581FELLOWSHIP OF MEDICINE

of developing vaccination pocks. The largest and oldestlesions showed necrosis in the centres and the formationof crusts. There was little or no pustulation. The distribu-tion of the lesions was general but they were more numerouson the lower limbs than on the trunk and upper part of thebody. The thoracic organs were healthy, except for someterminal congestion and oedema of the lung bases. The liverand spleen both showed areas of necrosis having thecharacters of vaccinia lesions. The other abdominal organsshowed no abnormality.

Microscopical examination of the skin lesions showed theseto have the character of vaccinia papules. The samecharacters were found in the focal lesions of the spleen andliver. No changes of importance were found by microscopicalexamination in the brain and spinal cord or in the otherorgans (suprarenal, heart, kidneys, pancreas) which wereexamined in this way.

It is obvious from the pathological report that thishas been a blood-borne infection. Dr. J. H. Dible,professor of pathology in the University of Liverpool,has stated that he has never seen a case of this kind.It can hardly arise from any septic infection, for the

parents and home were extremely clean and thereis no evidence of such infection being present. WhileI was in Persia several thousand vaccinations weredone either by me or under my supervision. Thescar was made and the lymph was allowed to dry on.It was impossible to keep either pads or bandageson the natives’ arms, so after drying they wereleft uncovered. No untoward result was ever seen.I have had several letters on the subject, and in onethe writer has reported to me a case of general vacciniawhich occurred in a baby that had been washed inwater with which an elder child, who had been

vaccinated, was bathed.

I am indebted to Prof. Dible for the report on hispost-mortem and bacteriological findings, and toDr. C. Rundle, the medical superintendent of

Fazakerley Fever Hospital, for his notes on the casewhilst it was under his care.

MEDICAL SOCIETIES

FELLOWSHIP OF MEDICINE

ON March 9th Lord MOYNIHAN took the chair ata meeting of the Fellowship of Medicine and Post-Graduate Medical Association which was held in therooms of the Medical Society of London and wasoccupied by a debate on

Operation for AppendicitisMr. R. M. VICK said it was a tragic thing that in

the year 1933, so long after Treves, so many doctorswere willing to discuss whether or not the appendixshould be removed when inflamed. He hoped thatthe revived expectant treatment would be stampedout and its ghost laid. He spoke only of those casesin which the diagnosis had been made as certainlyas was humanly possible and where the condition hadnot subsided by the time the surgeon arrived. In allsuch cases operation should be performed at once.This battle had been fought out long ago, and theneed for operation established. Hundreds of peopleto-day owed their lives to that recognition. Yet thedevil of doubt had arisen again-partly because ofthe universal fear of operation, partly because not alloperations were done by surgeons of experience, andpartly through the eternal desire for change. A risingmortality in appendicitis was coming, owing to thispernicious revival of expectant treatment. Soonerthan proffering statistics he would say :

" Behold,I have passed through the valley of the shadow andI have seen terrible things." Why should we postponean operation which was always successful, easy toperform, and which transferred the patient from astate of danger to a state of safety : the operationwithin 48 hours of onset He would, indeed, gofurther and advise operation on every inflamedappendix. What applied to adults applied a hundred-fold more to children. There would be no greatdanger and a certain amount of sense in waiting, ifit were possible to know what was happening to theappendix, but it was not possible. He proposed" That in every case of acute appendicitis immediateoperation was indicated."

Mr. V. ZACHARY COPE opposed the motion,particularly the words " immediate " and " in everycase." There were cases in which immediate operationwould be disastrous. He agreed with operativemeasures in unperforated cases, in cases of doubtabout perforation, in cases of well-formed abscess,

and in most children, but he did not operate inadvanced peritonitis ; or in cases with a well-formedlump not apparently getting worse ; or on patientswhose general condition was very bad, and in whompreliminary recuperative treatment, such as salineinfusion, might make the operation safe after 12 hours.Many patients had had no treatment before they sawthe surgeon and needed preparation for operation.Every case must be judged on its merits, or what wasthe use of surgical skill and eperience Expectanttreatment had not been tried in past years becausemost of the measures concerned had been unknownin those days. Was the rule of thumb to displaceexperience A skilled clinician could tell how the

pathological process was going in most cases. In

doubt, operation should be performed. There wouldbe no danger of calamity if the patient were putimmediately under the care of a skilled surgeon.

Mr. W. H. OGILVIE said that appendicitis was aneveryday problem and must be approached with anopen mind. He felt almost inclined to agree withMr. Cope. There were cases of appendicitis in whichimmediate operation was unwise, but he doubted ifthese cases were " acute." They were subsiding bythe time the surgeon saw them, and were not mani-festly ill. Nor was operation desirable in bad

surroundings. Nevertheless he only felt justified inwithholding operation in 1 or 2 per cent. His

experience had impressed him with the fallibility ofhuman judgment. With exactly the same historyand physical signs, the appendix might be founddistended with pus and about to burst, gangrenousand not distended, or apparently healthy with a littleinflammation inside only. Nor could he forecastwhat was going to happen, and he had much fear forthe watched case. The demand for revision of treat-ment was based on the Registrar-General’s figures,which showed that the total mortality had notdecreased. These figures, however, did not indicatethe great increase in the number of operations andthe improvement in diagnosis. He believed the

mortality to be no more than a third of what it hadbeen. In Denmark the mortality had been shown toincrease steadily with every day that elapsed betweenonset and operation. The real bone of contentionwas the third- to fifth-day case with rising temperatureand pulse-rate. Mr. Ogilvie confessed that he lackedthe courage to wait. At the beginning the risks couldbe foretold, but as time passed the gamble becamegreater. He had always operated and had lost only

582 FELLOWSHIP OF MEDICINE

one case : from pulmonary embolism on the tenthday. He put in a plea against being too clever insurgery. The general and the particular aspects ofa case were apt to be in conflict. Brilliant surgeonsand prognosticians had led humbler men into pathsof danger. Appendicitis was the job of the journey-man surgeon, and for him operation was the rightcourse and the safe course.

Mr. R. J. McNEILL LovE divided cases of appendi-citis into four groups. Everyone agreed that the earlycases demanded operation and the subsiding ones to beleft alone. The third group was that complicated bygeneral peritonitis. The fourth was the one needingcareful consideration : the patient was seen about48 hours after onset and showed some elevationof temperature and pulse-rate, localised rigidity, andtenderness per rectum. These cases were what olderpractitioners had termed perityphlitis. Operation wasdifficult, drainage was usually necessary, and localisedperitonitis became potential generalised peritonitis.On the fifth day the patient was in a negative phaseof resistance, and the operative mortality was about5 per cent. Complications, also, were encouraged byuntimely operation. Expectant treatment must

rigorously enforce the four F’s-Fowler’s position,fluids only, fomentations, and a four-hourly chart.Water only must be given by the mouth, and this didnot mean beef-tea and custard. Children should notbe treated expectantly, for they had usually had purga-tives. If the case were watched the inflammation mightsubside in 50-70 per cent. of cases, and a clean opera-tion without complications could be performed later.An abscess might form in 25 per cent., but this wasno occasion for panic; it showed that the resistancecould arrest spread of infection. Usually the abscesswould resolve, but should be opened if it increasedin size or was absorbed too slowly. Gas-and-oxygenand a small incision were adequate. Thirdly, in 10per cent. of cases, the patient might require emergencyoperation, but even here the mortality was only about6 per cent. The average mortality after expectanttreatment was no more than 3 per cent. The patientmust be under surgical observation the whole time.Localisation would probably occur if the appendixwere retrocaecal or paracolic, and infection would

spread from an appendix pointing inwards or upwards.Psychology played an important part in the publicestimate ; for if the watched patient succumbed every-body felt he might have survived if operation had beenperformed at once; but if he died after immediateoperation he was soon buried and forgotten.Mr. W. TURNER WARWICK said he would operate

a little earlier without the help of an experiencedsurgeon than he would if this were available. Theretrocaecal type of appendix might or might notdevelop an abscess ; these could be operated on atany time. The pelvic type should always be operatedon at once. Those that spread to the left fossa shouldbe opened up or there would be several separatecollections of pus. The retro-mesenteric appendixwas very dangerous, producing thrombosis or a smallabscess with obstruction of the ileum ; but whentreated early these gave a good prognosis. When theappendix ran behind the peritoneum on the posteriorwall a spreading cellulitis might result, and be almostimpossible to treat if suppuration were allowed tosupervene. His advice, therefore, was to distrustphilosophy and operate on the acute appendix.

Mr. A. TUDOR EDWARDS agreed that a waitingpolicy was advisable in two kinds of case-the sub-siding case, and the abscess in a patient whosetemperature and pulse were settling down. Otherwisehe was in favour of immediate operation.

Mr. HAMILTON BAILEY advocated the method ofSherren. In acute cases with a localised palpablemass, the mass usually disappeared ; if the abscessburst, prompt treatment would save life. Two and

preferably three months should elapse betweenresolution and appendicectomy. The rule of lettingout pus whenever it was present could frequently bebroken and, if so, the day of surgical judgment couldnot be said to be past.

Mr. W. B. GABRIEL was in favour of immediateoperation, and believed that the mortality was

extremely small. The expectant treatment of abscesshad found favour because some abscesses had been

injudiciously and crudely operated on.Mr. H. J. PATERSON said that appendicitis, if treated

intelligently, was not nearly such a serious disease aswas supposed. He opposed the motion. A perforatedappendix was not necessarily fatal. Nature was afar better surgeon than even the youngest of us. In1911 he had opened a debate at the British MedicalAssociation on the side of operation, but since then hehad learned wisdom. Thorough preparation wasabsolutely essential for any operation, and particularlyin acute cases. Very often the preparatory treatmentproduced such improvement that operation was

unnecessary. In the last two and a half years he hadhad 59 delayed cases with no deaths, and 26 immediateoperations with 2 deaths. He could see no objectionto drainage ; better a weak spot in the abdomen thana coffin, however well padded. That sepsis requireddrainage was one of the eternal verities of surgery.Was operation always desirable from the patient’spoint of view ? ‘ Immediate operation was not neces-sary in most cases of acute appendicitis, and cases ofgeneral peritonitis were better left alone. Surgerywas still an art, and there was still room for commonsense and clinical judgment.

Dr. A. CAMPBELL pleaded for the young graduatewho had been urged to let out pus whenever it waspresent. The expectant treatment demanded a degreeof skill that could not be demanded of a young man.It was safer for the young man to operate, providedhe worked with skill, and when he had had experiencehe could select cases for watching.

Mr. SINCLAIR thought that the expectant treat-ment sometimes left patients with unresolvedlumps. He operated in all cases, except that he didnot remove the appendix from a localised abscess,especially in children, in whom the risk was very great.

Mr. C. E. SHATTOCK was in favour of operation, andemphasised the importance of the technique.

Dr. BATEMAN was also in favour of operation.Mr. STANFORD CADE said that all acute appendices

should be removed early and then there would be noabscesses and fewer cases of peritonitis. He classified

appendicitis into two groups-the early in which thesurgeon operated, and the late in which the undertakerofficiated. Very few surgeons could say what a

particular appendix would do ; the risk of operationwas known and justifiable ; the risk of waiting wasunknown and unjustifiable. Conservatism in opera-tion was in direct proportion to the amount ofarterio-sclerosis in the surgeon’s arteries. There wasonly one treatment for appendicitis.

Dr. WALKER (Sydney) argued that no surgeon wasthinking of making appendicitis a medical disease.It was a disease that must be treated by operation;but the question was : when ? In some cases it waswise to stay the hand. The question was one of life.The figures demanded some improvement in treat-ment, and the improvement lay in the selection ofcases. Young men need not fear the difficulty of

583MEDICAL SOCIETY OF INDIVIDUAL PSYCHOLOGY

judgment ; in 20 years’ time all surgeons would beable to make the decision with ease.

Mr. M. J. PETTY agreed that early cases should haveimmediate operation, but if complications arose theyounger man should seek help. In the Argentinepatients travelled great distances to hospital, and signsof previous perforation were sometimes found. Manycases could survive non-interference. For amoebic

appendicitis operation should be immediate.Mr. CoPE, in reply, pointed out that early " cases

were not mentioned in the motion ; Mr. Cade’sremarks were beside the point. The motion declaredthat every case was to be operated on immediately,however ill the patient, however bad the conditions,however inexperienced the surgeon. Every speakeron the other side had immediately begun to makeexcuses and beg the terms at issue. Only throughbitter experience, and not arterio-sclerosis, had Mr.Cope come to the opinion that there were some fewcases which should be left, and if there were somefew cases the motion must be lost.

Mr. VICK accused Mr. Cope of playing with words.Nobody in his senses would operate on a patient dyingof acute peritonitis. The people who had spokenagainst operation had failed to appreciate the dangerof spread. General practitioners taught to watchtheir cases would not call in surgeons to help them.The CHAIRMAN, summing up, said that years ago

he had opened a debate in favour of immediateoperation. The really essential point in the debatehad been entirely omitted : the aperient treatment.Patients never died of appendicitis ; they died of itstreatment. All acute appendicitis was obstructive,and if no aperient treatment were ever given no casewould ever become really active. He had never seen agangrenous perforated appendix in which an aperienthad not been given and had not been the cause of theflagrancy. No danger would derive from expectanttreatment if aperients were withheld and if nothingwhatever-particularly not water-were given bythe mouth. A single drop of water caused intensewrithing activity of the ileocaecal valve. Geographicaland surgical conditions might be bad, but if theywere satisfactory and the case was seen early therecould be no question at all that operation was thebest thing, and no patient ought to be lost. The

question could not be answered with an absoluteaffirmative or negative, but only by the exercise ofclinical sagacity. Only in children was the greatestexpert apt to be at fault ; no child should be left alonewith his appendix for half an hour. Whatever the

surgeon might feel about prognosis he must inevitablyand without exception operate if an aperient had beengiven. If not, the best conditions might be soughteven at the price of some delay.On a show of hands the motion was declared passed

by 54 votes to 49.

MEDICAL SOCIETY OF INDIVIDUALPSYCHOLOGY

AT a meeting of this society held on March 9th,with Prof. W. LANGDON BROWN, the president,in the chair, a paper on the

Psychological Surroundings of the SurgicalPatient

was read by Mr. W. McADAM ECCLES. He beganby speaking of some general aspects of his subject,including the terror with which the word " operation "fills many people. He then considered specificallythe characters taking part in the drama of the surgical

operation. The general practitioner, he said, tookthe part of the prologue. He selected the surgeon ;and incidentally his implicit confidence in the manhe chose was a valuable preliminary to the establish-ment of that mutual confidence between surgeon andpatient. But not only confidence of the suffererin the surgeon, but confidence of the surgeon inhimself and in his team was essential. Certainminor pre-operative details helped to render themood of the patient suitable for undergoing an

operation. It was of value to permit him to enterthe hospital or nursing-home two nights before theoperation. On the first night the bed was strangeand the surroundings unfamiliar, so that in any casesleep might not be good, especially if an aperient wasgiven. It was better to give the aperient early nextmorning, and to allow the bowels to act during theday. The second night could be made more com-fortable by a simple sedative, and a small, hot cupof tea should replace a distressing early morningenema. The time of the operation should be fixeddefinitely, and the patient should be in the hands ofthe anaesthetist five minutes before. Those last fiveminutes before the hour were apt to be filled withdread, and the minutes after were regarded withveritable horror.

Speaking of the psychological effects of local, spinal,or rectal anaesthesia, Mr. Eccles pointed out that somepeople dread loss of consciousness. On the otherhand to be wholly or partially conscious duringan operation might have a disagreeable and lastingeffect upon memory, even upon mentality. Inaddition, a very definite, though often unmeasurablemental element entered into the causation of " shock."The period after the operation was also important.

To find oneself alone when returning to consciousnessmight be a real shock, and to be deadly sick withouta receptacle for the vomit was very distressing.Nothing in convalescence was more encouraging thanthe prospect of a speedy recovery, if such could beforetold. If, on the other hand, the surgeon knewthat recovery might take a long time, it was well tointroduce this necessity gradually to the patient’smind, and to prepare to mitigate its irksomeness.A discussion followed.

ROYAL ACADEMY OF MEDICINE INIRELAND

A MEETING of the section of medicine was held onMarch 3rd, with Dr. W. G. HARVEY, the president,in the chair.

Pernicious Anaemia

Prof. HENRY MooBE and Dr. W. R. O’FARRELLdescribed the case of a woman, aged 58 years, withanaemia, Addisonian in type, but with a normal curveof gastric hydrochloric acid in the fractional test-meal (done on three different occasions).The patient, Dr. Moore said, complained of weakness,

dyspnoea on exertion, looked sallow, and the appearanceof the tongue was typical of pernicious anaemia (beefy-red,furrowed, with atrophic papillae). The red cell count was2,490,000 per c.mm., the leucocyte count 2000, the haemo-globin 63 per cent., and the colour-index 1-32 ; there wasa distinct megalocytic tendency, the average size of the redcells, with a Price-Jones count, being 8-13 p ; there wasslight but distinct poikilocytosis, polychromatophilia, andpunctate basophilia ; no normoblasts were seen. Thedifferential count was normal. The blood bilirubin was1-9 mg. per 100 c.cm.

Liver treatment by mouth gave a reticulocyte response(10 per cent. in ten days) and in two months, with no otherform of treatment, the blood count showed red cells 4,640,000,leucocytes 4800, haemoglobin 100 per cent., and colour-