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THE DIFFICULT APPENDIX
1279 If the publicity you are giving to the disgracefully low standards that exist at the moment, induces the timid to feed the patients, and damn the consequences, I feel sure that the Treasury pig will be induced to jump over the stile. E. L. M. PULVERTAFT. London, S.W.3. THE DIFFICULT APPENDIX
SIR,-I am grateful to Dr. Horwitz (May 14) for drawing my attention to Dr. Charles McBurney’s original article,! which has recently been made available to me through the courtesy of the librarian of the Royal Society of Medicine. In 1940, Sir Hugh
Devine2 mentioned a position of the in which it extends under the terminal part of the " ileum and may give rise to umbilical pain and other atypical He " anomalous forms of acute went on: symptoms." appendicitis, too, are most difficult to diagnose in their early stages, and are the cause of many failures to make a prompt diagnosis." In abdominal diagnosis he reiterated the importance of a deep tender spot of visceral tenderness in localised inflammation, which is elicited by pressure of the finger point. In 1937, Bowen3 recommended palpating the iliac fossæ by trying to dip deep down on to the posterior abdominal wall with the fingers bent on the hand. He found that the local right-sided pain usually at or about McBurney’s point. " In rare cases local tenderness and resistance are entirely absent anteriorly, in the lumbar region and on pelvic examination. In one case of which I have notes, the appendix was in a fossa behind the mesentery, where it was securely hidden from prying hands." In 1928, Sir Zachary Cope4 warned against temporising and recommended always to make a very thorough attempt to elucidate the problem when the patient is seen for the first time. " It is only by thorough examination that one can propound a diagnosis, and if the early stages of the disease are to be recognised note must be taken of the earliest
appendix
"
symptoms."
He recorded that if the appendix be situated behind the or behind the end of the ileum and common mesentery, the inflammatory process will be somewhat masked by the gut lying in front. " The place where deep tenderness can almost always be elicited is the spot just below the middle of a line joining the anterior superior iliac spine and the umbilicus. This roughly corresponds with the base of the appendix. Tenderness over McBurney’s spot is not so constant. This tenderness appears to be localised actually in the appendix itself, for the site of the pain varies somewhat according to the position of the appendix." In 1889, Dr. McBurney published 8 cases illustrating the new and successful treatment of early removal of the inflamed appendix. " All will acknowledge that every case of appendicitis may, so far as the cleverest observer can tell, have to pass many very dangerous obstacles before reaching the smooth For my part, I would water of a comfortable abscess. endeavour to ensure safety early, before reaching the rapids, rather than trust to finding my way blindfolded through a dangerous passage." His case 7 was tethered retro-mesenteric followed by temporary ileus. He indicated the site of the greatest pain, determined by the pressure of one finger, as between 11/2 in. and 2 in. from the anterior spinous process of the ilium towards the umbilicus. " No one will dispute that if we could so improve our methods of diagnosis that we could recognize within the first few hours the serious nature of many cases, we would operate in these cases at once, willingly preferring to incur the risks of an operation rather than face the certainty of death from septic peritonitis. How may we improve our methods of diagnosis ? At present I see no clearer road than the exploratory incision permitting a direct inspection of the parts and a complete study of the disease." cascum,
No reference was made to the literature in my article April 9, which recorded local experience of early acute appendicitis in its various forms and physiological manifestations, with appropriate deep tender spots. of
1. McBurney, C. N. Y. med. J. 1889, 50, 676. 2. Devine, C. The Surgery of the Alimentary Tract. Bristol, 1940. 3. Bowen, W. H. Appendicitis, a Clinical Study. Cambridge, 1937. 4. The Early Diagnosis of the Acute Abdomen. London, 1928.
Cope, Z.
These are grouped in the form of a square, each ll,l2 in. from Zachary Cope’s spot, which is just below the middle of a line joining the anterior superior iliac spine and the umbilicus. The lower right-hand corner of the square is the site of appendix abscess, but this is a complication and was not included. The picture is completed by various outlying spots which are described. The chronological analysis of the symptoms and signs of the 7 cases illustrating the stages of inflammation of the tethered retro-mesenteric appendix revealed the constancy of the subileal deep tender spot and of the vertical line above this spot which is halfway between Zachary Cope’s spot and the umbilicus. Deep tender spots indicating subileal spread of peritonitis are also indicated. Congenital retro-mesenteric tethering appears to account for the successive occurrence of severe appendicitis with ileus in several members of one family. " The seat of the greatest pain determined by the pressure of one finger" must remain a cardinal point in
diagnosis. J. A. KERR.
Hastings.
Obituary REGINALD LANGDON LANGDON-DOWN M.A., M.B. Camb.
AMONG medical families and traditions the LangdonDowns of Normansfield hold an honoured place. For three generations they have been responsible for this home for mentally defective children, and, as its medical superintendent for some forty years, Reginald LangdonDown, the senior representative of the second generation, made a considerable contribution to the scientific understanding and humane treatment of mental defect. His father, J. L. H. Langdon-Down, F.R.C.P., came up from Devonshire to study medicine at the London Hospital, where he eventually joined the staff. In 1868, with the help of his wife, he founded Normansfield as a home where mental defectives would be treated as members of a family. He allocated each small group of patients to the care of a single nurse, who slept in their room. This system was
successfully
con-
tinued at Normansfield From until recently. small beginnings the home grew till it was able to accommodate 200 patients, and with it grew its founder’s reputation. He was the first to recognise and name mongolism, which is known in Russia as "
Langdon-Down’s
disease." was born in from Harrow he went to Trinity College, Cambridge, where he took a first class in the natural sciences tripos in 1888. He continued his medical studies at the London Hospital, qualifying in 1892. After serving as an assistant demonstrator of anatomy and a house-physician at the London he took the M.R.C.P. in 1894, and settled in private practice in Teddington. He was already drawn to the family specialty, and two years later, on the death of his father, he and his brother Percival took over Normansfield. He continued the tradition of a family relationship with the patients, in which the staff share. Later, when Normansfield became a limited company, he insisted on resigning his M.R.C.P., though to the regret of his colleagues. Today the home is part of the National Health Service,
Reginald
1866, and
SIR,-I am grateful to Dr. Horwitz (May 14) for drawing my attention to Dr. Charles McBurney’s original article,! which has recently been made available to me through the courtesy of the librarian of the Royal Society of Medicine. In 1940, Sir Hugh
Devine2 mentioned a position of the in which it extends under the terminal part of the " ileum and may give rise to umbilical pain and other atypical He " anomalous forms of acute went on: symptoms." appendicitis, too, are most difficult to diagnose in their early stages, and are the cause of many failures to make a prompt diagnosis." In abdominal diagnosis he reiterated the importance of a deep tender spot of visceral tenderness in localised inflammation, which is elicited by pressure of the finger point. In 1937, Bowen3 recommended palpating the iliac fossæ by trying to dip deep down on to the posterior abdominal wall with the fingers bent on the hand. He found that the local right-sided pain usually at or about McBurney’s point. " In rare cases local tenderness and resistance are entirely absent anteriorly, in the lumbar region and on pelvic examination. In one case of which I have notes, the appendix was in a fossa behind the mesentery, where it was securely hidden from prying hands." In 1928, Sir Zachary Cope4 warned against temporising and recommended always to make a very thorough attempt to elucidate the problem when the patient is seen for the first time. " It is only by thorough examination that one can propound a diagnosis, and if the early stages of the disease are to be recognised note must be taken of the earliest
appendix
"
symptoms."
He recorded that if the appendix be situated behind the or behind the end of the ileum and common mesentery, the inflammatory process will be somewhat masked by the gut lying in front. " The place where deep tenderness can almost always be elicited is the spot just below the middle of a line joining the anterior superior iliac spine and the umbilicus. This roughly corresponds with the base of the appendix. Tenderness over McBurney’s spot is not so constant. This tenderness appears to be localised actually in the appendix itself, for the site of the pain varies somewhat according to the position of the appendix." In 1889, Dr. McBurney published 8 cases illustrating the new and successful treatment of early removal of the inflamed appendix. " All will acknowledge that every case of appendicitis may, so far as the cleverest observer can tell, have to pass many very dangerous obstacles before reaching the smooth For my part, I would water of a comfortable abscess. endeavour to ensure safety early, before reaching the rapids, rather than trust to finding my way blindfolded through a dangerous passage." His case 7 was tethered retro-mesenteric followed by temporary ileus. He indicated the site of the greatest pain, determined by the pressure of one finger, as between 11/2 in. and 2 in. from the anterior spinous process of the ilium towards the umbilicus. " No one will dispute that if we could so improve our methods of diagnosis that we could recognize within the first few hours the serious nature of many cases, we would operate in these cases at once, willingly preferring to incur the risks of an operation rather than face the certainty of death from septic peritonitis. How may we improve our methods of diagnosis ? At present I see no clearer road than the exploratory incision permitting a direct inspection of the parts and a complete study of the disease." cascum,
No reference was made to the literature in my article April 9, which recorded local experience of early acute appendicitis in its various forms and physiological manifestations, with appropriate deep tender spots. of
1. McBurney, C. N. Y. med. J. 1889, 50, 676. 2. Devine, C. The Surgery of the Alimentary Tract. Bristol, 1940. 3. Bowen, W. H. Appendicitis, a Clinical Study. Cambridge, 1937. 4. The Early Diagnosis of the Acute Abdomen. London, 1928.
Cope, Z.
These are grouped in the form of a square, each ll,l2 in. from Zachary Cope’s spot, which is just below the middle of a line joining the anterior superior iliac spine and the umbilicus. The lower right-hand corner of the square is the site of appendix abscess, but this is a complication and was not included. The picture is completed by various outlying spots which are described. The chronological analysis of the symptoms and signs of the 7 cases illustrating the stages of inflammation of the tethered retro-mesenteric appendix revealed the constancy of the subileal deep tender spot and of the vertical line above this spot which is halfway between Zachary Cope’s spot and the umbilicus. Deep tender spots indicating subileal spread of peritonitis are also indicated. Congenital retro-mesenteric tethering appears to account for the successive occurrence of severe appendicitis with ileus in several members of one family. " The seat of the greatest pain determined by the pressure of one finger" must remain a cardinal point in
diagnosis. J. A. KERR.
Hastings.
Obituary REGINALD LANGDON LANGDON-DOWN M.A., M.B. Camb.
AMONG medical families and traditions the LangdonDowns of Normansfield hold an honoured place. For three generations they have been responsible for this home for mentally defective children, and, as its medical superintendent for some forty years, Reginald LangdonDown, the senior representative of the second generation, made a considerable contribution to the scientific understanding and humane treatment of mental defect. His father, J. L. H. Langdon-Down, F.R.C.P., came up from Devonshire to study medicine at the London Hospital, where he eventually joined the staff. In 1868, with the help of his wife, he founded Normansfield as a home where mental defectives would be treated as members of a family. He allocated each small group of patients to the care of a single nurse, who slept in their room. This system was
successfully
con-
tinued at Normansfield From until recently. small beginnings the home grew till it was able to accommodate 200 patients, and with it grew its founder’s reputation. He was the first to recognise and name mongolism, which is known in Russia as "
Langdon-Down’s
disease." was born in from Harrow he went to Trinity College, Cambridge, where he took a first class in the natural sciences tripos in 1888. He continued his medical studies at the London Hospital, qualifying in 1892. After serving as an assistant demonstrator of anatomy and a house-physician at the London he took the M.R.C.P. in 1894, and settled in private practice in Teddington. He was already drawn to the family specialty, and two years later, on the death of his father, he and his brother Percival took over Normansfield. He continued the tradition of a family relationship with the patients, in which the staff share. Later, when Normansfield became a limited company, he insisted on resigning his M.R.C.P., though to the regret of his colleagues. Today the home is part of the National Health Service,
Reginald
1866, and