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APPENDICITIS IN CHILDHOOD

THE LANCETLONDQN: SATURDAY, FEBRUARY 13, 1943

APPENDICITIS is not essentially different in childrenand adults, but its urgency is greater in the childbecause intraperitoneal infection is less likely toremain circumscribed. The formation of an abscess

efficiently isolated from the surrounding peritoneumshould never be expected, and even when an abscessdoes form it may leak or burst. For this lack of localisa-tion there are two likely explanations. First, inchildren the omentum is relatively short and may thusfail to reach the appendix and enfold it, as is itshabit in the adult. Secondly the leucocytic reactionis relatively slight ; S. S. JACOBSON/ in 918 cases,found no relation between- - leucocytosis and theincidence of appendicular abscess, and even in thepresence of general peritonitis only a quarter of thechildren showed a white-cell count of over 20,000per c.mm. JACOBSON nevertheless maintains thatthe severity of the disease may largely be forecastfrom the white-cell count on admission to hospital.The average stay in hospital was 9’5 days in the smallgroup with less than 5000 cells per c.inm. and’gradually increased to 18 days for those with a countof over 31,000. The mortality, on the other hand,showed no proportionate relation to the leucocytecount, and there were no deaths among 13 patientswith counts over 31,000.

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The child with abdominal pain is as a rule a par-ticularly good witness. The march of events frompara-umbilical pain to vomiting, and then to tender-ness in the right iliac fossa, can usually be traced withcertainty. Without this sequence the doctor is

ght to doubt the diagnosis of appendicitis. Butthere are snags. The appendix with its tip well overthe pelvic brim may give no signs at all on abdominalpalpation until the dreaded rupture spreads the

inflammatory process upwards. It follows thatrectal examination should never be neglected in achild who has a history of abdominal colic followedby vomiting. Diarrhoea is a very common aec’om-

paniment of pelvic appendicitis, especially in children;and it is fatally easy in the small child to make adiagnosis of gastro-enteritis, concluding from theabsence of all tenderness and guarding in the rightiliac fossa that the -appendix is not at fault. The

high retrocaecal appendix, with its tip touching theposterior parietes, may closely mimic kidney diseaseor perinephric abscess, even to producing a patchof cutaneous hyperaesthesia near the renal apgle andoedema of the subcutaneous tissues in the loin.Here careful attention to the development of theillness, with special inquiry for a central abdominalpain at the beginning, may prevent a wrong diagnosis.Appendicitis is the only important cause of per-sistent abdominal colic in a child, and when thiscolic is followed by right-sided pain appendicitiscan be presumed till its presence has-been provedor disproved by operation.The. treatment of appendicitis in children is

appendicectomy as soon as the diagnosis is made.

1. Jacobson, S. S. Amer. J. Dis. Child. 1942, 63, 1110.

The only two exceptions are that delay may be con-sidered in a case of obviously subsiding appendicitis,where the temperature, pulse and local signs are allimproving ; and that drainage of the peritonealcavity alone may be the safest procedure whereremoval of a very oedematous glued-on appendixpromises to do much local damage and open a largeabsorptive area around the caecum. JACOBSON’Sfigures encourage the hope that sulphanilamide isimproving the prognosis of perforative appendicitis.In his series a fatality-rate of 8-9% for patients withperitonitis during 1934 and 1935 fell to 4% during1936-40 when sulphonamide drugs were used.During 1940, when, in addition to oral and parenteraladministration, suphanilamide crystals were poureddirectly into the abdominal cavity through the

operation incision, there were no deaths. Otherfactors to which improvement is attributed werebetter preoperative and postoperative care, promptparenteral administration of fluids, and drainagethrough the Miller-Abbott tube in cases of intestinalobstruction.

MANAGEMENT OF SEVERE HEAD INJURIESDIFFERENCE of opinion about the treatment of

severe head injuries has continued since the StoneAge, but at least the contestants change their groundfrom time to time. MOCK and MOCK classify thecontroversies of the present century as follows.1900-10.-Trephining v. non-operative treatment. -.1910-20.-Subtemporal decompression v. spinal puncture

v. do-nothing treatment.1920-30.-Routine spinal puncture v. never do a spinal

puncture v. dehydration treat-ment.1930-40.-Spinal drainage when indicated v. routine

spinal puncture v. no spinal puncture. Radical v.mild v. no dehydration., Subtemporal decom-pressions (10% Dandy) f. exploratory decompressions(36% Munro) v. delayed operations for certaindefinite lesions.

There is no argument about the need for operationin cases of depressed and comminuted fractures ofthe skull, or of cerebral compression by intracranialhaemorrhage ; the variations in practice are in thetreatment of severe uncomplicated accidental headinjuries. Unfortunately the cause of death after thisform of injury is not known. Autopsy may revealareas of bruising on the surface of the brain, sub-arachnoid haemorrhage or small scattered haemorrhageswithin the cerebral hemispheres, and these are oftensaid to be the cause of death. But the explanationis seldom convincing, for every brain surgeon knowsthat operation on the brain may cause extensivedamage of this sort without the patient’s life beingendangered or even his consciousness being impaired.Some swelling of the brain is also occasionally seenpost mortem, but there is no evidence that thisincreases the intracranial pressure enough to causedeath. It is in fact highly doubtful in cases of headinjury whether increased intracranial pressure is eversufficient to endanger life in the absence of a grosshaemorrhage compressing the brain. Recent experi-mental studies support the ancient view that severeclosed head injury causes widespread commotion inthe brain with resulting paralysis of neuronal function.This may lead to death from paralysis of medullary1. Mock, H. E. and Mock, H. E. jun. J. Amer. med. Ass. 1942, 120,

498.2. Denny-Brown, D. and Russell, W. R. Brain, 1941, 64, 93.

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centres -without there being any visible injury onhistological examination of the brain-" invisiblecontusion," JEFFERSON calls it. Study of theclinical features of fatal cases and these experimentalobservations indicate that too much attention hasbeen paid to visible findings, while the essentialcause of death is usually an invisible injury to vitalcentres in the hypothalamus and brain stem, mani-festing itself by changes such as hyperglyceemia andhyperpyrexia, with a steadily rising pulse- and

respiration-rate preceding death. The controversies

regarding treatment have therefore arisen from whatnow appears to be a faulty conception-that death isusually caused by surface areas of contusion and

haemorrhage which lead to cerebral oedema and

compression. Surgeons who have critically reviewedthe results of operation on closed head injury 3 conz.clude that neither contusion of the cerebral hemi-

spheres nor swelling of the brain are necessarilypresent in patients who die, so their operative findingssupport the view that in many cases death cannot beexplained by visible damage.The value of lumbar puncture, dehydration and

decompression in uncomplicated head injury mustbe viewed in relation to the evidence that the cerebraldisorders they attempt to counter are not the actualcauses of death. It is not surprising therefore thatin most British head centres dehydration and decom-pression have been discarded, and that lumbarpuncture is used rather for diagnosis than therapy.The MOCKS give figures to show that moderatemethods of dehydration reduce the mortality, butit does not seem certain that they are quotingstatistically comparable samples. Current British

practice in the treatment of severe closed injurieslays special emphasis on careful nursing and de-tailed clinical observation directed towards theearliest possible recognition of complications suchas intracranial haemorrhage and seeping of cerebro-spinal fluid through the nose. Convalescencehad been shortened by graduated rehabilitation,as SYMONDS and RITCHIE RUSSELL 4 have latelydescribed ; old ideas regarding the invariable needfor long rest have been discarded and each patientis allowed to resume normal physical activity ata rate adjusted to his clinical state. The most

important organic effect of severe head injuryis intellectual impairment, commonly associatedwith change of personality. This is often de-monstrable when the duration of post-traumaticamnesia exceeds 48 hours, and when it exceeds 7 dayssome permanent intellectual loss is apparent in themajority. The degree of incapacity which this mentalslowing causes depends on a large number of factorssuch as the previous level of intelligence, the previouspersonality and the patient’s occupation. An essen-tial part of rehabilitation in severe injuries is

provision for the gradual resumption of responsibleduties, so that the patient can if necessary re-learnhis former job and thus recover sufficient confidenceand knowledge to continue responsible work withreasonable efficiency. Many who have been severelyinjured adapt themselves to a lower degree of efficiencywith remarkable success and continue to do usefulwork.

3. Jefferson, G. Glasg. med. J. 1942, 20, 77; McConnell, A. A.Brain, 1942, 65, 266.

4. Symonds, C. P. and Russell, W. R. Lancet, 1943, i, 7.

GLOVES OR NOT? SINCE HALSTED 1 introduced the rubber glove to the

operating-theatre in 1889, the proportion of surgeonswho operate with bare hands has steadily fallen untiltoday it must be very small. In the transition era,many converts to the glove have testified to its

greater safety in minimising wound infection and inprotecting the operator’s hands. Now, when rubberis scarce and the Ministry of Health has limited thenormal issue to six pairs of gloves per doctor or permidwife per annum, the bare hand may willy-nillyhave to be used again for surgical and maternitywork, and the possible hazards-and how to overcomethem-must be explored.

First let us see what can be done to prolong the lifeof the glove, of which there is ordinarily such a wast-age. Even the most careful dry-heat sterilisation-and too often gloves are harshly treated by too hightemperatures or imperfect drying-means a short lifeof 5-6 sterilisations before the gloves deteriorate.Gloves sterilised by boiling last longer, but wet glovesare unpopular and uncomfortable. However, it isnot sufficiently known that dry gloves can be sterilisedon the hands without inconvenience to the wearerand without apparent risk to the patient. Thefollowing procedure has given satisfactory results ina large general hospital. 2 The hands and arms arefirst scrubbed in soapy water ; the gloves are put on,avoiding wrinkles, and washed for 3-5 minutes in soapand water ; the sterile gown is donned, and the sleevesare fastened at the wrists over the gloves with sterilisedrubber bands ; the gloved hands are then steeped in1 in 50 lysol for two minutes-or if that is unprocur-able in liquor chloroxylenolis (NWF) or biniodide ofmercury 1 in 250. Substitution of this method ofsterilisation reduced the consumption of gloves to aneighth of the previous requirements. The greaterlongevity brings another problem to the forefront-theneedle-puncture which is much more common than isusually supposed. In one series of 4549 operationsof all kinds in a teaching surgical unit, 35,763 gloveswere used and 8602 (or 22%) became perforated.sPunctures are discovered by filling the gloves withwater, or more accurately by examining the air-filledglove under water : new gloves practically never showperforations. Tearing and needle-punctures are morecommon when the gloves fit badly or are put on whenthe hands are insufficiently dry, when the weareris clumsy or inexperienced, and when the operation isa deep abdominal one or carried out in a confinedspace. The role of the puncture in facilitatingwound infection, particularly if the surgeon is a

staphylococcal skin-carrier, was pointed out byDEVENiSH and MILES.4 Moreover, if punctures occurin 10-20% of used gloves, the life of the glove evenwith frequent patching must be limited. Patchedgloves are not liked for major surgery or plastic work,but can be used for minor operations, ward dressingsand maternity work. ,

Since the issue of surgical gloves is to be limited,methods for minimising the risk of infection from thebare hands must be popularised. It is virtuallyimpossible to sterilise the skin, which harbours what-1. Halsted, W. S. Johns Hopk. Hosp. Rep. 1890-91, 2, 255.2. Craig, N. S., Dodds, A. L., Tanner, N. C. and Vernon, H. K.

Brit. med. J. 1942, ii, 438.3. Weed, L. A. and Groves, J. L. Surg. Gynec. Obstet. 1942, 75, 661.4. Devenish, E. A. and Miles, A. A. Lancet, 1939. i, 1088.