567 
are almost always accompanied by an extension of a severe diphtheritis or 
other secondary involvement of the cecum. There are a number of 
cases of a very mild type of undoubted amcebic ulceration of the appendix, 
accompanied by the discharge of materia! through the patent lumen, 
with recovery under medical treatment. Unless there is some severe 
secondary. invader, the amcebic lesions are particularly apt to be near 
the cecum, and, when more distant, are less likely to produce serious 
trouble than in any other type of appendicitis. All varieties of combina- 
tions of the ten headings given may be encountered, and to deal success- 
fully with them requires a close study of the individual cases and a 
comprehensive knowledge of the subject. 
Prognosis and treatment.—If proper treatment is given, the prognosis 
is usually good in nearly all the conditions mentioned above, and it is 
particularly so when the appendix itself is not actually involved in an 
acute catarrhal or amoebic infection. However; in quite a number of 
patients when the symptoms which have been detailed supervene in a 
case complicated by very severe diphtheritic or gangrenous cecum or 
appendix, the outlook is bad, regardless of the treatment. The treatment 
of most of these conditions is medical, under close surgical consultation. 
Large, high enemas combined with saline cathartics and local applications 
permanently relieve most of these patients. When the appendix is 
really involved, although many of these cases undoubtedly get well under 
medical measures, the treatment should be surgical, but of a conservative 
nature. Great care in diagnosis should be used and unnecessary surgical 
intervention carefully guarded against, because the operation of necessity 
delays treatment of the dysentery. This may prove a very serious matter 
and in some instances in Manila has surely been responsible for the fatal 
outcome. ‘The operation of appendocostomy or cxwecostomy, as advocated 
by Tuttle and others, might occasionally serve a double purpose in these 
patients. This operation has been performed several times in Dr. Me- 
Dill’s surgical service in St. Paul’s Hospital and the cases will be fully 
reported by him. 
ANATOMIC DISPLACEMENTS AND MALFORMATIONS, such as ptosis, un- 
usually long mesentery, diverticula, etc., may be of serious enough import 
to be classed as complications. Enteroptosis, consisting of a V-shaped 
descent of the transverse colon which consequently forms a sharper angle 
at the hepatic and splenic flexures of the colon, may become of particular 
importance, due largely to the proneness which these two points have 
to severe amcebic involvement and the difficulty of securing satisfactory 
irrigation of such a bowel. Such positions of the transverse colon are not 
infrequently seen at autopsy and are to be at least partially, explained 
either by the increased weight of this portion of the intestine due to in- 
flammation or to adhesions between the intestine and omentum and some 
portion of the abdominal wall. Unusually long mesenteries and peculiar 
flexures in the sigmoid and rectum deserve to be mentioned eos of 
their importance in the introduction of rectal tubes. 
