- Email: [email protected]
POLIOMYELITIS FOLLOWING TONSILLECTOMY
432
T
myself. And coronary thrombosis and angina are doctors’ diseases anyway ! Here I made a firmer resolution than most I have made. While I am still forced to this miserable necessity of commuting, no more rushing. Better be late in this world than too soon in the next. Henceforward I will Look After My Arteries.... But I wonder ; wouldn’t they like it better if I gave them those few extra minutes every morning in bed ? on
*
*
*
we lost our county status and On the first Anninoble crest. versary Day paper in universal use appeared with an over-print-"XXXX GROUP HOSPITALS "-in blue so royal that an amused houseman took a few sheets home to show to her parents. In the bus she opened her rather full handbag to get her fare and on closing it noticed that the folded sheets had fallen on the floor. The gallant conductor picked them up, and intrigued by the serrated edge opened a sheet to read the name aright. He covered her confusion with : " ’Sall right, Miss, ours says LONDON TRANSPORT."
On the Appointed from our notepaper
Day
a
*
*
*
He was a classically grandiose G.P.i. but he had a streak’of artistry in him. He told me that he had just thrown a huge party, so I asked him how many people had attended. " Well, I’m not sure exactly," he said, " but it took twenty-four men twenty-four days to mix the mustard for the sandwiches." *
*
*
One thing about the Board of Control, they don’t lose heart. In their latest report they remark : " In their Report of 1846 to the Lord Chancellor the Commissioners in Lunacy wrote (then follows criticism of admission documents) " .. The situation is still unsatisfactory." I have thought of the Master in Lunacy as an awe-inspiring person, but in future I shall see him heaving a long-suffering sigh as the centuries roll by.
always
*
*
*
We made him a gift of ourselves en bloc. We gave him the hospitals, stock and Lock. And under the Criminal Justice Act We gave him Broadmoor, with staff intactWarders, boarders, bats, and trustiesAs a simple act of criminal justice.
" ...
and the
righteous cramp."
psychiatrist’s report said she had *
*
*
SIR,-I hesitate to criticise so distinguished a colleague as Dr. Pardoy (Aug. 27, p. 398) but, putting personal feelings aside, I must let him have it straight, ex humero summo.
Before launching my main grouse, however, I would mention his inconsistency. He admits, apparently, that the disease was first reported by Thomas Pearce (himself, surely, a lover of fair " play), professor of veterinary surgery at Widdecombe University, yet he refers to it as his disease. One has no wish to argue here as to who owns the copyright. This can, and unless Dr. P. is prepared to climb down, will, be done at the proper time and in the proper place. No-one could find fault with his article on literary grounds : it is admirably lucid, very informative, written in simple, almost basic, English, and an exhibition of the results of many years of clear thinking and deep learning. The qualities displayed are the more dangerous, however, because from a scientific point of view the doctor’s effusion is sheer balderdash. As everyone should know, Pearce’s " 3 cases " was a description of three phases in the same disease of one subject-namely, a mare. This unfortunate beast (suffering from some form of hereditary cyanosis) was in bad shape when handed over to me and my six colleagues and could by no stretch of imagination be described as a young adult. The aetiology of the disease in this, the only known example of it, was diagnosed during life as traumatic lordosis. Permission for P.M. was refused, but later interment (which almost spontaneously occurred) was carried out and confirmed the presence of ossa crepantia or ":mobile skeleton." Finally, please note that my paper of this year should be cited under the authorship not of Cobley et al. but of Cobbleigh et omn., and that my name is spelled: THOMAS COBBLEIGH, M.WID.C.V.S. "
Letters POLIOMYELITIS
to
the Editor
FOLLOWING
TONSILLECTOMY
SiR,—The death of two children from acute anterior
poliomyelitis after tonsillectomy raises a problem of great importance in clinical medicine. For twenty years I taught it as the " principle of the dominating lesion." It may be enunciated thus : " when a patient is suffering from two diseases, both of some severity, does the of them interfere with the prognosis and if so which is the lesion that is dominating ’’? When this problem is before you and the treatment of the other is the one that may harm the patient owing to the presence of the dominating lesion, should that treatment be forgone, or should the risk that the presence of the dominating lesion entails be taken" I learnt this in the early twenties from that particularly fierce Guy’s man, Dr. E. W. Goodall, at the North-Western Fever Hospital, in relation to mastoiditis in a case of diphtheria. It was the first time I had diagnosed this, and I said to the A.M.o. in charge of the case: Well, we had better get on with the job and ask them to get the theatre ready." "No," said Dr. Ursula Blackwell, now physician at the Western Hospital, " we must go and talk to the medical superintendent first." " I do not see why that is necessary," said I. I do not know about that," she said, " but here we have to." So we went. " What about that case ?" said Dr. Goodall. " She has a mastoid," said I. " What do you advise" he asked. " Oh ! we’ve got to operate," said I. He took a pace forward, thrust his face into mine with the jaw advanced like the 100% he-man of the pictures of that day, and almost growled at me : " Mr. Layton, will you that patient will die if you do not guarantee that " No, Sir, certainly not," I said. " Then," operate ?" said he, I will not allow you to do so." He then became the kindly urbane teacher that he usually was and went " In every case of diphtheria, even of moderate on : severity, I am quite certain that there may be so much damage to the heart-muscle that no anaesthetic should be given unless otherwise death is certain." In the subsequent 20 years that I remained in the fever service I never operated on a mastoid, except in one case, either in his or any other hospital to which I was attached, in a patient suffering from diphtheria, and I extended his rule to septic scarlet fever and measles in minute children. The exception was a woman of about 35 with a pharyngeal paralysis and her bed propped high, on whom I operated, with Dr. Goodall’s consent, under local anaesthesia. Again I had the assistance of Dr. Ursula Blackwell. Septic scarlet fever has, for a time, passed away. Diphtheria is controlled by the State ; and the clinician can modify measles into harmlessness ; but still the and and is of modification remains principle capable extension. It was a few years later that I met it in the following form. If an operation is advised in a patient who, during the period of convalescence, will be liable to communicable disease which may impair the efficiency of the operation, is this so imperative that the risk must be taken or should it be deferred until the chance of catching the communicable disease has passed1 The operation was tonsillectomy, and the communicable disease measles. It was a year in which there was a big epidemic, and we had eight cases of measles which had developed after tonsillectomy and subsequently had mastoiditis. We lost four of them. This series convinced me that of all forms of inflammation of the middle-ear cleft the tonsillectomy-measles-mastoiditis sequence is the worst. After that year I never took out tonsils during a measles epidemic from a child that had not already had measles.
treatment for in the other ;
one
,
"
11
"
433 Those who work only in hospitals where communicable diseases are not admitted are not faced with this principle of the dominating lesion. In the 35 years that I was on the staff of Guy’s I never had to deal with it in that hospital; but now the same problem that I had with measles has arisen with poliomyelitis and tonsillectomy. Wehad heard of this a year ago-some may say longerfrom Canada and it was discussed at two of the sections of the B.M.A. annual meeting in 1948. In the section of epidemiology Dr. Banks made an appeal to all those who operated on tonsils to desist when poliomyelitis was appearing in epidemic form. At the section of diseases of the throat and ear, however, two leaders in our specialty were unable to accept this guidance. One looked on the operation of tonsillectomy as being so important that he would not defer it, and the other reported that not everyone in Canada believed that there was any clinical association between the two. Now we have had it brought to our very door. What are we to do about it ?f The ideal is that everyone who takes out ’tonsils should use his own clinical judgment and desist from all operations in any year in which poliomyelitis is prevalent until it is no longer so, even if that means putting off all tonsillectomies from the early autumn until the end of February. It is not a question of absolute scientific proof ; but one of probability. But it is also one of death and mutilation. There is no’ time for everyone to become convinced by personal
experience. that tonsillectomy will not allow of not hold water. My predecessor at Guy’s, Mr. F. J. Steward, used to shut down all operations at outpatients from October to March-a practice in which I followed him and extended to all such operations about 20 years ago, since when I did no operations on tonsils during the winter months. No-one came to any harm thereby. And those who claim that a tonsil operation must be done at once have long been confuted by the waiting-lists which they have allowed to pile up all.over the country. If they really believed that these operations were urgent they would have clamoured years ago for the necessary accommodation. Can the administrators help us ’? Not by ordering. In one of the reports in the press it seemed to be suggested that the excellent memorandum circulated by the Ministry of Health last year was an order to desist. This, no doubt, was faulty journalism ; but it continued by quoting a pathologist on the postponement of the operation. If he was accurately reported this pathologist There is no seems to have gone beyond his subject. pathological evidence whatever that tonsillectomy leads to invasion of the body by way of the wound produced. The evidence is clinical entirely ; and it is for us clinicians to decide. We are less likely to persuade those who do not recognise the principle of the dominating lesion if other people start to dictate. It is, however, the business of all clinicians. For every clinician today sometimes comes across a case in which tonsillectomy may need consideration. There is a way in which the administrators may use their influence. Under no circumstances must they be allowed to put pressure on clinicians to perform operations against their better judgment. This must be opposed wherever it arises. But they may be entitled to call a halt where the opinion of the majority of the profession is against operations being done, as I think must be the case here ; and they can do it by withholding beds. Even here a loophole should be left for the clinician with the exceptional case. And that ought to be met by the insistence on a second opinion, not from another operator on tonsils but from a physician of his own choosing. Some such administration as this might well be set up not only to stop tonsillectomy in times when
The
argument
delay will
is rife but also during the whole of the the country. Finally there are the parents. They are in the end the persons responsible for the operation being done. That very wise little old man, Lord Snell, deplored the diminution of parental responsibility as being one of the danger signals of today. These cases bear out his grave
poliomyelitis winter all
over
warning. At
T. B. LAYTON.
sea.
THE DOCTOR’S PROFESSION
I express my admiration for this series of In my opinion they state very clearly the views of the minority who occupy the Christian position. Although they are unlikely either to edify or to win the approval of readers who divorce religion or the fear of God from living, they nevertheless deserve a place in THE LANCET, which claims to be a journal of medicine. Medicine untinctured by either politics or religion is a specialty which deserves a journal of its own. F. C. STALLYBRASS. Hill End Hospital, St. Albans.
SiR,-May
essays?
bin,—Modern medicine owes much to Christian thinking and more to the Christian men and women who have been, and are, leaders in the profession. It was therefore surprising to see that two correspondents were protesting about the series of articles under the above title. In this generation of advancing materialism, with its many ugly forebodings, it is surely high time that we were considering again our work as doctors in the light of our historic national faith. This is reason enough to welcome the articles. We have no business to allow others to do our thinking for us. Dr. Simmons (Aug. 20) appears to me to misrepresent the writer of the second article, who is singularly careful not to overstate his case. 1. The Christian doctor does not enter the world with a " hopeless attitude." The reverse is the truth. He is aware of man’s corruption but is far more aware of God’s power and plan to overcome that corruption. 2. If a doctor is concerned merely to relieve pain " his attitude is sentimental and, because it is sentimental, dangerous." No-one would suggest that it is a,Christian’s duty to withhold relief for physical pain and suffering, but, like the Master whom he feebly follows, he does desire first and foremost to preserve the divine gift of life. 3. I do not agree with all the article says about suffering but the writer does not fail to condemn those who refuse to use " all reasonable means " for its alleviation. The mystery of suffering is a very deep one ; it cannot be fully explained in terms of pain and disease on a physical level. Yet the Christian believes that he can see a little further into its meaning than the materialist. 4. The answer to Dr. Simmons’s question is-Yes, we are an unhealthy society if we pay too much attention to the needs of the body and in so doing neglect the soul of man and the demands of God upon him. C. G. SCORER. Iver, Bucks. have read with great pleasure the admirable timely essays in this series. As it is wellnigh impossible for those uninstructed in Christian ethic to appreciate them, I should like to suggest a few thoughts to your two correspondents who registered some classic arguments in disapproval. Mr. Whittingdale (Aug. 20) prefers you to serve your readers with medicine " untinctured by politics or religion." It is not impossible to dissociate medicine from politics because political principles rarely interfere with the theory and practice of medicine. On the other hand, religious principles .(particularly in
SiR,—I
and
T
myself. And coronary thrombosis and angina are doctors’ diseases anyway ! Here I made a firmer resolution than most I have made. While I am still forced to this miserable necessity of commuting, no more rushing. Better be late in this world than too soon in the next. Henceforward I will Look After My Arteries.... But I wonder ; wouldn’t they like it better if I gave them those few extra minutes every morning in bed ? on
*
*
*
we lost our county status and On the first Anninoble crest. versary Day paper in universal use appeared with an over-print-"XXXX GROUP HOSPITALS "-in blue so royal that an amused houseman took a few sheets home to show to her parents. In the bus she opened her rather full handbag to get her fare and on closing it noticed that the folded sheets had fallen on the floor. The gallant conductor picked them up, and intrigued by the serrated edge opened a sheet to read the name aright. He covered her confusion with : " ’Sall right, Miss, ours says LONDON TRANSPORT."
On the Appointed from our notepaper
Day
a
*
*
*
He was a classically grandiose G.P.i. but he had a streak’of artistry in him. He told me that he had just thrown a huge party, so I asked him how many people had attended. " Well, I’m not sure exactly," he said, " but it took twenty-four men twenty-four days to mix the mustard for the sandwiches." *
*
*
One thing about the Board of Control, they don’t lose heart. In their latest report they remark : " In their Report of 1846 to the Lord Chancellor the Commissioners in Lunacy wrote (then follows criticism of admission documents) " .. The situation is still unsatisfactory." I have thought of the Master in Lunacy as an awe-inspiring person, but in future I shall see him heaving a long-suffering sigh as the centuries roll by.
always
*
*
*
We made him a gift of ourselves en bloc. We gave him the hospitals, stock and Lock. And under the Criminal Justice Act We gave him Broadmoor, with staff intactWarders, boarders, bats, and trustiesAs a simple act of criminal justice.
" ...
and the
righteous cramp."
psychiatrist’s report said she had *
*
*
SIR,-I hesitate to criticise so distinguished a colleague as Dr. Pardoy (Aug. 27, p. 398) but, putting personal feelings aside, I must let him have it straight, ex humero summo.
Before launching my main grouse, however, I would mention his inconsistency. He admits, apparently, that the disease was first reported by Thomas Pearce (himself, surely, a lover of fair " play), professor of veterinary surgery at Widdecombe University, yet he refers to it as his disease. One has no wish to argue here as to who owns the copyright. This can, and unless Dr. P. is prepared to climb down, will, be done at the proper time and in the proper place. No-one could find fault with his article on literary grounds : it is admirably lucid, very informative, written in simple, almost basic, English, and an exhibition of the results of many years of clear thinking and deep learning. The qualities displayed are the more dangerous, however, because from a scientific point of view the doctor’s effusion is sheer balderdash. As everyone should know, Pearce’s " 3 cases " was a description of three phases in the same disease of one subject-namely, a mare. This unfortunate beast (suffering from some form of hereditary cyanosis) was in bad shape when handed over to me and my six colleagues and could by no stretch of imagination be described as a young adult. The aetiology of the disease in this, the only known example of it, was diagnosed during life as traumatic lordosis. Permission for P.M. was refused, but later interment (which almost spontaneously occurred) was carried out and confirmed the presence of ossa crepantia or ":mobile skeleton." Finally, please note that my paper of this year should be cited under the authorship not of Cobley et al. but of Cobbleigh et omn., and that my name is spelled: THOMAS COBBLEIGH, M.WID.C.V.S. "
Letters POLIOMYELITIS
to
the Editor
FOLLOWING
TONSILLECTOMY
SiR,—The death of two children from acute anterior
poliomyelitis after tonsillectomy raises a problem of great importance in clinical medicine. For twenty years I taught it as the " principle of the dominating lesion." It may be enunciated thus : " when a patient is suffering from two diseases, both of some severity, does the of them interfere with the prognosis and if so which is the lesion that is dominating ’’? When this problem is before you and the treatment of the other is the one that may harm the patient owing to the presence of the dominating lesion, should that treatment be forgone, or should the risk that the presence of the dominating lesion entails be taken" I learnt this in the early twenties from that particularly fierce Guy’s man, Dr. E. W. Goodall, at the North-Western Fever Hospital, in relation to mastoiditis in a case of diphtheria. It was the first time I had diagnosed this, and I said to the A.M.o. in charge of the case: Well, we had better get on with the job and ask them to get the theatre ready." "No," said Dr. Ursula Blackwell, now physician at the Western Hospital, " we must go and talk to the medical superintendent first." " I do not see why that is necessary," said I. I do not know about that," she said, " but here we have to." So we went. " What about that case ?" said Dr. Goodall. " She has a mastoid," said I. " What do you advise" he asked. " Oh ! we’ve got to operate," said I. He took a pace forward, thrust his face into mine with the jaw advanced like the 100% he-man of the pictures of that day, and almost growled at me : " Mr. Layton, will you that patient will die if you do not guarantee that " No, Sir, certainly not," I said. " Then," operate ?" said he, I will not allow you to do so." He then became the kindly urbane teacher that he usually was and went " In every case of diphtheria, even of moderate on : severity, I am quite certain that there may be so much damage to the heart-muscle that no anaesthetic should be given unless otherwise death is certain." In the subsequent 20 years that I remained in the fever service I never operated on a mastoid, except in one case, either in his or any other hospital to which I was attached, in a patient suffering from diphtheria, and I extended his rule to septic scarlet fever and measles in minute children. The exception was a woman of about 35 with a pharyngeal paralysis and her bed propped high, on whom I operated, with Dr. Goodall’s consent, under local anaesthesia. Again I had the assistance of Dr. Ursula Blackwell. Septic scarlet fever has, for a time, passed away. Diphtheria is controlled by the State ; and the clinician can modify measles into harmlessness ; but still the and and is of modification remains principle capable extension. It was a few years later that I met it in the following form. If an operation is advised in a patient who, during the period of convalescence, will be liable to communicable disease which may impair the efficiency of the operation, is this so imperative that the risk must be taken or should it be deferred until the chance of catching the communicable disease has passed1 The operation was tonsillectomy, and the communicable disease measles. It was a year in which there was a big epidemic, and we had eight cases of measles which had developed after tonsillectomy and subsequently had mastoiditis. We lost four of them. This series convinced me that of all forms of inflammation of the middle-ear cleft the tonsillectomy-measles-mastoiditis sequence is the worst. After that year I never took out tonsils during a measles epidemic from a child that had not already had measles.
treatment for in the other ;
one
,
"
11
"
433 Those who work only in hospitals where communicable diseases are not admitted are not faced with this principle of the dominating lesion. In the 35 years that I was on the staff of Guy’s I never had to deal with it in that hospital; but now the same problem that I had with measles has arisen with poliomyelitis and tonsillectomy. Wehad heard of this a year ago-some may say longerfrom Canada and it was discussed at two of the sections of the B.M.A. annual meeting in 1948. In the section of epidemiology Dr. Banks made an appeal to all those who operated on tonsils to desist when poliomyelitis was appearing in epidemic form. At the section of diseases of the throat and ear, however, two leaders in our specialty were unable to accept this guidance. One looked on the operation of tonsillectomy as being so important that he would not defer it, and the other reported that not everyone in Canada believed that there was any clinical association between the two. Now we have had it brought to our very door. What are we to do about it ?f The ideal is that everyone who takes out ’tonsils should use his own clinical judgment and desist from all operations in any year in which poliomyelitis is prevalent until it is no longer so, even if that means putting off all tonsillectomies from the early autumn until the end of February. It is not a question of absolute scientific proof ; but one of probability. But it is also one of death and mutilation. There is no’ time for everyone to become convinced by personal
experience. that tonsillectomy will not allow of not hold water. My predecessor at Guy’s, Mr. F. J. Steward, used to shut down all operations at outpatients from October to March-a practice in which I followed him and extended to all such operations about 20 years ago, since when I did no operations on tonsils during the winter months. No-one came to any harm thereby. And those who claim that a tonsil operation must be done at once have long been confuted by the waiting-lists which they have allowed to pile up all.over the country. If they really believed that these operations were urgent they would have clamoured years ago for the necessary accommodation. Can the administrators help us ’? Not by ordering. In one of the reports in the press it seemed to be suggested that the excellent memorandum circulated by the Ministry of Health last year was an order to desist. This, no doubt, was faulty journalism ; but it continued by quoting a pathologist on the postponement of the operation. If he was accurately reported this pathologist There is no seems to have gone beyond his subject. pathological evidence whatever that tonsillectomy leads to invasion of the body by way of the wound produced. The evidence is clinical entirely ; and it is for us clinicians to decide. We are less likely to persuade those who do not recognise the principle of the dominating lesion if other people start to dictate. It is, however, the business of all clinicians. For every clinician today sometimes comes across a case in which tonsillectomy may need consideration. There is a way in which the administrators may use their influence. Under no circumstances must they be allowed to put pressure on clinicians to perform operations against their better judgment. This must be opposed wherever it arises. But they may be entitled to call a halt where the opinion of the majority of the profession is against operations being done, as I think must be the case here ; and they can do it by withholding beds. Even here a loophole should be left for the clinician with the exceptional case. And that ought to be met by the insistence on a second opinion, not from another operator on tonsils but from a physician of his own choosing. Some such administration as this might well be set up not only to stop tonsillectomy in times when
The
argument
delay will
is rife but also during the whole of the the country. Finally there are the parents. They are in the end the persons responsible for the operation being done. That very wise little old man, Lord Snell, deplored the diminution of parental responsibility as being one of the danger signals of today. These cases bear out his grave
poliomyelitis winter all
over
warning. At
T. B. LAYTON.
sea.
THE DOCTOR’S PROFESSION
I express my admiration for this series of In my opinion they state very clearly the views of the minority who occupy the Christian position. Although they are unlikely either to edify or to win the approval of readers who divorce religion or the fear of God from living, they nevertheless deserve a place in THE LANCET, which claims to be a journal of medicine. Medicine untinctured by either politics or religion is a specialty which deserves a journal of its own. F. C. STALLYBRASS. Hill End Hospital, St. Albans.
SiR,-May
essays?
bin,—Modern medicine owes much to Christian thinking and more to the Christian men and women who have been, and are, leaders in the profession. It was therefore surprising to see that two correspondents were protesting about the series of articles under the above title. In this generation of advancing materialism, with its many ugly forebodings, it is surely high time that we were considering again our work as doctors in the light of our historic national faith. This is reason enough to welcome the articles. We have no business to allow others to do our thinking for us. Dr. Simmons (Aug. 20) appears to me to misrepresent the writer of the second article, who is singularly careful not to overstate his case. 1. The Christian doctor does not enter the world with a " hopeless attitude." The reverse is the truth. He is aware of man’s corruption but is far more aware of God’s power and plan to overcome that corruption. 2. If a doctor is concerned merely to relieve pain " his attitude is sentimental and, because it is sentimental, dangerous." No-one would suggest that it is a,Christian’s duty to withhold relief for physical pain and suffering, but, like the Master whom he feebly follows, he does desire first and foremost to preserve the divine gift of life. 3. I do not agree with all the article says about suffering but the writer does not fail to condemn those who refuse to use " all reasonable means " for its alleviation. The mystery of suffering is a very deep one ; it cannot be fully explained in terms of pain and disease on a physical level. Yet the Christian believes that he can see a little further into its meaning than the materialist. 4. The answer to Dr. Simmons’s question is-Yes, we are an unhealthy society if we pay too much attention to the needs of the body and in so doing neglect the soul of man and the demands of God upon him. C. G. SCORER. Iver, Bucks. have read with great pleasure the admirable timely essays in this series. As it is wellnigh impossible for those uninstructed in Christian ethic to appreciate them, I should like to suggest a few thoughts to your two correspondents who registered some classic arguments in disapproval. Mr. Whittingdale (Aug. 20) prefers you to serve your readers with medicine " untinctured by politics or religion." It is not impossible to dissociate medicine from politics because political principles rarely interfere with the theory and practice of medicine. On the other hand, religious principles .(particularly in
SiR,—I
and