1033

1. Paterson, R., Aitken-Swan, J. Lancet, 1956, ii, 857.2. Paterson, R., Aitken-Swan, J. ibid. 1958, ii, 791.3. Aitken-Swan, J., Paterson, R. Brit. med. J. 1955, i, 623.4. Paterson, R. Canad. med. Ass. J. 1955, 73, 931.5. Wakefield, J., Davison, R. L. Brit. med. J. 1958, i, 96.6. Aitken-Swan, J., Paterson, R. ibid. March 14, 1959, p, 708.7. Report on Teachers’ Conference, Disley, March 14-15, 1959. Man-

chester Committee on Cancer. Educational Project, 558, WilmslowRoad, Withington, Manchester, 20.

selves. Their success in limiting doctors to the " tech-nical " side is the more ironical because members of our

profession, beginning with Sir Thomas Legge, have donemore than others in this department to put it on thenational and international map. One of the greatest ofChief Inspectors of Factories, Sir Arthur Whitelegge,was himself a doctor; and perhaps the simplest way ofgetting over the present difficulties would be to make thisa precedent for the future.

PREJUDICE AND THE CANCERS

Advances against the citadel held by the cancers aretaking place on four broad fronts. There is the basicresearch in the laboratory, ranging from fundamentalproblems of cell-division to the composition of tobacco-smokes. There is the clinical research into the ways andmeans of improving the lot of individuals, with its medical,surgical, and radiotherapeutic tactics. There is the

epidemiological approach, typified by the statistical

inquiries into the xtiology of lung cancer. And there is theeducational front, whose purpose is to improve knowledge,reduce prejudice, and foster early treatment.The Manchester Committee on Cancer-a voluntary

body founded in the 1920s-scored its first success in

helping to elucidate the carcinogenic factor in mule-

spinners’ cancer, now happily under control. After the warthe committee entered untrodden territory with an inquiryinto the rationale and results of cancer education. For

many years previously, of course, cancer education hadbeen developed as a special form of health educationby pioneers such as Lombard of Massachusetts, Griswoldof Connecticut, and, almost alone in this country, MalcolmDonaldson. But no attempt had been made at controlled

experiments, comparing results in similar areas one ofwhich was subjected to cancer education and the other wasnot. Nobody had tried to assess the causes of delay inseeking treatment and thus to base the methods of

approach on sound grounds. And no inquiries had beenmade into the depths of public ignorance and prejudiceabout the cancers or into the changes following an educa-tional campaign. All these things the Manchester com-mittee were pioneers in attempting, and many of thepublished results have already proved valuable. For

instance, knowledge has been gained on the level ofinformation among the public,l 2 and it has been shownthat the causes of delay in seeking treatment vary with thesite-or at least that in uterine cancer a main factor is

ignorance while in mammary cancer it is fear.3 4 Thebelief that instruction about cancer necessarily producescancer phobia has been dispelled, as has the bogy of"

flooding of doctors’ surgeries " as a resultof it. 5Recentlythe first statistical results from the " educated " and thecontrol areas showed that after three years’ intensivecancer instruction the proportion of women with breastcancer seeking advice in under one month had risen from28% to 38%, whereas no such change was seen in thecomparable control area.6The latest development has been a two-day experi-

mental Teachers’ Conference on the theme " Makingcancer ordinary ... 11 In his closing address Dr. Ralston

1. Martin, C. J. in System of Medicine (edited by T. C. Allbutt and H. DRolleston). London, 1907.

2. Jutzy, D. A., Biber, S. H., Elton, N. W., Lowry, E. C. Amer. J. trop.Med. Hyg. 1953, 2, 129.

3. Ironmonger, C. J. Pacif. rur. Pr. 1889, 38, 67.4. Parrish, H. M., Pollard, C. B. Amer. J. med. Sci. 1959, 237, 277.5. Essex, H. W., Markowitz, J. Amer. J. Physiol. 1930, 92, 345.6. Kuwajima, Y. Jap. J. exp. Med. 1953, 23, 299.

Paterson said that " the big surprise was that the confer-ence so largely concerned itself with how soon and howbest to start instruction, rather than whether it should begiven at all." To many the idea of teaching school-children about the cancers is somewhat repugnant, butthe teachers present clearly accepted the view of Mr. JohnWakefield, the executive officer in charge öf the educationalside of the committee’s work, that " the question weshould ask is not’ dare we give older children informationabout cancer ? ’ but ’ dare we take the risk of deprivingthem of the knowledge that may later save their lives ? ’ ".The suspicion grows that on this subject our own pro-

fession is lagging behind public opinion instead of lead-ing it.

REPEATED SNAKEBITE

ONCE bitten twice shy does not seem to be true ofmany who habitually handle snakes. Martin recordedthe case of a snake-charmer who was bitten on manyoccasions by the Australian tiger snake-probably themost dangerous land-snake in the world. Jutzy et a1.2

reported that a herpetologist in the Panama Canal zonehad been bitten on some twenty occasions. Ironmonger 3claimed to have been bitten forty-nine times. Notunnaturally, many snake-handlers come to regard them-selves as immune. Parrish and Pollard 4 have latelyreported an investigation to determine whether repeatedbites by North American pit vipers resulted in immunityor allergy or had no effect on the result of subsequentbites. They studied 14 patients who were professionalherpetologists, snake-handlers, wild-animal dealers or

biologists. 1 subject had experienced twelve envenoma-tions, another ten: the remainder had received two tosix bites. Parrish and Pollard found no evidence of

immunity developing. Sera compared with controlsshowed no significant venom neutralisation. Of the 14,6 experienced severe poisoning from the latest snakebitedespite three or more previous bites. 5 had permanentlocal defects as a result of the bites (in 1 due to a neuro-pathic antivenene reaction). 4 showed hypersensitivityto venom by scratch tests, though none had experiencedanaphylactic reactions after bites. Parrish and Pollardconclude that the severity of repeated snakebites dependson the characteristics of the individual bite and not onthe cumulative effects of previous bites.

These findings could be anticipated from antiveneneproduction. Snake venom is a poor antigen comparedwith diphtheria or tetanus toxin. Immunity in animalsrises slowly, and even after several graded inoculationsunexpected deaths are not rare. In some animals virtu-

ally no immunity develops. Frequent booster doses areneeded to maintain immunity, which may drop to zerowithin three months in dogs 5 and two months in horseswhen rested. 6 Antiserum effective against diphtheria,tetanus, or snakebite toxxmia must be given in largedoses-much larger than a human being could tolerate.Parrish and Pollard attributed the lack of permanentimmunity primarily to long and irregular intervals be-tween envenomations. They give scant consideration tothe venom dose; but, of all the many variables in bitesfrom poisonous snakes, the venom dose is paramount indetermining the outcome. Many do not realise that