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Is your tonsillectomy really necessary?
PUBLIC
HEALTH
SOCIETY OF MEDICAL OFFICERS OF HEALTH No. 9. Vol. LXI.
JUNE, 1948 CONTENTS
EDITORIAL Is Your Tonsillectomy Really Necessary? . . . . . . . . . . . . . . . I m p r o v i n g the National Diet ... . . . . . . . . . . . . . . . . . . Encephalomyelitis after Vaccination .: . . . . . . . . . . . . . . . . I n f a n t Mortality and Stillbirths . . . . . . . . . . . . . . . . . . . . . Rhondda U.D. Rheumatism Clinic . . . . . . . . . . . . . . . . . .
PAGE 163 163 164 164 164
Early Diaguosis of Bronchial Carcinoma (A. E. Beynon) ......... N u t r i t i o n and Health Education (R. B. D. Stocker) . . . . . . . . . . . . BOOK REVIEW
173 173
Tuberculosis in Young Adtflts.
174
165
A. G . Glass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C . S . Thomson . . . . . . . . . . . . . . . . . . . . . . . . . . .
SPECIAL ARTICLES
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
NEWS A N D REPORTS Proposals for Health Centres ,.. . . . . . . . . . . . . Provisional Vital Statistics for 1947 . . . . . . . . . . . . . . . . . . T h e Centenary Celebration ir[ the City . . . . . . . . . . . . . . . T h e British Rheumatic Association .. . . . . . . . . . . . . . . . . . Tuberculosis Association Research Committee ............ London
C.C.'s
Prophit Tuberculosis Survey, 1935-44 ,..
OBITUARY
T h e Centenary of Public Health. Speech by H . R . H . Princess Elizabeth . . , Some Aspects of Prevention of Infection T h r o u g h Food and Drink. By W. R. ]Viartine, T,D., M.D.. D.P,H T h e Dental Care of the. C h i l d u n d e r the National Health Service Act. Memoraodum by Dental Officers' G r o u p of the Society . . . . . . . . . .
PAOI~
CORRESPONDENCE
165 167
167 172 172 173 173
EDITORIAL Is Y o u r TonsUleetomy R e a l l y Necessary? Dr. J . Alison Glover,* a doughty warrior, has again unsheathed his sword in defence of the child against unnecessary tonsillectomy. T h e administrative medical officer cannot stand on one side and view the fight with mere academic interest. Like the armament manufacturer, he may have to supply the ammunition which he hates and fears but which he has been told is essential for the peace of the child. As a humane person, he may be haunted by the fear of subjecting children to the risks of an operation; or he may feel tfiat unjustifiable interference on his part may result in children going on for months or years with diseased organs which he has always believed to be harmful. Pressed by the children's family doctors or by his own assistant school medical officers, he submits the children to examination by his nose and throat surgeon, and he must rely on his opinion. He may, however, be left wondering how it is that at Eton in 1938 it was found that some 83 per cent. of new boys were found to have been tonsilleetomised presumably.on the advice of surgeons of repute, whereas more of the children in his maintained schools. will have been found to. have escaped the operation. Unless there is some factor tending to make the children of the wealthier classes more liable to diseased tonsils, it means either that too many of the Eton entrants have been operated upon or too few of his own children. Dr. Glover maintains that too many children in all social classes are submitted to this operation. He does not attempt to prove that tonsillectomy is never necessary, but he brings forward evidence in support of his contention that it is carried o u t in many cases without any very clear assurance that it will do good. In his opinion, it is justified when there have been repeated attacks of acute tonsillitis w h i c h cannot be explained by extraneous infection. Frequent colds, chronic nasal catarrh and otitis media are doubtful indications. " T o remove the tonsils to cure sinusitis is to put the cart before the horse." He considers that bronchitis, asthma and nephritis are definite contra-indications, and the value of the operation in benefiting acute rheumatism is d o u b t f u l It has no value as a prophylatic against the comnlon infectious diseases with the possible exception of diphtheria. It is never urgent and should always I
* The Paediatric Approach tcr Tonsillectomy. J. Alison Glqr~," C.Bm., M.D., F.a.C.P., D.P.H., Arch. Dis. in Child. Vol. 23, No. I ~ " March, 1945.
THE SOCIETY OF MEDICAL OFFICERS OF HEALTH Ordinary Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . Council Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . General purposes Committee . . . . . . . . . . . . . . . . . . ;.. P l a n n i n g Committee . . . . . . . . . . . . . . . . . . . . . . . . Southern Branch .- . . . . . . . . . . . . . . . . . . . . . . . . . Welsh Branch ... M a t e r n i t y and C h i i d Weifare G r o u p : " P o s t - g r a d u a t e " Week'-end,"Bristol, April 23rd-25th . . . . . . . . . . . . . . . . . . . . . . . . . . . County Borough N[.O.H. Group Annual M e e t i n g . . . . . . . . . . . . Fever Hospital M.S. G r o u p . . . . . . . . . . . . . . . . . . . . .
175 175
175 175 177 180 181 181 181 viii viii
be preceded by a period of observation of six months after the completion of any necessary treatment of teeth or sinuses. It should not be done in the winter or early spring or during the prevalence of infectious diseases, especially of measles or influenza, and most of all w h e n poliomyelitis is epidemic. He holds that clinical examination alone cannot determine whether the tonsils are diseased or infected. Dr. Glover has given close attention to this subject for a number of years and his advice has not gone unheeded. Wholetime medical officers and part-time specialists employed by local education authorities have modified their views considerably, not perhaps as much as he would wish, but at any rate to a much greater extent than the medical advisers of entrants to Eton. U p to now they have been able to maintain control by engaging only experienced nose and throat surgeons and paediatricians (under the Handicapped Pupils and School Health Regulations to be approved by the Ministry of Education) mad by refusing, on the advice of their medical officers, to accept responsibility for treatment if it was felt that the necessary conditions had not been fulfilled. But it seems that under the National Health Service Act this control is to be abandoned and local educational authorities may have to " encourage and assist pupils " to undergo operations which their medical advisers may consider unjustifiable. Dr. Clover may share with us some consolation in knowing that the waiting list for operations is already impossibly long and that " m a n y be called but few chosen." But who will do the choosing, and will the right ones be chosen ? Is it too late to devise some way of avoiding this dangerously anomalous position ?
Improving the National Diet The Central Council for Health Education has produced a wise statement of aims for an improvement of the National Diet.* In a relatively few well chosen words the advisory committee of its Nutrition Bulletin has summed up the evidence upon which a sound diet can be evolv~ff emphasising the practical steps to be followed for production and for education. In the sphere of production it is, for example, recommended that we step up the yield of eggs, milk and cheese, maintain a lightly milled flour at 85 per cent. extraction, and promote research into methods by which to raise th~.>¥itamin content of home grown fruits, into those f0r t~/~'fffl~ ~nd distributing fish and. the best methods for pre: .....* I/R~r~)vernent of the National Diet.
t~'h~.~ 7£3.
The Lancet, May 8th,
HEALTH
SOCIETY OF MEDICAL OFFICERS OF HEALTH No. 9. Vol. LXI.
JUNE, 1948 CONTENTS
EDITORIAL Is Your Tonsillectomy Really Necessary? . . . . . . . . . . . . . . . I m p r o v i n g the National Diet ... . . . . . . . . . . . . . . . . . . Encephalomyelitis after Vaccination .: . . . . . . . . . . . . . . . . I n f a n t Mortality and Stillbirths . . . . . . . . . . . . . . . . . . . . . Rhondda U.D. Rheumatism Clinic . . . . . . . . . . . . . . . . . .
PAGE 163 163 164 164 164
Early Diaguosis of Bronchial Carcinoma (A. E. Beynon) ......... N u t r i t i o n and Health Education (R. B. D. Stocker) . . . . . . . . . . . . BOOK REVIEW
173 173
Tuberculosis in Young Adtflts.
174
165
A. G . Glass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C . S . Thomson . . . . . . . . . . . . . . . . . . . . . . . . . . .
SPECIAL ARTICLES
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
NEWS A N D REPORTS Proposals for Health Centres ,.. . . . . . . . . . . . . Provisional Vital Statistics for 1947 . . . . . . . . . . . . . . . . . . T h e Centenary Celebration ir[ the City . . . . . . . . . . . . . . . T h e British Rheumatic Association .. . . . . . . . . . . . . . . . . . Tuberculosis Association Research Committee ............ London
C.C.'s
Prophit Tuberculosis Survey, 1935-44 ,..
OBITUARY
T h e Centenary of Public Health. Speech by H . R . H . Princess Elizabeth . . , Some Aspects of Prevention of Infection T h r o u g h Food and Drink. By W. R. ]Viartine, T,D., M.D.. D.P,H T h e Dental Care of the. C h i l d u n d e r the National Health Service Act. Memoraodum by Dental Officers' G r o u p of the Society . . . . . . . . . .
PAOI~
CORRESPONDENCE
165 167
167 172 172 173 173
EDITORIAL Is Y o u r TonsUleetomy R e a l l y Necessary? Dr. J . Alison Glover,* a doughty warrior, has again unsheathed his sword in defence of the child against unnecessary tonsillectomy. T h e administrative medical officer cannot stand on one side and view the fight with mere academic interest. Like the armament manufacturer, he may have to supply the ammunition which he hates and fears but which he has been told is essential for the peace of the child. As a humane person, he may be haunted by the fear of subjecting children to the risks of an operation; or he may feel tfiat unjustifiable interference on his part may result in children going on for months or years with diseased organs which he has always believed to be harmful. Pressed by the children's family doctors or by his own assistant school medical officers, he submits the children to examination by his nose and throat surgeon, and he must rely on his opinion. He may, however, be left wondering how it is that at Eton in 1938 it was found that some 83 per cent. of new boys were found to have been tonsilleetomised presumably.on the advice of surgeons of repute, whereas more of the children in his maintained schools. will have been found to. have escaped the operation. Unless there is some factor tending to make the children of the wealthier classes more liable to diseased tonsils, it means either that too many of the Eton entrants have been operated upon or too few of his own children. Dr. Glover maintains that too many children in all social classes are submitted to this operation. He does not attempt to prove that tonsillectomy is never necessary, but he brings forward evidence in support of his contention that it is carried o u t in many cases without any very clear assurance that it will do good. In his opinion, it is justified when there have been repeated attacks of acute tonsillitis w h i c h cannot be explained by extraneous infection. Frequent colds, chronic nasal catarrh and otitis media are doubtful indications. " T o remove the tonsils to cure sinusitis is to put the cart before the horse." He considers that bronchitis, asthma and nephritis are definite contra-indications, and the value of the operation in benefiting acute rheumatism is d o u b t f u l It has no value as a prophylatic against the comnlon infectious diseases with the possible exception of diphtheria. It is never urgent and should always I
* The Paediatric Approach tcr Tonsillectomy. J. Alison Glqr~," C.Bm., M.D., F.a.C.P., D.P.H., Arch. Dis. in Child. Vol. 23, No. I ~ " March, 1945.
THE SOCIETY OF MEDICAL OFFICERS OF HEALTH Ordinary Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . Council Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . General purposes Committee . . . . . . . . . . . . . . . . . . ;.. P l a n n i n g Committee . . . . . . . . . . . . . . . . . . . . . . . . Southern Branch .- . . . . . . . . . . . . . . . . . . . . . . . . . Welsh Branch ... M a t e r n i t y and C h i i d Weifare G r o u p : " P o s t - g r a d u a t e " Week'-end,"Bristol, April 23rd-25th . . . . . . . . . . . . . . . . . . . . . . . . . . . County Borough N[.O.H. Group Annual M e e t i n g . . . . . . . . . . . . Fever Hospital M.S. G r o u p . . . . . . . . . . . . . . . . . . . . .
175 175
175 175 177 180 181 181 181 viii viii
be preceded by a period of observation of six months after the completion of any necessary treatment of teeth or sinuses. It should not be done in the winter or early spring or during the prevalence of infectious diseases, especially of measles or influenza, and most of all w h e n poliomyelitis is epidemic. He holds that clinical examination alone cannot determine whether the tonsils are diseased or infected. Dr. Glover has given close attention to this subject for a number of years and his advice has not gone unheeded. Wholetime medical officers and part-time specialists employed by local education authorities have modified their views considerably, not perhaps as much as he would wish, but at any rate to a much greater extent than the medical advisers of entrants to Eton. U p to now they have been able to maintain control by engaging only experienced nose and throat surgeons and paediatricians (under the Handicapped Pupils and School Health Regulations to be approved by the Ministry of Education) mad by refusing, on the advice of their medical officers, to accept responsibility for treatment if it was felt that the necessary conditions had not been fulfilled. But it seems that under the National Health Service Act this control is to be abandoned and local educational authorities may have to " encourage and assist pupils " to undergo operations which their medical advisers may consider unjustifiable. Dr. Clover may share with us some consolation in knowing that the waiting list for operations is already impossibly long and that " m a n y be called but few chosen." But who will do the choosing, and will the right ones be chosen ? Is it too late to devise some way of avoiding this dangerously anomalous position ?
Improving the National Diet The Central Council for Health Education has produced a wise statement of aims for an improvement of the National Diet.* In a relatively few well chosen words the advisory committee of its Nutrition Bulletin has summed up the evidence upon which a sound diet can be evolv~ff emphasising the practical steps to be followed for production and for education. In the sphere of production it is, for example, recommended that we step up the yield of eggs, milk and cheese, maintain a lightly milled flour at 85 per cent. extraction, and promote research into methods by which to raise th~.>¥itamin content of home grown fruits, into those f0r t~/~'fffl~ ~nd distributing fish and. the best methods for pre: .....* I/R~r~)vernent of the National Diet.
t~'h~.~ 7£3.
The Lancet, May 8th,