140 JAN. 25, 1930] ]RAD1UM TREATMENT. OF RECrAL CARCINOMA.

[ M DICALJOURNAA
25_90
destroyed. For the last two years the methiod has beeln to Sepsis is due l)artly to the fact that some necrosis in the
use much smlaller doses spread over a longer time. Needles inimmiediate ineighbourhood of the needles seems inevitable,
containiing 2 or 3 mg. of riadium are lout in and left for anid partly to the fact that the action of the radiumii is
seven to ten days. This miethod has given much better very markedly to lower the natural resistanice of the tissues
results, but it has been found nlecessary to increase the to infectioni. If proper car e is taken to avoid a pr imary
dose up to 6,000 mg. hours and mnore, anid also to increase sepsis at the time of the operation the sepsis is only
the screenling. Screens of 0.5 mm. of platinum cause seconidary, and therefore not ser ious, but it is -ery tire-
ilOecrosis arounid tlle needles and very dense fibrosis of the some and miakes conivalescenice -ery slow.
neighbouring tissues. We are now inicreasing the screeni- The chief indications for improvement in teclhniique in
ing.tO 1 mm. of platiiuum, with beneficial results. I lhave these difficult cases appears to me to lie in the direction
tried, in addition, placinig tlhe nleedles in rubber cathleters of: (1) Increased screening of the rladium to cut out the
to increase the distance between the radium and the actioni of unwanted riays. (2) The use of riadon seeds to
tissues, and- I think this tends to reduce local niecrosis, but barrage the growth aiid infected lymphatics fromli the abdo-
the insertion of the catheters is troublesome. mini:al aspect in place of nieedles. (3) More successful
Tlhe method of dealing witlh ogowths that I have clhiefly aseptic methods in respect of the wounds of access.
used has been to expose the rectum from belhind after It is too soon as yet to give aniy figures of the results
removing the coccyx, or suieh part of the sacrum as is of radliumLl treatmiienit in these cases. Somiie of the results
necessary, -and to insert 3 mg. needles into anid around the are good, somne very unsatisfactory. My object in wrliting
growth about 1 cmii. apart, thle object being to expose all this paper is to give some of the resuilts of my experienices
parts of the growth to a lethal dose of radium as uni- v. itli the treatment, in the hope that it miay encourage
formly as-possible. The needles are placed roughly parallel otlher sur;geons to do thie same. It is at the presenit timile,
to the bowel lumen. If in.serted at righlt angles to the wlheni the techniqute of treatment is doveloping, that an
lumen it is almost iml)ossible to avoid some of the needles exchange of viewi-s and expericnecs is most likely to be of
perforatinig the lumen, with consequent serious ilnfectionl. x naIlne.
The numi-iber of needles inserted depenids upoIn the size of
the growtlh and the amount of lymphatic spread into other
parts. After the needles have all been placed in positioni THE
the silks to which the nieedles are attached are tied togetlher O(J11 SNER-SIIERJRENi (DELJANED) TRE A TMA 15NT (OF
and pushed into the wound, whicih is closed witlh a sniall
draini. At the end of a week or ten (lays the wound is ACUTE APPENDICITIS:
reopened anid the needles remov-ed. After this the wouind INDICATIONS AND TECHNIQUE.*
is not reclosed, but is lefi openl anid fr eely drained with
tubes. BY
Tllis method hias to be Imiodlified wlleIL the growth is oni HAMILTON BAILEY, F.R.C.S.ENG.,
the anterior wall of the rectum. I have in such cases SURGEON, DUDLEY ROAD HOSPITAL, BIRMINGHIAM.
exposed the r ectum by an incision in fIronit across the
perineumi and bairraged the gr owth in a similar miiannler, I WAs brlought up in the belief that as soon as acute
care being taken inl a mnale subject not to pllace aniy nieedles app)endicitis was diagnosed immediate operation was always
quite close to the urethra andt not to get needles in front iil(licated iulnless the patient was obviously gettinig ov-er the
of the vesiculac seminales. In this way I have so far attack. Thlis was my faith' until I Lecam-e sui gical regis-
avoided causing danmage to the uirethla or bladder. ti ar to Jamiies Sherreln at the Londoni Hospital. Associa-
The greatest difficulty is in dealing witlh the area of tioii witlh this eminent surgeoni was responsible for alter-
lymphatic spiroad on- the plelvie and abdlomninal aspect. For ing my views; slowly I began to realize that ani appreci-
this purpose the abdomen has to be openled and the needles able number of deatths and many complications arc duie to
inserted inlto t'-le upperl)art of the miiesorectumn and the immediate operation- in certain phases of the disease.
areas oni each side of it. All the ear ly cases developed The " delayed treatmenit," as McNeill Love lhas called
a plastic peritonitis whichl ha1( to be dr ained and was the postponiing of operation in selected cases, was origi-
clearlv due to the action of the radiullm on the peritoneum. nated by Albeit J. Ochsnier of Chicago, who published his
To get over this, pac.kingy had to be iniserted over the first commiunicationi on the subject as long ago as 1002.
nieedles and free (drainage provided. This difficulty I am James Sherreni's treatnment differed from Oehsner's on
trying now to get over to a large extenit by using radon nmany poinits, anid some of the details of his miiethod lhave
seeds for the abdomiinal barrage in place of needles. This beeni still further miodified by his pupils.
at any rate saves having to reopen the abdomiiell at the end Trhe objective of the Ochsner-Sherreii school is to lhelp
of a week or ten (lays. to reduce the serious total miortality of appendicitis, which,
The results of ra.dium treatment are that the growtlh at thle presenit time, in spite of better transport, inereased
in the couirse of a few weeks begins to get markedly saiialler hospital facilities, better teclhnique, and a full post-war
a.nd the ulcerated area heals. In a successful case the comiiplement of a tenmporarily depleted medical profession,
growtll entirely disappears, leaving nor mal tissue ill its showN-s no abatemient. Not even its few ardent supporters
place. Very often there is a cuonsider able amounit of would attempt to deny that the delayed treatm-lenit of
scarring and tlhickened fibrous tissue in the situation of appenidicitis is openi to abuse, and if abused would defeat
the growth, but this tends graduallv to soften ill course of tlhe ver y object of its inception. Just as we believe
time. Unfortunately, wlat too often happenis is that the that its universal adoption under proper conditionis would
growtth is not eltirely destroyed, and the main niass dis- help to reduice mortality, so we freely admit that its mis-
appears, leaving islands of cancer tissue that have failed initerpetation would prove disastrous. Evil lies in the
to be destroyed. These islands can be attacked again with abuse of all good things.
radium needles or radon seeds, but it is very difficult to be The treatment is niot mei,ely a postpoonement of oper a-
sure that they have been adequately treated, and the tioni; it is not just the old " interval appendicectomy ";
dense fibrous tissue resultinig from the first treatment it is unfair ancd inaccurate to dub the treatment as tem-
nmakes insertion of the needles at the second operation porizinig; it is not a substitute for operation, but a pre-
peculiarly difficult. paration for it-essenitially a suLrgeon's treatment, to be
The maiin difficulty of the radiium treatmenit of cancer undertaken only in a
of the rectum is that of access to the growth. It is not inigly equipped nursinig surgical home,
hospital, or a corirespond-
with a nursing staff trained
easy to get satisfactory a;ecess to the upper part of the in the method. Above all, in a civilized
growth, wbhicl is in many ways the most importanit. One tieatment must always be carried, out on thecountry, the
very thres-
has to work at a considerable depth and. endways to the hold of the operating tb6atre. As private houses are not
main mass, also the bo)wel is thin, and itisvrim thuis equipped, it should be regarded criminial to attempt
portanlt nlot to injure the lumen,.svr m the treatmnenit in the patient's home. as But one cani picture
Another difficulty is that thec wounds alre very slowv inl
; An address
healing, anld conlsiderable sepsis is at present unavoidab)le.a 13thi, 1929. given to the Leicester Medical Society oni No\einber
 cTAN. 25, 1301 OCHSNER-SHERiEN TREATMENT OF APPENDICITIS
circumstanices-for instance, in a small ship at sea-where fittilng supplied b, Hoskins anid Sewell of Birminghami
to attempt the treatment would be less dangerous, by (see figure). This bed-lifter caii be readily attaclhed to
reason of these circumstances, than to attempt operationl. any bedstead, and it permits of the bed being -heeled
At houme the duty of the practitioner reimains as heretofore about without any alteration of the patient's position. A
to arrange for the admission of the patient to lhospital as useful fitting for maintaining the necessarv flexioni of the
soon as acute appendicitis is diagnosed-and by hiis ex-
ample and teacliing to mitigate the ingestion of purgatives
in cases of undiagniosed stomiiach-aclhe. With the advent
of that Elysiumi wheni all cases of acute appendicitis are
in the hands of the surgeon wlhile the disease is still limnited
to the appendix the need for tlhe Ochsner-Sherren treat-
ment will pass. Iin tlle rmeantime, the general adoptioni of
its principle w-ould doubtless prevent many deatlhs amonig
those patienlts-who arrive "'too late for the early operation
and too early for the late operation "; particularly wou-ld
it pre -ent manny of those deaths which comie under the
heading of disappointments, the victinms being far from
moribund at the time of admission.
Selectinig Cascs for thc " Dehiyed Treatmiienit."
The history is taken, and particular note is made of the
number of hours since the onset. The history begins " 10,
26, 55 houtrs ago," not " last Thursday," or " tlhree day-s
ago." The physical siglns are then recorded in dia-
grainmatic forim. Thb extent of the rigidity is marked
by shading; the presence of a lumiip is tdrawni as near as
possible to scale. The presence or absence of hvper-
aesthesia is always recorded, and the findings of a rectal
examiniation are not omitted. It is necessary to include
these particulars, for it is impossible to proceed w-ithout
minute attentioni to detail, fpr fear of beinig misunderstood.
If the diagnosis of acute appendicitis is miiade and the
hlistory is of unider lorty-eight hours' diratfionq, imllmetliate
operation is niearly always advised. If the diagnosis of
acute appendicitis is miade and the hlistory is orer fifty
houri-s' duration one shlould ask oneself the 'question, " Is
there any reason wyll this appendix sholdd lbe removed at
once? " The aniswer by- one triained in the delanec treat-
metnt is "It is safer to postpolne operationi for the timiie
beinig, ulnless . . ."
Exceptionis to the Ruiile.
Hyperaesthesia is pr-esent. Providing that the other
1.
signs aire consistelnt this may be taken as good eicdence
thlat the appendix is still iulnperforated.
2. Age unider 5 y-ears.
3. The diagnosis cannnot be made betweeni acute appen-
dicitis and some other iintra-abdominial catastrophe lnormnally
requiring imiimediate operation particularly perforated
diverticulitis and perforated duiodenal ulcer.
4. General peritonitis has superi-ereed. Only cases w-hiclh
hlave obvious genleral as opposed to pel%-ic peritoniitis are
excepted.
5. The recent ingestion of a powerful purgative may be
a justifiable indication for performiinig operation which
oth.erwise would be delaved.
The careful reader will have nioticed a disparity of two
hou'rs-between the forty-eighth and fiftietth. A little lati-
tude is left for the beniefit of individual judgemient. As
a general rule in my practice, uInless hyperaesthesia is
present, all cases which have passed the forty-eighth hour
since oniset are placed uponi the Oclhsner-Sherren treat-
miienit in the first instance. If any of the otlher contra-
indications enumerated above enter the pictuire the case
is re-examinied and reconsidered after a lapse of tw-o
hours.
Technique of the Treatnien t.
The patienitof is placed in Fowler's position. There are
many ways initerpretinig Fowler's position. When the
position is ordered for a case about to undergo the
Ochsner-Slierren treatmenit it is of paramount importance
to see that what is kLnown as high Fowler's position is
effectively maintained.
High Fowler's Position.-The head of the bed is raised
eighteen inches on wooden bllocks. What is more con-
venient and quite as efficient as tlle wooden blocks is a
E TH: BarTs
JOURNAL
MUEDICAL
141
Highl Fowler's position. The liea(l of the
bd( is rktiiscc 18 inethes.
knees is the Burton donkey, which is cleaner and cooler
in hot weather than the customary suspenided bolster.
ClTharts.-As a routine the l)lilse is riecorded ev-ery tw-o
hours in graphic formi oni a special chart. In cases where
anxiety is felt as to the advisability of ontinuinig the
tr eatmenit aii hourly clhart is employ ed. Oni several occa-
sions, w-hen the leritoiiitis lhas been widespread, I have
eveni liad a half-lhour-ly chart prepared through the niight.
Temllper'atulre, is relatively uniimportaiit, aiid it is 'recorded
ever-y fouir lhours. Instructions are given to the niurse to
rcor(l any vomitiiig on a separate piece of paper, knowii
as a vomiiit chart. On this is entered the timi-e at u liicil
the vomitu-s was ejected, together w ith the quiaintity and
character of the fluid.
DIiet.-Water olnly is given for four days, or occasionally
longer. This is very str-ictly adhered to. The amount of
plain' cold water the patient may lhave is uiilimited,
altlhougli le is niot encouraged to drink more than is
nolCcssarv to satisfy Ihis tlhirst. In order to prievent
accidents we have a niotice put over the patient's bed,
" Al'ater only; no purgatives." It is very desirable to
explaiii to lpatients that they are going to be starved-" in
order to lprexent the appenidix butrsting " is what I tell
thiem. OIn the fifth day, if the pulse anid temperature are
s,atisfactory an-d the patieiit feels hungry, feeding is com-
ieliced. Small feeds of Benger's food, alterniating witl
a cup of bovril, are given. On the sixth day culstard and
jelly are allow-ed. After that the diet is gradually
increased. Regardinig diet Ochsner himself iistructed,
" After tlie lpatien.t hias beeni normal for four days give
commiiercial beef-tea in small quantities, later broth, later
strainied gruels, later strained soii)s. Do not give milk
until at least a week after the patient is apparently well."
I was not aware unitil recently- that Ochsnier prohibited
milk. We have been giving it in the form of Beng6r's
food from the fourth day w-ith satisfactory resuilts.
Dretgs.-All drugs are forbidden. It slhoilld be particu-
larlv noted that no morphine or its der-ivatives are giveni.
IowekL.-The bowels are left conifined if they are niot
opened naturally. Oni the- fourth or fifth day a small
glycerol enema is giveen. No pturgatives of aniy kind are
giveni until resolutioln is complete-that is, until the
temperature anid pulse have beeni normal for a w-eek and
pain, anid physical signs are absent-theni liquid paraffin,
2 drachms thr ice daily, is prescribed.
Pain, as opposed to tenderniess, is very seldom complained
of after the first night of the treatmenit. A hot bottle maT
be gi-en to the patient to apply to the abdomen; but it ;iis
well to repeat that as long as the iniflamed appendix
renains in situt drugs are forbidden, for they may mask
those all-important signs which foretell that tlie delayed
treatment is not likely to stuceed.
Instructions are given for the nurse in charge to wratcl
the patienit and report immediately (1) a risinlg pulse rate;
 142 JAN. 25, T930) OCHSNER-SHERREN TREATMENT OF APPENDICITIS. Ti
I MJuD1AzBarani
JoVS
I

(2) vonmitinig; (3) paini; anid, in thle later stages of the the patient is lhanlded two cards to signi. On eachl is printed
tr eatmiienit, (4) (liarrhoea or the passage of mllucus in the the following wvords:
stools (pelvic abzecess). I calize that I leave juist beeni tided over an attack of appenl-
A ri.sing plulse r-ate in tlhe earlv stages is thle most reliable dicitis. The considered that in my case it wuas safer to
surgeon
single sign that is dangerous to lproceed witlh
it the delayed defer opcra ioin. I fully understanid the danger of leavingc tIme
itmethod. If the plulse ate has increased even tell poilits appelidix, aiid I agr ee (1) to conie iiito hospital on
r
imu the first fouir hours, operationi is ofteni iuldicated. I dio (2) to report at tIme lhos-pital immediately if I have any Symptom!s
miot feel at all alarmied at a, modereate riise in temiperature. beforo that date.
It qulito ofteni inidicates that the patieiit is exhibitinig a One card the patient talkes away; the other is inldexed
goold reaction to the iniflamimiatolry process; it dloes ]ot anid serves to remind the staff of the appointment, wshichl,
necessarily mean that a local abscess is developing, though excelpt in speeial cases, is miiade for a (late two mlouitlhs
this, of couirse, mlay be the case, anid w-ill be revealed hy after leaving. This miietlhod hals worked admnir ably, amid
the p)hysical examination. A moderate rise of temiiperatu-ire fr-ees the slurgeon of the responsibility of inadvertently
wi-itlh a piulse rate in tlhe eigllties or ninieties does inot omittinig to explain adequately the necessity for ev-entual
foretell failurie of the delaVed treatmlenit. operatioln.
X''omiitini(y after the fir st few hours slhould avwavs be
regardedl seriously, anid this bmy its;elf umay be a stfficient Appendix Abscess.
indication to abandon (elave(Il tr eatmenit. W'here thlere pits is mulstyou ouit
let it "
ani old is

A l)atient uncldergoinog (delaved tr eatmnenit shouldnlot all(l wise surgical axiomi. Neverltheless, it is well estab-
lisiled that the rlule mi-ay he br-oken in the case of sma.ll
(ompl)lain of pain, as opposedl to tend(lerneess, after tlle first anid
six houirs of tr-eatimienit. If lie (loes there is uisiually somie- mo(lerate-sized apienidix abscesses, for the.5e ca.-ses often
thlin- wronig, anid this is a strong- indic'ationi for operation. (10 excepitionally well under thle delayed tr eatmenit. The
In the few cases in which pain has be-en the (letelrinii g lump, wlichll
nio doubt is in part mlade iup of iMflan-,cd
factor in a(dvising oleratioll a large thli k-walled. um- omenituiin, buit in imost instances conitains at least sonie ps,
lelrforated appendix ha]s been fouii(d. The lpatient iv-is wvith starvation anid rest graduallVy gets smialler and smimaller,
exl)eriencinl g appeldicuflar co(l,i. anid finallyv disappear.s. When the time comes for thle
After six and(l a lhalf vear s' ex p)erlenlce of the Ochlsner- appenidix to lie remove(l one often ml-arvels at the freedomn
Shler-reni treatinietit I h;ave nothilg buit ralise for it. fr omn adhesioiis; perhaps there are a few dried-iip pieces
Several Iindir(i-ed cases have resolv ed ieN enitfnllv. As in of leathery substance stutck upon tlio appendix or the
smurgical pr actice onie alwas-s seemiis to oet ill fortilu)e ill jtuxta-appendictilar stiuctures, hut this is all th.At remails
hatches, it sonmetimies happens tlat severial cases in a short of whliat wNas once aiiuidoubted abscess givimig rise to a
pieriod of timiie fail to resolve. If the delaved treatntm,ent lump, say, thle size of cricket ball. To those familiar
a

fails, and tile patient hias been,.starved for somi-e days, the withi the delayed treatimiemit suclh a phenlomeneoni is coiimiiomi-
urinie should be examiiinied for acetone before the i ianes- place. But I find that to milost of my assistanits (trained in
thietic. In) aniy case glueose and salilne is lprescri!hed. Jf various parts of thie country) tIme resolving of aIn appendix
acetonie is present it is of-teni good practice to perform tle abscess anid the evenitial oper ation anid demon-str ationi of
operationi un,lder.spi-nal anaest h+esia. the comparatively uiormal-lookinig appenidix is a sur-ogical
I hiave ti-ied to emlpha.size the possible dang-ers of this aistoiiislmnient second to none.
treatmtlent in order that thiere shoulod be nio sl,knkess in its W!e wsill assume that the patienit hlas beeni adnmitted wxith
application. In order to strenigtheni the coniildence of aplenlicitis of several days' diuiration aiid a luniip is preseiit
tllose wh vo have not hlad the advantage of a tlhoroug in the righlt iliac fossa. The Oclhsner-Slherren treatmnenit i's
tiaining, in the metlhod I cani state wi-ith assurianice: carr-ied ouit in exactly the same way as hias just leen
The lperiphiery of th-e I-luip) is ouitliniedl oln -thie
1. Snbphrenic abscess is almost, unlhowni, atid I h)ave not described.aind 'each day this lumiip is examiniiied. A rectal ex-
lhad a case wlich coutl(d he attlibJutted to tile Oclbsiier- skin aniiiaatiolm is per formed ev-ery third dlay, oi miore oft(n if
1Sherri en treatment. the absvess hals invaded the pelv-is.
2. Pylephilebitis does not oecir. I lhave lad a mimiber of
cases of pylephlebitis, but not onice has it developed in
a patient undergoing delayed treat ment. Indications that th^e Abscess 01u1St be Draoiaie.
3. Initestinal obstruiction is Vel
netry
v ch r arer tihn after 1. Tfle lump is lnot getting smalller after the fifthi day,
imiediate operation. or, altein-atively, is ga-ttiiig' lar'ger befor'e this timiie.
4. The treatment is not a hardship to the patieit. 2. The lumilp is visible wsheni the abdomeni is viewed tan-
5. In the loing run there is very little wvastage of h-iospital gentially.
beds. But wvhat is thils in the mnatter of savinigo a useful 3. The temperature is swinging ioabove 10C0F. oni se\-eral
life ?
successive days. A moderate interimiittenlt mise in tenipera--
Oine of the inost important duities in a case w helc the tur'e is niot a contiailndicationl to delayed treatmenit.
delayed treatment has ploved sutccessful is to enisure that 4. Childhood. I now tieat childre-en above thle agoe of
the patient hlas his appendix remioved in due course. In 4 years by the delayed miletlhod, but 'i1ra inlig?e bcolmies
forimler days it was the custouii to perform aippendicectomny mole often than in the case of ad-ults.
before the patienit left lhospiital. This is, without quies- necessary elicited- a ar e occurrence ws hich
tioln, a great; mistake. Experience hllows that in aln average iiay inidicate thatcanthebe abscess
5. Fluctuationi
lias already bcim left too
case ail interval of twto moinths is necessar y for the pro-
ducts of inflammation to resol *o completely. Appeendicec- loDg.
tomy soon after clinical resoluition is often a veryv difficult 6. Pelvic abscess. It is difficult to estimate the size of
operlationl, aind the patient, bv reason of the starvation, is
ill pr epared to sLtanid it. If an initelrval of two miionths
ani abscess which lhas inivaded the pclvis. That a pelvic
abscess is developimig is alssays hmeraldcd by diarrhoea, amid
elapses between- the timne he is fit to be dischalrged anid the ofteni tlie passage of uimilculs ill the stools. Whmemi pielvie
oper'atioin it will he founIid tAint cv erything has settled down, abscess has been diagnosed a ectal examiimation is per-
foriiied daily. Whleln the abscess feels quite soft tllis often
the patielnt's general coiniditioii will hasveimpros ed, and the
operzationi will be comparatively easy. It is remiarkable how takes five or six days or longer I diain it ilito the rectumii.
few adlhesions are found. If delayed treatimienit lhas been tried, as I feel comilvinced
Unifortunately, a very meal dlanger creeps in. The patient
it shotild be, the nunibem of appeiidix abscesses wlhicil need
may fail to reappear for his operation. I founiid that more dr aina.lge will be comiiparatively smlall. Those that do iuot
thani 5 per cenit. of those who hlad successfully undergone require of pus wvill bo franlk aLbscesses, amid tlh
the Oclisiler-Sherren treatment failed to r eturn. They w-ere teclhniiqueevacu.ctiomi
miiay lie reduced to the simplest character, for the
writteni to and a p)roportioni relied, with varying excluses, of removinig the apilenidix at the time of tlho
the priincipal being that they hlad not understood. In question evacuation of the pus never arises. Tlis, lno doubt, lhelps
1926 I adopted the followinig plan. As soon- as it is evident to accoumnt fol the
that resolution of the disease iimay be coinidently expected treated on the aboveXcivlines. We
simmall mmiortality of aplpendix absces
are spared time possibility
 JAN. 25, 1930] OCUSNER-SHERREN TREATMENT OF
of turning a localized abscess into general peritonitis, a
tragedy which I have witnessed under the old regime of
immediate operation.
Acutte Appendicitis wsith Grave General Per-itonitis.
Wlhen the pulse is feeble in the neighbourhood of 140,
an'd the abdomen druml-like, or other comlbinations of signs
make it undeniable that the peritonitis is frankly general,
the interests of the patient are best served by adopting
a conseirvative attitude, at anv r ate for the time beiDng.
In addition to the usual delayed regime order:
1. Subcutaneous saline (rectal salinie may not be absorbed).
2. Concentrated anti-gas gangrene serum, 10 c.cm. intra-
muscularly.
3. Camphor in oil, 10u two-lhour-ly; tlhree doses. Repeat if
necessary.
4. An hourly pulse reading.
5. Aspirate the stomachl conitents if vormitinig is in evidence.
In all but the moribund some improvem-lent in the general
coniditioin takes place, and in a few lhours tlhe patient is
again examinied and the facts of the case reviewed. In
decidinig the momiienitous question what to do for the best
the following summary may be taken into consideration.
The day is not long past wlhen it was considered that the
patient's only clance lay in an operation, and, above all, in
free drainage. Close attention to the subject has shown that
the problem before us is not niearly so simlple as tlis.
It will be recalled that Ochsner himself first flamed his
method for cases of spreading peritonitis. Thlere is plenty
of evidence that certain cases of this type respond to the
method. The tr eatment aids natture in tr-ansforiming the
general peritonitis inlto a localized infra-umbilical or pelvic
collection of pus, which can theen be treated safely by simple
dr ainage.
Expelrience teaclhes us that simple d(rainage without re-
moval of the appendix before this localization has occurred
rarely saves the patienit's life. Indeed, inl many instances
it appears to hasten the end. On the otlher hand, in lmulst
cases the expeditious rlemoval of the appendix, togetlher
wIvith supirapubic drainage, is, I believe, the best line of
treatment in perforated aplendicitis with general pelri-
tonitis, but the oper-ation mulist be expeditious and the anaes-
-thesia as pelfect as possible. Should the operation prove
to be clifficult, ncoessitating considesable initra-abdonmin.l
manipuilations, or if the attempt to remove thie appendix
lhas to be abandolned in favour of simple drlainage, deatlh
usually follows. In these circumstances one must be pre-
pared to state that suclh a case might have been saved
by the delayed metlhod.
In the liglht of the above remairks it is at least necessary
for the suri-geon to pause for a moment before advising
immediate operation, and ask himi-self three qtuestionis:
1. Can I obtain for this case the services of an anaesthetist
skilled in the administration of gas and oxygen?
2. Have I had sufficient experielnce to remnove this appendix
reasonably quickly if it is mobile?
3. Is it likely that this appendix can be delivered without
muich trouble?
No one can answer the last question witli assurance, but
one can say this much: if the disease has been present for
more than sixty hours it is practically certain that the
(p)pefld iv will be matted to neighbouring strlvctures.
Unless these questions cani be answered satisfactorily
immediate operation is contraindicated and perseverance
with the delayed -method in the hope of localization of
the infectionis offers tlh,e patient his best chanice.
There are two niotable exceptions to this rule: (1) child-
liood and early adolescence; (2) whten there is good reason
to believe, that the genieral peritoniitis is due to the recent
burstinig of an appendix abscess. In childhood and early
adolescence localization of a genier al peritoneal infectioni
does not occur often enough to warrant a trial of the
dlelayed method uniless the circumstances are exteinua-ting.
If these is good reason to believe that tlle general peri-
tonitis is due to the r ecent bulrstinlg of an append(ix
ab)scess simplo)e drainage is a life-savinlg measure.
In thse tr eatmlenlt of acute applendiciti.s withl frank g;eneral
(as oppoCscd to pelvic) peritonitis there mulst be adequate
reasons for adopting the mlethod chosen. If those reasonls
APPENbICITIS. [ TH BRITISH 143
dictate delaving operation thren the surgeon mtust be
courageous, for in this instance it requires inore coura,ge
not to operate.
Statistics.
Statistics of acute appendicitis are prone to be difficult
to compile, for the notes on such a comnmon condition are
ofteni scanty, and unless they are made by the statisticiali
lhimself thero is little uniformiiity in nomenclature. For
want of a better term the busy house-suirgeoni often signs
up as " acute appendicitis " cases in which an apparently
normal appendix has been removed. Suclh examples aro
not rarities. These, together with subacute and a fexy
recurrent cases, tend to swell the total number to be
anialysed. I lhave analysed for a period of two and a
quarter years-f rom August, 1S27, to Novemiber, 1929-cases
of acute appendicitis treated by myself. During this period
all cases in which the remiioved appendix was not definitely
inflamed have been written up as " appenidicectomy," as
opposed to acuite appendicitis, and havo been discarded.
I might also add that the notes on all the cases, with very
few exceptions, have been made by myself.
Total number of cases of acuite appendicitis ... 315
Treated by operation* within six lhours of admis-
sion, inieluding 24 with general or sever e
peritoliitis ... ... ... ... ... ... 242
D ied ... ... ... ... ... 4
...
Treated by the Ochsner-Sherren method 73
Died . .. 1
... ... ...
... ...
* All patients with a gangrenous appendix received an intravenous
injection of niercuroclirome at the concluision of their operation.
Analysing further the cases treated by the delayed
method, in four cases removal of the appendix was under-
taken whilst the Ochsner-Sherren treatment was in pro-
gress, owinig to threatened failure of tllis treatment. Of
these one died. In twrelve instances an abscess riequired
draininig owing to failure of the abscess to resolve. Eight
of these were drained in the riglht iliac fossa and four
pelvic abscesses were opened into the rectum, all with
recovery. This makes the total mortalitv for all cases of
acute al)pendicitis during the period anialysed about 1.75
per cent.
Anialysis of Dcaths.
Two died of in-testinial obstruction following general peritonitis.
One ol these two months, and one two and a half months, after
operationi. Both the patienits were little gir ls.
One patient died a few hours after admnission following an
opverAtion for wlhat was thought to be intestinial obstlruction. At
operation ani appenidix abscess containinig about a pint of pus, with
tremendous distensioni of the small intestine, was found. This
death was hastenedl by an untimely operation due to a mistaken
diagnosis.
One boy died two months after removal of an acute gangrenous
unperforated appendix from pylephlebitis witlh multiple liver
abscesses. The patient had a rigor before operation, which I now
look upon as a strong indication for tying the ileo-colic vein.
Had this been done portal pyaemia might have been prevented.
A boy, aged 9, was admitted with general peritonitis of fotur
days' duration. He was treated by the Ochsner-Sherren method for
sixteen hours. His pulse then began to rise, and--appendicectomy
with suprapubic drainage was performed. Twenty-two days later
he had a venous secondary haemorrhage from the wound, anid
improved after a blood transfusion. A few days later the haemor-
rhage again started. Further blood transfusion and laparotomy
were performed. The haemorrhage was apparently coming from
the superior mesenteric vein, but no bleeding poinit could be found
to be li,gatured. He died twenty-seveni days after the first
operation.
Conclusion.
.1 feel that the key to lowering the total mortality of
appendicitis is to be foundi in the stanldardization of the
type of case to be treated by immliediate operation, togeth)er
wzith the proper selection of patients for tlle Ochsnellr-
Sherren treatment. This standardization is not yet finial.
I lhave tried to indicate a method of selecting cases for
eaclh formii of treatment based upon the pr actice of my
former miiaster, who was a wise surgeon, for hle knew when
to operate and also wlhen not to operate.
LITERATURE.
Love, R. J. McXeill: Brit. Jour,,. of SUrg., 1922-23, X, 520; Lanlcet, 1929,
O)chsner, A. J.: General ,Surgery, 1920, 468; 1921, 462.
Royster, H. A.: App)}endicitis, New York, 1927.
IBeatson, Sir George: Scottish Mfed. and Surg. Jlauraz., March, 1904;*
Lancet, May 11th, 1912.
Ad(ams, J. E. : Britisha Mfedical laurnal, 1925, 1, 72;3.
Bailey, Hamilton: Lanlcet, 1927, ii, 764.~