1302 I have stressed in my own survey, was the first to recognise the frequency of appendicular inflammation as the cause of right-sided abdominal abscess. From his experience of 24 cases of typhlitis, Tait made it clear that the allegedly numerous varieties of this disease could not be differentiated without operation and stated : " The conclusion is inevitable that the earlier operative intervention is employed the better for the patient... the risk of an unnecessary incision is so slight and the risk of a delayed incision, which was necessary, so enormous that I am disposed to lay down the imperative rule that as soon as a diagnosis of typhlitis is established no attempt should be made by delay to ascertain which variety it belongs to, but that a surgical operation in search of pus should at once be done." Like all his cotemporaries, Tait adopted a cautious attitude towards right-sided inflammation in the abdo- men and thought that it was often the result of typhoid fever-in seven of his cases there was a recent history of typhoid. It is clear, however, that between 1880 and 1890 he recognised increasingly the high proportion of cases of typhlitis which were due to primary disease of the appendix. As we read it today his article on typhlitis and his case-records could well be entitled the Surgical Treatment of Appendicitis. Had Tait not abhorred the egpression " appendicitis " he would long ago have been credited with the initial advances in the management of the disease. It is curious that, having safely removed at least two acutely inflamed appendices, he should have reverted to a conservative drainage procedure, but it must be recalled that up to 1890 elective intraperitoneal operations were still regarded as dangerous, that anrea. thesia, was by no means safe, and that there was a certain reluctance to remove even a vestigial organ such as the appendix, in case it served some important function. In 1890 Sir Frederick Treves was preaching a conservative doctrine for the management of appendicitis, but Lawson Tait was relatively immune to the influence of his contemporaries ! It t is probable that Tait returned to the advocacy of removal of the inflamed appendix soon after 1890 when the wave of enthusiasm for early appendectomy wa,s propagated across the Atlantic in the writings of Fitz, McBurney, Deaver, and Fowler. Although Lawson Tait recanted after his early successes he should be recognised as the pioneer in the treatment of acute appendicitis and it is surely worthy of record that this British surgeon has such an achievement to his already illustrious name. REFERENCES Burne, J. (1837) Med. Chir. Trans. 20, 200. - (1839) Ibid, 22, 33. Krönlein, R. U. (1886) Arch. klin. Chir. 33, 507. Shepherd, J. A. (1954) Lancet, ii, 299. Tait, L. (1889) Brit. med. J. ii, 763. - (1890) Bgham med. Rev. 27, 27. Public Health THE PUBLIC HEALTH IN 1955 Chief Medical Officer’s Report FROM year to year, in the opening lines of his annual report, the chief medical officer of the Ministry of Health recalls some of the features of the year that are not strictly under his authority or control-the weather, for example. Dealing with 1955 in the report published last week, Sir John Charles has the pleasant duty of referring to a dry and sunny summer with " abundant opportunities for recreation and relaxation." Next year his words may have a less happy ring. CANCER The report urges a more optimistic attitude to malignant disease, with greater emphasis on prevention. The professional and public attitude to cancer was very much in danger of becoming one of helpless resignation in face of the apparent inevitability of the disease ; and it was often forgotten that certain cancers, such as the scrotal cancers of chimney sweeps and mule spinners’ cancers, had been prevented and were now rarities. This had been achieved long before the discovery of the specific carcinogenic agent. It was not, therefore, too optimistic to hope that modern research might in time reveal the way to the prevention of the cancers which remain. Cancer of the lung was causing most anxiety. There could be little doubt that this condition was on the increase and had probably been increasing since 1920. Grave suspicion had been thrown on two exogenous sources of carcinogenic material-tobacco smoke and atmospheric pollution. The first is very much a matter of choice ; and in many countries, as the report points out, those who wish to avoid all contact with tobacco smoke are helped to do so by wider and more stringent prohibitions of smoking in public transport, cinemas, theatres, and other indoor places of public entertain- ment than is the case in this country. This practice, Sir John remarks, deserves at least study, if not imitation. On this important matter of carcinogens in everyday life, the report has this to say : 1. Report of the Ministry of Health for the year ended Dec. 31, 1955. Part II. On the State of the Public Health. H.M. Stationery Office. Pp. 264. 9s. *’Civilized man appears to be increasingly surrounding himself with an unnatural chemical environment whose carcinogenic potentialities are being gradually explored. To what extent human cancer is caused by environmental carcinogens is not yet known but, as more and more of the chemical sub- stances which man inhales, absorbs, or ingests are being proved carcinogenic to animals, it seems reasonable to infer that certain cancers of the human body may be initiated or promoted by such substances. The long latent period usually separating the first contact of an agent and the first signs of established malignant disease tends to make the ascertainment of direct proof of causation a long and laborious business and such proof may never be forthcoming." " Parallel with the search for specific environmental factors, the local health authorities can take every opportunity of acquainting the public with the known facts about it and of dispelling the misconceptions so commonly held about cancer and the secrecy surrounding it, whilst not neglecting to teach the importance of recognizing the earliest symptoms of cancer and of taking prompt effective action when such symptoms appear." UNIDENTIFIED NEUROTROPIC INFECTIONS Among the neurotropic infections of unidentified cause, the non-paralytic poliomyelitis element was again conspicuous in 1955. Though it was impossible to identify the disease from which many of the patients with signs of non-paralytic poliomyelitis were suffering, it was virtually certain that they did not harbour a known poliomyelitis virus. Similarly, no recognisable cause had been found for the outbreaks of aseptic meningitis. What the report calls " perhaps the most disturbing of these occurrences " was the outbreak of encephalomyelitis at the Royal Free Hospital in London, about which little has been made known since the statement issued a month after it began.2 There were 292 cases in this outbreak, including 149 nurses and 27 doctors. Despite very exhaustive epidemiological and laboratory investigations no clue whatever to the cause of the infection was uncovered. A neurologist visiting this country from Durban confirmed that the Royal Free condition was identical clinically with that seen earlier last year among nurses in a hospital in Addington, near Durban. 14 nurses were known to have left the Addington hospital and come to the United Kingdom after the Durban outbreak began, but no direct contact could be traced between them and anyone at the Royal Free. , 2. See Lancet, 1955, ii, 351.
Transcript
1302
I have stressed in my own survey, was the first to
recognise the frequency of appendicular inflammation asthe cause of right-sided abdominal abscess. From hisexperience of 24 cases of typhlitis, Tait made it clearthat the allegedly numerous varieties of this diseasecould not be differentiated without operation andstated :
" The conclusion is inevitable that the earlier operativeintervention is employed the better for the patient... therisk of an unnecessary incision is so slight and the risk ofa delayed incision, which was necessary, so enormous thatI am disposed to lay down the imperative rule that as soonas a diagnosis of typhlitis is established no attempt shouldbe made by delay to ascertain which variety it belongs to,but that a surgical operation in search of pus should at oncebe done."
Like all his cotemporaries, Tait adopted a cautiousattitude towards right-sided inflammation in the abdo-men and thought that it was often the result of typhoidfever-in seven of his cases there was a recent historyof typhoid. It is clear, however, that between 1880 and1890 he recognised increasingly the high proportion ofcases of typhlitis which were due to primary disease of theappendix. As we read it today his article on typhlitisand his case-records could well be entitled the SurgicalTreatment of Appendicitis. Had Tait not abhorred the
egpression " appendicitis " he would long ago have been
credited with the initial advances in the management of
the disease. It is curious that, having safely removed atleast two acutely inflamed appendices, he should havereverted to a conservative drainage procedure, but itmust be recalled that up to 1890 elective intraperitonealoperations were still regarded as dangerous, that anrea.thesia, was by no means safe, and that there was a certainreluctance to remove even a vestigial organ such as theappendix, in case it served some important function.In 1890 Sir Frederick Treves was preaching a conservativedoctrine for the management of appendicitis, but LawsonTait was relatively immune to the influence of hiscontemporaries ! It t is probable that Tait returned tothe advocacy of removal of the inflamed appendix soonafter 1890 when the wave of enthusiasm for earlyappendectomy wa,s propagated across the Atlantic inthe writings of Fitz, McBurney, Deaver, and Fowler.Although Lawson Tait recanted after his early successes
he should be recognised as the pioneer in the treatmentof acute appendicitis and it is surely worthy of recordthat this British surgeon has such an achievement to hisalready illustrious name.
Krönlein, R. U. (1886) Arch. klin. Chir. 33, 507.Shepherd, J. A. (1954) Lancet, ii, 299.Tait, L. (1889) Brit. med. J. ii, 763.- (1890) Bgham med. Rev. 27, 27.
Public Health
THE PUBLIC HEALTH IN 1955Chief Medical Officer’s Report
FROM year to year, in the opening lines of his annualreport, the chief medical officer of the Ministry of Healthrecalls some of the features of the year that are not
strictly under his authority or control-the weather,for example. Dealing with 1955 in the report publishedlast week, Sir John Charles has the pleasant duty ofreferring to a dry and sunny summer with " abundantopportunities for recreation and relaxation." Next yearhis words may have a less happy ring.
CANCER
The report urges a more optimistic attitude tomalignant disease, with greater emphasis on prevention.The professional and public attitude to cancer was verymuch in danger of becoming one of helpless resignationin face of the apparent inevitability of the disease ;and it was often forgotten that certain cancers, such asthe scrotal cancers of chimney sweeps and mule spinners’cancers, had been prevented and were now rarities.This had been achieved long before the discovery of thespecific carcinogenic agent. It was not, therefore, toooptimistic to hope that modern research might in timereveal the way to the prevention of the cancers whichremain.
Cancer of the lung was causing most anxiety. Therecould be little doubt that this condition was on theincrease and had probably been increasing since 1920.Grave suspicion had been thrown on two exogenoussources of carcinogenic material-tobacco smoke andatmospheric pollution. The first is very much a matterof choice ; and in many countries, as the report pointsout, those who wish to avoid all contact with tobaccosmoke are helped to do so by wider and more stringentprohibitions of smoking in public transport, cinemas,theatres, and other indoor places of public entertain-ment than is the case in this country. This practice,Sir John remarks, deserves at least study, if not imitation.On this important matter of carcinogens in everydaylife, the report has this to say :1. Report of the Ministry of Health for the year ended Dec. 31,
1955. Part II. On the State of the Public Health. H.M.Stationery Office. Pp. 264. 9s.
*’Civilized man appears to be increasingly surrounding himselfwith an unnatural chemical environment whose carcinogenicpotentialities are being gradually explored. To what extenthuman cancer is caused by environmental carcinogens isnot yet known but, as more and more of the chemical sub-stances which man inhales, absorbs, or ingests are beingproved carcinogenic to animals, it seems reasonable to inferthat certain cancers of the human body may be initiatedor promoted by such substances. The long latent periodusually separating the first contact of an agent and the firstsigns of established malignant disease tends to make theascertainment of direct proof of causation a long and laboriousbusiness and such proof may never be forthcoming."
" Parallel with the search for specific environmental factors,the local health authorities can take every opportunity ofacquainting the public with the known facts about it and ofdispelling the misconceptions so commonly held aboutcancer and the secrecy surrounding it, whilst not neglectingto teach the importance of recognizing the earliest symptomsof cancer and of taking prompt effective action when suchsymptoms appear."
UNIDENTIFIED NEUROTROPIC INFECTIONS
Among the neurotropic infections of unidentifiedcause, the non-paralytic poliomyelitis element was
again conspicuous in 1955. Though it was impossible toidentify the disease from which many of the patientswith signs of non-paralytic poliomyelitis were suffering,it was virtually certain that they did not harbour aknown poliomyelitis virus. Similarly, no recognisablecause had been found for the outbreaks of asepticmeningitis. What the report calls " perhaps the mostdisturbing of these occurrences " was the outbreak ofencephalomyelitis at the Royal Free Hospital in London,about which little has been made known since thestatement issued a month after it began.2 There were292 cases in this outbreak, including 149 nurses and 27doctors. Despite very exhaustive epidemiological andlaboratory investigations no clue whatever to the causeof the infection was uncovered. A neurologist visitingthis country from Durban confirmed that the RoyalFree condition was identical clinically with that seenearlier last year among nurses in a hospital in Addington,near Durban. 14 nurses were known to have left theAddington hospital and come to the United Kingdomafter the Durban outbreak began, but no direct contactcould be traced between them and anyone at the RoyalFree. ,
2. See Lancet, 1955, ii, 351.
1303
USE OF PROPAYLACTICS
- The growing number and variety of effective immunis-ing agents may shortly prove an embarrassment, thereport remarks. As most of them must be given byinjection during a fairly short interval in infancy, theirnumber has very nearly reached the limit to whichparents might be expected to allow their children tosubmit without question. To meet this objection,combined prophylactics have been used, but (quiteapart, it might be added, from greater risk of paralyticpoliomyelitis with combined antigens) there are tech-nical difficulties which impose a definite limit on howfar these substances may be mixed in a practicablevolume of vehicle and still retain a satisfactory immunis-ing power. A better solution may be to find prophylacticsthat are effective by mouth or to protect the infant atrisk by immunising his brothers and sisters so that he issurrounded in the family by immune persons who forma barrier against that particular infection until he canhimself be actively immunised. The report says thatB.C.G. might with advantage be used in this way.
TUBERCULOSIS
The striking decline in the damage done by tuberculosisin the past six years " must be a source of great encourage-ment to all concerned and justifies a sober hope that acontinuation of their efforts should see the end of tuber-culosis as an important public health problem in thenot too distant future." The gain would be great,the report adds, since tuberculosis still ranks as by far thechief of the group of infectious diseases, especially inthe most productive years of life. In 1955 it caused 67 %of all deaths due to infection, and no less than 78 % inthe age-group 15-39. Case-finding will become of evengreater importance, and the chief need is not for -newerand better methods, but for fuller and more judicioususe of the ones already available.
In 1955 the examination of contacts of diagnosed casesproduced 8% of new notifications. This may seem a dis-appointingly poor return for much difficult and time-consumingwork, the report continues, but it should be remembered thatcontacts are at greatly increased comparative risk. There isevidence that the search can be much more rewarding if it isnot confined to the patient’s nearest relatives. The need fora wider examination of contacts is reflected in the 1955 averageof only 4-3 contacts examined for every case diagnosed.In recent years mass-miniature radiography detected
no less than 18% of new cases. As tuberculosis incidencefalls, selective surveys should be made of areas and socialgroups where the infection-rate is high.The present B.c.G. vaccination schemes, the report
recommends, could profitably be carried out with moreintensity, especially round known sources of infection.
EXPECTATION OF LIFE
A table in the report compares the expectation oflife at birth and at one year throughout the past century.It shows the striking fact that infant mortality has beenvirtually eliminated as one of the causes of diminishedexpectation of life. In 1841 the expectation of thenewborn child was 7 years less than that of the survivorof 1 year of age for boys and 6 years less for girls.There was little improvement 70 years later when thedifferences were still 6 and 5 years respectively. Nowthere is no difference for boys and no more than 1 yearfor girls.
NATIONAL BLOOD TRANSFUSION SERVICE
Each year, since 1946, the amount of blood needed bythe hospitals has steadily increased ; and in 1955 justover 31/2 times as much blood was issued to hospitals asin 1946. The increase over 1954 was some 45,000 bottles,the largest annual increase since 1952. From 1947 until1954 there was an accompanying gradual drop in theconsumption of plasma ; but the increased use of plasma-substitutes has approximately balanced the reduction inthe amount of plasma given. In 1955 the quantity ofdried plasma issued increased for the first time since 1947.
INFECTIOUS DISEASES
For the second successive year there was no case of 8’mallpoxin England and Wales. But this ** should by no means
encourage the complacency which is so apt to blunt thevigilance which must be maintained if the country is to bekept free of this still serious and often fatal disease." It was
disappointing that such a low proportion of children wasvaccinated. The " acceptance-rate
" in 1955 was 36-4% oflive births.
Although the number of deaths from diphtheria rose from9 in 1954 to 13 last year, this was the second lowest total onrecord and compares with an annual average for 1933-42 of2783. The total of notifications (155) was the lowest ever.The small outbreaks that occurred in 1955 " emphasise thatif the proportion of unimmunised persons is high a diphtheriainfection can gain momentum." The number of childrengiven primary immunisation fell from over 100,000 in 1954to 86,579, and of those given booster injections from 588,288to 510,204. Only 36-7% of children were immunised beforetheir first birthday, " still barely half the number consideredto be advisable to ensure adequate and continuing communityprotection " ; unless steps are taken to impress the publicthat the protection of all infants is still essential, " theunnecessary sacrifice of child life is likely to go on, if notto increase."
In 1955 there were more cases of measles (693,803) than inany year since notification started in 1939 : in 1954 there hadbeen fewer than ever before (146,995). Although, as a resultof this increase, there were more deaths (176 compared with50), the fatality ratio reached the new low record of 0-025.There was a further remarkable drop in both the incidence
and mortality of whooping-cough. There were 79,133 cases(105,912 in 1954) and 88 deaths (139 in 1954). Of the deaths,60 were of children under 1 year of age. Discussing thetiming of whooping-cough immunisation, the chief medicalofficer says that as yet the evidence available is not sufficientto justify changing existing procedure.
It seems that certain strains of the paratyphoid bacillus arechanging their character and thereby causing an acute gastro-enteritis closely resembling food-poisoning, rather than a
typhoid-like fever. During 1955 there were a number ofoutbreaks in which none of the illnesses resembled classicalparatyphoid fever.
Notifications of dysentery continued to show an increasewhich would be alarming if the disease had retained the viru-lence it had 40 years ago. But the case-mortality ratio hasdeclined enormously, largely because of the preponderance ofinfections by Shigella sonnei. The increase is certainly partlydue to better notification, thanks to the coverage now offeredby the Public Health Laboratory Service and to the greaterinterest aroused among doctors thereby.
Vaccination against PoliomyelitisThe Ministry of Health announces that from the middle
of January supplies of poliomyelitis vaccine are to becomeavailable at regular intervals. For some time vaccinationwill be confined to the remaining 11/2 million childrenborn between 1947 and 1954 who were registered forthis purpose earlier in the year. General practitioners(regardless of whether they provide services under theNational Health Service) will have the opportunity tovaccinate any children thus registered who are theirpatients. A pamphlet (E.C.N. 218) on the storage and useof the vaccine has been prepared for the information ofpractitioners.
N.A.P.T. in a Wider Role
This year the National Association for the Preventionof Tuberculosis amended its constitution to includeresponsibility for diseases of the chest and heart. Theassociation’s first leaflet in this additional field dealswith bronchitis. 1
Trade Effluents
The Central Advisory Water Committee has set upa subcommittee to inquire into the law dealing withtrade effluents. Any person or body wishing to giveevidence should send a memorandum to Mr. H. R.Pollitzer, secretary of the subcommittee, at the Ministryof Housing and Local Government, Whitehall, London,S.W.I.
1. Bronchitis : its causes, treatment, and prevention. Publishedby N.A.P.T., Tavistock House North, Tavistock Square,London, W.C.1.
