the Editor

The right of being wrong in the diagnosis of appendicitis is the only sure means to avoid mortality from an essentially benign disease. ERWIN T. JACOB Department of Surgery B, NATHAN BAR-NATHAN Hillel Yaffe Government Hospital, MIGUEL IUCHTMAN. Hadera, Israel -


SIR,-We read with great interest the paper of Mr Gilmore and his colleagues (Sept. 6, p. 421) on the problem of right lower-abdominal pain misdiagnosed as appendicits. We are reviewing 1000 consecutive appendectomies from our department, which draws patients from a population of similar size (250 000 urban and rural) as their hospitals. The area is serviced by 120 general practitioners who have a high index of suspicion for appendicitis: the 1000 operated cases result from 4677 referred suspected cases. The diagnosis was made on the macroscopical appearence of the appendix during surgery. Acute appendicitis was diagnosed in 750 cases, and in 13-8% ruptured appendicits was found. In 250 cases the diagnosis of acute appendicitis could not be confirmed. However, 16% from this latter group carried other surgical conditions justifying ERROR-RATES AND MORTALITY IN APPENDICECTOMIES

celiotomy. Average length of stay in hospital was 8-9 days (range of 3-127 days). No patients died. In large published series of acute appendicitis from the Western literature, as well as in our series (see table), an inverse correlation between rates of error and rates of rupture could be detected. Furthermore, as expected, a direct correlation becomes apparent between rates of perforation and mortality. In the absence of highly specific clinical and biological methods for accurate preoperative diagnosis of the disease, the diagnosis of acute appendicitis remains mostly a decision made by the surgeon. Mr Gilmore and his colleagues suggest that with a diagnostic error-rate of some 22% in England and Wales, 15 000 emergency appendicectomies may have been unnecessary. However, the real issue is not the unnecessary appendicectomy but the unnecessary mortality deriving from under-

diagnosis. It is


belief that the removal of


provides additional support to a controlled liberal celiotomy policy in the face of suspected appendicitis. However, removal of innocent appendices in a rate exceeding 25-30% seems to be neither advisable nor necessary for the fall in mortality arising from ruptured appendicitis. tomies

Hobson, T., Rosenman, L. D. Am. J. Surg. 1964, 108, 306. Barnes, B. A., Behringer, G. E., Wheelock, F. C., Wilkins, E. W. J. Am.

med. Ass. 1962, 3. Kazarian, K. k.,

180, 122. Roeder, W. J., Mersheimer,

119, 681. Swink, R. L. Am. Surg. 1969, 35, 149.

W. L.

SIR,-We read with interest studies’-6 and reviews’ 8 which describe the role of -haemolytic streptococci in pyoderma and acute glomerulonephritis, both common in Ghana. In studies in the United States, 12 Panama,3 and Tanzania,4 over 90% of p-haemotytic streptococci isolates were group A. Recently nephritogenic group-A strains have been reported in northern Nigeria.’ Therefore, the finding of non-group-A streptococci in rural patients in southern Ghana should be of interest. From March to April, 1975, we conducted a survey of skin infections among residents of 20 villages within 50 miles of Accra. Cultures were taken from skin lesions in 76 persons who had pyoderma. For 56 subjects who had positive streptococcal cultures, representative colonies of i-ha:mo)ytic streptococci were subcultured and sent to the Streptococcus Reference Laboratory, Public Health Laboratory, Colindale, London. 46 of the 56 strains (82.1 1%) were group-G streptococci, and 10 (17.9%) were group C. There was a complete absence of group-A strains. We thought this distribution was extraordinary, but subsequently we saw a report6 from Lagos, Nigeria, where only 22% of skin streptococcal isolates were found to be group A. 34% were group C, 10% group G, and 34% other streptococcal groups. In the Nigerian patients, two-thirds of nose-and-throat isolates were groups C and G. These preliminary studies suggest that non-group-A streptococci are frequent causes of pyoderma in southern Ghana and Nigeria. Because most studies have investigated only the role of group A in glomerulonephritis, we wonder whether nongroup-A streptococci may not be a factor in pyoderma-nephritis in tropical areas. Group-G streptococci have produced outbreaks of pharyngitis,9 and three group-G strains were found to have M-protein indistinguishable from that of group A, type 12,10 a type often associated with glomerulonephritis. Although post-streptococcal glomerulonephritis has been believed to follow group-A infections only, perhaps the role of non-group-A streptococci has been overlooked. Further studies are in progress here to clarify the relationship of non-group-A to pyoderma and its complications. Danfa

Comprehensive Rural Health

& Family Planning Project, P.O. Box 13 Legon, Accra, Ghana.

Ghana Medical School, P.O. Box 4236, Accra, Ghana.


25% of innocent

appendices is bound to lower the rates of perforation and consequently the mortality. The discovery of other unsuspected surgical conditions in about a fifth of unnecessary appendicec-

1. 2.


Am. J. Surg. 1970,

4. 5. Egdahl, R. H. Am. J. Surg. 1964, 107, 757. 6. Cantrell, J. R., Stafford, E. S. Ann. Surg. 1955, 141, 749. 7. Babcock, J. R., McKinley, W. M. ibid. 1959, 150, 131.


SIR,-Dr Wood and others have suggested (Oct. 4, p. 657) that the tetrazolium-linked cytochemical method may be a useful adjunct to the diagnosis of G.-6-P.D. deficiency once hxmolysis has occurred. To support this view they present the case 1. Dillon, H. C. Am. J. Dis. Child. 1968, 115, 530. 2 Dajani, A S., Ferriert, P., Wannamaker, L. W. Archs Derm. 1973, 108, 517 3. Allen, A. M., Taplin, D. Am. J. trop. Med. Hyg. 1974, 23, 950 4. Mhalu, F. S. E. Afr. med. J. 1973, 50, 272. 5. Whittle, H. C., Abdullahi, F. F., Parry, E. H. O., Rajovic, A. D. Trans R Soc. trop. Med. Hyg. 1973, 67, 349. 6. Ogunbi, O. J Nig. med. Ass. 1971, 1, 159. 7. Wannamaker, L. W. New Engl.J. Med. 1970, 282, 23. 8. See Lancet, 1974, ii, 390. 9. Hill, H. R., Caldwell, G. G., Wilson, F., Hager, D, Zimmerman, R A ibid

1969, ii, 371. 10. Maxted, W R., Potter, E.

V. J. gen. Microbiol. 1967, 49, 119

1033 of a woman, apparently heterozygous for G.-6-P.D. deficiency. After separation of red cells by centrifugation’2 the fluorescent test for G.-6-P.D.3 4 was carried out. Although the results were normal, G.-6-p.D.-deficient cells were detected using the

cytochemical technique. This technique may indeed be helpful in establishing the diagnosis of G.-6-P.D. deficiency in females who have undergone haemolysis or in patients who have been transfused, but in untransfused males the centrifugation technique should be quite satisfactory. The essential point is that the principle involved in centrifugation is the selection of older, denser G.-6-p.D.-deficient cells from a mixed population in which the degree of deficiency is age-dependent. Particularly useful in males who have undergone recent haemolysis, this technique is entirely irrelevant for the detection of female heterozygotes, and has, in point of fact, never been proposed for this purpose. In female heterozygotes, as in patients who have been transfused, a genetically distinct population of G.-6-p.D.-normal cells exists.s These

are cells of all ages, and there is no reason that suppose centrifugation should separate deficient cells from normal cells in such persons. While it is probably feasible to carry out the cumbersome tetrazolium-linked cytochemical method in many hospital laboratories, its usefulness lies in the detection of heterozygous (or transfused) subjects. It is probably the best available technique for this purpose, but its value in the study of males is very limited. City of Hope Medical Center,


1500 E. Duarte Road, Duarte, Californa 91010, U.S.A.


SIR,-My clinical-chemistry colleagues Dr Bold and Dr Wilding (Nov. 1, p. 870) say "there have been no serious problems nor complaints, and the clinical staff have been most cooperative" in the change to SI units. One is grateful for these kind words. True there have been no formal complaints-just nattering across the luncheon table! This paints too rosy a picture of the difficulties and frustration that I and many of my clinical colleagues, from housemen to consultants, are experiencing. SI units started here on March 1 last. Only 1 out of a sample of 30 I have questioned says that he now thinks in the new units, but he still keeps a conversion booklet at hand. The rest, including clinical chemists, still think mainly in the old system. One, at least, has bought a calculator to convert back precisely. We were advised to learn SI units and forget the old system. But this is impractical. Data collected over many years will remain in the old units, as will previous medical literature, and current articles coming from the U.S.A., a country that may not change. We must be "bifocal". It is especially confusing that so many values have been altered at once. Also motivation is lacking because, except for pH, there seems little sense in changing. The main reason given is that communication with scientists in other disciplines will be possible. This is likely to be on the important though limited frontier of research. It is a pity that familiarity with SI units was not reserved for use at this point. Then the bother and cost caused by bringing the system into hospitals and general practice could have been avoided.

Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, Edgbaston, Birmmgham 815 2TH.


SiR,—The adoption of SI units raises many problems, one overcome by a molar balance-a precision

of which could be 1. 2 3 4 5

Herz, F., Kaplan, E., Scheye, E. S. Blood, 1970, 35, 90. Ringelhahn, B. Clinica chim. Acta, 1972, 36, 272. Beutler, E. Blood, 1966, 28, 553. Beutler, E., Mitchell, M. ibid. 1968, 32, 816. Beutler, E., Yeh, M., Fairbanks, V. F. Proc. natn. Acad. Sci U.S.A. 1962, 48, 9.

laboratory balance graduated directly in moles with a facility to "dial in" the molecular weight of the compound being weighed. Perth Hospital, Box X 2213, G.P.O. Perth, Western Australia 6001.







and Mr Webb

to see


of Dr Lever fine-needle as-


(Oct. 18, p. 775) paper piration cytology of the breast (Sept. 6, p. 446). In essence, they raise two matters. They suggest that there are better methods of preparing the slides, but the evidence we presented showed that the number of unsatisfactory specimens obtained was related not to the method of slide preparation but to the method of obtaining the aspirate from the breast. Indeed, as we have pointed out, the number of unsatisfactory preparations fell from 25% to 6% following a change in the method of aspiration. Thus, in our series at least, unsatisfactory specimens did not relate to the method of fixation or the staining. The much more important point raised, however, relates to the use of the procedure. Our study is a careful assessment of the cytologist’s opinion-indeed, as we pointed out, the on our


cytologist was unaware of the clinical diagnosis and was asked to report the specimens in a standard way so that her opinion could be objectively assessed. We fail to see how, if the cytologist had known that the surgeons were acting upon this opinion, it would have in any way influenced the outcome. Despite the excellent results obtained by Mr Webb himself,’ it is true to say that fine-needle cytology has not found wide acceptance as a diagnostic method in the United Kingdom. This has been related to several factors, not the least of which is the absence of a reliable cytological opinion in all hospitals. However, there have been doubts about the relevance and safety of the procedure and as to whether the insertion of a needle into a tumour may disseminate tumour cells. We presented the evidence which allays this anxiety. Having established in our clinic the reliability of an opinion on a satisfactory aspirate, we now intend to establish the place of the procedure in management. The amputation of a breast unnecessarily is a major clinical error and at least until our experience is extended further, we shall continue to carry out frozen sections before proceeding to mastectomy. However, aspiration cytology can be used in other ways. Certainly, in those patients with a positive cytological report, it is possible to discuss therapy very much more realistically with the patient. In addition, the procedure can be used as an initial screening tool before proceeding to other investigative procedures which are becoming increasingly important in the assessment of patients with breast cancer. We refer specifically to skeletal X-rays, bone scanning, and estimates of biochemical parameters, such as urinary hydroxyproline. The next phase of our work will examine the use of aspiration cytology in these respects. We hope to carry out aspiration cytology when the patient is first seen in the clinic and on an early report to divide the patients into two groups. Those patients with a positive cytological report will be submitted to a full series of investigations, and mastectomy will be discussed before proceeding to the operating-theatre for frozen-section examination (and mastectomy, should this examination confirm the cytological report). Those patients with a negative cytological report will be submitted to operation either under local anaesthesia or general anaesthesia on a day-case basis, the lump simply being removed. The excised lump will then be examined histologically and, should it be necessary to treat the patient further, she will be readmitted. Patients in whom an unsatisfactory aspirate or equivocal opinion is obtained will be assessed clinically and mammographically, and managed accordingly. In 1. Webb, A.

J. Ann.

R. Coll.

Surg 1975, 56,


Letter: Diagnosis of G.-6 P.D. deficiency.

1032 Letters to the Editor The right of being wrong in the diagnosis of appendicitis is the only sure means to avoid mortality from an essentially...
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