40

in the wall of the ileum was ulcerated and almost perforated.The appendix was gangrenous and the fsecohth had obviouslycome from a perforation at its base. The appendix wasremoved, without inversion. A drain was left in down tothe region of the ulcerated ileum and brought out througha stab wound in the right iliac fossa.The postoperative course was complicated only by a small

subcutaneous abscess in the upper part of the wound.On naked-eye examination of the appendices removed,

those from cases 2 and 3 showed definite obstruction tothe lumen with perforation. In case 1 no localisedorganic constriction was demonstrable although theappendix was distended with pus.

DISCUSSION

In case 1 nausea and shivering preceded the onset ofabdominal pain by several hours. This story, added tothe patient’s conviction that fish had upset him, probablyencouraged his doctor to make the diagnosis of gastro-enteritis. In view of the use of castor oil in early casesof gastro-enteritis, this point of differential diagnosis isextremely important. At a later stage the absence ofabdominal spasm, by no means unusual in retrocaecalappendicitis, even when well advanced, might have ledto the institution of expectant treatment. In case 2 theonset of pain was preceded by several hours of nausea,general malaise and vomiting. There was no history ofany previous attack. Questioned after recovery, thepatient seemed to be a reliable witness and the originalstory was confirmed. The history of a mild anxietystate may or may not be relevant ; psychoneuroticssometimes have a high threshold to the pain of an acuteunfamiliar pathological process. In case 3 pain was

preceded by 17 hours of malaise, fainting and vomiting,and it seems unlikely that perforation, abscess formationand ulceration of the ileum all took place in the timewhich elapsed after localisation of the pain in the iliacfossa-i.e., 4 hours. The appearances at operation weremore compatible with the 36-hour story.

In only one of these three cases was there any historyof previous indigestion, and only in case 3 was there ahistory of previous attacks of abdominal pain. This issignificant because many have maintained that recurrentattacks of appendicitis are likely to be atypical and thattherefore the order of origin of symptoms as describedby Murphy is only of value in first attacks. NeitherMurphy nor Moynihan make any such differentiation.

All three patients were carefully questioned afterrecovery, and all insisted that pain was not their firstsymptom. In case 2, laparotomy was clearly indicatedwhatever the diagnosis. Cases 2 and 3, however, couldjustifiably have been treated conservatively if appendic-itis could have been excluded. This we believe to bethe danger of a too rigid acceptance of the Murphy-Moynihan dicta.

SUMMARY *

In 3 cases of acute appendicitis here described painwas not the first symptom, and it is concluded that thedictum that pain is always the first symptom is misleadingand may lead to dangerous delay in operation.We have to thank Mr. A. K. Henry for his interest and

advice, Mr. Douglas for permission to make use of theparticulars of case 2, and Dr. Allen Daley, chief medicalofficer of the L.C.C. for permission to publish the three cases,all of which were treated in Hammersmith Hospital.

Reviews of Books

Abdominal OperationsBy RODNEY MAINGOT, F.R.C.S., senior surgeon to theSouthend General Hospital and the Royal WaterlooHospital. London: D. Appleton-Century Company.2 vols. Pp. 1385. jE5.

THIS book is planned on the same lines as Moynihan’swell-known volume. It is a comprehensive work dealingnot only with the general surgery of the abdomen butwith such rare procedures as partial pancreatectomy,and for these valuable references to the original sourcesof information are given. Every aspect of abdominalsurgery is included-the preparation for operation, theadvisability of operation, the difficulties of the actualtask, the details of each stage, the after-treatment, thelikelihood of success, the complications which may arise,and the causes of failure-so that the book is both aguide to the actual operation and a thoroughly usefulwork of reference to novice and experienced surgeonalike. When there are several methods to choose fromone is always wisely labelled as the standard operation.There are very few omissions, none of generally recog-nised procedures ; those few which can be noted seemto have been made deliberately as the result of Mr.Maingot’s experience. In the account of the abdomino-perineal resection of the rectum the pathology insistedupon by Miles is accepted without reserve, and theoperation made needlessly extensive in consequence.It is generally agreed now that in the stage of resecta-bility there is no lateral and downward spread of themalignant growth. But it seems hardly necessary tohave included accounts of cholecystogastrostomy, or

of simple excision for gastric ulcer, since these procedures,condemned by the results, are no longer employed.The illustrations are extremely well drawn and repro-duced, and have the welcome quality of depicting clearlythe meaning of the text.

An Agricultural Policy for Britainand a Policy for British Agriculture. By G. GODDARDWATTS. London : G. Allen and Unwin. Pp. 38. ls.

THIS well-written booklet is calculated to hold theattention of the reader whether he is agriculturallyminded or not. In this it fulfils one of its main objects,which is to educate public and political opinion in theimportance of preserving a thriving agricultural com-munity after the war ; and it demonstrates to farmers

that they can win over the townsman by dispelling theview that all farmers are grumbling inefficients who arenever satisfied with their lot, however much the Govern-ment may do for them. The author has many sensiblesuggestions to make on the maintenance of soil fertility.He examines the changes which have taken place inagriculture since war broke out, and pleads that theextended use of the plough is a thing worth keeping upwhen peace comes. He has the same hope about someof the improved marketing and educational systemswhich have recently been adopted. It would hardly bepossible to get unanimity on such a controversial sub-ject as a policy for agriculture ; it is evident that someof Mr. Watts’s arguments are open to criticism andwould not meet with approval from some agriculturaleconomists. Occasionally he makes claims which itwould be hard to substantiate, such as " It is a traditionthat three generations away from the soil will exhaustthe vitality of the family and that for re-vitalisationthat family must leave its urban surroundings andre-establish itself in rural life." But if he is somewhatopinionated, he has clearly had wide experience in botheducational and farming circles, and is entitled to expressdefinite views. ’

Office Clinical ChemistryBy EMANUEL M. ABRAHAMSON, M.D., adjunct attendingphysician, Jewish Hospital of Brooklyn ; assistantattending physician and chief of the diabetic clinic,Greenpoint Hospital. London: Humphrey Milford,Oxford University Press. Pp. 245. 25s.

As its title suggests this book is primarily for the useof practitioners who wish to carry out their owninvestigations in clinical chemistry. It is compact andsimple enough for the beginner to follow easily, but isnevertheless comprehensive and successfully covers mostof the standard tests. Dr. Abrahamson introduces twoideas which the unpractised reader will find particularlyhelpful: one is the presentation of methods of analyses,step by step, in illustrated form ; the other is a chapterdevoted entirely to the preparation of each reagentmentioned throughout the book. Many of the well-known methods have been modified by the author fromhis own experience. The changes are all towardssimplification of technique and economy in the use ofapparatus. The field to be covered is so wide that thereare bound to be some omissions-for example, there is nomention of faecal analysis. Nevertheless the book will bea stand-by to doctors interested in clinical chemistry.