THERAPEUTICS

DR. ALA~ E. LEE read a paper entitled: "Acute Appendicitis: Its Early Diagnosis" (see page 635). DR. M. GEANEY thanked Dr. Lee for his very important paper on a condition which was very common and was so important in surgery. With regard to the figures showing the increased death rate in the United States of America, it was alarming to think that there were so many more deaths from the disease than formerly. He considered that this increase was probably due largely to wrong diagnosis, though medical men were not any less likely to diagnose appendicitis now than then. Of course, appendicitis might be a more prevalent disease now than thirty years ago. With regard to the types of appendicitis, in the condition of acute infiammation of the appendix and in those cases in which there was no obstruction, the condition was not really a surgical one, but when further inflammation of the appendix occurred, the appendix was liable to perforate, and Dr. Geaney therefore thought that any acute inflammation of the appendiceal wall was a surgical condition. The patients became so used to having attacks of appendicitis that they diagnosed the condition themselves, left it too long, and the appendix was perforated when operation was performed. Also, once the wall of the appendix was damaged, being a redundant organ, it was liable to set up other conditions, for example, gall-bladder disease, peptic ulcer et cetera. Once it was damaged, therefore, the appendix was better removed. Leucocytosis was occasionally important in differentiating appendicitis from other diseases. As a house surgeon Dr. Geaney had carried out a leucocyte count on many cases of appendicitis, and he had never seen one of those cases of acute appendicitis operated on that did not have a good leucocytosis. Pyuria was another condition often found to confuse the diagnosis, and operation on a case of acute appendicitis might be deferred on account of it. A carefully taken history was valuable, for it would show that the pyuria did not mean a primary kidney or bladder condition. Dr. Geaney's experience was that the amount of pus in the urine due to irritation of the renal tract by an acutely inflamed appendix was much less than that of a primary kidney or bladder infiammation with the same constitutional disturbance. A low temperature was most commonly found in acute appendicitis, but occasionally the temperature would be raised to 104 F. Another condition resembling acute appendiceal obstruction, in which on operation the appendix looked very innocent, was threadworms. One did occasionally find patients who complained first of pain in the right iliac fossa, and, however carefully one took the history, one could not get them to admit upper abdominal pain or discomfort, and so one had to rely on phystcal signs sometimes. John D. Murphy in 1910 said that the cardinal symptoms of appendicitis were: pain in the abdomen, sudden and severe, often referred to the upper part of the abdomen; nausea and vomiting three to four hours after the pain (though Dr. Geaney considered it was sooner); elevation of temperature two to twenty-four hours after onset; leucocytosis. If the nausea and vomiting preceded the pain, the condition was not one of appendicitis. In contradiction to this, Dr. Geaney said he remembered one case in which the nausea preceded the pain by a couple of hours. A rise of temperature was never absent at some time in the first thirty-six hours. He had never found a leucopenia. Sargent in 1912 stated that the symptoms were sudden in onset and well marked, or else indefinite malaise, indigestion and constipation might precede them. Dr. Geaney agreed with Dr. Lee that the history was the main thing in the examination .of the patient as to whether the patient had an acute appendicitis, but the physical signs should not be neglected.