527

in the present series. Among the many factors whichmay influence this figure is of course the length of

follow-up, for most patients lose their symptoms as

time goes on.

TreatmentI shall not here discuss the differential diagnosis,

which has been fully treated elsewhere by Fitzsimons(1946), Aird (1945), and others, except to say that, whilethere are cases that can be confidently diagnosed assuffering from this condition, the dangers and difficultieshave often been minimised. All are agreed that, wheneverthere is doubt whether appendicitis is present, operationmust be done forthwith.

Laparotomy may well be harmful if there is, for

example, respiratory infection or incipient measles.Baker and James (1946) noted a high incidence of

postoperative pulmonary complications, but this was notseen in the present series.There are some, however, who believe that appendi-

cectomy is beneficial, and others that it is a specificcure for mesenteric lymphadenitis. As Fitzsimons (1946)has pointed out, this seems illogical for several goodreasons. First, the lymph from the appendix does notdrain into the affected nodes unless there is a congenitalabnormality of the lymphatic system. It is hard tobelieve that a normal appendix can be the cause of anobvious illness, or that its removal could cure the patient.The pain ascribed to mesenteric adenitis may continueor be observed for the first time, after appendicectomy.Finally, the results were similar in his large series of

patients treated by operation and without operation-although there may be sceptics who doubt the accuracyof diagnosis in all cases not submitted to surgery.Fitzsimons (1946) found that appendicectomy did notaffect the course of the disease, and concluded that theonly effective treatment was at least six weeks’ rest inbed. This strict routine has not found general acceptancein this country, where a convalescent home and ultra-violet light are, however, often prescribed. Champeau(1950), of Paris, on the other hand, observed recurrenceof the pain until an appendicectomy was performed.At the Radcliffe Infirmary, from the beginning of

1945 to the end of the first quarter of 1951,556 childrenof 14 and under have been treated for acute appendicitis,proved at operation, with 5 deaths, all in advanced orcomplicated cases, a mortality of 0-91%.

In considering the problem of treatment, then, thereis on the one hand a low mortality from appendicitis,and freedom from worry by the parent, practitioner, andsurgeon, and on the other hand an unnecessary operation,albeit with a low morbidity and negligible mortality.It should be possible, however, to reduce the latterwithout increasing the former.

SUMMARY

1. Non-specific mesenteric lymphadenitis is a con-

venient clinical diagnosis, but probably there are manyprimary causes of the condition. The difficulties of

assessing the incidence are discussed.2. Non-specific mesenteric lymphadenitis was found in

17-2% of 500 children operated upon for suspectedappendicitis or mesenteric adenitis.

3. It is likely that at least 3500 children suffering fromthis condition are admitted to hospital each year inEngland and Wales, and perhaps the majority are

operated upon.4. Of 63 children with this condition, 12 continued

to have similar attacks of pain more than a year afterappendicectomy.

5. These and other findings are compared with thosein the literature, and their bearing on treatment- discussed.

6. Operation must be performed if appendicitis cannot.be excluded, but there seems to be no reason to supposethat appendicectomy affects the cause of the disease.

I am indebted to the surgeons of the Radcliffe Infirmaryfor access to their case-records.

REFERENCES

Aird, I. (1945) Brit. med. J. ii, 860.Asencio, F. (1949) J. int. Coll. Surg. 12, 702.Baker, A. H., James, U. (1946) Lancet, ii, 232.Brown, A. E. (1937) Surg. Gynec. Obstet. 65, 598.Champeau, M. (1950) Pr. méd. 58, 964.Coleman, E. P. (1935) Illinois med. J. 68, 409.

— (1946) Amer. J. Surg. 72, 879.Fitzsimons, J. (1946) N.Z. med. J. 45, 248.Gage, I. M. (1939) Ann. Surg. 109, 834.Ingelrans, P., Vanlereuberghe, J., Lacheretz, M. (1950) Lille Chir.

29, 256.Klass, A. A. (1949) Manitoba med. Rev. 29, 183.Klein, W. (1938) Arch. Surg., Chicago, 36, 571. McFadden, C. D. F. (1927) Brit. med. J. ii, 1174.Madigan, H. S., Coffey, R. J. (1950) Arch. Surg., Chicago, 60, 1136.Menini, C. (1950) Chir. ital. 4, 165. Moloney, G. E., Russell, W. T., Wilson, D. C. (1950) Brit. J. Surg.

38, 52.Penner, D. W. (1949) Manitoba med. Rev. 29, 275.Postlethwait, R. W., Campbell, F. N. (1950) Arch. Surg., Chicago,

59, 92.— Self, W. O., Batchelor, R. P. (1942) Amer. J. Surg. 57, 304.

Raftery, A., Trafas, P. C., McClure, R. D. (1950) Trans. Amer.Surg. Ass. 68, 399.

Vuori, E. E. (1945) Acta chir. scand. 92, 231.Webster, R., Madore, P. (1950) Gastroenterology, 13, 160.Welcker, E. R. (1950) Dtsch. Gesundheitswesen, 15, 456.White, M. (1943) Trans. roy. med.-chir. Soc. Glasg. p. 38.

Reviews of Books

Diabetes Mellitus

Principles and Treatment. GARFIELD G. Duvenrr, -,NI.D.,clinical professor of medicine, Jefferson Medical College,Philadelphia. Philadelphia and London : W. B. Saunders.1951. Pp. 289. 298.

DIVISION of this book into short chapters, each dealingwith a single aspect of diabetes, makes for easy reading.But it is not so much a comprehensive survey as a state-ment of the author’s own opinions, which are not alwaysthose current in this country. In the foreword Dr.Frederick Allen reviews his early fundamental work inits relation to the modern treatment of diabetes, andpleads that abnormal diabetic metabolism should becorrected as completely as possible, results being checkedby the most delicate index-the blood-sugar.

Discussing diets, Professor Duncan recommends an unusu-ally low fat-content-less than 50 g. a day for patients knownto have had hypercholesterolæmia, and 50-100 g. a day forother diabetics. He believes this may minimise the dangerof premature arterial degeneration. The protein-contentrecommended is high at five-eighths of a gramme per lb. ofbody-weight per day ; the carbohydrate too is high, the exactamount being assessed somewhat arbitrarily. These recom-mendations are not in tune with the practice in this country,supported by the Ministry of Food’s allowance of considerableextra fat to diabetics. Professor Duncan expresses diets inthe form of milk, vegetable, fruit, bread, meat, and fat,’’

exchanges," which allow plenty of variety but are not,

always adequately described : for instance, patients are

recommended to measure rather than weigh their food ; butone bread " exchange " is listed as 1 slice of bread weighing25 g. The " exchange system " is now sponsored by theAmerican Diabetes Association and a number of other U.S.national organisations.The least satisfying section of the book is that dealing with

diabetic ketosis and coma. The author rejects Gerhardt’s.ferric-chloride test for urinary aceto-acetic acid—which othershave found to be a reliable indication of diabetic ketosis at a

stage requiring inpatient treatment-in favour of a modifica-tion of the more sensitive Rothera’s acetone test, which isperformed on both urine and plasma. Physiological salineis recommended as the initial fluid for intravenous infusion,though Butler has shown that it is too concentrated andcontains overmuch chloride to be truly,

" physiological "- for

this purpose. The advice on electrolyte replacement in thelater stages of treatment is inadequate. Early glucose infusionsare considered unnecessary but not-as an increasing volumeof evidence indicates them to be-actually harmful,

.

528

Nearly a third of the book is devoted to complications, theprevention of which is now a pressing problem. It is note-worthy that vitamin-Bl2 therapy has proved successful fordiabetic neuropathy, and that ligation of the femoral veinhas been found valuable in obliterative arterial disease ; butnot many would still recommend rutin in the treatment forretinal haemorrhages.

Despite its modest size. the book is self-sufficient as aguide to treatment, containing adequate dietary andheight-weight tables, and giving information on thenormal when illustrating the abnormal.

Dementia Praecox or the Group of SchizophreniasEUGEN BLEULER. Translator : JOSEPH ZiNKIN, M.D.

London: Allen & Unwin. 1951. Pp. 548. 63s.

THE substitution of " schizophrenia " for " dementiaprsecox " marked a ’considerable change in psychiatricthought. It was due to a Zürich group of psychiatrists,headed by Eugen Bleuler, who were eager to apply psycho-analytic methods and concepts to the gross disordersseen in mental hospitals. The most influential workthey produced was Bleuler’s masterly contribution toAschaffenburg’s System of Psychiatry. This classicalmonograph has had to wait forty years for a translationinto English. Its substance has been available inBleuler’s textbook, which A. A. Brill translated, but thedetails and argument were inaccessible to those whocould not read German. Dr. Zinkin has thereforedeserved well of psychiatrists in providing this correctand readable translation. He has added a bibliographyfor the period 1911-48 and a full index. It is always opento question whether a work of this kind, re-issued fortyyears after it was written, should not be annotated orsupplemented; but in the peculiar circumstances ofpsychiatric progress, which turns almost more on freshpoints of view than on precise and assured advances, thedecision to leave Bleuler’s monograph as it was is well-advised. In its new form it is bulkier but far easier onthe eye than in its original dress of 1911.

Medical BotanyALEXANDER NELSON, PH.D., D.SC., F.R.S.E., reader in

botany and lecturer to medical students in the Universityof Edinburgh. Livingstone: Edinburgh. 1951. Pp. 544.30s.

IT is a pity that a book so well produced as this shouldhave its matter so poorly presented, the more especiallvsince it is a most useful work of reference, crammed withfacts far beyond what a doctor, or even a medicalstudent, need know. Indeed, a student wishing to learnbotany for his preliminary examination is referred bythe author to his Introductory Botany. The presentvolume deals with such topics as vegetable foods (con-sidered both generally, as regards structure, chemicalanalysis, vitamin content, storage, processing, and

cooking, and in detail, under the classification of cereals,nuts, fruits, leaves, stems, and roots), vegetable drugsand poisons (especially those of the Ranunculaceae andSolanacese), and vegetable pathogens, such as allergensand fungi causing ringworm and dermatitis.

Nouvelles techniques operatoires dans la chirurgie ducancer

ANTONIO PRUDENTE, professeur a la Escola Paulistade Medicine, Sao Paulo ; HENRIQUE MELEGA, professeuragrege a la escola. Paris : Masson. 1951. Pp. 296.Fr. 2500.

METHODS of resuscitation, the control of infection, andadvances in anesthesia have made possible for the modernsurgeon operations of a magnitude which, hitherto,would have been deemed lethal. The two authors ofthis book have taken advantage of this fact to developthe principles of very wide excision of malignant tumoursand the removal of the draining lymphatic glands withthe intervening tissue intact and in continuity. Theydescribe very clearly, among other things, how theyexenterate the orbit and take away the parotid andglands in the neck all in one piece to eradicate a carcinomaof the lower eyelid, how they remove the lowerjaw and glands in the neck, clear out the axilla and groinwith a mass of tissue connecting these two areas for amelanoma, eviscerate the pelvis in men and women, and

so on. The steps of each operation are beautifullydepicted in numerous drawings, for the most part in line.Thirty years ago Sampson Handley enunciated theseprinciples when he described his extensive operation forcancer of the breast. Experience has led surgeons torestrict their efforts to a considerably less extensiveoperation nowdays. The spread of cancer is not so simplethat it can be dealt with on purely anatomical lines.Larger and larger operations which leave but the shellof a man would not seem to be the solution of the cancerproblem. But surgeons who pin their faith to theprinciples behind the treatment advocated in this bookcould not find a better or more instructive guide. Theymight also read the writings of Brunschweig and hiscollaborators in extreme surgical audacity with especialattention to the published results, over which they woulddo well to ponder.Instruments and Apparatus in Orthopaedic Surgery

E. J. NANGLE, M.B., F.R.C.S., formerly resident surgicalofficer, Royal National Orthopaedic Hospital, Stanmore,and Wingfield-Morris Orthopaedic Hospital, Oxford.Oxford: Blackwell Scientific Publications. 1951. Pp. 231.42s.

THE array of orthopaedic splints and apparatus isbewildering, and it is possible for an orthopaedic surgeonto mature without ever acquiring a basic knowledge oftheir principles. This means that some patients will behindered, instead of helped, by his prescriptions. Anyguide in this field is welcome, and Mr. Nangle’s is a goodone. It is not eclectic, but deliberately limited to thepractice of two of our greatest orthopaedic centres. Basicprinciples, indications for splintage, clinical examplesof the use of appliances, and manufacturing details areall to be found here ; a chapter on mechanical respiratorsand another (by Dr. J. T. Scales) on the use of plasticmaterials are particularly valuable. Mr. Nangle includesa description of his own method of mobile counterweightsuspension of patients in plaster beds and hip spicas-an important contribution to our means of overcomingthe ill effects of stagnation in these cases.The book is well produced and well, even elaborately,

illustrated. Young surgeons, who will profit most fromthe work, would possibly welcome a homelier andcheaper edition.

ExhibitionismL. K. RICKLES, M.D. London : J. B. Lippincott. 1950.

Pp. 198. 408.

IN this clinical study the author assumes that exhibi-tionism is the exaggerated expression of a form of sexualbehaviour which is normal in all human beings. Hetherefore distinguishes it from the sexual perversions,and attributes it to the influence of a dominating mother :the exhibitionist does not gain sensual pleasure fromexposing himself but is a compulsive neurotic who isforced to find this outlet for his frustrated desiresfor his mother. These pyscho-analytical views colourDr. Rickles’s account of the genesis and treatment of thecondition ; the evidence he brings forward in theirsupport has no great force to a non-Freudian reader,though some of the case-histories, reproduced in anappendix, illustrate his generalisation about the way theexhibitionist’s mother brings her son up. Like manyenthusiasts, Dr. Rickles rather exaggerates the importanceof his subject : he believes, for instance, that a sound

. solution of the problem of exhibitionism may be extendedto apply to many other cultural problems. In the main,however, his review of the social, legal, and medicalaspects of the condition is restrained and informative.

Cornell Conferences ori Therapy, Vol. IV. (New York:Macmillan. 1951. Pp. 342.$3-50.).-This record of Cornellstaff conferences, edited by Dr. Harry Gold and others,gives a kaleidoscopic survey of changing ideas on therapy.The racy style, the cross-examination technique, and thelive topics give it plenty of interest. There are good accountsof the treatment of neurosyphilis and of thyroid disorder.A discussion on hypertension is highly critical of sympathec-tomy and rice diet, but makes no mention of recent hypo-tensive drugs like veratrum derivatives and hexamethonium.Diabetic -emergencies and the use of gamma-globulin inimmunisation are discussed in thought-provoking chapters.