G. Monod
1913 BMJ (Clinical Research Edition)  
LMZDICAL Jo-L I5I3 dlirectly either by arsenic or antimony. My own opinion is that the other phases are destroyed by oxidizing enzymes, wIieh arsenic and antimony can. accelerate, as manganese does some plant oxydases. The spores contain little or no colloidal memiibrane and only nuclein, hence they cannot be easily oxidized; they may remain in tlle system for years untotuched, and then for no apparent reason start off the cycle again wllich results in the production of gametes anid so
more » ... es anid so symptomiis. It is becoming day by day miiore doubtful whletlher sypllilis is really cured directly by treatment; tllerefore wotuld it niot be wviser, considering that so muclh attention is being paid to treatmiient at present, if more tlhought were giveni to prevention ? It must be reminembered that no disease lias ever yet been stamiiped out by treatment, and history has an awkward way of repeating itself.-I ami, etc., London, Nov. 28th. J. E. R. McDON AGH. THE CRAZE FOR APPENDICECTOMY. SIR,--The subject brougLlt forward by Dr. Robert i-iutchison in the0 BRITISHI MEDICAL JOUIRNAL fOr November 15th, alid conitinued by otlher writers in later JOURNALS, opens up a very bigy question-namiiely, the comlparative value of the diagnostician and the operator. For sonle time past the siurgeon lhas lheld the field in. nearly all actute and clhronic abdolmlinal diseases on accounit of his daring, hiis sk-ill, anid hlis success. A reaction is now settilng in, for reasons wlhiclh have already been stated. The vast imiiportance of early diagniosis is beginning to be more appreciated, inot only by-ourselves but by the public. It requires greater knowledge, lmlore acumien, more experience to be a good diagnostician than to be a good operator. A miialn mnay be botlh, but tlle quialities of eaclh arc Inot as a rule evenily divided. Tllere has beeni, buit to less extenit niow, a want of relative inmportance of the valuLe betvecn tlle diagnosis of disease anid its treatment. Tlle diagnosis of disease is inefficiently rewarded; the treatment of it often receives too mucli. Wlhat is really requiired in these nmodern days of rusl anid stress is that more time, attention, tlhoualgt, and experience shotuld be given up to the unravelling of these abdolmiinal cases --of course I ami not referriug to tlle acute cases-and that tlle short cut slhould not be takeni of opening an abdomeen to make the diagnosis before all otlher mealns lhave beell uised.-I amn, etc., Folkestone, Dec. 1st. W. J. TYSONv. SIR,-It is interestinig to note hlow often the saiime iimedical topics are discussed simultaneously in Fralnce and in -England, and how close niay be the resem-iblance between the views of the extreine-faction on botlh sides of tlhe Clhanlnel. Here, as witlh you, the rage of appendicectomy is raimipant, and must surely have reaclhed its climiiax. Tiny clhildren play at appendicitis witlh their dlolls-a weird exam--ple of precocious suggestion-wllile damiies of hiigh degree take the same pride in the "d dear little scars" impriinted on the abdomien by faslhionable surgeons that a collector might in tlle remtstar-qtue of a clloice proof engraving. The change in the current of popular feeling hias, of necessity, exercised an influence oni the attitude of practitioners when dealing with cases in wvlichl there is nio indisputable need for surgical intervention. Whereas formerly it was the surgeon who advised interferenice, now the urgency com-es from tlle patient or his frienids, and, should thlere finally be a fatal issue, blame attaclhes to the surgeon only if he lhas lheld hiis band or performed the operation at a date lheld to hiave been too lonig postponed. The abstentionist muist, then, be sure of his grotund clinically, and be prepared to grapple with deeply rooted prejudice witlh calm serenity. As miiay be stupposed, in suichl an environlmiient many needles,s operationis are performed. Tlle most frequLenit errors in diaglnosis ml-ay be sumlllmarized as follows: 1. Hyperaestlhesia of the skin in ani actute fornm, conniiected sometimes witli affections of the bowels. 2. Attacks of paini in conjunction witlh the periodls, anid accompaniied by rise of temperature. 3. Biliary disorders (lithiasis). 4. Visceroptosis: (a) Coloptosis, witli kinhing at the hepatic flexure; (b) gastroptosis, witlh descent of the pylorus to MeBurney's spot; (c) nephroptosis with its comnplex semeiology. In conclusion, muchll more must be known of the root facts of the problemn as a whole before.we -can express our judgements in ternms of forinulae; wllile perlhaps the surest means of determining the boundary line of thle physician will be found in a patient appraisement of the final results of the forays of the surgeons in a territory formerly forbiddecn to tliem.-I am, etc., Paris, Nov. 28th. GUSTAVE MON-OD. SIR,-Like Sir Jamiies Goodliart, I think Dr. Hutclhison hias done good service in writing his letter on the " craze for appendicectomiiy.." It is good in that he is revealing, I Will not call it a craze, but a " possible disinclination " oni the part of some physiciaiis to diagnose definite abdomiinal disease whlen persistent pain is present. Tllat some cases are not cured by the remiioval of the appendix is surely no greater reproach tllan tlhat they are not cured by the long course of drugs, rest cure, miassage, colonic douches, and dietetic treatment meted out to theat by the physician before the question of operation is broaclhed. lt slhould be recognized, and is so recognized by most surgeons whlose practices deal muclh withi tlle appendix, thlat if at the operation there is not sufficient evidence of appeindicular disease, the pelvic organs, the gall bladder, tlle stoimiachl, and the duodenumi slhould be searclhed for tte cause of tlle pain. It is surprisinga lhow often disease of one organ will miiiiilic that of anotlher. There are cases, as Dr. Aldren Turner poinits ouit, of nervous diseases in wllichl the pain simulates disease of the appendix or gastric ulcer. Btit those of us whlo lhave lhad the privilege of findina we lhave made these miiistalkes walk circumispectly. The otlher side of the (1uestiOii. conies in, hlowever. Soimietimiies patienits wvitlh s-pinal lesions get clhronic appenidicitis. About a year ago a patient was sent to me with a view to an operation for abdoniiinal paini of some mrontlhs' duration. As the paini was indefinlite in its relation to food, altlhough in the left side of the epigastrium, and as he lhad suffeired fromii diplopia of sypliilitic origin (tlle puipil reflexes and knee-jerks werc present), I ventured to diagnose a syphilitic lesion of the cord. I prescribed mercury and potassium, iodide. His pain disappeared rapidly, and lie was apparently cured. However, two montlis ago I opened his abdomuen, ag for the previous two montlhs lie liad suffered from-1 pain and diarrlroca persistinig in spite of treatment. The suspicion of malignant disease of tlle colon made miie urge him to lhave an exploratory operation, tlhotgalh I told him that fromi previous experience it was possible I miiiglht find chronic disease of the appendix. The only abnormal conditionl found at tlle operation was ali appendix muteli bound dlown by inflammiatory adlhesions. He lhas niowv nio pain and no diarrlloea. This is the fourtlh case I hlave explored for epigastric pain and diarrhoea pcrsistingr in spite of from two to three months' treatmeint in wlliclh I liave found chrolic appendicitis, and in wlhicl tle renioval of tlle appenidix lhas curecl thLe symptoms. Witilout operation these cases lmiglht have beeln looked uponl as examples of maluicous colitis. 'Tile diagunosis of acute appendicitis is sufficienltly well known to be beyond the liimiits of this discussion; but in thie clioioiic cases the only reliable sign is tenderness over the region of the appendix-undoubted localize(d tenderiness. A hiistory of attacks of pain, followed vby disconifort on standing erect, or stiffness in the muscles over the right iliac fossa, is also significant. In tle coui-se of operating upon somiie lhundreds of cases of " appendicitis " (tlhe majority typical), amiongst those whliose prinicipal trouble was clhronic abdominal pain tlho clhief mistakes in tlle diagnosis were gall stones or cliolecystitis, gastiic or duodenial ulcer, pyosalpinx, or a lheavy displaced nterus, associated with or present in place of the diaanosed chlronic appendicitis. Mv experlienice is that it is iare for people to rush into operations before a thorouall trial has been made of miedical treatmiienit for abdomiiinal pain, and that, wlheni appendicectomny has failed to relieve, the appendix wvas not the cause of the symptoms, but soele otlher abdominal discase existed, wllichi might lhave been discovered and remelcdied att the timl-e of the operation. Finally, that there will be cases which will disappoint
doi:10.1136/bmj.2.2762.1513-a fatcat:5cujje33xzbzhd57hsai3pqn3u