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SMALL-POX AND VACCINATION.
75
OPERATIONS FOR DISEASE OF THE
THE LONDON:
LANCET.
SATURDAY, JULY 14,
1923.
SMALL-POX AND VACCINATION. WE printed in the last issue of THE LANCET the official figures giving the notifications of small-pox for the preceding week in England and Wales ; those of the following week, bringing the account up to June 30th, have now been published, and are quoted in a statement with regard to the small-pox situation which has been issued from the Ministry of Health and appears on p. 92. This statement dwells in the first instance on the failure at Gloucester to control the disease when control would have been easy. There were cases of small-pox in the city as far back as April, and official warning was received from the Ministry of Health by the sanitary authority early in May that in other cases occurring in distant localities the source of infection had been traced to Gloucester; but notification by local practitioners was refused by the medical officer of health, in the view, presumably, that the diagnosis was in error. The question as to whether the disease was in fact small-pox was finally settled by expert advice, both official and other, when the local authority was immediately assisted, under the superintendence of Dr. W. H. DAVISON, senior assistant to the medical officer of health at Birmingham, to set up a special hospital and special vaccinating stations, to trace contacts, and to do everything possible to stamp out the infection locally, and to prevent its further spread. The statement from the Ministry of Health, which includes figures proving that the incidence of smallpox is at present widely spread in the country, is uncompromising in its recommendation of vaccination as the only practical remedy now that the infection has been introduced. No one denies that the decline of small-pox, as of most epidemic diseases, is influenced by a rise in the standard of the sanitary conditions and the economic opportunities of the population, but no serious student of epidemiology can doubt that in vaccination we have a practical method of controlling further spread of this disease when an outbreak has occurred. The value of universal compulsory vaccination and revaccination would be well worth discussing in the light of all the information now available and outside the murky atmosphere of dialectics. For the moment it is happily an academic question for the greater part of the country, and even admitting that the influence of vaccination is neither individually infallible nor permanent, this need not impart a hesitating quality into our advocacy of the procedure in face of a local outbreak of disease. The outcome of the frank views of the Ministry of Health is believed in some quarters to be the prelude to amendment in the law, but Mr. NEVILLE CHAMBERLAIN has expressed his belief that no special legislation is necessary.
GALL-BLADDER. of the biliary tract is passing through
THE surgery the stages which have characterised the evolution of surgery of other abdominal organs. The perfecting of technique by specialist operators has shown the general practitioner how, in case of need, intervention in gall-stone disease may be undertaken with a moderate assurance of an immediate happy outcome. The result is that, rather prematurely perhaps, this branch of surgery is being practised by a large number of men, before knowledge has become sufficiently exact to indicate in all cases the proper course to follow. It is pertinent, too, to remember that the available and reliable statistics are those of the most experienced surgeons who, in their writings, characteristically fail to lay stress upon that perfection of technique which has done so much to furthering their favourable results. For these operators, biliary surgery has passed beyond the stage of developing a technique of intervention to that of deciding what procedure will
best meet the existing pathological and physiological processes at work in each particular patient, so that, amongst them, controversy centres round the advisability of cholecystectomy or cholecystostomy, when exist without complications. There seems growing conviction amongst operators of experience, not only in this country, that the end-results of cholecystectomy are very much better than those of the simpler cholecystostomy. At a recent meeting of the Royal Society of Medicine, where the surgery of the common bile-duct was under discussion, Mr. JAMES SHERREN emphatically declared that " when the correct treatment for disease of the gall-bladder is carried out," meaning cholecystectomy, " we shall cease to have to discuss and carry out operations for the removal of duct calculi." In other words, his experience has led him to the conclusion that the recognition of early cholecystitis should be followed by removal of the gallbladder. Cholecystectomy is, indeed, being very widely practised just now. It must be accepted as a fact that a large percentage of favourable results ensue when they are vouched for by the leaders of gallbladder surgery, but it is relevant to ask whether we have not travelled too far in this direction ; whether, with a more careful selection, certain gall-bladders which are now sacrificed might not be preserved to play their part in the physiological economy of the individual. The fact that patients from whom the gall-bladder has been removed show few signs of being different from normal people, demonstrates no more than the marvellous powers of adaptation the body possesses, for there is abundant evidence that the organ has very important functions to perform. After the gall-bladder has been removed, either there is a varying but constant flow of bile into the duodenum, or, should the sphincter of Oddi remain continent, a dilatation of the bile-ducts behind it, in order to accommodate the dilute bile which is no longer reduced to one-tenth of its volume by gall-bladder activity. In either case the physiology of digestion is disturbed. Achylia occurs in 47 per cent. of cases of gall-stones.lI In dogs cholecystectomy gives rise to achylia. It has also been found associated with a stone impacted in the cystic duct, which suggests that it is due to loss of gall-bladder function. Some observers, on the other hand, have demonstrated that in man the gastric juice may show normal acidity after removal of the
gall-stones to
be
a
1 Rydgaarde : Arch. f. Klin. Chir., 1921,
cxv., No. 3.
OPERATIONS FOR DISEASE OF THE
THE LONDON:
LANCET.
SATURDAY, JULY 14,
1923.
SMALL-POX AND VACCINATION. WE printed in the last issue of THE LANCET the official figures giving the notifications of small-pox for the preceding week in England and Wales ; those of the following week, bringing the account up to June 30th, have now been published, and are quoted in a statement with regard to the small-pox situation which has been issued from the Ministry of Health and appears on p. 92. This statement dwells in the first instance on the failure at Gloucester to control the disease when control would have been easy. There were cases of small-pox in the city as far back as April, and official warning was received from the Ministry of Health by the sanitary authority early in May that in other cases occurring in distant localities the source of infection had been traced to Gloucester; but notification by local practitioners was refused by the medical officer of health, in the view, presumably, that the diagnosis was in error. The question as to whether the disease was in fact small-pox was finally settled by expert advice, both official and other, when the local authority was immediately assisted, under the superintendence of Dr. W. H. DAVISON, senior assistant to the medical officer of health at Birmingham, to set up a special hospital and special vaccinating stations, to trace contacts, and to do everything possible to stamp out the infection locally, and to prevent its further spread. The statement from the Ministry of Health, which includes figures proving that the incidence of smallpox is at present widely spread in the country, is uncompromising in its recommendation of vaccination as the only practical remedy now that the infection has been introduced. No one denies that the decline of small-pox, as of most epidemic diseases, is influenced by a rise in the standard of the sanitary conditions and the economic opportunities of the population, but no serious student of epidemiology can doubt that in vaccination we have a practical method of controlling further spread of this disease when an outbreak has occurred. The value of universal compulsory vaccination and revaccination would be well worth discussing in the light of all the information now available and outside the murky atmosphere of dialectics. For the moment it is happily an academic question for the greater part of the country, and even admitting that the influence of vaccination is neither individually infallible nor permanent, this need not impart a hesitating quality into our advocacy of the procedure in face of a local outbreak of disease. The outcome of the frank views of the Ministry of Health is believed in some quarters to be the prelude to amendment in the law, but Mr. NEVILLE CHAMBERLAIN has expressed his belief that no special legislation is necessary.
GALL-BLADDER. of the biliary tract is passing through
THE surgery the stages which have characterised the evolution of surgery of other abdominal organs. The perfecting of technique by specialist operators has shown the general practitioner how, in case of need, intervention in gall-stone disease may be undertaken with a moderate assurance of an immediate happy outcome. The result is that, rather prematurely perhaps, this branch of surgery is being practised by a large number of men, before knowledge has become sufficiently exact to indicate in all cases the proper course to follow. It is pertinent, too, to remember that the available and reliable statistics are those of the most experienced surgeons who, in their writings, characteristically fail to lay stress upon that perfection of technique which has done so much to furthering their favourable results. For these operators, biliary surgery has passed beyond the stage of developing a technique of intervention to that of deciding what procedure will
best meet the existing pathological and physiological processes at work in each particular patient, so that, amongst them, controversy centres round the advisability of cholecystectomy or cholecystostomy, when exist without complications. There seems growing conviction amongst operators of experience, not only in this country, that the end-results of cholecystectomy are very much better than those of the simpler cholecystostomy. At a recent meeting of the Royal Society of Medicine, where the surgery of the common bile-duct was under discussion, Mr. JAMES SHERREN emphatically declared that " when the correct treatment for disease of the gall-bladder is carried out," meaning cholecystectomy, " we shall cease to have to discuss and carry out operations for the removal of duct calculi." In other words, his experience has led him to the conclusion that the recognition of early cholecystitis should be followed by removal of the gallbladder. Cholecystectomy is, indeed, being very widely practised just now. It must be accepted as a fact that a large percentage of favourable results ensue when they are vouched for by the leaders of gallbladder surgery, but it is relevant to ask whether we have not travelled too far in this direction ; whether, with a more careful selection, certain gall-bladders which are now sacrificed might not be preserved to play their part in the physiological economy of the individual. The fact that patients from whom the gall-bladder has been removed show few signs of being different from normal people, demonstrates no more than the marvellous powers of adaptation the body possesses, for there is abundant evidence that the organ has very important functions to perform. After the gall-bladder has been removed, either there is a varying but constant flow of bile into the duodenum, or, should the sphincter of Oddi remain continent, a dilatation of the bile-ducts behind it, in order to accommodate the dilute bile which is no longer reduced to one-tenth of its volume by gall-bladder activity. In either case the physiology of digestion is disturbed. Achylia occurs in 47 per cent. of cases of gall-stones.lI In dogs cholecystectomy gives rise to achylia. It has also been found associated with a stone impacted in the cystic duct, which suggests that it is due to loss of gall-bladder function. Some observers, on the other hand, have demonstrated that in man the gastric juice may show normal acidity after removal of the
gall-stones to
be
a
1 Rydgaarde : Arch. f. Klin. Chir., 1921,
cxv., No. 3.