeal diverticulum could be diagnosed which the mucosa was herniated, such as that between without examination ; if the patient talked two or the two portions of the inferior constrictor at the three minutes, the movements forced air into the Langerman-Ackerman area. Or there might be a weak mouth and interrupted his syllables-in other words, spot at the place where a vessel passed through the bubbles of air escaped into his voice. There were very intestinal wall ; such was seen in the large intestine few operations in surgery so difficult as that of removing

Medical Societies.

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in the condition known

as

diverticulitis.

Or the

intestinal wall might be weakened by the passage of duct. In people with visceroptosis the part of the duodenal .wall where the common bile-duct passed through might be weakened, and then a small portion of mucous membrane might be herniated through it. Or a diverticulum might occur as a result of the weakening caused by a chronic duodenal ulcer. A traction diverticulum almost always occurred owing to adhesion of a gland to the outside of the intestine. a

one of these diverticula : the muscles must be retracted to get at the attachment with the most minute accuracy. The serious danger was that if one opened the planes of the neck extensively to expose the diverticulum they must be closed with meticulous care, otherwise infection would occur, because the contents of the sac were very foul, and such conditions were very difficult to heal. When diverticula occurred in the stomach it was generally along the greater curvature. If a patient

1246 not suffering, even if the radiologist found a affected eye. Now she could only discern shadows at diverticulum, he should be left alone ; but often such the periphery. There was no conjunctivitis or circumsupposed cases who suffered were found to have a gall- corneal congestion, and the cornea was clear. There bladder full of stones. A large number of diverticula was a detachment of the retina at the macula, ovoid occurred at the entrance of the common duct into the and regular in shape, of smooth surface, and greyishwas

duodenum ; he showed the photograph of such a case. These pouches might occur in the small intestine at any point, but they were more numerous at the upper end of the small intestine than elsewhere. He showed photographs of specimens with numerous diverticula. Diverticula might also occur at any part of the large

white in colour. There was choroidal pigmentation below the surface of the swelling. The tension was plus 8 to 10. W.R. negative. He had advised the patient to have the eye removed, but asked the views of members.-Sir JOHN PARSONS said the history was a long one for a condition which started in the macula. intestine, though they were vastly more frequent on The late Gunn had had a case of small tumour in the left than on the right side. In 1906 a man was the macular region which manifested itself by a dissent to him from Carlisle who gave a typical history turbance of central vision at a very early stage. At of duodenal ulcer, and Sir Berkeley Moynihan operated the lower part of the fundus in that case there was a upon him for it. In addition, the man had what seemed large simple detachment of the retina, separated from like appendicitis, and the rest of the abdomen was a very shallow detachment just over the growth. examined, according to custom when that could be Possibly the same kind of thing had occurred in the done. Sir Berkeley Moynihan found what he took to present case. be carcinoma in the sigmoid flexure, for which enterectomy was done. Subsequent examination of the speciWEST LONDON MEDICO-CHIRURGICAL men showed it was typical diverticulitis, and it was the SOCIETY. first case of that kind which had been recognised in this condition had been the diagnosed country. Previously as rupture of the appendix epiploicee. Diverticula might A MEETING of this Society was held on June 2nd, burst acutely, causing acute perforative appendicitis. with Sir GEORGE LENTHAL CHEATLE, the President, If the inflammation was subacute and recurrent, there in the chair, when Dr. LEONARD DossoON read a was a typical condition of appendicitis on the left paper on side ; such could be met with in cases of transposition Rheumatoid rth7°itis and its Practical Treatment. of viscera. An abscess might form, a stricture might Dr. Dobson defined the condition as an acute or chronic form, there might be perforation into the bladder, an external fistula might occur, and so on, and especially disease of the joints, of infective, toxic, or septic carcinoma might result. Sometimes the whole intes- origin, due to specific infection by micro-organisms tine could be drained and so the condition be quieted ; mostly of low virulence. The disease began usually, but the diverticulum should either be taken away in the subacute or chronic forms, about middle age, in women the menopause being a likely time completely or left entirely alone. The general picture of a case Diverticulitis could be diagnosed during life by of occurrence. evidences of auto-toxsemia. means of X rays. had the condition without gave many Usually Many being aware there was anything wrong. He had never there was a local focus of infection. Diseased tonsils, oral sepsis, pyorrhcea, nasal catarrhs, intestinal seen trouble arising from diverticulum of the ascending colon, nor operated upon such a case. The series of derangements, uterine discharges, and chronic conphotographs he showed gave evidence of barium stipation should be carefully searched for. In autoremaining in the diverticula many daysafter the toxaemia of gastro-intestinal origin, stasis and constipation were important factors. Indican and indol barium meal had been given. in the urine gave evidence of such condition. The tubercle bacillus, the gonococcus, and the Spirochmta were causes of infection by micro-organisms pallida ROYAL SOCIETY OF MEDICINE. of low virulence, producing varying symptoms of A condition of impaired health and disarthritis. turbance of the gastro-intestinal functions might pave SECTION OF OPHTHALMOLOGY. the way and set up the first stage of a rheumatoid Exhïbition of Cases, Specimens, and Jlndels. arthritis. A CLINICAL meeting of this section of the Royal Regarding symptoms, in the rarer acute form of the Society of Medicine was held on June 9th, Sir JOHN disease pain was a marked feature. Many joints PARSONS, F.R.S., presiding. were involved and the patients were generally Mr. J. F. CuNNiN&HAAf showed for diagnosis a case young women, in association with pregnancy, and in which a mass obscured the optic disc at its lower sometimes children. The subacute and chronic forms part. The mass was very indefinite, and it was uncer- were by far the most common. The pain in these tain whether it was of congenital origin or the result of cases was not so severe and only one or two joints trauma.-Sir JOHN PARSONS thought it more likely were at first involved. The progress of such cases to be a congenital excess of fibrous tissue on the disc was usually one of alternate improvement and relapse than retinitis proliferans. -deformities of the joints appeared-pain became Mr.P. G. DoYNE exhibited a patient who showed syra- more severe, the patients gradually becoming more metrical swellings of the upper lids. These were said to and more helpless with increasing deformities of the date from birth and not to have appreciably increased joints affected. in size. When pressure was exerted, they gave a In considering treatment, Dr. Dobson emphasised sensation of lobulation, such as a lipoma would give. the necessity of careful search for local foci of infection. - Mr. J. B. LAWFORD pointed out that the swellings He deprecated the existing fashion or craze for wholereceded readily under pressure ; this and the fact sale extraction of teeth wherever there was the slightest that there had been practically no change for 40 years trace of pyorrhoea or sepsis of the gums. He felt were against the idea of dermoid, for he had not known sure that in a large number of cases this was utterly dermoids to be quite stationary, whether orbital or wrong. He considered that pyorrhoea was often a extra-orbital. The diagnosis lay between lipomatous secondary result and not a primary cause of general prominences and congenital hydroma. The softness septic infection. Autogenous vaccine was useful favoured the former view. when any local source of infection could be found. Mr. H. R. JEREMY showed a patient with retinal Bacteriological examination of the urine and faeces detachment at the macula. A fortnight ago the woman, should be made in cases where a local focus could aged 38, attended at hospital stating that she had been not be discovered. He advocated the treatment by unable for two years to see with her left eye. When prolonged blistering of the spine, or by thermo8 years of age she had been struck in the eye with cautery as a substitute. Constipation and stasis a stone. When first seen she could distinguish fingers must be eradicated. For enteroptosis, of frequent at the periphery ; there was no central vision in the occurrence in advanced middle age, measures must be