148 The Philippine Jownal of Science i9i8 



Case II. — American, aged 40, clerk, walked into the hospital, com- 

 plained of abdominal discomfort and, as he had had several attacks of 

 amoebic dysentery, was admitted to the medical service. The patient 

 continued up and about the ward during the first day of his stay in the 

 hospital; however, as the abdominal discomfort continued, the surgeon was 

 asked to see the case, the resident physician in medicine having followed 

 the course of events in Case No. I a few days before the present case 

 was admitted to the ward. 



This case presented a flat, easily examined abdomen, which showed 

 nothing of interest save a thickened large bowel with general slight 

 tenderness a little more marked below the level of the umbilicus, with 

 practically no increased rigidity of the abdominal wall. The leucocytes 

 numbered between 13,000 and 14,000. 



Operation was advised, and, with the other case with a history of 

 recurrent dysentery in mind, was performed at once, the patient walking 

 into the operating room unassisted. The appendix was found perforated 

 near the base. The entire structure, as well as the walls of the entire 

 large bowel, was greatly thickened and leathery. The peritoneum contained 

 a considerable amount of bowel content and fibrin, fairly well localized to 

 the lower right quadrant. The lack of pain and the extremely slight 

 reaction on the part of the patient to the condition found were remark- 

 able in this case, even more so than in the previous one. From these 

 two cases and others of a similnr type it would seem that the resulting 

 chronic changes in the bowel and peritoneum following recurring attacks 

 of amoebic dysentery extending over a long period have exerted a definite 

 influence. Neither of the above cases has had a recurrence of dysentery 

 since the removal of the appendix. 



We have then a group of cases of appendicitis occurring 

 in persons, especially Europeans, who have had a previous 

 dysentery extending over some time, in which cases the patho- 

 logical processes may have progressed to a point out of all 

 proportion to the manifestations of the disease exhibited clini- 

 cally, and it is in these cases that we must exercise great care 

 lest we make the mistake of not emphasizing sufficiently the 

 necessity for immediate operative interference. 



We have purposely laid less emphasis upon acute appendicitis, 

 as it is not only more readily diagnosed than the various chronic 

 forms, but its differentiation from other conditions — such as 

 a perforated ulcer of the stomach or duodenum — is, so far as 

 treatment is concerned, not so essential since both conditions 

 demand immediate surgical intervention. On the other hand, 

 it is the more or less obscure cases dependent upon a slowly pro- 

 gressing chronic change in the appendix, often without definite 

 indications pointing to this organ as the underlying cause, to 

 which we wish particularly to draw attention. If we will recall 

 that the variety of the manifestations of these chronic changes 

 may be innumerable and consider the possibility of appendicitis 



