5504

FEBRUARY 23, 1929.

Hunterian LectureON THE TREATMENT OF

SOME ACUTE ABDOMINALDISORDERS.

Delivered before the Royal College of Surgeons ofEngland on Feb. 4th

BY R. J. McNEILL LOVE, M.S. LOND.,FELLOW OF THE COLLEGE; LATE SURGICAL REGISTRAR AND

ASSISTANT AT THE LONDON HOSPITAL; ASSISTANTSURGEON TO THE METROPOLITAN HOSPITAL.

I.-ACUTE APPENDICITIS.

I OFFER no apology for introducing such an

apparently threadbare subject as acute appendicitis,for, according to the Registrar-General’s returns,nearly 3000 deaths occur every year in this countryfrom this condition. When one remembers that thistoll is taken chiefly from those in the second and thirddecades, then this mortality is even more perturbing.

In spite of improving diagnosis and earlier opera-tion, the annual mortality remains at a little over70 per million. Probably, as Rendle Short hasrecently emphasised, one of the influences whichcounteracts improved surgical measures is the diminish-ing amount of oellulose consumed in civilised diets.At one period of the war I was medically responsiblefor the health of an Arab town and district with apopulation of about 15,000. The staple diet of thepeople consisted of dates, unpolished rice, and barleybread, and during my stay of six months I saw no<case of appendicitis. Under corresponding circum-stances in a civilised community one would haveexpected about half a dozen cases.When I returned from the war to take up the

duties of surgical registrar at the London Hospitalthe following state of affairs intruded itself upon mynotice-that in some wards every case of acuteappendicitis was treated by an emergency operation,whilst in other wards cases in which mischief hadapparently spread beyond the appendix were treatedexpectantly. Such discrepancy demanded investiga-tion, and consequently I reviewed all the cases treatedat the London Hospital from 1920 to 1924, totalling2018.1 Ignoring the early cases in which the infectionis still limited to the appendix and which are univer-sally treated as a surgical emergency, an analysisof the remainder indicated that cases treated withdiscrimination, and not according to rule of thumb,showed a lower immediate mortality and a much lessformidable proportion of complications and sequelaethan the cases operated upon as soon as seen.

TABLE I.

Partly, I believe, as a result of these statistics andconclusions concerning this subject, interest anddiscussion were rearoused, and 1115 cases at St.Thomas’s Hospital were reviewed and published.2 2Since then intermittent correspondence has appeared

11-1

in medical journals, and only last year a reviewappeared of 245 cases treated at the Manchester RoyalInfirmary.3 3 It has been said that there are threekinds of lies-the ordinary lies, black lies, andstatistics. However, when statistics assume massiveproportions and are compiled from different sources,then discrepancies due to chance and coincidencecorrespondingly diminish. I have accordingly com-bined the figures from the London Hospital, St.Thomas’s Hospital, and the Manchester RoyalInfirmary. The figures given in Table I. do notinclude early cases in which the disease was limitedto the appendix, and the summary from the threehospitals shows that 607 cases were treated on

expectant lines with a mortality of 3-9 per cent., andin 2706 cases in which immediate operation wasperformed the mortality was 6-7 per cent.

Treatment of General Peritonitis.Cases of acute appendicitis may be divided clinically

into three groups-the early cases, those in whichthe general peritoneal. cavity is involved, and inter-mediate cases in which the infection has spreadbeyond the appendix but is limited to the right iliacfossa. We need not consider the early cases whichare properly dealt with as emergencies. I shall onlybriefly refer to the second group-that is, those ofgeneral peritonitis. In these cases a comparativelyhigh mortality is to be expected, owing partly to thevirulence of infection as compared with the patient’sresistance, which is indicated pathologically by theinability of the tissues to form protective adhesions.

In cases of general peritonitis, appendicectomycertainly appears to be the rational treatment ratherthan temporising with a perforated or gangrenousappendix which provides a constant stream of infec-tion. However, there are two points which meritbrief reference.

1. If operation is performed the appendix shouldalways be removed if reasonably possible, but witha minimum of exposure and manipulation. Anyunnecessary manipulation increases lymphatic andvenous absorption of toxins. The old-fashionedprocedure of evisceration and scrupulous peritonealcleansing produced acute toxaemia which was empha-sised by the term " post-operative shock," but inreality was a massive and lethal dose of toxaemia.

2. If the general condition of the patient is pre-. carious so that the operative risk is obviously high,then expectant treatment should be given a trial,L and it is surprising how some hopeless cases respond

, and either resolve or else form a localised abscess.

, In profoundly toxic cases the administration of-

glucose in rectal saline is a valuable adjunct to: treatment, and if an anaesthetic is administered: chloroform should be regarded as a poison owing to

its deleterious effect on the liver cells, which are

already seriously impaired by toxaemia. I havecollected 12 cases in which jejunostomy was per-formed almost as a last resort in cases of peritoniticileus. There were nine deaths and three recoveries.This may not seem very encouraging, but it must beremembered that the three recoveries were threepleasant surprises. These patients are desiccated byvomiting and may be unable to retain fluid in theform of enemata ; jejunostomy is therefore valuablein that it allows administration of adequate quantitiesof saline and glucose, with consequent dilution oftoxins in the body fluids. Antigangrene serum appearsto be of some value in these cases, but choline isdisappointing.

3. The third group demands critical consideration,and comprises those cases in which inflammation islimited to the right iliac fossa, and which presentthemselves from the second day of the disease onwardsas a localised peritonitis or a circumscribed abscess.In both cases three quadrants of the abdomen are

l relatively free from tenderness or rigidity, and ifl localised peritonitis is present rigidity is marked in. the lower right quadrant, and an indefinite and tenderz mass may be palpated. If suppuration ensues thel rigidity becomes less marked and the swelling more

H

376 1kiR. MENEILL LOVE: SOME ACUTE ABDOMINAL DISORDERS.

defined. When localised peritonitis is present appendi-cectomy may be extremely difficult, and I have onmor&ecirc; than one occasion witnessed an attempt atappendicectomy abandoned after prolonged searchingand considerable trauma to tissues. The congestionand turgidity of the bowel and omentum, the friabilityof the tissues, and the presence of adhesions are allstumbling-blocks to a well-executed operation. More-over, however gentle interference may be, or howevercarefully packing is inserted, the early protectiveadhesions are easily separated, and general peritonitismay result when originally only a local infection waspresent. During my military service I twice assisteda surgeon in India to literally tear out two appendiceswhich were firmly matted and behind a turgid ceecum.Both cases ended fatally, and in the light of subsequentobservation I believe that these cases would havesubsided, or rather were actually subsiding, at thetime of operation. If a localised abscess is present,attempts at appendicectomy, as far as the localcondition is concerned, may be even more dangerous.Besides the risk of contamination by pus there is thedifficulty of knowing when to cease searching for,or endeavouring to separate, an unwilling appendix,and this problem may tax the judgment of the mostexperienced.

Technique of Delayed Treatment. ;

It will perhaps be expedient to epitomise the routine I

adopted when delayed treatment is employed. Ifinfection has spread beyond the confines of theappendix, the patient is placed in Fowler’s position,fomentations are applied locally to relieve pain, andonly water is allowed by the mouth until the patientexpresses a desire for nourishment, which usuallycoincides with the fall of temperature. A four-hourlychart is kept, so that temporary variations of pulseand temperature are recorded. No aperient is given,if flatulence or distension cause discomfort, then asmall soap and water or glycerine enema is admini-stered. Sudden distension of the rectum by a largeenema should be avoided, as an abscess has beenruptured by this means. If the signs and symptomsabate, then the patient should be kept in bed for aweek after the temperature and pulse have beennormal, or until the lump has disappeared. In theminority of cases the surgeon’s hand may be forcedand intervention may be necessary in delayed casesfor the following reasons :-1. Persistence of rapidity of pulse or elevation of tempera-ture, particularly when considered in conjunction withlocal signs.2. The formation of an abscess which increases in size,owing to the risk of rupture into the general peritonealcavity. Gas and oxygen anaesthesia is usually sufficient forthese cases.

3. Slow absorption of an abscess, in which case degenera-tion of viscera may occur.

A case has been referred to in one paper on thissubject in which delayed treatment was successfullyadopted in a healthy man, but after subsequentappendicectomy fatal heart failure supervened. Atpost-mortem examination the heart muscle was

found to be degenerated and fatty, and this waspresumed to be due to toxsemia following the absorp-tion of the abscess.

It must be clearly and emphatically stated thatdelayed treatment can only be adopted when thepatient is under continuous supervision and completecontrol-that is, usually in a hospital or nursinghome-and the routine treatment already indicatedmust be adhered to rigidly. Delayed treatment isgenerally unsuitable in patients whose resistance is ata low ebb&mdash;e.g., at the two extremes of life, or followingsevere illness or pregnancy. Acute appendicitiscarries a mortality of about 13 per cent. in childrenduring the first decade, and these cases are unlikelyto subside, partly as a result of the energetic exhibitionof purgatives. As Adams dramatically states4: " Themother may be an unconscious murderer of her ownchild, and a dose of castor oil may be as poisonous asa dose of hemlock." Recently an account appearedin THE LANCET of 50 cases analysed from Addenbrooke’s

Hospital 5 in order to gauge the effect of castor oiFwhen administered to children with acute appendicitis,and it was found that the appendices in eight cases inwhich oil had been given were all gangrenous, whereasin 42 cases which had been spared the oil only twowere gangrenous. It should be realised that gangreneis not entirely due to the stimulating and irritatingeffect of the purgative, but also to delay whileawaiting the result of the administration. Further-more, the age and intelligence of children naturallyhandicap them in expressing their symptoms, andthus symptoms may be missed in the early stages orerrors may be made in diagnosis.

The Time for Surg-ical Intervention.If delayed treatment is successful then the question

arises as to the best time for appendicectomy. It issurprising how long is needed for the last dregs ofpus to be absorbed, and, although pus is relativelyinnocuous after resistance has been established, itappears wise to wait until all traces of acute infectionhave subsided. Probably the best plan to adopt is forthe patient to leave hospital and return three months.after for a clean appendicectomy. This affords ampletime for visceral regeneration, presuming som&

degeneration had occurred, and it is unlikely that a

I FIG. 1.

recurrent attack will supervene in the interval.Further delay is fraught with risk of another exacerba-tion, and it has been calculated that 80 per cent. ofcases of acute appendicitis relapse within two years.

Surgical interference appears to be particularlydangerous between the third and fifth days. Duringthis phase natural immunity to infection is exhaustedand acquired immunity has not yet been established--that is, the patient is in a " negative phase." Operativeinterference with exposure of fresh planes to infection-accelerates the absorption of toxins at a period whenthe patient is unprotected and least prepared to dealwith them. The series of cases from the LondonHospital have been analysed in order to compare themortality of acute appendicitis on different days of the-disease, and it is found that the mortality during thesecond day is 2-8 per cent., from the third to fifthdays inclusive 10-2 per cent., after which period themortality rapidly dwindles. This corresponds veryclosely to a series of 708 cases reported by Owen, whichwere operated upon on the third day with a mortality-of 10-7 per cent.

It may be suggested that the mortality between thethird and fifth days is naturally high, as this includesthe majority of cases of general peritonitis with theirassociated heavy risks. However, analysing theLondon Hospital cases from this point of view, andexcluding cases of general peritonitis, it is found that401 cases were operated upon between third and fifth.

377MR. MCNEILL LOVE: SOME ACUTE ABDOMINAL DISORDERS.

days with either local peritonitis or local abscess, and36 ended fatally-that is, the operative risk, wheninfection was localised to the right iliac fossa, was- 9 per cent.

In an endeavour to find some pathological supportfor the high mortality during this dangerous period,I have compiled a series of leucocyte counts ondifferent days of the disease. The accompanyingchart (Fig. 1) indicates the average total number ofleucocytes present in the blood in a series of 29 patients,.all of whom presented an inflammatory mass in theright iliac fossa, and who responded to delayedtreatment.From this it will be seen that there is no marked

rise in the total number of leucocytes until after thefifth day. An even more significant fact is that thereis no marked increased proportion of polymorpho-nuclear cells until after the sixth day. This is- admittedly a small series of cases, but presuming thata leucocytosis bears some relation to the resistance toinfection, then the chart supports the contention thatthe third to the fifth days may be regarded as the,dangerous period.

Criticisms of Delayed Treatment.It may now be advisable to consider some of the

’Criticisms levelled against delayed treatment. Fourmain objections have been advanced which may be,summarised as follows : the refusal of the patient toallow subsequent appendicectomy ; the influence on’public opinion ; expediency ; and surgical reputation.

In considering these objections in further detail,reference has already been made to the necessity ofTemoving the appendix about three months afterinflammation has subsided. In some cases it may be,difficult to persuade an obstinate patient to return

.-for operation, or he may delude himself in the hopethat he will be fortunate enough to escape recurrence.’This difficulty is overcome if the proper relationship- exists between patient and surgeon-that is, one ofimplicit confidence. The main planks of the surgeon’s-argument are not only the risk of recurrent appendi-citis, but the possibility of subsequent associateddisease of other organs, and that interval appendicec-tomy has a negligible mortality and a limited andknown period is required for convalescence.

It has been stated that " If the public recognisethat immediate operation yields the best results inappendicitis, the doctor’s duty will be simplified. Ifve change this point of view the public will get theidea that appendicitis should be treated on medicaland not on surgical lines." This objection suggeststhat the diagnosis of appendicitis is made by thepublic, but even if such a state of affairs existed thedoctor would probably be consulted in order toconfirm or disprove the diagnosis. Now the doctor’sduty is clearly defined. Any case of acute appendicitis.at whatever stage is in urgent need of surgical treat-ment, either by operation or supervision, and public-opinion will reflect this standpoint whichever line oftreatment is subsequently adopted. It appears anintolerable position that surgeons should allow publicignorance or prejudice to influence them in pursuingany line of treatment.

Delayed treatment certainly imposes a considerabletax upon the time and skill of the surgeon, as frequentvisits and examinations are necessary in order to noteprogression or retrogression of infection. Further-more, considerable judgment is necessary in order to-decide when interference should be adopted if suchis necessary. However, it will be agreed that time andtrouble are of no consequence if repaid by diminishedmortality lists. If, of course, for geographical or

other reasons the surgeon cannot maintain constantcontact with the patient, then, unless a firm smallmass is present, appendicectomy is probably a wisecourse. On the other hand, delayed treatment maybe the safest line to adopt in any stage of appendicitis,-even at the onset, if surgical conveniences and ameni-ties are not available.

Recently an appendix was removed on a small passengertboat in the South Atlantic. The operation was performed

during rough weather by an unassisted and recently qualifiedship’s doctor, using spoons as retractors, with the purseracting in the r61e of anaesthetist. The passenger survivedand was carried ashore at Plymouth with a suppuratingwound, and the ship’s doctor received grateful thanks fromthe patient and congratulations from the ship’s company.In reality, the risk to which the patient was exposed byoperation under prevailing conditions must have been veryconsiderably greater than if he had been starved in Fowler’sposition.When inflammation has spread beyond the appendix,

whatever treatment is adopted, a small but definitemortality must be expected. If a case treated ondelayed lines ends fatally, it is usually regarded as atragedy, and all concerned may have lingering doubtsin their minds as to whether immediate operationwould not have saved the patient. On the otherhand, if the appendix is immediately removed andthe patient succumbs, the general impression is that,because active treatment was adopted, everythingpossible was done and the fatality is accepted philo-sophically. The point I wish to stress is that amasterly inactivity demands a high standard ofcourage on the part of the surgeon and the implicitconfidence of the patient.

If delayed treatment is successful, not only is theactual mortality of acute appendicitis diminished, butpost-operative complications are reduced to aboutone-third of the number which follow immediateoperation. Immediate complications-e.g., focalfistula and secondary abscesses-are favoured by thenecessity for drainage and separation of adhesions,whilst sequelae, such as adhesions and incisionalhernise, are to be expected after drainage of theperitoneal cavity and infection of the parietes.

I would here make a suggestion regarding themethod of drainage when such is necessary in acutecases. If a gridiron incision has been made and pelvicdrainage is needed, this should always be obtained bya separate suprapubic incision. In analysing theseries of cases from the London Hospital complica-tions, fatal and incidental, were more than twice ascommon when the pelvis was drained through thegridiron incision than by more direct suprapubicdrainage. This is accounted for by the shorter andmore dependent suprapubic route, and the absence ofpressure by the tube on the inflamed caecum whichpredisposes to fecal fistula.

I note with considerable relief that most recentpapers on this subject now at least consider themerits of delayed treatment, and I heartily endorsethe conclusions of Rayner based on observations atthe Manchester Royal Infirmary,3 which I quoteherewith, as they approximate to my own views.He states : " I think we may, from our clinicalexperience and observation at operation, recognisecertain types in which it is safer, and in other waysbetter for the patient, that immediate operationshould not be undertaken, such for example are thefollowing :-

1. The patient who presents a firm, hard mass in theright iliac fossa, right loin, or over the forepart of the iliaccrest; the mass is ill-defined at its edges, often extensive,and free from marked tenderness. Such a case willcommonly subside entirely, or the mass slowly resolve intoa well shut-off abscess, which can be easily and safely opened.Immediate operation is difficult and unsatisfactory, andconvalescence prolonged and troublesome.

2. The patient who presents an area of well-localisedmuscular rigidity without extreme tenderness over theappendicular site. His temperature is raised and the pulsemoderately accelerated. Such a patient is by no meansbest dealt with by immediate operation, and the followingcircumstances should be regarded as indicating a temporisingpolicy: (a) retrocaecal position ; (b) general conditionunfavourable by reason of stoutness, bronchitis, emphysema,alcoholic tendency ; (c) history of preceding attacks whichhave subsided ; (d) unfavourable environment.

. Subsequently he adds : "I I believe it is possible toexercise discrimination in some cases without addingto the risk of others."

Sherren,6 after over 20 years’ experience at theLondon Hospital, states : " The only change I have

378 BIB. MCNEILL LOVE : SOME ACUTE ABDOMINAL DISORDERS.

made has been to greater conservatism and morepatience in dealing with cases of appendix abscess."

Conclusions.These statistics, observations, and opinions all

constitute a very earnest plea for discrimination indealing with cases where infection has begun tolocalise, and has already localised in the right iliacfossa. The 9 per cent. mortality, which is the pricepaid for immediate interference in these localised orlocalising cases during the third and fifth days, istragically high when one considers that nature hassuccessfully erected a barrier to infection and thatimmunity is increasing daily.When the pathology of acute appendicitis was first

appreciated the pendulum of treatment swung frompurely medical, under the care of a physician, to IIimmediate operation by the surgeon, and normal ibeneficent reaction of tissues to inflammation wasregarded with suspicion. In discriminating hands thependulum in coming to rest in an intermediate position,and I anticipate the day when the rule-of-thumbsurgeon, who operates on every case as soon as hesees it, will be as out of date as the physician who,in years gone by, treated perityphilitis by purgativesand enemata.

II.-ACUTE CHOLECYSTITIS.

The problems concerning the treatment of acutecholecystitis resemble to some extent those whichhave been discussed in connexion with acute appendi-citis, and it is apparent that surgeons still differ asto whether cases of acute cholecystitis should besubmitted to immediate operation, or whether oppor-tunity should be given for remission. On the onehand, a well-known surgeon states that " Chole-cystectomy during the acute stage is an unwarrantabledanger," and on the other hand a surgeon of inter-national repute recommends immediate operation,cholecystectomy being the objective.

In reviewing Continental and American literatureone finds that the treatment tends towards expec-tancy-that is, of allowing acute inflammation theopportunity to subside with subsequent operationafter remission of symptoms. Hotz, in a paperpresented to the German Surgical Association in 1923,produced figures which indicated that the mortalityof operation during an acute attack was double of thatwhich followed operation after remission. Followinga discussion at the Surgical Society at Lyons in 1923the French schools were doubtful of the wisdom ofimmediate operation and were of the opinion that ifoperation was indicated during an acute attack ofcholecystitis, then drainage of the gall-bladder waspreferable to removal, and in 1926 these views wereconfirmed by Pauchet. Last year Bruggeman 7 reada paper before the Western Surgical Association of theUnited States and produced statistics supportingexpectant treatment.

In comparing the pathology of acute cholecystitiswith that of acute appendicitis, it is found thatgeneralised infection of the peritoneum is a muchless common complication in cases of inflammation ofthe gall-bladder. The gall-bladder is rapidly shut offby adhesions between the liver, transverse colon,mesocolon, and omentum, so that perforation of thegall-bladder into the general peritoneal cavity is anuncommon event. In acute cases it is easy to imagineat operation that the gall-bladder is on the point ofbursting, and that the operation has fortunately justaverted this calamity. Turgidity may be confusedwith distension, and in acute cases the wall of theoedematous gall-bladder may measure half an inchor more in thickness. Popular opinion pictures thegall-bladder bursting like an overblown balloon, butperforation is probably in all cases due to localgangrene of the wall of the gall-bladder.

I have reviewed 107 cases of acute cholecystitis, themajority of whom were admitted to the LondonHospital during the period 1922-26, and have dividedthem into those treated expectantly and those

operated upon immediately (Table II). On examiningthese figures we find a mortality of 20 per cent.associated with immediate operation. This is duein some measure to similar causes to those mentioned inconnexion with acute appendicitis-that is, transitorylack of resistance of the patient and increased infec-

TABLE II.

tivity of gall-bladder contents during the exacerbation,and the greater difficulty of an operation conducted.on acutely inflamed viscera.As compared with acute appendicitis, however, an

additional factor manifests itself in the shape of lungcomplications. Out of eight cases which died followingimmediate operation, no less than three deaths wereattributed to pneumonia. The association of acute’ .

cholecystitis and pneumonia has been emphasised byWilkie,8 and no doubt the anaesthetic and limitationof movement of the diaphragm following operative etrauma precipitates pneumonia in these cases.

If cases are treated expectantly the routine adoptedis similar to that already described for acute appendi-citis, with the addition that a dose of morphia isadvisable when it has been definitely decided topostpone immediate operation. The mortality of allcases treated expectantly was 13 per cent., and inter-vention was necessary in nine cases out of 52 whichwere treated on expectant lines. In two of these casesgeneral peritonitis was present following gangrene ofthe gall-bladder. In four of the remainder a localisedabscess formed around the gall-bladder ; in one case-stones were found in the pus, indicating perforationThe remaining three cases did not subside, althoughinfection was still limited to the gall-bladder. Chole-cystectomy was performed in the majority of caseswhich subsided, obesity and shrunken adherent gall-bladders preventing removal in only five out of 43 cases.Four deaths occurred, two of them being due to

pulmonary embolism,. both on the sixth day afteroperation. One of these cases was operated uponwhen the temperature had barely settled and thepathologist reported that the gall-bladder showed" acute haemorrhagic and focal necrosis." This suggests.that operation was somewhat premature and that the-return of temperature to normal does not coincide withsubsidence of inflammation. Probably a suitable timefor operation would be one week after the disappear-ance of all signs and symptoms. Of the other twodeaths which occurred in cases which had subsidedone was due to subphrenic abscess and the otherapparently to lung complications.Not only is the mortality lower in cases treated

expectantly, but in a much greater proportion ofpatients the satisfactory operation of cholecystec--tomy may be performed rather than mere chole-cystostomy. Of 38 cases operated upon immediatelythe gall-bladder was removed in 22-that is,58 per cent.-whereas of 52 cases treated expec-tantly, cholecystectomy was performed in 41, 01

79 per cent.

379MR. MCNEILL LOVE : SOME ACUTE ABDOMINAL DISORDERS.

There are two main objections to be levelled atdelayed treatment :-

1. The patient may refuse subsequent operation.In this series, out of 69 cases which successfullysubsided, in 17 no subsequent operation was per-formed. Some of these cases were unsuitable forsurgical treatment, most commonly on the grounds ofobesity, and so no operation was urged, but in atleast five cases operation was definitely refused. It

appears to be a human characteristic that as thesands of time run low, to regard them as increasinglyprecious, and the older the patient the less willing arethey to submit to what they consider " the risk of anoperation."

2. The second objection is the greater possibility ofan erroneous diagnosis as compared with acuteappendicitis. Perforated ulcers, intestinal obstruction,acute pancreatitis, and inflammation of a highappendix may all be mistaken for acute cholecystitis.Right basal pneumonia with reflex rigidity of theupper part of the right rectus is another possible error,and, as already mentioned, the two conditions may beassociated.

These two objections to expectant treatment arecountered by laying facts plainly before the patientand explaining that interval operation is the lesserof the two risks, and the risk of erroneous diagnosisis reduced by careful clinical examination. Of course,if a reasonable element of doubt exists regardingdiagnosis, then the expectant treatment is not recom-mended ; also in this condition, as with appendicitis,expectant treatment can only satisfactorily beadopted when the patient is under supervision andcontrol.A dissertation on the differential diagnosis of acute

cholecystitis would be wearisome, but there is onephysicial sign which is frequently present and veryreassuring when elicited. This sign, associated withthe name of Boas, consists of hyperaesthesia of theseventh, eighth, and ninth thoracic segments. It isbest detected below the angle of the right scapula,and depends upon distension of the gall-bladder withconsequent stretching of the visceral peritoneum.In cases of a distended high appendix hyperaesthesiawill be located in the usual appendicular triangle-that is, an area the apex of which is at the umbilicusand the base along the outer half of Poupart’s liga-ment-and the location of hypersesthesia may be avaluable and convincing sign in distinguishing acuteinflammation of the gall-bladder and appendix.From these statistics one is enabled to draw the

following conclusions : 1. Operation during an acuteattack of cholecystitis carries a high mortality. Inthis series of cases 21 per cent. 2. Most cases treatedexpectantly will subside. In this series out of 69 casestreated expectantly, in only nine cases was interventionnecessary. 3. If expectant treatment is successful,then in a much larger proportion of cases the completeand desirable operation Qf cholecystectomy is possible.Hence the review of these cases support the con-

tention that expectant treatment carries a lowermortality and allows of safer and more efficientsurgical treatment, as compared with immediateoperation.

IIL-ACUTE PANCREATITIS.

The incidence of acute pancreatitis is about onecase in every 5000 surgical emergencies. 9 It is aprevalent opinion that acute pancreatitis is commonerin the male sex, but most recent papers on the subjectfail to support this contention. I have collected51 cases admitted to the London Hospital between1911 and 1924,10 and of these 31, or 68 per cent.,occurred in females. With regard to the predisposinginfluence of age, the commonest decade is the fifth,but the age-incidence varies within wide limits, andin this series the youngest was a girl of. 11 and theoldest a female of 73.

Until recent years the diagnosis of this conditionwas unusual before the abdomen was explored on theoperating table. More careful attention to clinicalfeatures now results in accurate diagnosis in the

majority of cases. The sudden onset, continuous-vomiting, and cyanosis are all suggestive. As withperforation of an ulcer, marked prostration is alsopresent, and as Moynihan points out, " shock " is anincorrect term to apply to this condition, as it is notassociated with marked diminution of the bloodpressure. Abdominal rigidity varies inversely to thedegree of prostration, and therefore is absent for a,

variable time after the onset of infection-i.e., duringwhich period the prostration is still profound.

Special tests have naturally little scope for applica-tion in emergency surgery, but the adrenalin mydriasistest of Loewi may be of value in establishing adiagnosis. Positive results were obtained by Waringand Griffiths in three out of four cases, and byHamilton Bailey in four cases out of five. Thediastase index of the urine is of no significance, as itmay be increased in other acute abdominal conditions-e.g., pneumococcal peritonitis. The previous historyof many cases of acute pancreatitis is of interest inthat it indicates that the condition may be progressive,and that less severe attacks sometimes precede thefinal catastrophe. Excluding as carefully as possibleattacks of abdominal pain due to other causes, in thisseries of 51 cases no less than 31 gave a history ofprevious similar attacks and five were inconclusive,leaving a residue of 15 patients whose first attackneeded surgical intervention.A striking example of a successive attack was a case

in which laparotomy was performed for abdominalpain of obscure origin. A condition of " chroniepancreatitis " was diagnosed and the abdomen closed.One month later the patient was hurriedly returnedfrom convalescent home with an attack of acutehaemorrhagic pancreatitis, which was confirmed atpost mortem. An even more illuminating instance ofthe recurrence of the condition with increasing severitymay be quoted in more detail :-

Case of A. B., brewer’s drayman.1907 : Aged 36. Was suddenly seized with acute

abdominal pain. The diagnosis of " acute alcoholicgastritis " was made, and the patient attended the medicalout-patient department. He was discharged a few weekslater as cured.

1910 : Drank a glass of cold water and was suddenlyseized with severe pain, similar to previous attack, vomitedseveral times, and was admitted to hospital. On examina-tion some tenderness and rigidity was present over the gall-bladder area. The symptoms abated and he was discharged.

February, 1924 : Third severe attack while rolling barrels.Pain so acute that patient became unconscious. On admis-sion to hospital prostration was well marked, cyanosis waspresent, and rigidity was entirely absent. A diagnosis ofacute pancreatitis was made, and the abdomen openedthrough a right paramedial incision. Fat necrosis wasgeneral, the pancreas was swollen and cedematous, and thegall-bladder was distended, but no stones were present.Cholecystostomy was performed and the patient recovered.

I July, 1924 : The patient was seized with a fourth attack, similar to those described above. He was admitted moribundand died shortly afterwards.

Causation.The causation of acute pancreatitis is still obscure.

The two theories most commonly held are eitherinfection by lymphatic spread, or regurgitation ofinfected bile along the pancreatic duct. Experimentalwork, such as the injection of organisms into theneighbouring lymphatic glands, has failed to supportthe theory of lymphatic spread, although this routeis still suggested in cases in which the biliary passagesare healthy. Regurgitation of infected bile is almostself-evident in cases in which the ampulla of Vater isobstructed by an impacted gall-stone, and acutepancreatitis has also been associated with sarcoma ofthe ampulla, and, as in a case reported by Sir HughRigby," followed blockage of the duct by a round-worm. Even in cases in which no gall-stone or otherobstruction is present, the regurgitation theory maystill be accepted on the assumption that reflex spasmof the sphincteric muscle of Oddi diverts the flow ofbile along the pancreatic duct, the stimulus precipitat-ing the reflex being some other pathological conditionor derangement within the abdomen.

380 MR. MCNEILL LOVE : SOME ACUTE ABDOMINAL DISORDERS.

Among the post-mortem records of the LondonHospital there are reports of two cases of death dueto strangulation, both of whom showed fat necrosisin the region of the pancreas. This association suggeststhat venous stasis may possibly predispose to acutepancreatitis. Over 50 per cent. of cases of acutepancreatitis are assoclated with cholecystitis or gall-stones, and many of the remainder with some otherabdominal focus of infection. As a free communica-tion exists between abdominal lymphatics, adenitisof the subpyloric glands in the head of the pancreasmay result from abdominal infection, particularlybiliary. It is possible that enlargement of these glandsobstructs the venous return from the pancreas.Again, acute pancreatitis is relatively more common inthose of alcoholic tendency, and the resulting gastritismay be an additional cause of adenitis of the

pancreatic glands. Furthermore, obesity definitelypredisposes to acute infection of the pancreas, andexcessive fat encourages generalised venous stasis.

Surgical Treatment.With regard to the surgical treatment of acute

pancreatitis three operative measures are commonlyadopted. These are: 1. Local drainage of thepancreatic area. 2. Drainage of the gall-bladder orbiliary passages. 3. Incision and drainage of thepancreas itself.

I have collected from hospital records and publishedstatistics 52 cases in which one of these threeprocedures has been adopted, excluding those cases inwhich a combination of measures was deemednecessary. Out of 18 in which local drainage only wasadopted five died-that is, a mortality of 28 per cent.In 28 cases drainage of the gall-bladder or commonbile-duct was performed with 11 deaths-that is, amortality of 39 per cent. In all these cases eithergall-stones or previous infection of the gall-bladderwas present. These figures suggest that the prognosisis worse if pathological conditions of the biliarypassages coexist.

In six cases the pancreas itself was incised anddrained ; five of these terminated fatally-that is,a mortality of 83 per cent. These are scanty figures,and possibly in these cases infection may have beenmore advanced or extensive, so that incision of thegland was considered necessary. However, incision,or even stabbing the gland with blunt forceps appearsto be inadvisable for the following reasons :-

1. Incision causes local haemorrhage and superimposestrauma on infection.

2. Non-infected areas are exposed to infection andincision encourages the spread of infection to healthy partsof the gland.

3. The pancreatico-duodenal arteries may be injured, andcases of duodenal fistulee have occurred after incision of thegland.

These figures suggest that in all cases of acute

pancreatitis it is wise to incise the peritoneum care-fully over the pancreas so as to avoid injury to thegland. If the gall-bladder contains stones, is fat-laden, or its colour other than the normal slate-blue,then cholecystostomy should be performed in additionto drainage of the pancreatic area. Mere distensionof the gall-bladder should be ignored, as one wouldexpect oedema of the head of the pancreas to causesome degree of obstruction to the common bile-duct,Archibald 12 has suggested that the sphincter of Oddimight be divided transduodenally in order to overcomespasm and relieve possible tension in the pancreaticducts.

It has been shown experimentally that relaxatiorof the sphincter is produced by painting the duodenamucosa with a weak solution of magnesium sulphat((which possibly explains the beneficial effect attributecto the early morning dose of salts). However, iiwould seem more practical to inject with a syringeand fine needle a few cubic centimetres of a 5 per centsolution of magnesium sulphate into the first part othe duodenum. This manceuvre would be free frondanger and occupy but a moment. Presuming thaspasm of the sphincter is in certain cases the actualor even a contributing cause of acute pancreatitis

and that the physiological relaxation of the sphincteris obtained under pathological conditions, then intra-duodenal injection of magnesium sulphate shouldproduce a beneficial effect.With regard to drainage of the pancreatic area the

drainage-tube should be wide in calibre, as surprisinglylarge sloughs may separate and these need a roomy exit.In cases which survive the first week some anxietymay arise during the ensuing days on account of thissloughing of masses of pancreatic tissue which maybe associated with some degree of secondary hmmor-rhage, in addition to the difficulty of their dischargealong the path provided.The tube itself should emerge through a separate

stab wound rather than through the laparotomyincision, as pancreatic enzymes, activated by mildinfection, may cause early disintegration of catgut orweakening of the scar with consequent breaking downof the wound, which may need secondary suture, orlater cause an incision hernia. Posterior drainage ofthe pancreas may be obtained either by an incisionbelow the twelfth rib on the left side, or after resectionof part of the tenth left rib. This route is unlikely tobe practicable in cases of acute infection as, if adoptedas a primary measure in diagnosed cases, the surgeonremains in ignorance regarding the condition of thegall-bladder, and only limited drainage can beobtained in the region of the tail of the pancreas. Ifthe abdomen is already opened from the front thenthe acquisition of posterior drainage necessitatesfurther incisions, and change of posture in a patientwhose condition already causes anxiety. In cases ofpancreatic cyst the ’advisability of posterior drainageshould certainly be considered.With regard to after-treatment, reference has already

been made to the digestive properties of the fluiddischarged, and excoriation of the surrounding skinshould be prevented by some mineral fat, if necessarycontaining a weak acid in order to prevent activationof the enzyme.Owing to the pancreatic deficiency which naturally

follows destruction and infection of at least a portionof the gland, pancreatised food or some pancreaticpreparation must be given in order to maintainadequate nutrition of the patient. In this connexionit will be recalled that persistent abdominal discomfortand dyspepsia is sometimes a troublesome sequelaafter cholecystectomy for gall-stones. Many of thesecases are relieved by pancreatic preparations, owingto the association of chronic pancreatitis and pancreaticdeficiency with infection of the biliary passages.

Glycosuria is an occasional sequela to acutepancreatitis, and in one case the urine contained2-5 per cent. of sugar, one month after operation.Possibly chronic pancreatitis had previously affectedthe islands of Langerhans. The possibility of glyco-suria should be borne in mind so that a suitablemedical regime may be instituted if necessary.Reference has already been made to the contentionthat mild attacks of acute pancreatitis commonlyprecede a surgical catastrophe, and the corollary isalso true ; thus subsequent attacks may occur in apatient who has already been tided over an acuteattack by a timely operation. In one case in this

: series a recurrent attack occurred while the patient,

was still in bed, 22 days after cholecystectomy hadi been performed for acute pancreatitis. The attackabated under t_ie influence of morphia.: In reviewing the series of cases which form the,

basis of this paper, it appears that recurrent attacks

1 are commoner in cases associated with gall-stores and

cholecystitis. This suggests that when once pancreatic

infection is established then an infected condition ofthe biliary passages predisposes to reinfection of the

pancreas.3 IV.-SPINAL ANAESTHESIA.

. Methods ef anaesthesia other than induction viaf the respiratory passages are much less popular in1 this country than on the continent. In many Frencht schools splanchnic anaesthesia is used almost as a, routine for abdominal work. In this country spinali, anaesthesia is most commonly used in cases in which

381DRS. BANKS & MACKENZIE : INTRAVENOUS ANTITOXIN IN SCARLET FEVER.

cardiac or pulmonary conditions constitute an

additional risk to the administration of a generalanaesthetic, and this method is commonly consideredundesirable in cases of shock or diminished bloodpressure, as owing to complete relaxation of theabdominal wall splanchnic stasis is encouraged.

Most of the instances in which fainting or collapse,of the patient causes anxiety or alarm are readilypreventable by posture. After a period of seven toten minutes, during which the anaesthetic becomesfixed to the nerve elements, the table should alwaysbe tilted so that the head is lowered. In gynaecologicaloperations under spinal anaesthesia conducted in theTrendelenburg position the condition of the patientseldom gives rise to concern. The effect of postureshould always be borne in mind, not only during butalso after the operation. I have seen sudden collapseof a patient on the stairs of a nursing home, downwhich she was being carried feet first. Lack of thissimple precaution has caused calamities which tendto bring a valuable measure into disrepute. If con-sidered advisable an additional precaution may beobtained by auto-infusion-that is, firmly bandagingthe patient’s limbs so as to limit the amount ofblood in the systemic circulation.A somewhat inexplicable and fortuitous advantage of

spinal anaesthesia occasionally occurs in cases of paralyticileus. On two occasions I have seen copious relaxation ofthe bowels occur on the operating table within a few minutesof injection, and other surgeons have experienced thishappy result.

Cases of acute intussusception furnish an excellentinstance of the advantages of spinal anaesthesia. Ithas been suggested that owing to the relatively longerspinal cord in infants that this structure is endangered.However, it will be recalled that even at birth thespinal cord only reaches to the upper border of thethird lumbar vertebra, so that an injection at the usualsite-that is, between third and fourth lumbar vertebrse-is obviously devoid of risk. In semi-shocked infantsunder general anaesthesia a narrow margin separatesmuscular rigidity from surgical relaxation, and a safeyet efficient degree of anaesthesia is difficult to main-tain even with a skilled anaesthetist, and emergencysurgery frequently precludes expert assistance. Theoperation for acute intussusception under indifferentanaesthesia results in excessive escape of bowel,ungentle manipulation and delay, and difficulty insuturing the parietes. It is still a tradition in somehospitals that in order to limit the risk of a " burstabdomen " the stitches in cases of acute intussusceptionare not removed until the twelfth day instead of theusual tenth day. If the child is incompletelyanaesthetised the task of systematically approximatingthe peritoneum and parietes may be insurmountable,and recourse may, of necessity, be made to simplethrough-and-through suture. This crude proceduremust obviously predispose to subsequent ventralhernia, and in addition cases of obstruction fromadherent bowel have been reported.Hamilton Bailey,13 in an amplified personal com-

munication, reports 16 cases of acute intussusceptionreduced under spinal anaesthesia, with one death, andI have personal notes of 23 cases treated on theselines with three deaths, in two of which the gut wasgangrenous. In none of these 39 cases was difficultyexperienced in suturing the abdominal wall, nor didsubsequent healing give rise to apprehension. further-more, complete relaxation undoubtedly saved timeand trauma in manipulation and suturing, andimproved the prognosis in many cases.With regard to the technique of administration of

stovaine in children, the usual dose for a child betweensix months and one year is 0-2 c.cm., which amountmay be varied according to the weight of the child.The Barker’s needles commonly used for spinalpuncture are too large, and a shorter and finer needleshould be substituted. The syringe must be plainlygraduated so that the dose can be accurately measured.After injection the child may be placated by beingallowed to suck a strip of gauze moistened withglycerine.

In conclusion, I would advocate the more generaluse of spinal anaesthesia in acute abdominal surgery,provided that the necessitv of posture is constantlyborne in mind. In acute intussusception in particular,the ease and gentleness of manipulation and speedyefficient closure of the abdomen undoubtedly dimin-ishes both the immediate operative mortality and therisk of sequelae and complications associated withimperfect suture of the abdominal wound.

Finally, I must express my indebtedness to varioussurgeons at the London Hospital for their readypermission to amass statistics from cases under theircare and treatment.

REFERENCES.1. Love, R. J. McN.: Brit. Jour. Surg., 1924, xii., 232.2. Adams, J. E.: Brit. Med. Jour., 1925, i., 723.3. Rayner, H.: Ibid., 1928, i., 700.4. Adams, J. E.: Post-Grad. Med. Jour., 1927, ii., 97.5. Billington, H.: THE LANCET, 1927, i., 970.6. Sherren, James : Brit. Med. Jour., 1925, i., 727.7. Bruggeman, J. : Ann. of Surgery, 1928, lxxxvii., 423.8. Wilkie, D. P. D.: Tr. Med. Chir. Soc. Edin., 1924-25,

pp. 50-64.9. Chamberlain, D. : Brit. Jour. Surg., 1927, xiv., 390.

10. Love, R. J. McN.: THE LANCET, 1926, ii., 1262.11. Rigby, Hugh: Brit. Jour. Surg., 1923, xi.12. Archibald, E. W. : Surg., Gyn., and Obst., 1919, xxviii., 529.13. Bailey, Hamilton : THE LANCET, 1926, ii., 648.

INTRAVENOUS ANTITOXIN IN SCARLETFEVER.

BY H. STANLEY BANKS, M.B. GLASG., D.P.H.,MEDICAL SUPERINTENDENT, CITY HOSPITAL AND SANATORIUM,

LEICESTER ;

AND

JOHN C. H. MACKENZIE, M.B. GLASG.,SENIOR ASSISTANT MEDICAL OFFICER TO THE HOSPITAL.

OBSERVATIONS on the treatment of scarlet feverby the specific antitoxin have been made by a numberof workers, both in America and in this country,during the past three or four years. Their reportsare, however, chiefly based upon the results of sub-cutaneous or intramuscular injection of the serum,and the intravenous route has, we believe, beenemployed only in relatively few severe or toxic cases.The results obtained are concisely summed up inSir George Newman’s Annual Report for 1927." Scarlet fever antitoxin is being increasingly usedand has proved effective in the treatment of thisdisease. Although it appears to have no directeffect on the cure of complications, its early adminis-tration lessens the toxsemia, and cases so treatedhave shown less tendency to develop septic compli-cations. Its use reduces the average stay in hospitaland should assist in reducing the number of hospitaladmissions. A small dose, 2-5 c.cm. to 5 c.cm. of theconcentrated serum, can be used to confer a tem-porary passive immunity of from one to two weeks’duration on the immediate contacts of the case."This general statement of the present position maybe supplemented by reference to certain details dealtwith by J. C. B. Craig in a recent comprehensive paperon this subject. Craig describes the results obtainedin Edinburgh by intramuscular injection of theserum in a series of 500 cases, mostly of a mild type,with controls. The following important practicalpoints, amongst others, were brought out :-

1. Beyond the third day of the disease, antitoxin seemsto have little effect in influencing the incidence of subsequentcomplications.

2. The incidence of otitis media in cases treated withserum during the first three days of the disease was 8-3per cent.

3. It does not seem advisable to reduce the quarantineperiod to less than four weeks. Fresh complicationsdeveloped after the fourth week of disease in 14 serum-treated patients.From the figures quoted, it appears that the average

stay in hospital of the serum-treated cases was

1 THE LANCET, 1928, ii., 1123.