260 MEDICAL SOCIETY OF LONDON

more frequent intervals in the course of a pyelogram.Ordinarily exposures were made at intervals of from10 to 15 minutes ; if plates were taken at intervalsof one minute a record might be obtained of the con-tractions described by Dr. Jona. He also suggestedthat kinking of the ureter was fairly common andnot by any means confined to pregnant subjects.

Mr. A. W. CUBITT discussed the bearing of intra-vesical pressure upon ascending infection of the

urinary tract with special reference to cases in whichprostatectomy had been performed. In such cases

drainage of the bladder led to the conversion of apositive pressure into a negative one. He thoughtthis might facilitate an ascending infection, and forthis reason advocated complete closure of the bladder.He also described the relief of pain effected byatropine in a case of vesical stone.

Dr. JONA, in reply, remarked that cases such asMr. Yates Bell had described were undoubtedlyforthcoming if they were looked for. His onlyobjection to Dr. Vilvandre’s suggestion was basedupon expense, which would be considerable. ToMr. Cubitt he expressed doubt as to whether thepelvis of the kidney would stand a negative pressure.

MEDICAL SOCIETY OF LONDON

Prof. G. E. CASE, the president, took the chair ata meeting of this society held at 11, Chandos-streeton Jan. 27th, when Mr. V. ZACHARY COPE opened adiscussion on

A A d...discussion on

Acute AppendicitisEven after the fifty years which had elapsed, he said,since Fitz’s famous paper of 1886, the mortalityfrom acute appendicitis was still considerable anddid not show diminution. The main problemshad always been to decide the best time to operateand how much ought to be done at the operation.J. B. Murphy of Chicago, than whom no one haddone more to put the surgery of appendicitis on asound footing and who had had an operative mortalityof about 4 per cent., which would be considered goodto-day, had emphasised the great importance of

operating on all cases early and before perforationof the appendix. He had called this the first stage ofthe disease, applying the term " second stage " to thatperiod, for about three days after perforation, whenthe inflammatory process was increasing and spread-ing. The operation, he had written, must then be alimited one : simple opening of abscess and reliefof pus tension in the affected area, with the removalof the appendix if it were accessible and easilyamputated. There should be the least possibleseparation of agglutinations. When the patientwas apparently overwhelmed with intoxication, a

simple incision was made and pus tension relievedwith a large drainage-tube. In the third stage, thestage of subsidence of the acute symptoms, he hadgenerally operated and let out pus. He had therefore

operated promptly in nearly all cases. Where,however, the surroundings or low state of the patientand the absence of a competent surgeon contra-indicated an immediate operation, he had recom-mended Ochsner’s treatment, with the warningthat it required a great deal of judgment. Ochsnerhad aimed at changing a dangerous acute into a

relatively harmless condition by inhibiting peristalsisand giving the peritoneum an opportunity to removethe infection by absorption or circumscription. Hehad not sought to avoid operation but had chosenthe most favourable time for it. He had not onlyoperated at once on every case in which he had thought

ihe appendix was still unperforated, but had often>perated promptly upon appendicular peritonitis.For the past thirty years the majority of surgeonsiad followed the teaching of Murphy. During the.ast few years, however, a number of the youngersurgeons had questioned the wisdom of prompt)peration at all stages. They regarded cases inwhich symptoms had been present for fifty hours assuitable for delayed treatment ; they put the patientin the high Fowler position, allowed no purgativesand gave no morphine. They allowed only waterby mouth. They did not recommend delay in youngchildren or where the diagnosis was uncertain, andthey regarded as additional indicationsfor operation theprevious administration of a strong purgative, super-ficial hyperaesthesia, and obvious general peritonitis.

IMMEDIATE AND DELAYED OPERATION

The advantages of the so-called immediate opera-tion were that the exact pathological condition wasascertained, the infective focus was usually removed,the infective field was drained where necessary, andthe patients and relatives were saved a trying delay.Its disadvantages in cases with perforation of theappendix were said to be the danger of spreading theinfection, the greater frequency of intestinal obstructionand ileus, and the frequency of secondary abscesses,faecal fistulae, and incisional hernia. The advantageof the Ochsner method was said to be that operationwas undertaken when the infection was localised andthe risk minimal. Its drawbacks were that if theinfection did not become limited the patient mightbe in a worse state than before ; extra work andstrain were thrown on all concerned ; treatment mustbe carried out on the threshold of the theatre by thesurgeon himself ; and delay with mistaken diagnosismight be fatal. There was a great deal of truthin these criticisms, but they were of varying weight.

Mr. Cope said he was doubtful whether statisticscould solve the problem of which was the bettermethod, and he thought there was need of a thoroughinvestigation into the whole question of appendicitismortality by a responsible and impartial body.From his clinical experience, in spite of the com-parative and average success of prompt operation,he had from time to time had cases in which delayhad seemed to.be the better plan. He still alwaysadvised immediate operation, not only for the unper-forated appendix but also for perforative appendicitiswith diffuse peritonitis, so long as the patient wasnot too toxic and was reacting well to the inflamma-tion. The cases which he decided upon their meritswere those with a definite and circumscribed lump andthose with advanced peritonitis. If he thought thelump represented a subsiding inflammation with

perhaps a small, ill-defined abscess, he sometimestried the starvation treatment of Ochsner. If he

thought there was a well-defined abscess, he usuallyopened it. With advanced peritonitis and a toxicand dehydrated patient it was better to wait a fewhours and sometimes a day or two while the patientwas hydrated and detoxicated by intravenous andrectal saline. It would be a retrograde step to teachthat delay was the usual correct treatment. Delayshould not be practised except by experiencedsurgeons.

Mr. Cope described his own technique and, in

conclusion, recommended that whenever possible anexperienced surgeon should be in charge of any caseof appendicitis.

EXPECTANT TREATMENT

Mr. R. J. McNEILL LovE said that in appendicitisthat had become limited to the right iliac fossa or

261MEDICAL SOCIETY OF LONDON

pelvis immediate operation might be extremelydifficult. Although a practised surgeon could removethe appendix with the minimum of disturbance,many cases fell into the hands of the less experienced,whose operative results were buried in the records oftheir hospitals. The main points of expectant treat-ment were the four " F’s " : Fowler’s position,fomentation, the four-hourly chart, and fluids bythe mouth in minimal quantities. He had never felt

very happy about fluids by mouth, but preferredintravenous infusion for four or five days. If

expectant treatment was adopted for the localisedcondition, the disease followed one of three courses.In about 65 per cent. of cases the infection subsidedand swelling disappeared, and three months laterthe appendix was removed at a clean operation withnegligible mortality. In 25 per cent. of cases an

abscess formed, showing that infection had becomelimited and resistance increased. Expectant treat-ment could be still carried on, but it was wise todrain the abscess. In 10 per cent. of cases expectanttreatment must be abandoned because of increase ofpain, tenderness, rigidity, and fever. The surgeonwas then faced with the necessity of operating on amore toxic patient. Expectant treatment had beencriticised on the ground, among others, that it wasimpossible to gauge the condition of the appendix.Once localisation had occurred, the surgeon knewsomething much more important: the condition ofthe surrounding peritoneum, omentum, and bowel,which were all acting as a wall to the inflammation.Discharging wounds and faecal fistulas were morecommon after the immediate operation. In suitablecases the mortality following expectant treatmentwas about 3 per cent. less than that obtained fromimmediate operation by experienced surgeons. Theclean operation three or four months after the acutecondition had subsided could be performed safelyby a surgeon of less experience.

THE STATISTICAL ASPECT

Mr. H. C. W. NUTTALL, speaking of the statisticalaspect, said that with a mortality of 2-53 per cent.he considered that he still had something in hand.Two points of view had to be distinguished: that ofthe full-time surgeon and that of the general prac-titioner who did a certain amount of surgery. Thelatter might easily be taught to operate carefully ;it was more difficult to teach him to watch the

patient. House surgeons must be taught never toattempt to remove the appendix if there were anydifficulty. Hyperaesthesia was of very little value indiagnosis, as it was present in 50 per cent. of cases.The most difficult cases were those in which thecondition had been established for some time and the

surgeon could not tell where the infection had startedand where to make the incision. Mr. Nuttall wouldstill advise operation if the appendix region wereincriminated. Some patients suffered severely fromthirst unless they were given water by the mouth ;to do so made little difference to the abdomen if the

drainage were adequate. In the vast majority of

straightforward cases he did not drain, but he alwaysdrained for the slightest amount of haemorrhage, foia blood-clot in an infected abdomen was very serious.He did not regard the diminution of mortality-rate by 3 or 4 per cent. by the expectant treatmentas good enough ; the immediate operation gavebetter results in the end over a large series of cases.Mr. HuGH WHITELOCKE stated that at the RadcliffE

Infirmary, Oxford, the staff delayed operation onlin two or three cases a year, yet the figures hadimproved for two reasons : the introduction ojcontinuous intravenous drip in severe toxic cases

and the careful suction of local peritonitis, particularlyfrom the pelvis. He had rarely drained by a stabincision over the pubes. By inserting a tube drainto the base of the pouch of Douglas and by with-drawing it about half an inch every day with a slightrotation, almost any pelvic abscess could be satis-

factorily drained through a lateral gridiron incision.Mr. JULIAN TAYLOR adduced as a reason for the

low mortality at University College Hospital thatthe honorary staff dealt with practically all appendixcases. If the surgeon were experienced, it did notmatter which principle he followed. The generalpresumption of the exponents of delayed operationthat patients died from the dissemination of infectionfrom an abscess was quite wrong ; this was the rarestpossible occurrence.

Mr. G. H. COLT said that some drainage statisticswhich he and a colleague had compiled and shownto a professor of statistics had illustrated the dangerof any but a lateral incision. The mortality froman appendix abscess was approximately 3 per cent.,but from spreading peritonitis it rose to 80 per cent.at about the tenth day. When the appendix andthe more local inflammation had been removed andthe operator saw clear lymph pouring into the localfocus, he should leave a tube in for a short time ;otherwise the risk was less if no drain were used. Thedifficulty lay in deciding what and what not to leave.

Mr. W. E. TANNER remarked that in some caseswhere the appendix was bound down to the back of theabdominal wall and the caecal end was healthy he haddivided the caecal end, invaginated the caecum,

pulled out the mucosa of the appendix, and inserteda drain ; the patient was saved a second operation.When a very old patient had an appendix of thistype a transfusion of 200 c.cm. of blood would promotelocal suppuration and the patient would get better.This was far superior to giving vast quantities offluid intravenously.

Sir JAMES WALTON also considered that the

important factor was not so much the method as theman who carried it out. The important thing wasthe teaching which the surgeon was to give to students.Every general practitioner was likely to regard himselfas a skilled surgeon for the purpose of deciding ondelay. The enormous improvement in results hadbeen due to the fact that practitioners were learningto send cases up for early treatment. When anabscess was localised and well defined the surgeonshould always operate, and the only question waswhether the appendix should be removed. Therewere three factors : what the patient would stand,how difficult the appendix was to get out, and howquickly the individual surgeon could get it out.

Mr. J. E. H. ROBERTS agreed that a new body ofstatistics should be obtained from hospital surgeons.A form would have to be filled up when each casewas seen and the treatment was planned, and thematerial would have to be submitted to a professionalstatistician. A clear exudate in the peritoneum didnot necessarily mean general peritonitis but mightbe due to infection passing through the walls of anunruptured abscess. He could not believe that whenthere was a general infection of the peritoneumand the source of infection continued, it was notadvisable to remove the rest of the appendix.

Prof. J. PATERSON Ross considered that the main

argument for delayed treatment arose when theabscess was diffuse in the peritoneal cavity. Evenwith a diffuse peritonitis he removed the appendix,just as he would remove a rusty nail from an infectedknee-joint. After that, the Ochsner treatment wasthe right one.