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TONSILLECTOMY
132 were not extortionate and were by no without moral standards. Broadly, they condemned the wantonness and folly of contemporary youth, the callous lust of husbands, the treatment accorded to the unwanted and illegitimate (" I don’t believe in children with no fathers "), and the law which, in their view, compelled them to do what should be done by doctors in clinics. They knew they were law-breakers but were by no means convinced of sin. " I’m not ashamed of what I’ve done, even though it’s against the law. It’s human nature and women have to help each other." Neither, it seems, did their neighbours condemn them. " The people down our street was ever so nice— they wished me luck. Hoped I’d get off." A factory forewoman said that when she left, at the time of the trial, the girls collected for her, and gave her flowers and presents. Sometimes the prisoners felt strongly that they had done good-e.g., when they had relieved a wife of the results of " unfaithfulness " while her husband was overseas and thus preserved the marriage, or had enabled a schoolgirl to stay at school and take her examinations. Mrs. Woodside is sparing of comment; but her evidence throws some further light on a very formidable problem. It shows once again that a great many otherwise law-abiding citizens do not believe in the sanctity of embryonic life, or accept the laws based on it. And, as Lord Devlin is quoted as saying, " in matters of morality about which the community as a whole is not deeply imbued with a sense of sin, the law sags under a weight which it is not constructed to bear ".
it has risen
means
Moreover, bottles
STORAGE OF BLOOD FOR TRANSFUSION
TECHNICAL and administrative advances have gone
a
long way to reduce mishaps associated with transfusion of blood. Blood-grouping and cross-matching are on the whole adequate, although accidents still arise occasionally, owing usually to relaxation of the necessary technical precautions. Fortunately, freshly shed blood exerts a considerable bactericidal effect which will usually deal with chance contaminants; but this mechanism cannot be relied on to sterilise the blood completely, and any bottle may contain a few organisms which, given suitable conditions, may multiply to dangerous levels. Prevention of such growth depends on efficient and continuous refrigeration. Blood is maintained at 4-6°C (36-42°F) at bloodtransfusion centres, from which it is delivered to hospitals, still within this temperature range, in refrigerated vans. When no refrigerated vans are available for transport, insulated containers must be used 1: the principal requirement is that these shall keep the temperature of the blood at between 0°C (+32°F) and 10°C (50°F) for 24-48 hours. Refrigeration is most likely to be interrupted within the hospital, after the blood has left the laboratory. No bottle of blood should be left out of refrigeration (or insulated box) for longer than an hour. After the bottle or pilottube_is sampled, it should be returned immediately to the refrigerator, and not be left out on the laboratory bench. For transport within the hospital, particularly when the laboratory is some distance from the wards or theatre, insulated boxes are essential. Ward refrigerators should never be used for " stand-by " blood. In ward refrigerators blood has been frozen by being placed too near the freezing compartment; but more often 1.
Farr, A.
D.
Vox
Sanguinis, 1962, 7,
504.
to
accepted safe level. forgotten and pushed farther dark, seldom-explored recesses
temperatures above the
fees; but they
may be
and farther back into the by successive deliveries of milk and lemonade bottles. At least one transfusion death has followed such an incident. In another case a bottle was finally retrieved and returned to a blood-transfusion centre sixteen years out of date.2 TONSILLECTOMY
IN the museum of outmoded surgical procedures prominent places are reserved for nephropexy, Lane’s colectomy, lingual fraenotomy, and lancing the gums. Poised, hesitant, at the entrance is tonsillectomy. How shall we know in which way to encourage its movement, when one report suggests its uselessness and another that it justifies the time and money spent on it ? The answer may seem to lie in a carefully controlled experiment, and McKee3 set himself to this difficult task-difficult because there is no easy way of measuring results, difficult because bias must be excluded, and difficult because controls are not readily come by: there is no possibility of anything like a double-blind trial. In the past, most controlled studies have compared the health in two large but similar groups of children in one of which tonsillectomy had been undertaken. McKee sought to get a more comparable group of controls by including all the cases referred to one surgeon at one clinic, thus obtaining a similar baseline opinion on all children at the time of referral. These cases were divided into three groups: (1) those requiring urgent tonsillectomy; (2) those not requiring tonsillectomy; and (3) those who, in the opinion of the surgeon, might, because of certain defined criteria, benefit from tonsillectomy. Groups 1 and 2 were not included in the study; and the omission of group 1 is a pity since the creation of such a group indicates a preconceived idea that in some cases tonsillectomy is both urgent and beneficial-a view that would not be
universally supported. 413 cases in group 3 were admitted to the study, and divided into 231 children who had an early operation and 182 who were put on a waiting-list and had the operation deferred for two years. The second group were the controls; and care was taken to see that the two groups were similar in distribution according to age, sex, and social status. Unfortunately doubt must arise whether this control group was suitable for comparison, since where a case is on a waiting-list for an operation somebody must think the operation necessary, and this is apt to produce an attitude that no improvement can be expected until it is done. The fact that 34 cases in the control group were withdrawn for urgent tonsillectomy suggests that this attitude was probably not entirely absent. Results were assessed by trained-nurse field workers, paying regular visits to the families every two months and recording the events during the preceding period. It was found that the episodes of illness, the number of days confined to bed, the number of days lost from school, and the number of medical attendances required was reduced by up to 30% in the tonsillectomised group. This certainly seems impressive. But quantitative study is not quite so reassuring. For example, in the first year tonsillectomised children lost on average 12 days frolI1 school, whereas the control group lost 17-8. When, however, one remembers that at least a week is lost by
were
2. 3.
Zeitlin, R. A. Medicine, Science, and the Law, July, 1962, McKee, W. J. E. Brit. J. prev. soc. Med. 1963, 17, 49.
p. 294.
133
having the operation,
the
advantage lies slightly with
the
control group; and under most of the other headings by which results were measured, addition of the operationtime, illness, and complications offsets any seeming benefits. This study was conducted with great care and im-
partiality ; but it does not settle the controversy surrounding tonsillectomy. BRUCELLOSIS
THE conscientious medical officer of health who tries to prevent the spread of undulant fever has no easy task. Human infections within his district may or may not come to his notice, and when they do the source of infection may be difficult to define. Some patients drink milk from several sources. Others say that they never drink it at all -and it is worth asking these if they enjoy cream. Not all infections are milkborne, and in country districts the occupation may be the most relevant item in the patient’s history. If the M.O.H. institutes a methodical and continuous survey of all the milk which is sold unpasteurised, it will cost quite a lot in time and money without any promise that it will prevent more than a very few infections. The ring test has simplified such routine examinations. It is quick and cheap; and, subject to an error of about 1%, Brucella abortus will not be found in any milk which does not show a + + or + + + ring test. Unfortunately for the M.o.H. the Ministry of Health has ruled that the ring test by itself is not evidence of immediate danger to the public health. A positive ring test indicates the presence of brucella antibodies in the milk and no more. (If all the members of the public who showed antibodies to Salmonella typhi were removed to isolation hospitals... !) To justify an order for the compulsory pasteurisation of a milk supply the Ministry insists that Brucella spp. must have been isolated from it. Until a few years ago this entailed animal inoculation and a delay of some weeks, during which the infected cow or cows might have gone dry or been sold. Mair’s cultural method of isolating these organisms may not be quite so efficient as inoculation, but it gives an unequivocal positive answer in a few days. It should be used more widely. When the organism has been isolated and identified, the M.O.H. can at last issue his compulsory pasteurisation order; but his troubles are not over. The order will involve either the farmer or the ratepayers in some expense and everyone concerned in a good deal of trouble, and there will be strong pressure to remove it as soon as possible. All these difficulties are vividly described in a welldocumented article by Parry1 which recounts his difficulties in dealing with an outbreak of brucellosis in Cheshire. The outbreak was remarkable only in the number of cows (7/35) found to be excreting the organism when they were first examined. One of the curiosities of this disease is that usually only a small proportion of the herd show active infection at any one time. It may be that the argument for a compulsory pasteurisation order is now mainly a moral one-that no medical officer of health is justified in allowing the sale of milk which might cause human disease. But perhaps 5-10% of herds contain infected animals; many thousands of people still drink unpasteurised milk, from choice or by necessity; yet the total number of human infections each year is
probably no 1.
more
than 500. Milkborne
Parry, W. H. Med. Offr, 1963, 109, 397.
epidemics
involving no-one,
more
so
far
than half as we
a
dozen victims
are
rare; and
know, has demonstrated that the
routine testing of all raw milk has reduced the number of human infections. In man oral administration of the organism can cause the disease only rarely, especially when most of the milk is taken in tea at a bactericidal temperature. In rural districts at any rate, undulant fever is now largely an occupational disease of farmers, their wives and employees, and of veterinary surgeons; and it is a reasonable guess that most of these are infected while delivering an infected cow of her calf. The only way in which these infections-and milkborne ones too-can be prevented is by eradicating the disease in cattle; and the Ministry of Agriculture now has in hand a scheme to this end. We hope that it will be as successful as that for the eradication of bovine tuberculosis, but we gather that so far the response has been no more than lukewarm. The farmer tends to accept losses of stock as a part of his sorry lot. He is not likely to suffer many pangs of conscience about a disease which is uncommon and seldom fatal; and, as for his own health, he is of tougher fibre than some patients. The other day a doctor was asked to see a farmer suspected of having undulant fever. He was found milking a herd of thirty without help and excused his lateness by saying that he had spent the afternoon muck-spreading. His temperature was 103°F, and his blood grew Br. abortus in abundance.
BEHAVIOUR THERAPY
IN the past few years behaviour therapy has become established as a reputable form of psychiatric treatment, based firmly on the results of experimental psychology. Apart from Wolpe’s large series,! most reports hitherto have dealt with single cases. This subject however has now been accorded its own journal.2 The first issue contains eleven papers, which on the whole are of an encouragingly high standard. As a start, S. Rachman and J. Wolpe are mainly polemical: their papers provide rallying-cries for the rather scattered forces of behaviour therapy, and Wolpe looses off occasional volleys at psychoanalysis. These censures do not compare with more serious critical studies, such as that by Farrell.3 More damaging to the dynamic cause is a review by E. E. Levitt of 22 evaluation studies of psychotherapy in children. This claims to show that the proportion improved was similar to that in patients who - were accepted for treatment but who never attended. But pooling results from different series always raises statistical doubts. Rachman says that behaviour therapy has already reached the stage where large field tests, with adequate controls, are both possible and necessary. He claims that such therapy is not " superficial ", in the sense either of being incomplete or of being useful only for less severe neurotic conditions. Two papers in the first issue describe the successful treatment of monosymptomatic phobias, which Freeman and Kendrick4 have previously shown to be particularly suitable for reciprocal inhibition treatment. There is also a further report on the treatment 1. Wolpe, J. Psychotherapy by Reciprocal Inhibition. Stanford, 1958. 2. Behaviour Research and Therapy. Published quarterly by Pergamon Press Ltd., Headington Hill Hall, Oxford. Editor-in-chief: H. J. Eysenck, Maudsley Hospital, London, S.E.5. Annual subscription: personal, £5; libraries, &c., £10. 3. Farrell, B. A. New Society, June 20, June 27, 1963. 4. Freeman, H. L., Kendrick, D. C. Brit. med. J. 1960, ii, 497.
it has risen
means
Moreover, bottles
STORAGE OF BLOOD FOR TRANSFUSION
TECHNICAL and administrative advances have gone
a
long way to reduce mishaps associated with transfusion of blood. Blood-grouping and cross-matching are on the whole adequate, although accidents still arise occasionally, owing usually to relaxation of the necessary technical precautions. Fortunately, freshly shed blood exerts a considerable bactericidal effect which will usually deal with chance contaminants; but this mechanism cannot be relied on to sterilise the blood completely, and any bottle may contain a few organisms which, given suitable conditions, may multiply to dangerous levels. Prevention of such growth depends on efficient and continuous refrigeration. Blood is maintained at 4-6°C (36-42°F) at bloodtransfusion centres, from which it is delivered to hospitals, still within this temperature range, in refrigerated vans. When no refrigerated vans are available for transport, insulated containers must be used 1: the principal requirement is that these shall keep the temperature of the blood at between 0°C (+32°F) and 10°C (50°F) for 24-48 hours. Refrigeration is most likely to be interrupted within the hospital, after the blood has left the laboratory. No bottle of blood should be left out of refrigeration (or insulated box) for longer than an hour. After the bottle or pilottube_is sampled, it should be returned immediately to the refrigerator, and not be left out on the laboratory bench. For transport within the hospital, particularly when the laboratory is some distance from the wards or theatre, insulated boxes are essential. Ward refrigerators should never be used for " stand-by " blood. In ward refrigerators blood has been frozen by being placed too near the freezing compartment; but more often 1.
Farr, A.
D.
Vox
Sanguinis, 1962, 7,
504.
to
accepted safe level. forgotten and pushed farther dark, seldom-explored recesses
temperatures above the
fees; but they
may be
and farther back into the by successive deliveries of milk and lemonade bottles. At least one transfusion death has followed such an incident. In another case a bottle was finally retrieved and returned to a blood-transfusion centre sixteen years out of date.2 TONSILLECTOMY
IN the museum of outmoded surgical procedures prominent places are reserved for nephropexy, Lane’s colectomy, lingual fraenotomy, and lancing the gums. Poised, hesitant, at the entrance is tonsillectomy. How shall we know in which way to encourage its movement, when one report suggests its uselessness and another that it justifies the time and money spent on it ? The answer may seem to lie in a carefully controlled experiment, and McKee3 set himself to this difficult task-difficult because there is no easy way of measuring results, difficult because bias must be excluded, and difficult because controls are not readily come by: there is no possibility of anything like a double-blind trial. In the past, most controlled studies have compared the health in two large but similar groups of children in one of which tonsillectomy had been undertaken. McKee sought to get a more comparable group of controls by including all the cases referred to one surgeon at one clinic, thus obtaining a similar baseline opinion on all children at the time of referral. These cases were divided into three groups: (1) those requiring urgent tonsillectomy; (2) those not requiring tonsillectomy; and (3) those who, in the opinion of the surgeon, might, because of certain defined criteria, benefit from tonsillectomy. Groups 1 and 2 were not included in the study; and the omission of group 1 is a pity since the creation of such a group indicates a preconceived idea that in some cases tonsillectomy is both urgent and beneficial-a view that would not be
universally supported. 413 cases in group 3 were admitted to the study, and divided into 231 children who had an early operation and 182 who were put on a waiting-list and had the operation deferred for two years. The second group were the controls; and care was taken to see that the two groups were similar in distribution according to age, sex, and social status. Unfortunately doubt must arise whether this control group was suitable for comparison, since where a case is on a waiting-list for an operation somebody must think the operation necessary, and this is apt to produce an attitude that no improvement can be expected until it is done. The fact that 34 cases in the control group were withdrawn for urgent tonsillectomy suggests that this attitude was probably not entirely absent. Results were assessed by trained-nurse field workers, paying regular visits to the families every two months and recording the events during the preceding period. It was found that the episodes of illness, the number of days confined to bed, the number of days lost from school, and the number of medical attendances required was reduced by up to 30% in the tonsillectomised group. This certainly seems impressive. But quantitative study is not quite so reassuring. For example, in the first year tonsillectomised children lost on average 12 days frolI1 school, whereas the control group lost 17-8. When, however, one remembers that at least a week is lost by
were
2. 3.
Zeitlin, R. A. Medicine, Science, and the Law, July, 1962, McKee, W. J. E. Brit. J. prev. soc. Med. 1963, 17, 49.
p. 294.
133
having the operation,
the
advantage lies slightly with
the
control group; and under most of the other headings by which results were measured, addition of the operationtime, illness, and complications offsets any seeming benefits. This study was conducted with great care and im-
partiality ; but it does not settle the controversy surrounding tonsillectomy. BRUCELLOSIS
THE conscientious medical officer of health who tries to prevent the spread of undulant fever has no easy task. Human infections within his district may or may not come to his notice, and when they do the source of infection may be difficult to define. Some patients drink milk from several sources. Others say that they never drink it at all -and it is worth asking these if they enjoy cream. Not all infections are milkborne, and in country districts the occupation may be the most relevant item in the patient’s history. If the M.O.H. institutes a methodical and continuous survey of all the milk which is sold unpasteurised, it will cost quite a lot in time and money without any promise that it will prevent more than a very few infections. The ring test has simplified such routine examinations. It is quick and cheap; and, subject to an error of about 1%, Brucella abortus will not be found in any milk which does not show a + + or + + + ring test. Unfortunately for the M.o.H. the Ministry of Health has ruled that the ring test by itself is not evidence of immediate danger to the public health. A positive ring test indicates the presence of brucella antibodies in the milk and no more. (If all the members of the public who showed antibodies to Salmonella typhi were removed to isolation hospitals... !) To justify an order for the compulsory pasteurisation of a milk supply the Ministry insists that Brucella spp. must have been isolated from it. Until a few years ago this entailed animal inoculation and a delay of some weeks, during which the infected cow or cows might have gone dry or been sold. Mair’s cultural method of isolating these organisms may not be quite so efficient as inoculation, but it gives an unequivocal positive answer in a few days. It should be used more widely. When the organism has been isolated and identified, the M.O.H. can at last issue his compulsory pasteurisation order; but his troubles are not over. The order will involve either the farmer or the ratepayers in some expense and everyone concerned in a good deal of trouble, and there will be strong pressure to remove it as soon as possible. All these difficulties are vividly described in a welldocumented article by Parry1 which recounts his difficulties in dealing with an outbreak of brucellosis in Cheshire. The outbreak was remarkable only in the number of cows (7/35) found to be excreting the organism when they were first examined. One of the curiosities of this disease is that usually only a small proportion of the herd show active infection at any one time. It may be that the argument for a compulsory pasteurisation order is now mainly a moral one-that no medical officer of health is justified in allowing the sale of milk which might cause human disease. But perhaps 5-10% of herds contain infected animals; many thousands of people still drink unpasteurised milk, from choice or by necessity; yet the total number of human infections each year is
probably no 1.
more
than 500. Milkborne
Parry, W. H. Med. Offr, 1963, 109, 397.
epidemics
involving no-one,
more
so
far
than half as we
a
dozen victims
are
rare; and
know, has demonstrated that the
routine testing of all raw milk has reduced the number of human infections. In man oral administration of the organism can cause the disease only rarely, especially when most of the milk is taken in tea at a bactericidal temperature. In rural districts at any rate, undulant fever is now largely an occupational disease of farmers, their wives and employees, and of veterinary surgeons; and it is a reasonable guess that most of these are infected while delivering an infected cow of her calf. The only way in which these infections-and milkborne ones too-can be prevented is by eradicating the disease in cattle; and the Ministry of Agriculture now has in hand a scheme to this end. We hope that it will be as successful as that for the eradication of bovine tuberculosis, but we gather that so far the response has been no more than lukewarm. The farmer tends to accept losses of stock as a part of his sorry lot. He is not likely to suffer many pangs of conscience about a disease which is uncommon and seldom fatal; and, as for his own health, he is of tougher fibre than some patients. The other day a doctor was asked to see a farmer suspected of having undulant fever. He was found milking a herd of thirty without help and excused his lateness by saying that he had spent the afternoon muck-spreading. His temperature was 103°F, and his blood grew Br. abortus in abundance.
BEHAVIOUR THERAPY
IN the past few years behaviour therapy has become established as a reputable form of psychiatric treatment, based firmly on the results of experimental psychology. Apart from Wolpe’s large series,! most reports hitherto have dealt with single cases. This subject however has now been accorded its own journal.2 The first issue contains eleven papers, which on the whole are of an encouragingly high standard. As a start, S. Rachman and J. Wolpe are mainly polemical: their papers provide rallying-cries for the rather scattered forces of behaviour therapy, and Wolpe looses off occasional volleys at psychoanalysis. These censures do not compare with more serious critical studies, such as that by Farrell.3 More damaging to the dynamic cause is a review by E. E. Levitt of 22 evaluation studies of psychotherapy in children. This claims to show that the proportion improved was similar to that in patients who - were accepted for treatment but who never attended. But pooling results from different series always raises statistical doubts. Rachman says that behaviour therapy has already reached the stage where large field tests, with adequate controls, are both possible and necessary. He claims that such therapy is not " superficial ", in the sense either of being incomplete or of being useful only for less severe neurotic conditions. Two papers in the first issue describe the successful treatment of monosymptomatic phobias, which Freeman and Kendrick4 have previously shown to be particularly suitable for reciprocal inhibition treatment. There is also a further report on the treatment 1. Wolpe, J. Psychotherapy by Reciprocal Inhibition. Stanford, 1958. 2. Behaviour Research and Therapy. Published quarterly by Pergamon Press Ltd., Headington Hill Hall, Oxford. Editor-in-chief: H. J. Eysenck, Maudsley Hospital, London, S.E.5. Annual subscription: personal, £5; libraries, &c., £10. 3. Farrell, B. A. New Society, June 20, June 27, 1963. 4. Freeman, H. L., Kendrick, D. C. Brit. med. J. 1960, ii, 497.