5...”

V,~—~.

\ 5
.39“ \“ '

,

262665“ l /J l /&’v A.
/ MINISTRY OF HEALTH
4/ u». C ./
.e c [J

1‘

IN OUTLINE OF THE
13RACTICE OF
PREVENTIVE MEDICINE

A M emomndum addressed to the Minister of Health by

S tr George Newman

K.C.B., M.D., F.R.C.P.

Chief Medical Ofiicer of the
M iii-£3250» of Health

 

LONDON:

PUBLISHED BY HIS MAJESTY’S STATIONERY OFFICE

To be purchased directly from H.M. STATIONERY OFFICE at the following addresses:
Adastral House, Kingsway, London, W.C.2 ; 120, George Street, Edinburgh ;
York Street, Manchester; 1. St. Andrew’s Crescent, Cardiff;
15, Donegall Square West, Belfast ;,
or through any Bookseller.

1926

Price 13. 0d. Net, Paper Covers.
,, 2s. 6d. Net, Cloth.

 

MINISTRY OF HEALTH

vAN OUTLINE OF THE
PRACTICE OF _
PREVENTIVE MEDICINE

A Memorandum addressed to the Minister of Health by

Sir George Newman

K.C.B., M.D., F.R.C.P.

Chief Medical Officer of the
Ministry of Health

 

LONDON:

PUBLISHED BY HIS MAJESTY’S STATIONERY OFFICE

To be purchased directly from H.M. STATIONERY OFFICE at the following addresses:
Adastral House, Kingsway, London, W.C.2 ; 120, George Street, Edinburgh ;
York Street, Manchester; 1, St. Andrew's Crescent, Cardifi;

15, Donegall Square West, Belfast;
or through any Bookseller.

1926

Price Is. 0d. Net, Paper Covers.
,, 23. 6d. Net, Cloth.

$.5me m agwfl “'25

' ' 2*“?!5NHK '53“ «‘11.? )«fi
. ; ~ . . .‘ . - .4-
‘Jo". ‘2‘ 3317‘}: EKH'L‘NQ‘S” ‘4‘?!)
‘ "8;; t w‘ w‘ -
4 5: *2th .

Lilfi‘luh . {in ,L "13‘: 213* M
“SW aural-.155 763"

 

P; h W
- 1/
I 7; <2
Of (14' (ff
//far 4 ’7;

J ,
*
4/05 '

THE RIGHT HON. NEVILLE CHAMBERLAIN, M.P., Minister
of Health.

SIR,

I have the honour to submit, in accordance with your instructions,
a new edition of the Memorandum on some of the principal medical
matters relating to the practice of Preventive Medicine, first issued
in 1919 at the time of the establishment of the Ministry of Health.
The Memorandum has been out of print for some time, but the
demand for it both in this country and abroad is such that you
thought it desirable that it should be re-issued. The form of the
document has remained unchanged, but a considerable amount
of new matter has been added to the text, and the whole of it has
been revised. ‘

I trust the Memorandum may be useful to Local Authorities,
their Medical Officers, and my colleagues and fellow—workers in
Preventive Medicine generally, in reminding them of some of the
principal subjects which call for their consideration. I hope also
that it may be of service to numerous voluntary workers of all
classes who are devoting themselves with public spirit to the
health and well-being of the nation.

The indispensable condition of the advance of any community
is health.

The declaration of Herophilos, Greek philosopher and physician,
remains true “ that Science and Art have equally nothing to show,
that Strength is incapable of effort, Wealth useless, Eloquence
powerless, if Health be wanting.”

I have the honour to be,
Sir,
Your obedient Servant,
GEORGE NEWMAN.

WHITEHALL,
A pril, 1926.

(B_32/931)g M81369“ A 2

\; ‘51!

. "F

r. Va
Véi‘i'va
,,

.:

:,.

 

AN OUTLINE OF THE PRACTICE OF
PREVENTIVE MEDICINE.

CONTENTS.

PAGE
I.—THE PURPOSE OF PREVENTIVE MEDICINE .. .. 7

II.—THE RISE OF PREVENTIVE MEDICINE . . . . 11
(i) The growth of Medicine as knowledge . . . . . . . . 11

(ii) The growth of application of Medicine . . . . . . 14
III.—THE NATURE OF DISEASE . . . . . . . . 20
The dominance of the body . . . . . . . . . . . . 20
The infecting agent . . . . . . . . . . . . . . 21
The external conditions . . . . . . . . . . . . 24
Principles of epidemiology . . . . . . . . . . . . 25
IV.—-THE PRESENT PROBLEM . . . . . . . . . . 27
Results of present conditions . . . . . . . . . . . . 28

(i) The Public Health Service . . . . . . . . . . 29

(ii) The School Medical Service. . . . . . . . . . 30

(iii) The National Health Insurance System—(a) Number of
insured persons seeking medical advice; (b) amount
of time lost from employment owing to sickness;

(c c) the character of the sickness . . . . . . 31
(iv) Hospital— —treated disease . . . . . . . . 36
(v) The Returns of the Registrar—General . . . . . . 38
Conclusions . . . . . . . . . . . . . . . . 41
V.—THE BROAD LINES OF REFORM . . . . . . 44
(i) Need for synthesis and integration in Medicine ; biology,
physics and chemistry ; physiology . . . . . . 44
(ii) Need for new application in Medicine. . . . . . . . 49
VI.—SOME OF THE ELEMENTS OF A NATIONAL POLICY . . 53
(i) Heredity and race—Alcoholism ; syphilis ; feeble-minded-
ness .. .. .. .. .. .. .. .. 54
(ii) Maternity . . . . . . . . . . . . . . . . 61
(iii) Infant Welfare . . . . . . . . . . . . . . 64
(iv) The School Child. . . . . . . . . . . . . . 68
(v) The influence of environment——Water supply ; public
health and the dwelling-house ; public food supply . . 71

(B 32/931)g A 3

6
PAGE
(vi) Industrial Hygiene . . . . . . . . . 80
(vii) The Prevention and Treatment of Infectious Disease—
Measles; tuberculosis; influenza; epidemic nervous
diseases . . . . . . 83
(viii) The Prevention and Treatment of Non-Infectious Disease—
Acute rheumatism, chronic rheumatism; heart disease;
rickets; mental disease; dental disease; indigestion and
alimentary disease; diabetes; preventive surgery 94
(ix) Public Education in Hygiene—(i) the practice of hygiene;
(ii) the teaching of mothercraft ; (iii) physical education ;
(iv) open-air education . . . . . . . . 118
(x) Investigation in relation to preventive medicine . 125
Conclusion . 131
VII.—AN ADEQUATE MEDICAL SERVICE . . 133
(i) The medical practitioner . . 133
(ii) Auxiliary services . . 139
(iii) Clinics and dispensaries . . . . . . 139
(iv) Hospitals and residential institutions . . . . 141
(v) Public medical services . . . 143
VIII —SOME PRINCIPLES OF MEDICAL ADMINIS’I RATlVE
MACHINERY .. . . 145
Central Medical Administration . 147

Local Medical Administration

. 152

AN OUTLINE OF THE PRACTICE
OF PREVENTIVE MEDICINE.

SECTION I.
THE PURPOSE OF PREVENTIVE MEDICINE.

1. The first duty of medicine is not to cure disease, but to prevent
it. In its simplest terms, therefore, the purpose of the science and
art of Preventive Medicine is to apply human knowledge to the
prevention of disease. It is the common and universal experience
that life is crippled or curtailed by the occurrence of disease, which
leads to a greater or less degree of disablement, incapacity and
premature death. To prevent or avoid such disease is to lengthen
the period of life and make it happier and more effective. Hence
we may express the objects of Preventive Medicine as follows :—

(i) To develop and fortify the physique of the individual and
thus increase the capacity and powers of resistance of
the individual and the community.

(ii) To prevent or remove the causes and conditions of disease
or of its propagation.

(iii) To postpone the event of death and thus prolong the span
of man’s life.

Much has already been achieved in these three directions. No
one can read the records of social and physical life in Britain in the
days of Alfred, in the Middle Ages or in the last four centuries without
recognising that a vast improvement has taken place, and that
to—day human life is potentially a better thing than in the past.
Leprosy, sweating sickness, epidemic scurvy, and the plague have
disappeared in England ; cholera has not been epidemic since 1866 ;
the small-pox, though liable to outbreak, appears to be vanishing
under our eyes, and compared with only a century ago, is relatively
a rare and mild disease which, if not always avoided, is at least
avoidable ; typhus, or gaol fever, is rarer still; typhoid and
diphtheria are yielding to improved sanitation, isolation and the use
of antitoxin ; hospital gangrene and sepsis in their gross forms have
largely disappeared in response to the application of antiseptic
treatment; and some of the great scourges of the world, such as
malaria, hookworm, and yellow fever, are coming steadily under
control.

2. Indeed, a broad survey of the situation of the human family
in respect of pestilence shows that, apart from war, man is becoming

(B 32/931)Q A 4

(in co-operation with his fellows) master of his fate. Probably it
is true to say that the most potently injurious set of conditions
affecting communal health are those created by international war.
We in this generation are not likely to overlook this fact, [for we
ourselves have been witnesses of it. The pestilences of the Thirty
Years War, the epidemic of typhus after Napoleon’s Russian Cam-
paign, the small-pox after the Franco—(Brennan War of 1870, the
devastations of disease which accompanied and followed the European
War of 1914, all furnish indisputable evidence of the terrible losses
of both sides from disease both during and subsequent to the actual
campaigns. “ If we cover our country,” says Dr. F. G. Crookshank,
“ from John o’Groats to Land’s End, with the most perfect web of
sanitary organisation and mechanism ; if we notify every conceivable
disease and segregate every possible carrier'of microbes ; if we set
half the population to lecture and inspect the other half, and con-
tinue our efforts for a generation ; even then we shall not achieve
anything that will not be destroyed by six months of war involving
the organisation of a nation in arms." * The application of modern
methods of Medicine and Surgery have proved of immeasurable
value and relief during military operations, and of utility at sub-
sequent stages, but war, famine and pestilence march in organic
relationship to each other.1' The only radical logic is the avoidance
or reduction of war ; and the League of Nations has made manifest
both the practicability of such reduction and the positive service of
an organisation which seeks the establishment of international
health.

3. Great and far-reaching medical problems, as we shall see,
lie before us, but the advance in the public health has been remark-
able in degree, wide in scope and steady in occurrence, in spite of
the fact that since the spacious days of Queen Elizabeth the popula-
tion of England and Wales has risen from 315 millions to 384; millions,
and the stress and strain of life have increased beyond measurement.
We have, therefore, substantial grounds of hope for the future.
Yet this must not blind our eyes to the issues remaining. Though
the death rate of England and Wales has fallen from 20.6 per 1,000
living in 1868 to 12-2 in 1924, and the infant mortality rates from
155 to 75 per 1,000 births, we still lose in England every year upwards
of 180,000: lives by the death of persons under the age of 50, we still
lose upwards of 50,000§ infants and many still births ; and though the
public health is steadily improving, there is still a vast burden of
sickness and disease involving much suffering and the loss of millions
of pounds of wages and production every year, and of millions more
on expenditure for treatment and insurance, and this in spite of the

 

3‘ Science and Civilisation, ed. F. S. Marvin, 1923, p. 276.

1' Prinzing’s Epidemics resulting from Wars (Westergaard, 1916).
1'. 189,966 in 1924.

§ 54.813 in 1924.

9

fact that the exigencies of the times demand increasing output and
production. We cannot forget, too, that in this relatively enlightened
age it is estimated that six million lives were sacrified to the plague
in India in 1901—1910, that four millions died from cholera in India,
1902—191 1, that upwards of six millions died from influenza in India
in 1918,* that 100,000 persons died of influenza in England and
Wales alone in 1918, that a million children of school age are unable
to derive reasonable benefit from the education the State provides,
and that a million recruits were found to be unfit for effective enlist—
ment. The problem before us is thus partly a problem of the defeat
of “ the captains of the men of death ” and partly a problem of
husbanding and strengthening the normal physique of the people as
a whole in order that life may be happier, more satisfying, and more
productive.

4. The science and art of Medicine is not restricted to the
diagnosis and cure of disease in its gross forms ; it includes also a.
knowledge of how disease comes to be, of its earliest beginnings, and
of its prevention. It is, in fact, the science and art of Health, of
how man may learn to live a healthy life at the top of his capacity
of body and mind, avoiding or removing external or internal con-
ditions unfavourable to such a standard, able to work to the highest
power, able to resist to the fullest, growing in strength and efficiency.
Preventive Medicine must not be understood to consist only of
external sanitation. It is something wider than ” Public Health ”
—-one of 'a dozen subjects in the medical curriculum. In regard to
disease, it is something more than the closing of its channels of com—
munication, something more than an avoidance of the ways and
means of its infection and invasion, certainly much more than a
registration of its effects, a record of the morbidity and mortality
which follow in its train. The turning point of the battle is elsewhere.
“ The chief factor in the production of disease,” said Galen, “ is the
preparation of the body to suffer it.” Thus, the first line of defence
is a healthy, well-nourished and resistant human body. And to this
end the whole man must be dealt with, for he is something more
than animal. His body is, in greater or less degree, the instrument
and expression of emotion, intellect and will. There is thus a
psychological aspect of clinical and preventive medicine hitherto
greatly neglected. Nor is the individual, taken at any one moment,
the whole of the issue. His life history, his heredity, his family,
his domestic life, his personal habits and customs, his rest and his
occupation, his home as well as his workshop, have also to be con-
sidered, even his relation to his fellows and his environment and

 

‘ The general insanitary conditions and the relatively low standard of
living in India were largely responsible, in all probability, for this amazing ,
scourge, which is said to have affected over 50 per cent. of the population of
India. See [Moral and Material Progress and Conditions of India, 1917—18.
(1919. No. 143, p. 184.) .

10

theirs. In short, Preventive Medicine to be effective must deal
with the man, the whole man, as an individual as well as a member of
society. It must deal with the causes of his health, for then it may
discover the causes of his disease. “ Happy the man,” wrote Virgil
in his villa at Naples, “ who has attained to the knowledge of the
causes of things,” and four hundred and fifty years afterwards
St. Augustine added, “ there are none which it concerns us more
to know than those which affect our own health.”

5. The human body is a finely-adjusted physiological instru—
ment, which must not be wasted, much less destroyed, by ignorant
'or wilful misuse. For, apart from moral considerations, it must
not be forgotten that a working man’s capital is, as a rule, his health
and capacity to perform a full day’s work. Once that is impaired
or damaged beyond recuperation, two things happen ; first, if the
bodily defence be undermined by stress and strain the man falls a
ready prey to disease; secondly, his whole industrial outlook is
jeopardised, and instead of being an asset he becomes by rapid stages
a liability, and even a charge on the community. Therefore, as
the problems to which reference is made in these pages concern
the future as well as the present, so also they have regard to that
interpretation of Preventive Medicine, the aim and purpose of which
is the removal of the occasion of disease and physical inefliciency,
combined with the husbanding of the physical resources of the individual,
in such a way and to such a degree that he can exert his full powers
unhampered, at home or in the workshop, over a reasonably long
life, and with benefit and satisfaction to himself and all concerned.
Its ideal is to restrict, subdue and, in the far distant future it may be,
annihilate the tendencies to marked variation in the healthy body
of man. lts object is to prevent not only the spread of disease
but its unnecessary occurrence, to remove its occasion, to save the
time which it loses and the suffering which it causes.

The spirit and purpose of Preventive Medicine must not be
confined to sanitation or the “ public health” alone, but must
pervade and inspire all branches of Medicine. For it is concerned
with the causes and conditions of disease, which must be sought and
known, then brought under control ; in achieving this, or attempting
to achieve it, Preventive Medicine must define and secure the
maximum of those conditions of life for the individual and the
community which are the frontier defence against disease, and
establish the foundations of sound living. For the health and
physique of the people is the principal asset of a nation, as disease
is its principal liability.

 

11

SECTION II.
THE RISE OF PREVENTIVE MEDICINE.
(i) The Growth of Medicine as Knowledge.

6. The practice of Preventive Medicine had its origin in the
ancient world. Long before the days of Hippocrates (460-377 B.C.)
men had sought to stem the tides of disease which threatened to
overwhelm them. Even in Britain it was the ravages of pestilence in
the Middle Ages—of leprosy from the twelfth century, of the “ black
death ” from the fourteenth, of sweating sickness in the sixteenth,
of cholera and of the small-pox—which compelled attention to the
conditions which seemed responsible for such epidemics. But over
all the centuries which record these pestilences in this and other
countries there broods the darkness of ignorance, veiling the truth
and seeming to mock at man’s helplessness. It has slowly dawned
on his mind that without knowledge of the nature of disease and of
infection he is without hope of discovering the rational means of
prevention. The history of Preventive Medicine is the history
of the seeking and finding of these essential things.

7. At the end of the golden age of Greece, Hippocrates was at
his zenith. He first systematized the existing knowledge of medicine
and classified the causes of disease into those concerned with seasons
and climates and external conditions, and those more personal causes
such as the food, exercise and habits of the individual. He wrote
also on the “ huinours ” of the body and the “ elements ” of thera-
peutics, and laid down the principle that the process of disease
consists of its invasion of and dispositionin the body, combined with
the reaction of the body in its own defence, the twofold struggle
in which Nature attempts to overcome disease. Hence Hippocrates
taught the sufficiency and healing power of Nature, and that the
true physician observed her method and copied rather than modified
it. Five and a half centuries after him came Galen, the famous
Greek physician Who lived in Rome in the days of Marcus Aurelius,
Commodus and Severus. He gathered up all the medical knowledge
of his time, and his books fixed it so firmly that the Galenic tradition
lasted through East and West for fourteen hundred years. As a
great medical historian, Haeser, has said, “ to every question it (the
' Galenic system) had‘an answer, for every problem a solution ; and
this spurious air of infallibility led the spirit of man in fetters for
centuries and shattered any hope of progress.” Through the Middle
Ages medicine slept, and the scourges of leprosy and plague taught
it little. In the fourteenth century there were the plague tractates
and various ecclesiastical provisions against disease. Then with
the Renaissance came the new learning, which threw a flood of light
on the nature both of health and disease. It revolutionized the

12

whole content of Medicine, and gave it an Arabic orientation. At
first the revival of learning in the West consisted of the diffusion—
by the Fall of Constantinople, the invention of printing, and the
extension of the Arab Empire—0f Greek knowledge, and the result
might well have been merely a widening sphere for Galenic doctrine.
But happily, in fact, new knowledge and new understanding arose,
for there was escape from the trammels and domination of authority,
of tradition and of abstract theory, and an acceptance of the return
to what Vesalius called ” that true bible of the human body and of
the nature of man.” The fifteenth century gave us Leonardo da
Vinci—whose genius foreshadowed some of the greatest advances
in science which we owe to the Renaissance—the sixteenth, Vesalius
himself; the seventeenth, Galileo and Descartes, the philosophers,
Harvey, Willis, Malpighi and Helmont, the experimentalists,
Mayerne and Sydenham, the practitioners—who with their contem-
poraries taught that “ epidemic constitutions,“ seasons, contagion
and telluric conditions had relation to the prevalence of disease—
and these men revolutionized the philosophy of science, anatomy,
physiology, and the clinical study of disease. It is not too much to
say that they relaid the foundations of Medicine. The eighteenth
century gave us the systematic naturalists, Buffon and Linnaeus;
the physiologists, Haller and his disciples ; the pathologists,
Morgagni and Bichat ; and the mighty practical unifiers, John Hunter
and Edward Jenner, who opened the book of the future. Thus was
provided not only a more accurate and living knowledge of the
structure and functions of the human body but the fundamental
facts of morbid anatomy, abnormal structure, perverted function,
and the resultant signs and symptoms, in short, the nature of
disease. More than that was provided, for these epoch—makers
subdued to practice the scientific method as basis both of knowledge
and its application. They handed down to us a body of information
and also a way of working. Their method was to drink at the
source. “I profess both to learn and to teach anatomy,” wrote
Harvey, ” not from books but from dissections; not from the
positions of philosophers but from the fabric of nature.” This was
the beginning of the modern science of Preventive Medicine.

8. Perhaps the way of learning had in the long run a greater
effect than the learning itself. For close upon the heels of the
cellular pathology of Morgagni and Virchow came the new knowledge
of Infection, the acquisition of which forms one of the most fascinating
chapters in the whole range of Medicine, a chapter which has made
bright our own times. For long centuries men had believed that
certain diseases were caused by external living agents and conveyed
by contagion. Aristotle himself had taught this, but in the sixteenth
century the doctrine began to be defined more clearly. Jerome
Fracastor in De Contagious (1546), and Cardan in De rerum varietate
(1557), conceived that infection was due to seeds of disease capable

13

of reproduction in the human body. This view, which had been
foreshadowed by Paracelsus, gained increasing acceptance as men
came to believe, like Fallopius in 1564 (in phthisis) and Kircher a
century later (in plague), that the “ seeds " of disease bore some
relation to the corpuscles of the blood, as they came to think in
terms of the atomic theory enunciated by Descartes, as they familiar-
ized themselves with the idea of parasitism, as they conceived fermen-
tation and putrefaction to have a vital cause, and as eventually they
saw for the first time with their own eyes some of the forms of
micro-parasites. At the end of the first half of the nineteenth
century a beginning had been made in the discovery of specific
organisms in diseased tissues. (POHender’s bacillus of anthrax.)
Then came the immortal work of Louis Pasteur on the causes of
fermentation in 1857, on the diseases of wine in 1863, on viruses in
1877 and on vaccines in 1880-82. His vision and technique and
that of Robert Koch—with his solid culture media and precise
methods of identification—opened the gates of a new kingdom.
They had great reward, for in trooped the long line of their successors.
From 1870 to 1905 there followed that wonderful succession of
discoveries which have distinguished for all time the age in which
we live, and which gave us the bacillus of leprosy (Hansen), the
gonococcus (Neisser), the typhoid bacillus (Eberth-Gafiky), the
micrococci of suppuration (Ogston), the bacilli of tuberculosis (Koch),
of cholera (Koch), of diphtheria (Klebs-Loffler), of tetanus (Nicolaier)
and of plague (Kitasato and Yersin), all between 1871 and 1894.
In 1880 Laveran announced the discovery of the plasmodium malaria,
and eighteen years later Ross demonstrated its relation to the
mosquito. In 1878 came the trypanosoma of Lewis, to be followed
by various members of its genus ; in 1883 Friedlander described the
pneumococcus, and four years later Weichselbaum the meningococcus
and Bruce the micrococcus of Malta Fever. The last to be named
in this brief review is Schaudinn’s spirochwta of syphilis, discovered
in 1905. These then were the principal authentic representatives
of that unseen world the existence of which had been long foretold.

9. But the discovery of the disease—producing bacillus was only
the first step in establishing a trinity of knowledge. What did the
bacillus do P and what could restrain, prevent, or control its activity ?
In 1888 came the brilliant work of Roux and Yersin, in which they
demonstrated by filtration the existence of the toxins of the bacillus
of diphtheria and thus opened a new chapter in pathology. Only
the year before Metchnikoff had shown the bactericidal powers of
the leucocytic cells of the healthy body and had introduced his
famous theory of phagocytosis, and two years later (1890) Behring
and Kitasato completed the case by producing the antitoxin of
diphtheria—the final step in the establishment of the far—reaching
conception that though the healthy body of man may be subject to
the bacillus and suffer its toxic effect, it is able of its own cells and

14

fluids to provide defence, in the form of the destruction and assimila-
tion of the invading bacillus. Thus was built our modern conception
of the bacillus as agent, of the toxin as product of the bacillus, of the
antitoxin as the body’s defence against the effects of the toxin.
Further research by many living workers has added knowledge in
regard to the antitoxins of tetanus, of cholera, of typhoid; it has
detected the filterable viruses ; it has given us the beginning of an
_‘ understanding of the place of opsonins, agglutinins, and precipitins
in the body defences ; it has provided us with autogenous and other
vaccines. Lastly, in 1910, Paul Ehrlich announced his discovery of
606, the arsenical compound salvarsan, which is able to destroy in
the living body the parasite of syphilis. Thus was the illuminating
chapter in the new learning respecting the agents of infection and the
body’s natural defences begun in 1857 by one chemist and so far
completed in 1910 by another—a significant illustration of the inter-
dependence of the Sciences in the pursuit of truth. ” All sciences
gain,” said Pasteur in 1878, ” by mutual support.”

The discovery of particular micro-organisms in association with
particular diseases, and possibly even causally associated, is not,
however, the whole story. Men soon learned that bacteria are
unstable and variable, and that their functioning, action and reaction,
is dependent upon many circumstances, both within and outside the
living body of their host.

(ii) The Growth of Application of Medicine.

10. Alongside the growth of medical knowledge there slowly
came into being an extension of its application. Like the rise of
medical learning this also sprang, in its origin, from the prevalence
of disease. During the ten dark centuries which separated the end
of the Western Roman Empire from the discovery of America and
the opening of the New World, there had been a steady increase in
man’s apprehension of the scourges of disease. Leprosy, scurvy,
the epidemics of the Middle Ages, the black death, the Levantine
plague, famine, sickness and ague spread misery and death among
the great mass of the people all through the West. The great
monastic orders, and some of the historic cities, like Rome, Venice,
London, provided comfort, refuge and sustenance for the afflicted,
and in 1388 was passed the first Sanitary Act in England directed
to the removal of nuisances. Following this famous precedent,
the application of Preventive Medicine came shortly into being,
nearly always in the track of the plague. In 1518 was made the first
rough attempt at certification and segregation of the patients; in
1543 came the first plague order recommending separation and cleans—
ing; under Elizabeth scavenging became more stringent ; in 1568
the Aldermen of the City of London received instructions as to dealing
with infected houses and persons; before the end of the century

15

" searchers ” and death registration were in vogue ; and by the time
of the Great Plague quarantine was a well-recognised institution.*
Two factors were involved in the progress of the application of
Preventive Medicine in England in the seventeenth and eighteenth
centuries. First, there was the new medicine itself, and secondly
there was the new humanity. The former had for its exponents
such practitioners as Thomas Sydenham, Willis, Morton and Richard
Mead, the latter had for its prophets the practical philanthropists,
Oglethorpe, John Howard and the religious revivalists. There was
new light in science as there was a dawning altruism in politics.
It was in 1720 that Dr. Richard Mead published his famous Short
Discourse concerning the necessity of quarantine against foreign
countries and the proper management of infected places in England.
“ There is no evil,” he wrote, “in which the great rule of resisting
the beginning more properly takes place than in the present case."
Hence, instead of penalizing infected families and houses or marking
them with a cross, he advocated (a) certification to the magistrates,
(b) early visitation by official medical advisers, (0) separation of the
infected families, “ the sick to different places from the sound, the
sound to be stripped of all their clothes and washed and shaved before
they go into their new lodgings,” and (c0 cleansing of the house.
Mead also recommended that “ all expenses should be paid by the
public, and no charges ought to be thought great which are counter-
balanced by the saving a nation from the greatest of calamities.”
Indeed, he suggested that a reward should be paid to the person
who makes the first discovery of infection. In all this we see the
foundations of the administrative practice of modern Preventive
Medicine, of which Mead was one of the great inventors.

11. Yet Mead was the forerunner of others. Heberden and
Huxham studied fevers ; Fothergill described malignant sore throat ;
.Smellie and William Hunter practised- and advanced the art of
obstetrics, hitherto almost exclusively in the hands of midwives,
and Charles White applied antiseptic principles to it; Haygarth
of Chester introduced notification and isolation of infectious disease ;
Richard Bradley studied plague at Marseilles; Sir John Pringle
began hygienic reform in the British Army; Lind laid down the
principles for the abolition of scurvy among seamen and the
prevention of typhus fever; Sir George Baker wrote on the cause
of Devonshire colic and palsy; Sir Gilbert Blane served with the
Fleet and studied the diseases of the Navy; Percival denounced
the lack of hygiene in crowded factory towns and initiated what
we now call " industrial welfare ” ; and at the close of the eighteenth

* The profession of medicine was now an organised body. The Medical
Registration Act of 1511, the foundation of the College of Physicians in 1518
and the Incorporation of the Company of Barber Surgeons in 1540 provided

its machinery which was, in our own time, strengthened by the Medical
Act of 1858.

16

century Edward Jenner introduced vaccination for small-pox in
place of the inoculation method practised for seventy years before.
Elsewhere, I have drawn attention to these achievements of the
eighteenth century practitioners.* Moreover, the eighteenth century
was the period of the foundation of the great London hospitals,
Westminster, Guy’s, St. George’s, the London and the Middlesex—
St. Bartholomew’s and St. Thomas’s already existed—and near
its end came the Industrial Revolution, which brought with it
public health problems of its own.

12. The applications of State medicine in the nineteenth cen-
tury found their inspiration in England in two sources, and
their expression in legislation. The twofold inspiration came
from the recurrent outbreaks of cholera and consequential com-
missions of enquiry, and from popular demand for reform. The
legislature placed on the Statute Book a wonderful series of en-
actments. The alarm caused by the ravages of cholera in 1831
led to the first steps in administrative sanitary reform; in 1849
there was a second visitation of cholera, and in 1854 a third.1'
Concurrently with and following upon these epidemics there were
various commissions of investigation. In 1838—9 the Poor Law
Commissioners drew attention to the prevalence of epidemic
diseases and their relation to poverty ;1 in 1843 Sir Robert Peel,
at the instigation of Edwin Chadwick, advised the issue of a Royal
Commission to inquire into the outbreaks of disease in large towns,
and the best means of improving the public health, the Report
of which led to the passing of the comprehensive sanitary measure
of 1848, the establishment of the General Board of Health and the
appointment of Medical Officers of Health. In 1869 was appointed
the Royal Sanitary Commission, on which sat Thomas Watson,
James Paget, Henry Acland, Robert Christison and William Stokes,
and before which Simon, Budd and Farr gave evidence. Speaking
broadly, the 1843 Commission found the existence of a serious
national evil of insanitation and ill-health, and recommended
legislative remedy, whereas the 1869 Commission found that the

 

* The Private Practitioner as Pioneer in Preventive Medicine, 1926. (Oxford
University Press).

TThese cholera epidemics led to a new appreciation of the insanitary
condition of the country as a whole, to an understanding of the nature of the
disease and its epidemicity, to the establishment of “ cholera dispensary
stations,” and to the passing of the Infectious Diseases Prevention Act, 1855.

I’l‘hese Reports by Neil Arnott, Kay, Southwood Smith and Chadwick
were the predecessors of another famous series of investigations in 1859—65
by Greenhow and his colleagues under the Privy Council into epidemic
diarrhoea, pulmonary disease, infant mortality and ague; and also into the
four " elementary requisites of popular healthiness," viz. : food supply, house
accommodation, physical surroundings and industrial circumstances. They
led the way to the new applications of medicine for the removal of nuisances,
the prevention of contagion and infection, and industrial hygiene and welfare-

17

remedy had proved ineffective and recommended that “ the present
fragmentary and confused sanitary legislation should be consoli-
dated.” They proposed, in fact, for the first time, a Ministry of
Health ; but the case miscarried and the Local Government Board
was created ,in 1871.* The Commission’s summary of the national
sanitary minimum of ” what is necessary for civilised social life "
is the grand inventory of that period. Here it is :—

(i) The supply of wholesome and sufficient water for drinking
and washing.
(ii) The prevention of the pollution of water.
(iii) The provision of sewerage and utilisation of sewage.
(iv) The regulation of streets, highways, and new buildings.
(v) The healthiness of dwellings.
(vi) The removal of nuisances and refuse, and consumption
of smoke.
(vii) The inspection of food.
(viii) The suppression of causes of diseases and regulations in
case of epidemics.
(ix) The provision for the buri'al of the dead without injury
to the living.
(x) The regulation of markets, &c., public lighting of towns.
(xi) The registration of death and sicknessri‘

13. Half a century ago that programme represented the most
enlightened thought of the time regarding the sphere and scope of
Preventive Medicine. Even now it is almost a complete summary
of the elements of a sanitary environment. But this pre-
scription was not all the advice the Commissioners felt called
upon to furnish. First, they showed how it could be worked out
in practice, by laying down the general principles to be followed
and by drafting a new Statute. Secondly, they diagnosed with
unfailing accuracy the causes of imperfect sanitary administration:
(a) The variety and confusion of authorities concerned in the public-
health, (1)) the want of sufficient motive power in the Central
Authority, (0) the non-coincidence of areas of various kinds of local
sanitary government, ((1) the number and complications of enact—
ments, (e) the needless separation of subjects, (f) some general Acts.
to be left to voluntary adoption and the permissive character
of other Acts, and (g) the incompleteness of the law. This, which
might have been written yesterday, was 55 years agofit Finally,
the Commissioners lent all the power and prestige of their position
and experience in unreserved support of the great principle of local
self-government.

 

* Two illuminating chapers on the history of this period will be found in
Sir John Simon’s English Sanitary Institutions, pp. 322—432.

1' Report of the Royal Sanitary Commission, 1871. Vol. I, p. 20.

iLoc. cit., p. 22.

18

14. The Public Health Act of 1875, which emerged from the
labours of the Royal Sanitary Commission, may be regarded as
marking a great advance in the development of sanitary admini-
stration. Before that time sanitation was interpreted in large
measure as a negative policy, in a word, the removal of nuisances ;
after that time sanitation received a new connotation, positive,
constructive, remedial. That is the reason why this Act forms
the great line of division, the watershed, in the progress of modern
Preventive Medicine on its environmental side. The report of
Sir Robert Peel’s Commission, in 1845, contains a significant
suggestion in its recommendation that each local governing body
should have a medical officer whose duty it should be “ to ascertain
the true causes of disease and death, more especially of epidemics
increasing the rates of mortality, and the circumstances which originate
and maintain such diseases, and injuriously aflect the public health.”
No one can read the preamble of the Report of the Commission
of 1869 on the History of the Sanitary Laws enacted up to that date
without being impressed with their character. They deal, almost
monotonously, with nuisances and their removal, sewerage and drains,
sewage utilisation, the paving, lighting and cleansing of streets,
common lodging—houses, the supervision of artisans’ 'dwellings,
smoke nuisances, local government, and the burial of the dead.
The only group of laws directly concerned with disease was the
Vaccination Acts. Then came the Public Health Act of 1875,
which in conception and working led for twenty years to enactments
on the prevention of river pollution, the protection of water supplies,
the provision of housing accommodation and isolation hospitals,
and the notification and prevention of infectious disease. The
Elementary Education Act of 1870, and the Public Health Act
of 1875 were forms of germinative legislation bearing fruit in a
single generation.

15. While sanitation was thus developing under the impetus given
by Chadwick and Simon, other influences had been at work. The
labours of the great philanthropists of the nineteenth century,
and especially of Lord Shaftesbury, had roused the public conscience
to a sense of responsibility for the evil conditions under which masses
of people lived and worked and of the need of protecting those who
were least able to protect themselves. This movement found part
of its expression in the Factory Acts. The result was a new outlook,
“ a developed apprehension of the meaning of social justice,” as it
was truly described. For, in fact, this new outlook was a result
not only of the movements already named but of the spirit of social
reform and altruism which sprang out of the despair and the aspira—
tions of the Industrial Revolution. The growth of the towns and the
over-employment of women and children (1780—1820)—as apprentice
children, as piecers in the cotton mills, as trappers and drawers in
the mines, and as chimney-sweepers and climbers—were predominant

19

factors in demonstrating the need for a reform guided by medical
science.* Thus it was that Preventive Medicine became more personal,
social and apposite than formerly, more nearly related both to the
new knowledge of medicine and to the problems to be solved, based
more upon the child, concerned more with the individual than the
environment, dealing more with the true causes of disease, and
finding its scope in the ever—increasing affinity between Preventive
and Curative Medicine. In the last decade of the nineteenth century
came the London Public Health Act, legislation on housing and on
industrial betterment, on the cleansing of persons as distinct from
properties, and on the education of blind, deaf and defective children.

16. With the new century came a significant series of. Acts dealing
with midwives, the employment of children, the provision of school
meals, the protection of food, the notification of births, thermedical
inspection and treatment of school children, the Children Act itself,
pensions for the aged, for widows and orphans, the insurance of the
adolescent and adult against sickness, accident and unemployment.
There were two groups of Acts concerned, first with housing reform,
industrial welfare, education, maternity nursing, and dentistry; and
secondly, with some of the prevalent diseases, tuberculosis, mental
deficiency, lunacy, blindness, and the venereal diseases. No one
individual planned this significant sequence, no single factor
explains its emergence. It represents a new social spirit, a new
application of science to the life and labour of man.

 

 

* See “ The Town Labourer, 1760-1832,” by J. L. Hammond and Barbara
Hammond (Lougman’s), 1920,

20

SECTION III.
THE NATURE or DISEASE.

17. The foundations of Preventive Medicine are built upon a
body of knowledge concerning the nature of disease. As we have
seen, there have been attempts since the time of Hippocrates, and
long before his day, to define the nature of disease. Before the
germ theory emphasis was laid upon the individual who was the
subject of disease, his bodily form and habit, his heredity, customs
and environment ; in the heyday of the germ theory the tendency
was to attribute the origin of disease to the germ, its prevalence,
invasion and virulence. Subsequently it has become clear that
disease is a complex expression of the sum total of the inter-action
of parasite and host, a matter of relationship and relativity of many
factors, including chronic and metabolic changes. Disease is not
something conveyed as such to the body ; it is the abnormal con-
ditions resulting from the reaction of the body to morbid agents or
irritants. The human body is seen to be a complicated organism,
grown and fashioned through the ages from a variety of organic and
inorganic elements, designed to withstand the pressures and strains
of the surrounding universe, and developed in response to the
necessity of functioning. Man's healthy life depends upon the
orderly sequence of a series of processes and functions. If they cease
or become impaired or irregular, there is dis-ease, imperfect corres-
pondence, absence of rhythm. The essentials of disease are thus
the soil, habit and powers of resistance of man’s body ; the seeds or
germs or agents of abnormal action, their point of entrance, means of
access or site of operation ; lastly, whilst between the seed and soil
there is interaction and reaction which produce disease, the whole
process is profoundly modified by a vast concatenation of variable
social, personal, external and even economic factors.

The Dominance of the Body.

18. First of all then the body is the dominant factor : its heredity,
its nurture, its degree of nutrition, its habit. For on these conditions
depends its form of resistance to poisoning, accident or infection.
A person of sound heredity may become susceptible to disease by
poor social circumstance, lack of food or unsuitable food, unwhole-
somexsurroundings, excess of alcohol, fatigue, cold, diminished vitality,
previous disease or condition of body tissues ; conversely, the
effects of an unfavourable ancestry may be modified by favourable
surroundings or by improved nutrition in its broadest sense. Man’s
survival in Nature is evidence of the predominance of the body and
mind in the struggle, and this cardinal fact is after all the foundation
of Preventive Medicine. Many subsequent and collateral issues
must be considered in the fight against disease, but first and last

21

stand the nurture and harnessing, the strengthening and husbanding,
of the natural resources of the individual; in this task the racial
character of the individual, the age and sex, the idiosyncrasies and
susceptibilities, the predispositions, the laws of Nature by which
he lives and dies must be considered. Above all must be taken into
account the powers and properties of the human body which furnish
its defence against infection, for it is essentially these resources
which make the body predominant. They are of two kinds. First
there is the cellular mechanism; and, secondly, the bio-chemical
process. The former consists of the epithelial cells of the skin or
mucous membrane, the leucocytes which have phagocytic powers,
and the cellular changes of the inflammatory or necrotic process;
the latter consists of the chemical metabolism of the cells and fluids
of the body which furnishes offensive and defensive sera, “ anti-
bodies,” able to oppose and destroy the products of infection. “ The -
living human body is, surely, the most complex mass of matter in the
known world,” said Sir James Paget, forty years ago.

“ In composition it surpasses the highest powers of chemical analysis ,-
in mechanism it is as far beyond the calculations of the physicist; its
structures are but dimly seen with even the most perfect microscope;
all the known forces of nature are constantly and coincidentally at work
within it ; through circulating blood and a nervous system every part is
in swift communication with all the rest, and it includes the apparatus
of a mind from whose influence no portion of its matter is distantly
removed. And in this body the pathologist has to study not that which is
fixed, orderly and natural, but that which is in disorder and unsettled.”

The I nfecting Agent.

19. Secondly there is the infecting germ or agent, the opera-
ting habit or trauma, which disturbs the structure or function of
the body. In regard to the bacterial or parasitical agents of
infection, it must be borne in mind that they also are governed by
laws of evolution and degeneration, of development and decay.
Disease following their activity is dependent not alone upon the
body they attack but upon their own character, virulence and
pathogenicity, quantity or quality, the path of admittance to the
body, the locus of their operations, their mode of action. It is
not enough merely to know that a virus is present in the human
body and is due to invasion by a bacillus. We must know also
what is the character of the invading bacillus, whether it is human
or animal in origin, whether its virulence be high or low, and in
what way or degree variable, whether it is present in great numbers
or few, where it entered the body; where it operates in the body,
and what is its plan of campaign. Some bacilli remain local,
others become generalised; the material presence and multi-
plication of some bacteria in the body produces effects on the tissues
(infection) ; others act only or chiefly by the secretion of ferments
or toxins (intoxication) affecting the body generally. These facts
must be known before the methods of Preventive Medicine can be

22

effectually applied. Again, there is the question of point of entry
and site of action. The tubercle bacillus, for example, may enter
through the respiratory tract, the alimentary canal, a decayed tooth,
an open wound or an abrasion of the skin. It may remain local or
become general. Finding itself in a suitable nidus in different tissues
or organs of the body it may, proceeding by the same pathological
process (reactive and necrotic tissue changes and disturbances of
metabolism), set up the same disease, but manifesting itself in quite
different form. In the lung and respiratory tract it will produce
various forms of phthisis; in the alimentary canal, tubes mesen--
terica, tuberculous ulcers, &c., in the glands of the neck,‘ the
scrofulous condition; in the brain coverings, tuberculous menin--
gitis ; in the skin or naso-pharynx, lupus ; in the bones, or limbs,
skull or spine, tuberculosis of the bone (e.g., Pott’s disease of the
spine) ; and in the joints, tuberculous synovitis or arthritis, e.g., hip-
disease. Thus the tubercle bacillus may originate disease in skin,
muscle, bone, or in the nervous and glandular tissue, or in all or«
any of the systems of the body, always a similar pathological
process, but profoundly modified by the point of entry, the site
of action and the cellular defences of the body. The body is
the soil, the bacillus is the seed; they interact upon each other.
The seed affects the soil and may make it ultimately immune;
the soil modifies the action of the seed and may excite or depress
its pathogenicity. Further, our conceptions of pathological
process are continually expanding, in relation both to new knowledge
of pathology and to the variations in the ” clinica ” character and
type of disease. For disease is a process, as Morgagni showed in
the eighteenth century ; it is not a fixed entity. It has, as Virchow
taught a hundred years later, a local focus and a cellular origin. It
may affect the whole body or only a special organ or tissue ; but
it begins in the cell. In modern understanding all pathology is
cellular pathology, which may or may not issue in recognisable
disease from a clinical standpoint. Indeed, we are beginning to
get further back still to the physico-chemical changes taking place-
within the cell ; and in this way our study of the disease process in
man, and our means of checking or controlling it, are inter-related
not only with anatomy and physiology, not only with pathology,
with clinical observation and with post inortem examination, but
with new applications to Medicine of the sciences of physics, of
chemistry and of biology. " Diseases are not individual,” said Sir
Clifford Allbutt, “ but various states of individuals. Being qualities,
not things, they can no more be divided into,genera and species
than colours can be.” It was the same authority who said of
Cullen, ” he dethroned disease and set up the patient; he dis—
trusted systems, and saw that the only real is the individual.”

20. The stages by which men reached this understanding are
almost infinite in number. Even if we begin no earlier than Thomas

23

Sydenham, the reformer of English Medicine, we find in his Observa-
tiones Mediocre (1676) the basis of nosology. He saw that among
the diseases most prevalent in the London of his time that certain
fevers had an epidemic character, which bred true with a regular
conformity of symptoms, which enabled him to make a classification
of them. But they had also variations and dissimilar aspects.
Next he found that the typical and atypical forms prevailed at certain
times dependent upon climate or other external conditions. Following
Fracastor, Cardan and Kircher, he reached out after the idea of
contagion. Finally, he conceived his “ epidemic constitutions,”
which he observed to be periodical, long or short.* The nosologists
of the eighteenth century, who confirmed and followed his doctrines,
made new differentia on an anatomic basis. The Paris School of
Pinel, Bichat, and Corvisart brought such classifications down to the
time of Laennec, who developed the clinical methods of differentiation
carried on by Louis, Bretonneau, and others. Hospital facilities
made possible the use of physical instruments of precision, and Addi-
son, Bright and Hodgkin combined the anatomical with the clinical
characters of disease. The Germans meanwhile pressed forward
on the physiological side, holding very soundly the view that patho—
logical anatomy and clinical observation could not be divorced,
nor alone differentiate disease. Pathology, said Magendie, is the
physiology of the diseased individual. So came in experimental
medicine. “ Pathological physiology takes in questions partly
from pathological anatomy, partly from practical medicine,” wrote
Virchow in 1847. “ It creates its answers partly from observations
at the bedside, and thus it is a part of clinical medicine, and partly
from experiments on animals. The experiment is the ultimate and
highest resort in pathological physiology.” Thus the laboratory as an
adjunct to the ward came to the aid of the clinician, and to Claude
Bernard experimental medicine was synonymous with scientific
medicine. Pasteur, Koch and Loffler brought into the clinical and
experimental laboratory the new knowledge of bacteriology, and
concurrently the growth of the Darwinian hypothesis became the
foundation of the functional diagnosis and constitutional pathology
which mark our own day.

21. If then our object be, as I submit it is, (a) to determine the
causes and conditions of disease, (17) to define and explain the morbid
state, above all (c) to interpret its meaning to the living patient,
and (d) to control it, then we must learn that Preventive Medicine
concerns not only the external environment of man, not only the
clinical and morbid phenomena of disease, but implies an under-
standing of those unseen processes of attack and defence which
find their sphere in the cells and fluids of the body, and their in—
fluence upon the infecting or disturbing agent. There is opened

 

* Thomas Sydenham, Reformer of English Medicine, 1924.

24

to us a vast new field, not only of biology, of the part played by the
cell in Nature, but of practical medicine, of antiseptic surgery,
of the natural defences of the body, of vaccine and anti—toxin, and
of serum therapy. How far indeed is all this from Galenic doctrine,
from the pathological conception of the Middle Ages,from “humours”
and “ spirits,” from “ visitations ” and penalties! And how far
removed may the new Preventive Medicine be in aim, practice and
achievement from the days of witchcraft, of papal bulls, of charms,
and of the ” dooms ” of the early English Kings! Little wonder
that Sir Clifford Allbutt called us to see in all this profound revolu—
tion of scientific thought a new birth of Medicine.

The External Conditions.

22. In the third place there is a group of conditiOns outside
both the subject and the infecting or disturbing agent, namely, the
general environment and the effect of treatment. The incidence
of disease is affected by climate and by a series of factors of a com—
munal nature. The physical world and its atmosphere, the climatic
conditions in which people live, play their part in the creation of
disease. Tropical, temperate and cold climates, marine or mountain
climates, wind, rainfall, altitude, dryness or moisture of atmosphere,
all exert their influence and must be included within our compre-
hension. They affect both the individual and the causal agent.
Then there are communal conditions contributory to environment,
the density and movements of population—especially the aggre—
gations of non-infected population—its age and sex distribution,
its character and occupation, the marriage rate, the birth rate, peace
or war, food supply or famine, the price of wheat, urban life or
rural, and the means of intercommunication. Then, once more, there
are the near environmental conditions, the housing and still more
the home life of the people, the family, the school, domesticity,
the workshop—all these outward circumstances govern the issue of
the incidence, manifestation and prevalence of disease.

23. The treatment of disease and the relation of a people’s
attitude to it modifies its nature and affects its prevalence. The
immunity of England from ergotism, the ancient liability of the
Normans to leprosy, and of the Italians to pellagra, had relation
to food; variolation modified small-pox in the eighteenth century,
as did vaccination in the nineteenth; the introduction of disease
into a virgin soil seems to result in acute Virulence (as in typhus,
measles and small-pox), even as that virulence is reduced in a
population subject to, or immune from, the disease; the use of
quinine modifies malaria, inoculation against typhoid modifies
enteric, isolation modifies measles and influenza, and anti-toxin
modifies diphtheria. In this way, as in others, every healed person

25

in every town and village of the land is a recruit secured for the
great army of Preventive Medicine. He not only proclaims its
principles, he embodies tliem.

Principles of Epidemiology.

24. These remarks apply generally both to epidemic and spor-
adic disease, but it should be added that in epidemiology we must
recognise that we are faced with a condition of things which compels
not only the broad view but the long View also. Here, more even
than elsewhere, it is necessary to take into account the whole history
of each disease over years, and even for centuries. For there
is a secular trend, “ a long-period modification, in virtue of which
a specific type becomes dominant in a particular epoch and then
gradually or suddenly gives place to a rival ”*; 'there is also,
to use Sydenham’s term, an epidemic constitution cycle, in which
“ certain types of epidemic or certain features of morbidity tend
to prevail at a given time to the exclusion of other types”; and
lastly, there are seasonal cycles, “ short-period oscillations in
epidemicity” due to seasonal prevalence. The historic scourges
of plague, ague and small—pox illustrate this cyclic phenomenon,
and we have examples now with us in the characteristic wave
incidence or periodicity of such maladies as measles, throat diseases,
influenza and the epidemic nervous diseases. In all of these there
are climatic factors. which may induce an endemic disease lying
concealed or in abeyance to become active and epidemic; there
is ”importation of infection ; there are immunisation factors which
spring out of the resistant condition or susceptibility of the people ;
and there is the biological change of state of the virus. Thus,
whilst there is a certain constancy of behaviour in epidemics,
there are wide variations, inter—epidemic periods, endemic, epidemic,
and pandemic characters, as yet only partially understood.
Influenza shows different signs and symptoms predominant in
different epidemics, in fact, it affects different systems of the body,
gastric, nervous, pulmonary. Some authorities hold that the primary
attack of influenza is always upon the cerebro-spinal nervous
system, and whatever be the variations in symptomatology, there
is, they think, this abiding unity in the disease which gives it
relationship to other epidemic nervous disorders, such as encephalitis
lethargica. We know also there are atypical forms of scarlet fever,
diphtheria, small-pox and enteric. They show diversity in form
and behaviour, even in degree of response to control. What
Heberden said of scarlet fever is true of all infective disease, it is
“ sometimes so slight as to require no remedies, and sometimes
so violent as to admit of no relief." It is known that pathogenic
bacteria may have a saprophytic cycle of life, that they may be

 

"‘ International Congress of Medicine, London, 1913, Section 18, Part 1,
p. 52 (Greenwood).

26

” carried ” in the body of man or animal without producing disease,
and that they vary greatly in degree of pathogenicity. It is known,
too, that man himself varies greatly in degree of susceptibility,
due to health or disease, and that the accumulated susceptibility
or insusceptibility of a community is a factor in the rise or fall of
epidemics. “ What hopes seized upon me,” wrote Pasteur, ” when
I realised that there must be laws behind so many obscure phe—
nomena.” Disease is not capricious. It follows laws of cause
and effect, and it is our business to study and observe those laws,
to investigate and understand their action and meaning—in
brief, (i) to collect with patience vast bodies of natural facts ; (ii)
to check these natural facts by observation and the experimental
method, and note the atypical and variant conditions; (iii) to
differentiate and classify these natural facts; (iv) to draw valid
deductions and standardize them by the plumb—line of experience ;
and (v) to integrate the facts, building a synthesis, as far as may
be, and seeking ways and means of application. “ Without sure
reason,” said Sir Clifford Allbutt, ” facts are dross.”

25. This is the rational method, but to find truth it must be
applied in the scientific way. The scientific way is the way of
Nature rather than artifice. If we examine bacteria in a laboratory
under conditions wholly unnatural to them, we must expect false
returns—a chemical stain, precipitation of albumin by heat, the
organism itself modified in structure and function by artificial
cultivation, may, indeed must, profoundly affect the issue. Similarly,
the clinical study of disease artifically carried out or hide-bound
by tradition can but reproduce the errors of those who went before.
We must, as far as we can, study the germ and the patient under
natural conditions, allowing for stages of modification and evolution
to be taking place immediately before us, allowing the germ and
the disease to speak for themselves. We are students of the book
of Nature—“ that universal and publick Manuscript, that lies
expans’d unto the Eyes of all,” as Sir Thomas Browne called it—
of her signs and symptoms, objective and subjective, as far as
possible at their beginnings, unmodified and unaffected by mechanical
design or artificial contrivance. Those signs and symptoms and
their cause and meaning are the “ facts ” we seek. We must study
and observe, and observe and study. Here is a vast uncharted
world, only partially explored, immediately at our doors ; to watch
and investigate, vigilantly and with patience, over a long period
of time and in many fields, is to make our knowledge of the true
nature of disease wider, deeper and more accurate. “ Now we
govern Nature in opinions,” said Lord Bacon, ” but we are thrall
unto her in necessity. If we could be led by her in invention, we
should command her in action.”

 

27

SECTION IV.

THE PRESENT PROBLEM.

26. The present position of the practice of Preventive Medicine
may be stated in few words. We have an immense body of know-
ledge and experience, new and old, on the one hand, and vast effort
and desire to apply it on the other; but there is lack of correlation
of the knowledge and there is lack of appreciation of the precise
problems to be solved and of the ways and means by which they
may be faced. The result is a certain degree of wastefulness and
confusion, individual and public effort sometimes tending to become
arbitrary, sporadic, and perhaps a little capricious. This is entirely
natural, and possibly inherent in the situation, which is itself
transitional and progressive.

In the first place, in Medicine itself the new knowledge and
methods are insufficiently shared by the whole profession, they are
separated from each other in water-tight compartments, and are
not brought into practice. Their energy is potential and not yet
kinetic. The new physics is not yet sufficiently penetrating the
new physiology; the new physiology is not yet made generally
available for the uses of hygiene or pathology ; the physiology and
pathology are not yet fully brought into clinical practice ; clinical
practice itself must be aided, though not dominated, by the new
knowledge in bacteriology, epidemiology and therapeutics. The
physiological interpretation of medicine, in its broadest meaning,
must be brought to bear upon the patient, in the clinical labora-
tory, the hospital ward and the sick room. There must be fuller
recognition of the part played by the nervous regulation of the
body, its composition and functions, for it is this vis medicatrix
nature, no longer an abstraction but an ordered sequence of actions
and reactions, which the wise physician and surgeon will seek not
to destroy or pervert but to release and supplement at the bedside.
The present situation reveals then this lack of inter-relation, of
inter—dependence, of co-operative systematic handling; it is
characterized too much by spasmodic ” tunts,” too little by unified
and sustained effort.

27. Secondly, the administration of the local public health
service (which is the application of préventive medicine to
communities), is insufficiently co-ordinated and unified. The
service has grown up as we have seen, almost haphazard; it
is casual and anomalous in formation; often overlapping and
sometimes redundant. Thus it is less effective than it might be.

28

There are several departments concerned in Whitehall; there
are half a dozen in every local area. Complete unification is
impracticable, and indeed, with so great a variety of duties, un-
desirable, but there is some need for simplification, economy
of administration and effective co-ordination. There are several
thousand medical men engaged in one capacity or another, and in
greater or less degree, in the local medical services (excluding
the practitioners working under the National Insurance Act),
but full value is not being obtained from their services because
of lack of appropriate association, differentiation of duty and
co-operation.

28. Lastly, there is all over the country inadequate treatment
of the sick and incapacitated, in quantity and quality. The
beginnings of disease are still very largely ignored. The treat-
ment provided for the majority of the sick is insufficient and
inadequate; it does not represent the best of present medical
knowledge. Whole groups of disease are neglected as far as pre-
vention is concerned, for prevention has been too exclusively
concerned with certain infectious diseases, and much disease is
allowed to “go by default,” untended and untreated. Well—
known and compendious text-books are still being published
without any regard to the use and application of preventive
methods, although there has been in recent years substantial
advance of our knowledge of means and methods. The provision
of facilities for residential hospital treatment of patients requiring
it (with the exception of the insane and the infectious) falls far short
of what is necessary if they are to be healed and returned to the
ranks of efficiency.

29. Thus, the outstanding defects in our practice of Medicine
in England to—day are, first, the absence of correlation of medical
knowledge and its application to the real focal point of the problem;
secondly, much anomalous and overlapping local administration,
which is too spasmodic, uncertain, unequal and discontinuous to
yield its proper national effect ; and thirdly, the indifferent diag-
nosis and treatment of disease in tens of thousands of patients, in
ordinary practice and in the casualty departments of hospitals.

Results of Present Conditions.

30. The steady advance of Medicine in conjunction with social
betterment, particularly in the eighteenth and nineteenth cen-
turies, has won astonishing victories. Vast sections of the popu-
lation live healthy and fully occupied lives. The expectation of
life has increased, and many gross forms of disease haVe almost

29

disappeared.* There have also been conquests in the realm of
prevention. Leprosy, typhus, gaol fever, scurvy and the plague
have vanished from Britain, and whole groups of tropical diseases
are steadily coming under control. Yet we are often defeated
and unready, and such a disease as influenza sweeps through the
world finding us almost helpless. The imperfections in the national
health have lately been unveiled or confirmed in a variety of ways
and spheres in the domestic and industrial life of the people, the
facts of which furnish a body of accumulated evidence which cannot
be doubted or gainsaid, and which has not been similarly avail-
able before. This evidence comes at a time when our potential
capacity to prevent and treat disease has been overwhelmingly
demonstrated in the Great War, and when our national and
Imperial need of a virile race is afresh borne in upon us. Let
us consider briefly to what this evidence amounts.

(i) The Public Health Service.

31. The external sanitary circumstances of the country have
shown in recent years enormous improvement. Water supplies
and sewerage have been brought, on the whole, to a fair standard
of efficiency; food, meat and milk are steadily coming under
supervision ; factories are controlled ; nuisances are abated ; pro-
vision is made for the removal of refuse and street cleansing;
widespread action is taken against the ordinary infectious diseases.
No student of the official local sanitary reports can doubt the
steady improvement which has taken place in the external sanita—
tion of town and country. Gross overcrowding and domestic
insanitation spell, inevitably, disease and degeneration of race, as
no one can doubt who appreciates the effect of slum life, as seen in
all our great cities and in many country villages. Moreover, it must
be remembered that though infectious disease is a relatively small
direct contributor to the death rate, it is relatively a large
contributor to disablement and incapacity.

The following table shows for the years 1921 and 1924 the
number of cases of the principal infectious diseases notified
annually in England and Wales and the number of deaths from
each disease registered.

 

* There has been, at all ages, a reduction in the death-rate (1921—24 com—
pared with 1871—80), varying from 14 per cent. (ages 75—85) to 53 per cent.
(20-25) ; the expectation of life at birth (males), which was 41-35 years in
1871—80, 43-66 in 1881—90, 44-13 in 1891-1900, reached 48-53 in 1901-10
and in 1910—12 became 51 -50, an improvement of more than 10 years.

30

 

 

 

Cases Notified (ex- Deaths (including
eluding non-civilians). non-civilians).
Diseases.
1921. 1924. 1921. 1924.
Cerebro-spinal Fever . . . . 411 397 416 301
Diphtheria (including Membranous
Croup) . . . . . 66,506 41,980 4,772 2,501
Dysentery . . . . . 1,223 388 261 130
Enteric Fever (including Para—
typhoid Fevers) .. . 3,835 4,121 613 496
Erysipelas 13,231 12,879 729 676
Malaria . . . . . *10 *4 143 98
Measles and German Measles 131,785 T109655 2,256 4,846
Ophthalmia Neonatorum 8,313 6,267 40 19
Plague . . . . . . — — — —
Pneumonia (Acute Primary) 134,708 $38,970
,, (Acute Influenzal) 33’830 60’794 §3,853 §8,545
Poliomyelitis (Acute) . 488 777 129 122
Polio-Encephalitis (Acute) . . 51 83 40 35
Encephalitis Lethargica (Acute) 1,470 5,039 729 1,407
Puerperal Fever . . . 2,211 2,183 1,171 1,018
Scarlet Fever. . 137,073 84,654 1,305 888
Smalldpox . . . . . . . 315 3,765 5 13
Tuberculosis (Respiratory System) 59,299 57,737 33,505 32,690
,, (other forms) . . . 15,653 18,711 9,173 8,413
Typhus . . 3 8 — 5

 

 

 

 

 

on

* Contracted in England and Wales.

T The Order rescinding the general notification of measles came into operation

lst January, 1920.

I Broncho-pneumonia, lobar pneumonia, and pneumonia not otherwise defined.

§ Influenza with pneumonic complications.

Most encouraging is the maternity and infant welfare work
now undertaken by local authorities and voluntary societies in
association with them. The infant mortality has shown a steady
decline, and tens of thousands of mothers are attending the
2,100 maternity and infant welfare centres. Increased attention
is also being given to particular diseases, including tuberculosis,
cancer, venereal disease, rheumatism, pneumonia, and epidemic
nervous diseases.

(ii) The School Medical Service.

32. The national system of supervision of the health of the
child of school age began in 1908 under the Education (Adminis—
trative Provisions) Act, 1907, s. 13. Speaking generally, there

. is here also much to encourage us. The majority of the children

at school are, in most respects, healthy. That is the fundamental
fact: Nevertheless, the actual findings and experience of eighteen
years and the medical examination of ten million children show
that physical impairment of these children is somewhat wide in

1

31

distribution and serious in effect upon adolescence and adult life.
Malnutrition, anaemia, defective vision or hearing, dental caries,
and disease of special organs are either too prevalent or insufficiently
remedied, with the result that a foundation is being laid for enfeeble—
ment or subsequent disease. ,

33. In estimating its extent we must include (1) the disabilities
of the great group of children in attendance at school; then (2)
the disabilities of the group of defective children, blind and deaf,
halt and lame, feebleminded and epileptic, for many of whom the
special schools (containing, in 1924, 43,360 children) have been
provided; and (3) the large number of children not in attendance
at any school on account of sickness or invalidism.* Children
in all three groups are ” children of school age,” and of all the
children in the last two groups, numbering tens of thousands,
it must be said that their physical condition debars them from
obtaining reasonable advantage from the system of education
provided by the State. Of the children in attendance at school
in England and Wales (5-; millions), it is estimated from the school
medical inspection returns that upwards of half a million, though
not specifically ” feebleminded,” are so dull and backward mentally
as to be unable to derive full benefit from schooling. There is also
a varying percentage of uncleanliness and malnutrition. Then we
come to disease. Perhaps the largest contributor is dental disease,
which handicaps children almost as seriously as it does adolescents
and adults. Again, half a million children suffer from eye defects.
Many of them need spectacles, some ophthalmic treatment, others
special “ myope classes,” and all of them careful supervision and
attention. Next we must add diseases of the ear, throat and
lymphatic glands, another quarter of a million in a relatively
serious condition. Then there come skin diseases, disorders of the
‘heart, infectious disease, and tuberculosis. Many of these children
suffer from more than one disability, but a moderate computation
yields not less than a million children of school age (not, be it
observed, children in school attendance) as being so physically or
mentally defective or diseased as to be unable to derive reasonable
benefit from the ordinary form of education which the State provides

(iii) The N ational Health I nsm’ance System.

34. The National Insurance Act, which was passed in 1911,
provides a system of insurance against ill—health for all employed

 

* According to the Census the child population in England and Wales for
1921 between the ages of 5 and 14 years was 6,450,877. The number of
children on the registers of Public Elementary Schools is 5% million. The
number of children of school age not on the registers was, therefore,
approximately 950,000. Many of these had left the elementary school, many
others were at public, secondary, proprietary, reformatory, or poor law schools,
and an unknown number were absent from the registers on account of
chronic invalidism of one sort or another. .

32

persons between certain ages and within certain financial limita-
tions. The advantages include “medical benefit ” (medical
attendance and treatment), “ sickness benefit ” (weekly cash pay-
ments during the first 26 weeks——commencing usually from the
fourth day—~of incapacity for work), “ disablement benefit ”
(reduced cash payments in incapacity extending beyond 26 weeks),
and “ maternity benefit,” as well as “ additional benefits ” (dental,
ophthalmic treatment and optical appliances, convalescent homes,
surgical appliances, nurses, etc.).

Upwards of 13 million persons in England and Wales are eligible
for medical benefit. There are approximately 13,000 doctors engaged
in examining such patients as submit themselves and in providing
treatment for them. Here, therefore, we have a new means of
gauging the health of the State. Whilst it is too early to obtain
well considered and properly corrected returns, there are certain
broad findings which can be stated, namely (a) the number' of
persons who actually seek medical advice, (1)) the amount of time
lost from employment in the aggregate on account of sickness, and
(0) some general View of the character of the sickness.

(a) Number of Insured Persons seeking medical advice.

The estimated number of insured persons in England entitled
to medical benefit (i.e., treatment and attendance in sickness) for
1924, was approximately 13,670,000. From inquiries made by
the Regional Medical Staff, it appears that the number of those
who in 1924 received medical treatment under the Act was equi—
valent to between 45 and 50 per cent. of the whole number entitled
to medical benefit. In other words, nearly half the insured popu-
lation in the year 1924 came under review by insurance practitioners
within the twelve months. In certain industrial practices the pro-
portion claiming and receiving treatment was as high as 70, 75
or even 80 per cent. of those eligible.

(b) Amount of time lost from employment owing to sickness.

This is only measurable on a basis of expenditure on benefits
paid. The following table shows approximately the sums expended
in Sickness and Disablement Benefit by Approved Societies in
England and Wales during the years 1921 to 1924 :—

 

 

 

Sickness Benefit. Disablement Benefit.
Men. Women. Men. Women.
:5 . £ £
1921 . . . . 4,861,000 2,313,000 1,701,000 988,000
1922 . . . . 5,706,000 2,506,000 2,155,000 1,172,000
1923 . . . . 5,248,000 2,532,000 2,430,000 1,324,000
1924 . . . . 5,919,000 2,859,000 2,632,000 1,499,000

 

 

 

33

The full normal rates of benefit payable are: sickness benefit
as from the fourth day of incapacity, men, 158. per week, women,
123. per week; disablement benefit, men and women, 73. 6d. per
week. A reduced rate of sickness benefit is payable, and disable-
‘ment benefit is not payable, to new entrants during their first two
years of insurance. Sickness or disablement benefit is not payable
where equivalent compensation has been received under the pro-
visions of the Workmen’s Compensation Act.*

Regard being had to various uncertain factors, it is somewhat
difficult to determine the average rates of benefit paid for the whole
insured population, but the total number of weeks represented by
the sickness and disablement payments in 1924 may be estimated
at about 7% million weeks’ sickness and 6% million weeks’ dis-
ablement for men, and at 5 million weeks’ sickness and 4 million
weeks’ disablement for women. These figures, which do not include
the first three days of incapacity for which sickness benefit is not
payable, give a total of 23} million weeks’ work 10st in 1924 through
sickness, or a period of 447,115 years. That is to say, in England
and \Vales there was lost to the nation in the year, among the insured
population only, and excluding the loss due to sickness for which
sickness or disablement benefit is not payable, the equivalent of
12 months’ work of 447,115 persons. Moreover, it must be re-
membered that it is not only the working equivalent of 447,115
persons that was lost, but also the labour and expense involved in
their care during their incapacitation.

(c) The character of the sickness.

A moment’s reflection will make it clear that this vast body of
insured population—which is practically synonymous with the
mass of the workers of the country—suffers from sickness and
disease in the following degrees :—

(1) there is sickness which does not come under medical notice,
wide in extent, relatively light in burden ;

(2) there is sickness which is included in medical benefit, the
patient being ill enough to come to the doctor and
receive advice and treatment:

(3) there is sickness which, in addition to requiring medical
treatment, incapacitates for work, thus entitling the
sufferer (according to its duration) to “ sickness ” or
“ disablement ” benefit ;

(4) there is sickness requiring treatment in hospitals and other
residential institutions, to which the insured have access
on the same conditions as the rest of the population ;

(5) there is sickness resulting in death, the records of which are
included in the returns of the Registrar-General.

 

“ See 0% the State of the Public Health, 1924, p. 16.
(B 32/931)Q B

34

35. We may go a step further: a special scrutiny of the
insurance medical} records relating to the year 1924 was made
by the Regional Medical Officers with a view to ascertaining
the causes of sickness which led insured persons to consult their
insurance doctors. For this purpose the records of 553 practices,
distributed in 400 representative areas, urban and rural, were
examined, the number of insured persons on the lists of the practi-
tioners concerned being 903,000. From each practice airepresenta-
tive sample of records containing a diagnosis, usually from 100 to
300, was taken in uniform alphabetical order. The total number of
records so selected was 92,315, and the number of cases of illness
recorded on them during the year was 107,796. The chief causes
of sickness recorded are set out below :—

Insured Persons in Representative Areas, Urban and Rural—Pro-
portion of Certain Diseases to Total Cases—1924.

 

 

 

Total. Male. Female.
Disease. Per Per Per
1,000 1,000 1,000
No. of No. of No. of
1 Total. Total. . Total.
1 l
1. Influenza .. 14,068 130-5 9,950 137-7 4,118 115-9
2. Tuberculosis, all forms 1,215 11-3 790 10-9 425 12-0
3. Organic heart disease 1,458 13-5 1, 014 14-0 444 12-5
4. Anaemia . . 2,261 21-0 135 1-9 2,126 59-8
5. Bronchitis, bronchial

and nasal catarrh,
cold, &c. .. . 20,996 194-8 14,535 201-1 6,461 181-9
6. Pneumonia and other
diseases of the re-

spiratory system . . 1,840 17-1 1,412 19-5 428 12-0
7. Diseases of digestive

system .. .. 12,798 118-7 8,374 115-9 4,424 124 - 5
8. Diseases of genito-

urinary system . . 2,732 25-3 1,134 15-7 1,598 45-1

9. Diseases of nervous
system and special

 

senses . . . . 4,887 45-4 3,099 42-9 1,788 50-3
10. Skin diseases . . . 3,955 ‘36-7 2,405 33-3 1,550 43-6
11. Injuries and accidents 11,305 104 - 9 9,745 134 - 8 1,560 43-9
12. Abscess, boils and
other septic conditions 8,196 76 - 0 5,734 79-3 2,462 69-3
13. Lumbago, rheumatism,
&c. .. 10,073 93-4 7,444 103-0 2,629 3 74-0
14. Debility,neuralgia and I
headache . . . 5,360 49-7 2,606 36-1 2,754 77-5
15. Malignant disease . . 204 1-9 149 2 -1 1-6
16. Other diseases . . 6,448 59-8 3,746 51-8 2, 702 76- 1

 

O

 

1
Total . . . . 107,796 1000-0 72,272 1000-0 35, 524 [1000-

 

 

 

 

 

35

INSURED PERSONS IN REPRESENTATIVE AREAS, URBAN AND RURAL—-
PROPORTION OF CERTAIN DISEASES T0 TOTAL CASES 1924.

 

 

:\
u.
m
3
U3
3“
.A
I:
S‘-
i
E?
.

§
§
2
~<
(A
2‘51
:4
3
1

N
'2"
1A!

 

Whilst it is not permissible to draw far-reaching deductions from
these returns, they are full of interest and suggestion. They re-
present, in a broad way, the maladies of the great mass of the
industrial population, from which they suffer and by which they lose
time and money, though not often, or directly, life itself. Approxi-
mately, we may say that 20 per cent. of these patients came to their
doctor in 1924 for bronchitis, catarrh or, the common cold ; 14 per
cent. for rheumatism, lumbago, debility or neuralgia; 13 per cent.
for influenzal conditions ; 12 per cent. for indigestion ; 10 per cent.
for injuries ; and 7 per cent. for boils and local septic conditions.
Here is 76 per cent. of the illness. It will be noticed that the killing
diseases are not prominent in the table; that the women suffer,

(B 32/931)Q B 2

36

as we should expect, in greater degree than the men from anaemia,
skin disease, debility, and nervous and digestive disease ; and that
the principal burden of malady belongs to the category of pre-
\‘entable disease. It is a deeply interesting and significant return.

(iv) H ospital—treated Disease.

36. Such being the diseases which take patients to their insurance
doctor, we may well ask what diseases take them to the hospitals.
The following table sets out in comparative form the principal
conditions of sickness for which patients were admitted to the wards
of a large London hospital, in 1924.

A LARGE LONDON HOSPITAL—PROPORTION OF CERTAIN DISEASES
T0 TOTAL CASES—IN-PATIENTS, 1924.

 

1
i Number iProportion

 

 

Disease. 3 of 1 per
1 Cases. 1,000 cases.
|
1. Tuberculosis, all forms . . . . . . . . 261 18-7
2. Cancer, excluding Gynaecological Cases . . . . 603 433
3. Organic Heart Disease . . . . . . . . 149 10-7
4. Other Diseases of Circulatory, Lymphatic and
Hmmopoietic Systems . . . . . . 398 28.6
' 5. Bronchitis .. .. .. . . . . .. 169 12-1
6. Pneumonia and other Respiratory Diseases ex—
cluding Pulmonary Tuberculosis. . . . . . 635 45-6
7. Diseases of the Digestive System . . . . . . 3,396 243-6
8. Diseases of the Genito-Urinary System . . 710 50".)
9. Gynaecological Cases and Diseases of the Female
Breast .. .. .. .. .. .. 1,740 124.8
10. Diseases of the Nervous System and Special
Senses .. . . .. . . .. .. 2,007 144 -0
11. Skin Diseases . . . . . . . . . . 329 23-6
12. Injuries and Accidents . . . . . . . . 1,082 77-6
13. Acute Inflammations unspecified . . . . . . 390 28-0
14. Chronic Inflammations unspecified . . . . 79 5-7
15. Infective Diseases . . . . . . . . . . 169 12 - 1
16. Nephritis and Bright’s Disease . . . . . . 126 9-0
17. Congenital Debility, &c. .. .. .. . . 191 137
18. Orthopaedic .. .. .. . . .. .. 460 33-0
19. Diseases of Ductless Glands . . . . . . 310 22-2
20. Venereal Diseases . . . . . . . . . . 550 39-5
21. Other Diseases .. . . .. .. .. 186 133
Total . . . . . . . . 13,940 1,000 -0

 

 

 

37

A LARGE LONDON HOSPITAL—PROPORTION OF CERTAIN
DISEASES TO TOTAL_CASES—IN—PATIENTS, 1924.

 
    
 

‘6

   

23

PISEaSE 5

  
   
 

59mm

 
 
 

 

 
 

3‘17” naive :nvuu page
C
WM 0N» :9qu wmmmum/o

 

 

  

 

  
 

53’035‘17

 
 

Hus/‘9

”'1 57:7 jlf {o

 
 

9 {b2

  

Obviously these figures deal with cases of greater severity than
those coming under the observation of insurance practitioners.
As a rule a patient is less inclined to enter hospital than to consult
his insurance doctor (upon whose advice he may consider himself
as having some claim), and therefore a hospital return is likely
to represent more serious conditions, especially as it is not customary
to admit patients with incipient or relatively slight disease. Hence
this return shows, as we should expect, a higher proportion of
tuberculosis, cancer and venereal diseases, and from the figures
there also appears to be a substantial rise in digestive diseases, in
diseases of the nervous system. and in constitutional disease, and a
large fall in bronchitis, bronchial and nasal catarrh and the common

(a 32/931)g B 3

38

cold. But here also there is much disease which might be prevented
or postponed. Speaking generally, if these insurance practice and
hospital returns are taken with the defects found in school
children, and are compared with the death returns, it will be
found (1) that the conditions which impair the health, and even
lead to the disablement of men, women and children, are not
chiefly the conditions which kill them, though they may in many
cases predispose to mortal disease, and (2) that a substantial pro-
portion of this sickness is preventable. Other London general
hospitals and many city and county hospitals would yield similar
records.
(v) The Returns of the Registrar-General.

37. The annual report of the Registrar-General is the final
inventory of the physical condition of the English people. In its
pages may be found the fullest digest available of the actual
facts respecting the beginning and ending of life, the births and
deaths—the great army passing in, the great army passing forth.
Knowing approximately the causes of death, we can draw certain
general deductions in regard to the physical state of the living.

In this place it is only possible to refer briefly to the two funda-
mental events, birth and death.

38. The birth rate in 1924, the latest year under report, was 18-8
per 1,000, being, with the exception of the war years, the lowest on
record, and 5-0 below that for 1914, the last year unaffected, in this
respect by war and post—war conditions. During the last 20 years of
peace the birth rate fell from 29-6(1894) to 23-8 (1914), namely 5-8
per 1,000 ; in the last five yearsit has fallen from 25-5 to 18 -8, namely
6~7 per 1,000, just over 26 per cent. The highest birth rates
usually occur in the small towns of Wales, the next highest in the
manufacturing towns of the north and the lowest in the rural
districts of the South of England. In 1924 the total number of
births registered was 729,933 (or 28,198 fewer than in 1923),
including 30,296 of illegitimate children.

Speaking generally, the birth rate in the country has now
declined to the extent of nearly one—half within the last forty-six
years. In 1878 it was 35-6, in 1924 it was 18-8. This decline has
not been uniformly distributed. The birth rate depends, of course,
upon many factors, the age at marriage, fertility, social position,
occupation, etc.‘ Dr. T. H. C. Stevenson, the Medical Super—
intendent of Statistics, has shown that fertility decreases regularly
as the size of the tenement increases till six or seven rooms are
reached, and thereafter remains constant, that infant mortality
decreases regularly as the size of the tenement increases, being for
tenements of ten rooms or more less than half the average, and less
than one—third of that in one-room tenements; that the saving
of infant life in the more comfortable tenements compensates to only
a slight extent for the lower fertility; and that fertility differs

39

widely in different occupations, being for coal miners nearly twice
that of doctors, and so forth. The ,birth rate is lower among the
more prosperous classes. It is said that conscious limitation
of fertility is widely practised in various forms.*

39. The death rate in England and Wales in 1924 was 12-2 per
1,000, being among the lowest in the history of this country. In
1924 there were registered 473,235 deaths; 54,813 deaths of
infants under one year of age, yielded an infant mortality rate
of 75 per 1,000 births or 16-4 per cent. below the average of the
preceding ten years. The recent decline in the infant death rate
(1920—24) has taken place throughout the first year, but least of
all in the first month (at which time convulsions, congenital
malformations, premature birth and atrophy are the four chief
causes of death). On the other hand, diarrhoea and respiratory
diseases, the chief causes of death in infancy after the first month,
have yielded substantially to preventive measures. Of the total
deaths, and excluding still-births, 189,966 (or 40 per cent.) occurred
under 50 years of age.

BIRTH RATES, DEATH RATES, INFANT MORTALITY RATES.
(England and Wales) for 1899—1924.

 

 

 

Year Birth Rate Infantthiné’tahty Death Rate
‘ (per 1000 livmg). (per 1000 births). ‘ (per 100011vmg).
1904.. .. .. 28-0 145 16-2
1905.. .. .. 27-3 128 15-2
1906.. .. .. 27-2 132 15-3
1907 .. .. .. 26-5 118 14-9
1908 .. .. .. 26-7 120 14-5
1909 .. .. .. 25-8 109 14-3
1910 .. .. .. 25-1 105 13-2
1911.. .. .. 24-3 130 14-2
1912.. .. .. 23-9 95 13-0
1913.. .. .. 24-1 108 ‘13-5
1914.. .. .. 23-8 105 13-7
1915.. .. .. 21-91‘ 110 14-83:
1916.. .. .. 20-9T 91 13-47;
1917.. .. .. 17-8’r 96 13-5:
1918.. .. .. 17-7T 97 17-63“.
1919 .. .. .. 18-5 89 13-7
1920.. .. .. 25-5 80 12-4
1921.. .. .. 22-4 83 12-1
1922 .. .. .. . 20-4 77 12-8
1923.. .. .. 19-7 69 11-6
1924.. .. .. 18-8 75 12-2

 

 

 

 

* The declining Birth Rule .' its causes and (finals (Chapman and Hall), 1916.
T Based upon populations specially estimated for this purpose.
1 Based upon civilian deaths and estimated civilian population.

(B 32/931)Q B 4

40

40. The principal causes of death at all ages are, in order,
(i) Bronchitis, pneumonia and other respiratory diseases ; (ii) Diseases
of heart and circulation ; (iii) Cancer and malignant disease;
(iv) Diseases of the nervous system ; (V) all forms of tuberculosis——
not, it will be noted, the conditions which in the main form ground of
sickness benefit under the Insurance Act. The remarkable decline
in the death rate due to the principal epidemic diseases has been
maintained.* The following table gives the principal causes to
which death was attributed in England and Wales in 1924 :—

 

 

 

Proportion
Disease Number of per 1,000
‘ Deaths. deaths from
all causes.
1. Measles . . .. . . .. . . .. 4,834 10
2. Whooping Cough . . . . . . . . 3,983 8
3. Diphtheria . . . . . . . . . . 2,501 5
4. Influenza . . . . . . . . . . 18,986 40
5. Tuberculosis of respiratory system . . . . 32,690 69
6. Other forms of tuberculosis . . . . . . 8,413 18
7. Cancer—Malignant disease . . . . 50,389 106
8. Diseases of nervous system and sense organs 47,277 100
9. Diseases of the heart . . . . . . 60,650 128
10. Other diseases of circulatory system . . 18,778 40
11. Bronchitis . . . . . . . . . . 37,786 80
12. Pneumonia (all forms) . . . . . . 38,970 82
13. Other diseases of respiratory system. . . . 5,857 12
14. Diarrhoea and enteritis . . . . . . 7,460 16
15. Other diseases of digestive system . . 18,278 39
16. Non-venereal diseases of genito-urinary 18,512 39
system.

17. Premature birth and diseases of early infancy 21,235 45
18. Old Age .. .. .. .. .. . . 25,735 54
19. Violence (all form ) . . . . . . . . 17,183 36
20. Other causes . . . . . . . . . . 33,718 73
Total . . . . . . 473,235 1,000

 

 

 

* Comparing the annual mortality per million 1838—42 with 1924, small-pox
has fallen from 575 to 0, measles from 539 to 124, scarlet fever and diphtheria.
from 797 to 87, whooping cough from 504 to 103, and typhoid from 1,053
(including typhus) to 13 per million.

41

ENGLAND AND WALES—PROPORTION OF DEATHS FROM THE PRINCIPAL
' CAUSES TO TOTAL DEATHS—1924.

v

 

Mamet/”5:5 a; HIM/mm Jmm— 8.9

"3
I /
"\
Q'
,‘3
\I
\/
3’
2
DA
/
/
RWN
’04
//
4%,?
S!
1:?
3
L
c»
o

 
   

4%
J j #644:
I \ Z8
‘ b
2 \
2
r: “1;
3 "’t
s \
. >
F»

   

r78 ‘6 W01

 

This table has been drawn up in the same form as the tables of
sickness returns, with an accompanying graph.

Conclusions .

41. The data from these five sources, taken as a whole, provide
something in the nature of a physical survey of the English people,
fuller in compass and more comprehensive than any former in—
vestigations have yielded. Whilst it is true that the death rate
is declining, and decimating scourges and famines are a thing of
the past, at least as regards the British Islands, we cannot escape
from the conclusion that there remains a serious amount of prevent-
able sickness and avoidable disablement, the tendency of which must

42

inevitably be to undermine the physical stamina of the people and
reduce their capacity. Moreover, the nation is slow to realise the
vast mass of disability and incompetency which results from wide-
spread maladies, usually regarded as trivial and negligible, which
may not reach the doctor and of which there is no record, such as
anaemia, dyspepsia, constipation, septic wounds, accidents, colds,
chilblains, eye-strain and dental inefficiency—and which do not
appear in such returns as those quoted above.

42. Taking the whole record as it stands the following broad
deductions may be drawn from the facts and figures in regard
to the physical condition of the English people :—

(1) There is a steadily falling birth rate, which in 1924 reached
a figure (18-8) seriously affecting the source of the nation ;

(2) There. is a death rate (12-2) which shows a steady decline
at all ages (1841—45 compared with 1916-20), and there
is an increased expectation of life from birth upwards ;
nevertheless, 40 per cent. of the deaths occur under
50 years of age;

(3) Although the infant mortality rate (75 per 1,000 births)
is one of the lowest recorded, there is still unnecessary
loss of life in infancy and before birth (abortion, mis—
carriage and still birth) ;

(4) There is a relatively light burden of epidemic and infec-
tious disease, which, with certain exceptions, is steadily
decreasing in incidence and mortality, an indication
of the victory of Preventive Medicine over some in-
fectious diseases ; ~

(5) Tuberculosis, measles, cancer, rheumatism and influenza
are, however, still prevalent and, with venereal disease,
lead to much disablement and mortality;

(6) There has been in recent years remarkable and continuous
improvement in sanitary environment, though the
problem of insufficient or unsuitable house accommo-
dation remains ;

(7) The systematic medical examination of school children
since 1908 has revealed a substantial degree of physical
and mental impairment ; ,

(8) The expenditure on sickness and disablement benefit, and
other returns respecting the system of national in-
surance, denote that more than half of the insured
persons claim and receive treatment, and that a very
serious amount of time is lost from employment (amount-
ing to upwards of 447,000 years per annum) owing to
invalidity or disablement, much of which arises from
sickness and disease which is preventable.

43

The most impressive facts in this survey are the falling birth
rate and death rate, the prevalence of minor invalidity, the
increasing control of the principal infectious diseases, the high pro-
portion of deaths taking place under 50 years of age, and the vast
burden, at all 'ages, of preventable invalidity. Thus, the problem
lying immediately before. Preventive Medicine is, first, to rear
and maintain a healthy race of people, and, secondly, to continue -
its exploration into all forms of infection and to initiate an attack
upon all forms of preventable sickness and invalidity. For physical
impairment or bodily disablement involving loss of capacity and
even unemployability may be a greater evil and a heavier burden
to a nation than a rise in the death rate. Our attention therefore
must be directed not only against the death rate but against pre—
ventable morbidity and invalidity of all kinds.

44

SECTION V.
THE BROAD LINES or REFORM.

(1) Need for Synthesis and Integration in Medicine.

43. The student of the history of general or particular move-
ments in human affairs is well aware that at any given point in
progressive thought he will find one or other of two character-
istics dominant, namely, extension or consolidation. The extension
reveals itself in a reaching-out after new conceptions and expression,
analysis, differentiation and specialism. At other times there comes
the need of summary, of unification, of synthesis as the governing
idea—not necessarily of new discovery but of new and wider appli—
cation and inter—relation. Sometimes both proceed simultaneously.
The examples are numerous. In the practical affairs of the world
there is, as we all know, the time of expansion of many forces of
divergent direction, followed by the emergence of. unity of command,
of national oneness, or of inter—state federation. The same is true
in social evolution ; we have in the history of our own country the
great synthetic periods—the age of King Alfred, the end of feudalism,
the rise of Parliament, the Reformation, the introduction of printing,
the steam engine, the industrial domination, the growth of communal
action. In the history of English learning, too, there are abundant
illustrations, reflective not seldom of foreign thought, of an under—
lying unity and aspiration towards a wider synthesis. In philosophy,
the steps pass in orderly fashion through the problems of psychology,
of knowledge, of evaluation, of being and cosmology. In physics
there was the great unification effected by the Newtonian mechanics,
then a period of differentiation and analysis, another synthetic
system crystallizing around the principle of the conservation of
energy, again differentiation, and once more in our own time the
tendency to synthesis indicated in the quantum hypothesis, the
principle of relativity and other generalisations. In English Litera-
ture, Chaucer lays the foundation of a unity by weaving together
strands of French, Italian, and‘English origin, and the Canter-
bury Tales provide a sort of miniature, not'of English poetry only,
but of mediaeval literature; then there was the zenith of the
Renaissance in the dramas of Shakespeare, followed in due course by
a third synthetic period in the Romantic revival. Sir Walter Scott
discovered Scotland for its people and interpreted it to others.
The history of biology before Darwin shows a progressive analysis
of structure and function which finds in the epoch he created a
synthesis in the evolution idea. Even in the realm of Religion
men seek for and aspire towards a synthesis composed of constituent
elements which are, they hope, integrally related and possibly even
unifiable. This search is not, perhaps, for fundamental verities
so much as for co-ordinated truth.

45

44. In the history of medicine in England there are likewise
abundant illustrations of summarising and synthetic periods.
Even as regards the external form of the profession, we have the
Medical Act of 151], the foundation of the College of Physicians
in 1518, the incorporation of the Barber Surgeons in 1540, the
great Herbals 0f the sixteenth century—the precursors of the
pharmacopoeia—the charter of the Apothecaries of London in
1617, followed, in the nineteenth century, by the establishment
of the College of Surgeons in 1800, the introduction of the Census
(1801), the registration of births and deaths (1836), the General
Medical Council (1858), and the public health acts from 1848 to
our own day. Even more synthetic in ultimate result were the
unifying work and methods (1) of Harvey; (2) of Sydenham,
Glisson, Mayeme, Willis, Lower, Morton, and the great practitioners
of the seventeenth century; (3) of Hunter and the school of
pathology ; (4) of Mead, Fothergill, Heberden, Huxham, Haygarth,
and the epidemiologists of the eighteenth century ; (5) of Edward
Jenner and the inoculationists; and (6) of Lister and his school
in the early days of the Germ Theory. All through there has
been analysis followed by synthesis, variation on the one hand and
unity of type on the other, periods of new knowledge, seeds sown
on stony ground but coming to their fruition in time of application
and consolidation. So much fluctuation and agitation, ebbing
and flowing, that we may sometimes despair of discerning any law
in its movements, and yet they lead ultimately, in spite. of hetero—
geneous materials and various histories and fortunes, to some—
thing in the nature of an enduring harmony. “ On through ever—
widening sweeps of differentiation and integration,” wrote an Oxford
philosopher, “ till the whole body of thought is seen in its organic
unity and development, every fibre of it alive with relation to the
whole in which it is a constitutent element.”

45. A new time of summary and application, of inter-relation

and synthetic unity, in Medicine seems to have arrived. “ At
this moment,” wrote Sir Clifford Allbutt, ” Medicine has come to a
new birth. . . . It is nothing less than its enlargement from

an art of observation and empiricism to an applied science founded
upon research ; from a craft of tradition and sagacity to an applied
science of ‘analysis and law; from a descriptive code of surface
phenomena to the discovery of deeper affinities; from a set of
rules and axioms of quality to measurement of quantity.”* In other
words, Medicine has lately passed through a period of gestation
characterised by germination, new formations, sub-division and
differentiation—not without its analytical, schismatic and centrifugal
dangers—and it is come now in our day to the need of integration.
For an underlying unity is necessary if we would avoid that dis-
integration and dissolution which follow when differentiation proceeds

“ Greek Medicine in Rome, 1921, pp. 491-563.

 

46

in one-sided fashion. The predominant need, both in medical educa-
tion and application is simplification and integration, first in the
understanding of the meaning and destiny of Medicine, secondly in
practice. This need lies at the basis of any new apprehension of
Preventive Medicine.

Biology, Physics and Chemistry.

46. The curriculum of the medical student contains a dozen
separate subjects taught all too frequently in water—tight com-
partments; he is examined on the same basis and must in some
degree desert each subject in turn to prepare for the next test;
even in practice there is a tendency to early specialisation. My
submission is that, in spite of certain advantages, this separate-
ness and disjunction must as far as practicable be avoided. Con-
sider the part played by the teaching of biology in the mind of
the medical practitioner. The doctor who sees human medicine
as the embodiment of comparative anatomy, physiology and
pathology sees the great Vision. To him the principles of selection
and evolution become daily working axioms. Like Hippocrates he
works with and not against Nature ; his patients are examples of
the effect of her laws; his triumphs are her fruits; his practice
is along the line of her method. But how few is the number of
medical biologists, and how many are those who tend to become
technicians only, swept by force of circumstances into an attitude of

narrow specialism. ” From over-specialisation scientific men are
in a more parlous state than are the Humanists from neglect of
classical tradition,” wrote Sir William Osler. “ The salvation of

science lies in a recognition of a new philosophy—the scientia
scientiarmn, of which Plato speaks: ‘Now when all these studies
reach the point of intercommunion and connection with one
another and come to be considered in their mutual affinities, then,
I think, and not till then, will the pursuit of them have a value.’ ”*

Or consider the relation of physics to modern medicine. If we
open a modern text-book or catechise a medical practitioner, we
shall find that the measurement of physical properties, motion,
pressure, tension, diffusion, osmosis, aeration, the action of colloids,
and the flow of liquids, bear a new relation to the modern practice of
Medicine ; and even closer relation obtains in regard to ‘the physics
of mechano-therapeutics, massage and manipulative surgery, of heat
and thermometry, of light and the laws of reflection and refraction,
of electricity, X—rays and radium. The application of these matters
to remedial medicine is a daily routine in certain branches of work,
and in all branches they profoundly affect our conception of the
form, movement, and structure of the cell, of air pressure in the
lungs and blood pressure in the circulatory system, of the passage

 

* The Old Humanities and the New Science, 1919, p. 27.

47

of lymph, of renal and cutaneous excretion, of the conditions of the
cerebro—spinal fluid, or of the secretions of the liver, the salivary
and ductless glands.

47. Even more intimate and far—reaching is the relation of the
new chemistry to medical practice. “ The old experimental method,”
wrote Sir William Osler, ” combined with the new chemistry,
applied to disease has opened a glorious chapter." For here, too,
there is immediate application in serum and organotherapy, in
pharmacology and therapeutics, in surgery ; there is also the profound
effect on our understanding of fatigue, infection, and immunity,
and, above all, of mentality and Virility. Bio-chemistry is revolu-
tionizing the whole of our conceptions of nutrition and assimilation.
For. example, the new knowledge of vitamins, whether “ fat soluble
A,” the growth factor of animal fats, or “ water soluble B,” of
cereal seeds, or “ water soluble C,” of fruits and vegetables, or
possibly others yet to follow, alters our conception of dietetics and
moves its centre of gravity to a factor hitherto unconsidered. It is
not only protein, carbohydrate and fat which must now be thought
of as capable of maintaining life and furnishing energy ; it is also
this precious accessory substance. If it be not present, whatever
else there may be, nutrition may be absent, indeed even disease
may supervene. This is the new light on the deficiency diseases
——beri-beri, scurvy, rickets and malnutrition.

Physiolog v.

48. But vitamins are not alone the mystery. There are the
familiar internal secretions, saliva (ptyalin), the gastric juice (pepsin),
the pancreatic fluid (trypsin), and bile, exerting their digestive
effect on food consumed, the exact bio—chemistry of which is being
more fully worked out. In addition, there are the hormones (or
” excitors ”), chemical substances produced in cells in one part
of the body and carried by the blood to other organs which
they stimulate to active functioning. What is the relation of these
hormones to the growth and development of the body? What is
their relation to its powers of resistance to disease and in what way
ought we to seek to integrate and synthesize our knowledge of their
action in the advance of preventive medicine? For instance, the
secretion of the thyroid is a necessary condition of the normal growth
and functions of many tissues of the body, yet if present in excess
exophthalmic goitre may arise, and if lacking, myxoedema or
cretinism may supervene. The secretion of the pituitary body may
promote growth in bony tissue, excite unstriated muscle, or affect
the central nervous system. Adrenalin, active in excessively minute
quantities, may raise the blood pressure, excite the functions of the
sympathetic nervous system, and bring into action various specific
tissues of the body ; and there are a whole series of allied substances

48

(Dale). The internal secretion of the pancreas appears to be con-
cerned in the assimilation of carbo-hydrates. The hormones of the
reproductive organs have a correlation with those of the thyroid
and the thymus, and may affect the whole virility and mentality
of the organism. Of the existence of these five typical secretions
there is a growing recognition, but is any understanding of their
place in Preventive Medicine gaining ground P Yet it would seem
that, invisible and behind the scenes, these and other hormones
may have a part to play in the defences of the body comparable
with that of the vitamins in nutrition. In respect of both there is
the question of nervous regulation of nutritional processes. What
is the effect of the conditions of temperature and blood pressure on
the regulating centres of the brain? and what is the relation of
bio-chemistry to the mental processes in health and disease?

49. Thus, Physiology is too little integrated with Medicine.
The practitioner thinks in terms of morbid anatomy or perverted
function; he treats too often the symptoms which present them-
selves, insufficiently recognising that pathology and symptomatology
have their groundwork in biology, physics and chemistry, as applied
to the patient before him. In fact, the patient is a case of anatomy
and physiology, to be interpreted and treated on grounds and by
means which are in essence physical, chemical, and physiological.
The science of physiology should be brought into closer touch with
clinical and preventive medicine and surgery. A foundation has been
laid in Sir Charles Sherrington’s course of experimental physiology
at Oxford. There is the profound truth of the organic regulation by
the nervous system; there is the relation now being more fully
worked out between psychology and physiology in regard to the
human mind. But the parts of the subject immediately applicable
are innumerable. “ In life,” as Dr. Haldane has said, “ the whole
is in the parts, and the past is in the present.” Surgical shock, heart
disease, transplantation of muscle and bone, many of the new
orthopaedic lines of treatment, the treatment of goitre and blood
pressure, nerve suture, injuries of the spinal cord, the antiseptic
treatment of wounds, the problems of disease in abdomen, thorax,
or brain, the great field of psychoneurosis, psychology and mental
. disease—the effective and scientific treatment of all these conditions
illustrates the direct application of physiology.

50. Once more, there is need for a closer integration between
preventive and curative medicine. They are essentially parts of
one process. In all cases the cause of disease, not in the abstract
alone but in the particular patient under consideration, must be
sought ; the relation of the disease to what has gone before must
be ascertained; the relation of the local signs of disease to the
whole man and the whole disease, of which the local condition
is but one expression; and the actual treatment provided must,

49

as far as practicable, be preventive. Too frequently a case of
disease is conceived as an " entity ” separate and detached from
its ancestry and dealt with on ad hoc lines. Yet in truth it is a
process, a progressive reaction of the body. Tuberculosis, a
common example, has behind it an ancestry of conditions, of
previous disease or of predisposition, which must be faced in any
sound remedial action. Malnutrition, measles, unresistant tissues,
have played a part. The child is father of the man, and we cannot
rightly deal with tuberculosis apart from the proper treatment
of the disease in infancy and childhood, possibly the chief age—period
of its infection and invasion, perhaps even of its immunization,
and certainly the opportunity of its treatment. Of endocarditis,
diabetes, nephritis, duodenal ulcer, gall stones, nervous disease—
tum where we will—the same ancestral story is to be told. Measles
predisposes to tuberculosis, rheumatism is the forerunner of heart
disease, scarlet fever of renal complication, influenza of pulmonary
disease, malnutrition of rickets. Thus if medicine is to be made
a powerful controlling factor not only must the various branches
of medicine be integrated but it should be recognised that the chief
manifestations of disease bear intimate relation to each other;
and the treatment of one is the prevention of others. In a score of
different fields curative medicine should be the base of prevention
and treatment the genesis of immunity. Our whole understanding
of Medicine should proceed, as Sir Clifford Allbutt has urged, “ on
Aristotle’s double track, the track of the one into the many and of
the many into the one.” For “ as the individual is but a link
. in the chain, so the human chain is a strand in the web of all living
things. We must know all disease to understand its several phases. . . .
In the fundamental phenomena of life in animal or plant there is
a fundamental unity.” Nor must the synthesis of the future be
only one of conception and of interpretation; there must also be
adequate provision of facilities for the medical man to practise
the whole art of medicine, to correlate his medical and surgical
knowledge, his preventive and curative efforts, to exercise his
full wide function to the benefit of the community.

(ii) Need for New Application in Medicine.

51. The second predominant requirement in respect of Preven-
tive Medicine has regard to application and organisation. We
have seen that in recent years there has been an enormous increase
in legislation on behalf of the health of the people. The nineteenth
century was extremely fertile in this respect; yet whilst there
may well be occasion for unification and consolidation of the
sanitary laws of the country, and even for further legislation, one
of the principal needs is not now statutory. As regards Preventive
Medicine it is rather rearrangement and readjustment of medical
practice. There is machinery, though not perhaps in all cases

50

appropriate machinery, and there is knowledge. But the two are
not together brought to bear on the focal point, for, as we have seen,
preventable disease is not in fact being prevented and remediable
disease and invalidity are not being adequately treated. I submit
that the immediate necessities of the present period of application
as regards Preventive Medicine are a new and wider apprehension
of the movement as a whole, as regards :—

(i) Improvement in Medical Education, and
(ii) The provision of an adequate medical service.

The changes which have taken place in the evolution of
medicine in England since the middle of last century have of
themselves made essential some reform in the education of the
medical man. There has been an immense growth of knowledge;
_ to leave the curriculum approximately as it was two generations
ago would be to pour new wine into old wine skins. There has been
something of a revolution in the public duties imposed upon the
medical practitioner; to fail to equip him for these new duties
would be to send a soldier to battle unarmed. The financial,
personal and social interest of the private citizen in medicine have
been enormously increased by Insurance legislation; and thus
has come about an extension of medical practice on behalf of the
State undreamed of a generation ago. This is not the place to
discuss the details of an approved system of medical education,
which indeed has been considered in outline elsewhere.*

52. These are some of the conditions and circumstances which
led the General Medical Council in 1922 to revise the medical
curriculum in this country. The chief reforms introduced into
the new curriculum have been (a) the strengthening, without
the lengthening, of the teaching of the basal subjects of anatomy,
physiology and pathology as the living science of Medicine ; (b) the
more thorough training in clinical medicine and surgery, and par—
ticularly in obstetricswa fuller integration, a closer application
of intermediate subjects and laboratory work to clinical subjects;
“the medical sciences are independent,” said Huxley, “ in pro—
portion as they are imperfect ”; (c) the more intimate personal
study of the beginnings of disease, of its earliest signs and of its
subjective symptoms. for no laboratory experiment or mechanical
device can serve as a substitute for this first-hand fundamental
knowledge, of the conditions of the patient, to which indeed the
other matters are but ancillary and auxiliary; (d) the wider
apprehension and application of therapeutics, including not only

 

* See Some Notes on Medical Education, 1918. (Cd. 9124); Recent
Advances in Medical Education in England, 1923 (H.M. Stationery Office) ;
and [Medical Education .- A Comparative Study, by Abraham Flexner. (New
York, The Macmillan Company, 1925.)

51

modern medication, but the use of the ancient Hippocratic means
of fresh air, sunlight, physical exercise, hydrotherapy, massage,
and the rest; (6) the practice of Preventive Medicine in all forms
of clinical work ; and (f) the provision of appropriate post-graduate
training, both as a method of revision and for the inclusion of
certain special subjects which cannot well be included in the
curriculum before graduation. A revision proceeding on these
lines is, of course, a reformation, and it cannot be doubted that in
the new medical curriculum a larger place has been found for the
application of physiology to the healing art and for the integration
and correlation of the preliminary sciences and basic subjects
with the art and practice of , clinical medicine and surgery. Above
all, there is for the first time the preventive atmosphere ; ” through-
out the whole period of study,” says the General Medical Council,
"the attention of the student should be directed by his teachers
to the importance of the preventive aspects of medicine.”*

53. A second requirement, urgent and insistent, is the provision
of an adequate medical service for the people as a whole. The
nation is not receiving the full benefit and advantage of modern
Medicine, and all too many of the Local Authorities upon whom
Parliament has imposed public medical duties, continue to conceive
of those duties too narrowly as concerned only with environment.
Even in medical practice, many patients who need medical treat—
ment or advice are not getting the best or most effective advice.
They are all too often being treated on the same sort of lines as
their grandfathers. Again, there is need for extension and suitable
differentiation of institutional accommodation for the treatment of
disease. Lastly, medical knowledge is as yet, also, extremely partial
and fragmentary ; but where it exists, and where it is applicable to
the remedying of disease or the removal of disablement, it is surely
the only sound business and the only true science to apply it,
promptly, continuously and adequately. Yet, it is to be feared,
that is what we are not doing. The result is that vast numbers of
persons of all ages are physically impaired, incapacitated, or suffering
from preventable disease, or dying prematurely—a condition of
things which is costly to the State, which undermines its stability,
and which involves inexcusable waste of treasure and life

54. The time has more than come for taking further steps in
the organisation of a systematic and ordered attack on the strong-
holds of preventable disease—particularly that mass of crippling
morbidity and minor invalidism which is undermining the capacity
and efficiency of the people—an attack which will depend for its
achievement upon a close partnership and co-operation between

 

* For a further discussion of the new medical curriculum, see Recent
Advances in IvIedical Education in England, 1923.

52

all branches of medicine, between the medical profession and the
public, and between the governing authorities and those who are
governed. We cannot continue wisely to rely upon piecemeal
effort, divided counsels, and conflicting authorities. If the nation
desires ever to rid itself of the common enemy there must be unity
both of purpose and action—and even so the task will be a long one.

“ Let no man think that sudden in a minute
All is accomplished and the work is done ;—
Though with thine earliest dawn thou shouldst begin it
Scarce were it ended in thy setting sun.”

55. I venture now to suggest for the consideration of my pro—
fessional colleagues, on the one hand, and of that great body of
opinion and power engaged in the local health government of this
country, on the other, some general and particular propositions—
it cannot be more than in outline—which in my view form a working
basis for the practice of Preventive Medicine.

53

SECTION VI.
SOME or THE ELEMENTS or A NATIONAL POLICY.

56. It is proposed in the present section to suggest briefly some
of the principal elements out of which may be constituted a national
policy of Preventive Medicine. Such a presentation can only be
provisional and contributory. It cannot be exhaustive or final.
Even the construction of a provisional outline is encompassed by
inherent difficulties. For instance, we are as yet far from possessing
satisfactory knowledge of the scope and opportunity which lie
before the science and art of medicine in its relation to the com—
munal and social life of the people, yet before a comprehensive
policy comes into being we must be assured of the validity, order and
completeness of the body of knowledge and experience which is
available. Again, much depends on the community itself, its
intellectual apprehension, preparedness and willingness. Wise
government depends on the consent and support of the governed,
and these predicate an educated, enlightened and well—informed
public opinion. It is true, as the motto of the New York Depart-
ment of Health declares, that “ Public Health is purchaseable ”—
but the purchase clearly involves desire to purchase, understanding
of what is to be bought, and financial resources.

57. There is a third difficulty, in that no statement, however
informal, can present a policy which can be executed by one instru-
ment, whether that instrument be a Ministry of Health at the
centre, a local authority, or an individual or set of individuals.
Indeed, we cannot in this general way do more than discuss a sequence
of ideas and propositions, of which some may be initiated, guided
or aided by the State ; some obviously fall within the province of
the local authority ; others lie as clearly in the sphere of individual
predilection, practice, or duty. There are these three difficulties,
to name no others, which we meet at the threshold of any attempt
to formulate a comprehensive policy of Preventive Medicine—the
limitations of knowledge, the unreadiness of the community, and
the distribution of executive duties.

58. Yet these reservations should not debar us from taking at
least the first constructive steps. For there is a practical urgency
in this matter ; the problems we have been considering now await
solution, indeed, they do not brook delay. If it be true, as many
believe, that Preventive Medicine is one of the great answers to
human ill or national disability, it is high time to define its purpose
and narrow its engagement within reasonable compass and to
practicable measures. There are many forces and negligences now
hurting the State, as there are many legitimate national aspirations,
which lie outside the province of Medicine but which profoundly

54

affect its contribution. If it be true, as many believe, that there is
abroad a conception of Preventive Medicine which, on the other
hand, restricts its scope to environmental questions, even to what is
popularly called ” drains,” it is again high time to urge the wider
claim. As the science and art of curative medicine is not comprised
in the “ bottle of medicine " idea, so also is Preventive Medicine
not concerned only or chiefly with ” drains ”; nor can it prove
adequate to the nation’s needs if it is dependent, as too often in the
past, upon piecemeal effort, spasmodic endeavour, or convulsive
action, inspired by emergency, “ stunt ” fear, or panic. The health
authorities all over the country—for counties, for great cities, for
small villages—are now called upon to exercise large duties in
behalf of the physical life and capacity of the people. It is essential
they should have a clear and serviceable apprehension both of the
problem of national health and of the means of its solution. How
otherwise can they devise their schemes of reform ? How else can
they secure a sense of proportion and of sound setting, a vision both
of the narrowness and of the width of their engagement ? Obviously,
the problem is complex-it involves, on the one hand, a practical
proposition in local ways and means, in pounds, shillings and pence ;
and, on the other, large questions of heredity and nurture, of environ—
ment and personal hygiene, of the nature of disease and its prevention
and remedy, of education and research. All the more important,
therefore, is it that there should be, as the common possession of
all, some knowledge of the power of control, a sense of proportion and
sequence, discernment and good understanding, in short, the data
of a national policy. Not all its items can be practised at once, but
all its items should be in firm and correct setting ; emergency action
will still be necessary, but deliberate plan, foresight, ordered pre-
paration must henceforth have their place. There must be both
direction and co-operation—forward looking, steadily pursued,
patient, relentless. Then emergency and temporary measures,
necessary by the exigencies of circumstances, will fall into their
subsidiary place, and not become the routine or dominant practice.

What, then, are the constituent parts of a national policy in
Preventive Medicine to be borne in mind by central and local
authority P

i.
Heredity and Race.

59. The fundamental fact which lies at the foundation of Pre—
ventive Medicine is the healthy individual. Environment, in-
fection, the accidents of life, and disease undoubtedly exert direct
or indirect effect upon him, but it is his own body, with its growth
and development, its resistant soil, its natural powers of defence,
which forms the basis of health and of scientific prevention. To
start a man fairly on life’s journey he requires a sound foundation

55

of physique. We have to think in terms of race, and thus it comes
about that the idea of parentage and ancestry cannot be ignored.
If we are to grow a sound and healthy race of men we must begin,
where all breeding begins, at the source. If we permit ourselves
to favour and provide for the unguided propagation of a population
of poor physique or of persons marked from birth with the stigmata
of alcohol, venereal disease or mental deficiency, we shall sooner
or later discover that we are building on false foundations, and
without taking sufficiently into our reckoning the Laws of Heredity,
of transmission, and of ante—natal infection: Whilst the subject
of practical eugenics is surrounded with doubt and difficulties,
there are some things we know. We are certain the race is improved
by the mating of healthy parents ; we know that children should be
born and nurtured under wholesome conditions ; we are sure that
particular disease or excesses should be reduced. These are ample
principles on which to proceed.

Alcoholism.

60. The excessive consumption of Alcohol in one form or another
has exerted its baneful effect upon the human race for many centuries
and in many lands. Its modes of action are various. It may affect
the race by affecting vast numbers of individuals with a greater or
less degree of physical or mental degeneration, accident or disease ;*
it may render a man liable to venereal infection ; it may, by devital—
ising the tissues of the body, reduce its powers of resistance to
infection, as in tuberculosis or syphilis ; it may shorten the expec-
tation of life by as much as fifteen years; it may lead to neglect
and malnutrition of the child of the dissolute parent; or it may
possibly impair the reproductive cells of the parent and thus affect
injuriously the offspring. Inquiries into the defective development,
disease or early death of the children of alcoholic parents, or into
the pathological condition of the reproductive organs of alcoholic
subjects or alcoholised animals, yield significant evidence as to the
potentiality of. alcohol as an injurious agentT

61. There are two methods of removing, or at least mitigating
these physical evils of alcoholism, namely, individual moderation or
abstinence and State control of the liquor trade. There is now in-
disputable evidence of the practical benefit which may result from
either or both such means of Preventive Medicine. On the one hand
the effect of individual abstinence from, or moderation in the con—
sumption of, alcoholic beverages is a matter of common knowledge.

 

* This was especially demonstrated during the first half of the eighteenth
century when the nation was indulging in an orgy of spirit drinking (1720—
1750). During this period the number of deaths greatly exceeded the births.
The evil was becoming so widespread that, but for the intervention of Parlia-
ment, gin would indeed have proved " the real grand destroyer " of the race.

T Alcohol : Its action on the Human Organism, 1924, pp. 110—114.

56

On the other, conclusive evidence was obtained of the value of
State measures of control in the experience of the Liquor Control
Board established in 1915. The principal measures taken by the
Board on physiological lines were (a) the severe curtailment of the
hours of sale of alcohol; (b) the provision of facilities for non-
alcoholic refreshment in industrial canteens; (c) the prohibition
of the sale of spirits of excessive strength ;* (d) the prohibition of
incentives to excessive consumption (such as “ treating,” credit
sales, and canvassing for liquor orders); (e) disinterested management.
The social and physical results of this policy were remarkable
and establish the fact that national alcoholism can be checked
by suitable preventive measures.

“ It is no longer doubtful,” declares Lord D'Abernon, " that under
an appropriate system of restriction a high level of temperance can be
attained in this country, and that thus national efficiency can be en-
hanced, and general prosperity and happiness increased. But to attain
these ends the regulation must be both restrictive and constructive, and
the restrictions must involve a certain constraint alike upon those who
require no protection against themselves and those who do. The question
is Whether these sacrifices-if such they can be called—will be accepted
by public opinion and by Parliament. Unless they are, all talk about an
aspiration to a healthier and more efficient Britain becomes mere rhetoric.”T

The physical effect of the restrictions imposed by the Liquor Control
Board were shown in increased sobriety and capacity, in lessened
fatigue, and in a lowered death rate from all forms of alcoholism.
The Registrar-General’s returns state that in 1913 and 1914 (before
the war and therefore before the Liquor restrictions) the number of
deaths certified as due to or connected with alcoholism (excluding
cirrhosis of the liver) in England and Wales were respectively
1,831 and 1,816. But in 1916 these fell to 953, in 1917 to 580, and in
1918 to 296, affecting both men and women. Even cirrhosis of
the liver declined by 60 per cent. (from 1913 to 1918). The number
of cases of attempted suicide also fell from 2,426 in 1913 to 810 in
1918. Yet more remarkable was the decline in delirium tremens in
certain Poor Law Institutions by 65 per cent. in males and 76 per
cent. in females in the second complete year following the im-
position of the restrictions: In the Registrar—General’s Report for
1917 Dr. Stevenson points out that the remarkable decline in deaths
from alcoholism in that year affected women (a decline of 63 per
cent), men over 45 years of age, and therefore beyond military
service (58 per cent), and deaths due to violence certified by coroners.

 

‘ On the varying effects of dilution of alcohol and conditions affecting its
absorption, see Medical Research Council's Report, No. 31, by Dr. E.
Mellanby.

T The Control of the Drink Trade in Britain, by Henry Carter, 1919, p. xii.

i Loo. cit., pp. 249—254. See also " Public Health and the Control of the
Liquor Traflic,” jam. State of Medicine, 1917, and the reports of the Central
Control Board (Liquor TraffiC), in June, 1919.

57

The mere withdrawal of men for military service could not therefore
have been the predominant factor.

62. We are not here concerned to advocate total abstinence
from alcoholic beverages or any particular form of administra-
tive restriction. Our case is the simple proposition that it is com‘
mon knowledge that the excessive consumption of alcohol may
lead to individual and “ racial” poisoning, and that there are
possible and practicable means of reducing its effect. Such means
are a measure of Preventive Medicine which cannot be ignored or
neglected if we would escape the physical evils of alcoholism. It
may, however, be added that, other things being equal, the man who
takes little or no alcoholic drink is likely to be healthier in life
than the man who habitually drinks a considerable amount, even
though he is never intoxicated. It is widely believed in the States
that one effect of prohibition in America (whether expedient or
not) has been an improvement in health and in capacity.

Syphilis.

63. A second example of a disease affecting the race is Syphilis,
the fourth of the killing diseases, as Sir William Osler termed it.
It may be transmitted from a diseased mother, and possibly from
a diseased father, without the mother being obviously affected.
In the unborn embryo and in the child after birth congenital Syphilis
may be an even more serious disease than in its acquired form,
since it attacks tissues still in process of development. It is a frequent
cause of sterility and of ante-natal death, producing abortion,
miscarriage or still—birth ; it plays its evil part in the production
of infant mortality ; it is also followed by various forms of congenital
disease. In the case of 175 pregnancies in 34 syphilitic mothers,
there were 104 premature births, still-births, or deaths in early
infancy, 41 seriously diseased offspring, and only 30 apparently
healthy children. (Mott) The effects of Syphilis are not termin-
ated with the subsidence of the acute attack. Noguchi and Moore
first found the organisms of Syphilis in the brains of persons dying
from general paralysis of the insane, and later abundant patholo-

. gical proof was given of the widely prevailing clinical experience that
this disease and tabes dorsalis (locomotor ataxia) were due to
syphilis. Evidence was given at the Royal Commission on Venereal
Disease, 1916, showing that 5 per cent. of syphilitics subsequently
developed General Paralysis. It is difficult to estimate the real
extent of the havoc wrought by syphilis; it is known that a
large proportion of the deaths from organic disease of the
brain and spinal cord is due to this cause. Likewise aneurism
and a large proportion of valvular and other disease of the heart.
Syphilis affects, it is estimated, a substantial number of the whole
population in the large cities of civilized countries and produces
in its total area of destruction a heavy mortality. Gonorrhoea is

58

even more prevalent as the cause of widespread disablement,
chronic disease and sterility.

64. In 1905, Schaudinn discovered the cause of Syphilis, the
Spirochata, or Treponema pallidum. Further, the Wassermann
Reaction has provided a bio-chemical test for diagnosis, and Ehrlich
and others have placed in our hands methods of effectual treatment.
One of the chief functions of a Ministry of Health is to
make reliable improvements in the treatment of disease available
for the population generally ; and in no other branch of medicine
have recent efforts been so quickly crowned with success as
in the prevention and treatment of venereal diseases. The
total number of approved Treatment Centres at the Close
of 1925 was 184 in England and 9 in Wales, a total of 193.
These Centres have provided approximately 738 weekly sessions,
585 in voluntary hospitals, 95 in special premises used solely
for venereal diseases, and 58 elsewhere. At 159 Centres pro-
vision is made for the intermediate treatment of Gonorrhoea. _The
193 Treatment Centres are staffed by 401 approved Venereal Disease
Officers. Beds for in—patient treatment are available in connection
with most of the Treatment Centres. Institutions have been es—
tablished for the accommodation of women and girls, and for the
reception of pregnant women suffering from venereal disease. In
1920, 85,531 persons suffering from venereal disease were dealt with
for the first time at the Centres in England and Wales.* In 1924,
the number of such persons treated was 54,380. This progressive
decline in the number of new cases is chiefly due to the effective

 

* The returns from Venereal Disease Centres for 1924 and previous years are given
in the following table, which shows the number of persons dealt with for the first time
at the Centres in England and Wales :—-

 

 

 

 

 

 

Number of persons dealt with for the first
time. ‘
H 1 Number
England _ ‘ ‘A’ I“? i 0f
and g Q- g is $21“ ea . Clinics
Wales. u; :25 4: - ,c: g o tten '1 at end
3'5 ‘6 b > t g ances. l of year.
.3 4-3 C: O 73 Q.) ' 76 l
g r 1:“ a *5 4: Q. *5 3
m (B L) (3 1—4 I 5 > I—< g
l .
1917 . . —— — —— — — 29,036 204,692 113
1918 .. 26,912 806 17,635 45,353 6,622 51,975 488,137 1 134
1919 .. 42,134 2,164 38,499 82,797 15,447 98,244 1,002,791 ‘ 160
1920 .. 42,805 2,442 40,284 85,531 19,654 105,185 1,488,514 . 190
1921 .. 32,733 1,654 32,433 66,820 17,459 84,279 1,612,592 1 194
1922 . . 25,762 1,108 29,477 56,347 16,988 73,335 1,560,568 1 191
1923 .. 23,927 1,110 30,908 55,945 17,668 73,613 1,605,617 , 192
1924 .. 22,010 1,098 31,272 54,380 18,842 73,222 1,645,415 1 193

 

 

 

 

59

treatment of Syphilis. In 1920, there were 42,805 cases of Syphilis ;
in 1924, only 22,010. Gonorrhoea shows less diminution, the figures
of new cases being 31,372 in 1924 as compared with 40,284 in 1920.

65. One result of the treatment of syphilis lies in the lessened
incidence of consequent nervous maladies, especially tabes dorsalis
and general paralysis of the insane. Not only is it the View
of leading neurologists that fewer cases of this nature are met
with both in hospital or private practice, but this impression is
corroborated by the returns of the Registrar—General. In 1915,
the crude annual death rates per million were returned for general
paralysis of the insane and tabes dorsalis as 63 and 21, respectively;
in 1923, the returns under this head had fallen to 44 and 19 per
million. Even when general paralysis of the insane is established,
the outlook is not so black as formerly ; in some cases, the malarial
treatment of this disease has proved encouraging, and by this means
general paralytics have been enabled to resume an active and useful
life.

66. Preventive Medicine allied with effective medical Ereatment
is, therefore, making a vigorous attack on the stronghold of venereal
disease. In addition to the provision of facilities for the prevention
of the spread of the disease, for its early diagnosis, and for its prompt
and continuous treatment, co-operation between the authorities
concerned in social control, public education and enlightenment, the
development of recreative schemes, reasonable and sympathetic
handling of the affected man and woman and, above all, a high
standard of moral life, must play their part.

F eeble—mindedness.

67. A third example of “ racial ” poison of a different and
more obscure nature, is the form of mental deficiency known as
Feeble-mz'ndedness. With the exception of certain types of amentia
due to definite lesions of the brain the bulk of feeble-minded-
ness must be looked upon as a definite form of ”imbecility”
due to an arrest in the normal development of the brain itself,
an arrest characterised by an insufficient number of nerve cells,
an imperfect formation of the cells and an inadequacy of association
fibres of the cells and thus of the co—ordinating structure of the
brain. The condition is therefore a retrogressive variation of the
normal brain, permanent in nature and possibly hereditary in
cause. Feeble-mindedness may be due to unfavourable conditions
affecting the germ plasm of the parent (insanity, epilepsy, syphilis,
alcoholism, consanguinity, &c.); acquired causes or factors may
affect the foetus in utero (mental stress, alcoholism, tuberculosis,
syphilis, physical injury to foetus, &c.); and lastly, there may
occur ” acquired” cases in which it would appear that an infant

60

may be born with a fairly normal brain tissue the subsequent
development of which is arrested owing to unfavourable post-natal
conditions or diseases.

68. Feeble-minded women are, on the whole, more prolific
than normal parents and have larger families than the average.
Here, therefore, we have a disease conveyable by heredity,
relatively incurable and yet likely to recur in large families;
in other words, a racial malady. Much can be done by proper
training and custodial care to alleviate the social and physical
condition of the feeble-minded person, but, at best, not more
than a quarter to one-third of these cases can be taught to main-
tain themselves, wholly or partly, and with or without super-
vision. The Royal Commission on the Feeble—minded, 1904 (report-
ing in 1908) estimated the number of feeble-minded persons in
England and Wales to be approximately 150,000, of whom 48,000
were children. The magnitude of the problem is therefore obvious.
The means of amelioration are training of the educable, custodial ‘
care of the ineducable, supervision and after-care of both.

69. Here are three types of degenerative processes—and tuber—
culosis and lead poisoning might well be added—which may affect
the individual in such a way or degree as to affect the race. In
some form or other Preventive Medicine must handle them,
separately and jointly, not forgetting that their inter—relationship
is intimate. Alcoholism may lead its victim into venereal infection,
venereal disease may lead to feeble—mindedness or insanity, feeble-
mindedness may propagate itself and once more start the vicious
circle. Hence the necessity of treating each disease specifically
and adequately. But there is a clear case for doing more than this,
and that such a view is widely held is indicated bysuggestions
which are made. Some recommend the prohibition of alcohol,
others the sterilization of the syphilitic, others the compulsory
incarceration of the feeble-minded, and yet others again a statutory
system of marriage health certificate. There may appear to be
logical grounds for such recommendations, but they are impracticable,
and some of them are inexpedient. The problems to be solved are,
in fact, of much deeper root, much more profoundly social in origin,
much more far—reaching than many have supposed. They call
for investigation, for more knowledge, for truer and more serious
understanding. What is needed is nurture and education, and
the study and practice of the science of eugenics—~including the
encouragement of worthy parenthood, the discouragement of
unworthy—right through civilised society, at every age period, and
in every class. Francis Galton urged that progress towards increased
race efficiency could be made along two routes, ((1) the scientific
study of the laws of heredity and environment, and (b) widespread
education in regard to the vital national importance of these matters

61

and the depth of our present ignorance and negligence. But
always concurrent with eugenics there must be the other mighty
factor, nurture, education and the development of high character.
The relationship between morality and preventive medicine is
intimate and profound.

ii.
Maternity.

70. The nation is not obtaining the supply of new lives it ought
to receive; in a word, the birth rate is rapidly declining; that is
the first aspect of the problem of maternity. The nation is subjected
to a loss by death, both in mothers and children, which it can ill
afford ; that is the second aspect. Yet that is not the whole problem.
For associated with the issue of maternity there is a burden of
invalidism, suffering and incapacity which, though unrecorded in
the national statistics, is exerting a serious effect upon the well-
being of the community.* A vast number of women are made
invalids for life, or lose a large part of their economic value, or
become sterile, or die ultimately from injuries received or disease
acquired while fulfilling or attempting to fulfil the function of
motherhood. How great and widespread is this kind of physical
disability was brought to light in the excessive and unanticipated
sickness returns of women claiming benefit under the National
Insurance ActT and further evidence is obtainable in the over-
crowded women’s departments of the general and special hospitals.
Yet the function of reproduction and child birth is, under satis-
factory conditions, natural and physiological. Its exercise ought
not to entail a high death or sickness rate or result in the physical
impairment of the mother. Speaking generally, however, there
is a serious and not decreasing burden of gynaecological disease
now existing, major and minor in degree, traceable principally
to two preventable conditions, venereal infection and neglected or
unskilful midwifery practice. The problem of maternity in this
country is, therefore, threefold :—

(1) The potential fertility of married women is not yielding
its due proportion of births. In other words, the
nation is not, on the basis of its marriage-rate, getting
its fair measure of new lives. This is, of course, due
in part to profound social conditions lying outside the
sphere of Preventive Medicine. But in part it is due
to the hazard and uncertainty of child-birth, and the

 

* Maternity: Letters from Working Women, 1915. See also Maternal
Mortality, Ministry of Health Report, by Dame Janet Campbell, M.D., 1924.

1' Report of Departmental Committee on Sickness Benefit Claims under the
National Insurance Act (Cd. 7687), 1914, pp. 47—52. See also, Report of
Royal Commission on National Health Insurance, 1926, Cmd. 2596, price
65. 6d.

62

absence of facilities and preparation for it. This aspect
concerns the relation of Preventive Medicine to the
survival of the race.

(2) Secondly, there is the high death rate associated with
child-birth, affecting the mother and the child. We
lose upwards of 2,700 mothers a year and not less
than 50,000 infants out of 700,000 born.

(3) Thirdly, there is the serious burden of disablement and
invalidism due to lack of knowledge and to insufficient or
unskilful medical and midwifery attendance. “ Much
of the suffering entailed in maternity, much of the
damage to the life and health of women and children,
would be got rid of if women married with some know-
ledge of what lay before them, and if they could obtain
medical advice and supervision during the time of
pregnancy and motherhood.”*

71. It is impossible to consider this situation—a situation charac-
terised by some unreadiness and improvisation, and a good deal
of incompetent midwifery—without being convinced of the necessity
of State intervention in regard to the function of maternity. Yet
it is only in recent years that the State, as such, has recognised its
responsibility in this regard. It is true that midwifery has been
practised in England for centuries, but up to the middle of the
eighteenth century it was in the hands of ill-trained and unlicensed
midwives, and though schools of obstetrics and lying-in hospitals
existed, there was little or no systematic supervision of maternity.
Smellie, William Hunter and Charles White were among the first
medical obstetricians, and did much to reform the whole practice
of midwifery. The Midwives Act of 1902 (amended in 1918) was
designed “ to secure the better training of midwives and to regulate
their practice.” But much remains to be done to ensure that every
woman in child—birth shall receive proper and adequate attention—
ante-natal, natal, post—natal. The midwifery and medical attend-
ance thus made available must be competent. At each period such
assistance is required; but, to mention the ante-natal only,
who can doubt that skilled supervision and aid in regard to the
general physical, abdominal and pelvic conditions (including examina-
tion of urine, &c.) throughout pregnancy and the puerperium, to
pelvic measurements and contracted pelvis, to correction of mal-
presentation, or to the treatment of syphilis,T early toxaemia,
or cardiac conditions, would save many mothers and infants ? There
is also the hygiene of child—birth and the post-natal period. A large
proportion of midwifery practice is, and is likely to remain, in the

 

* Maternity, loo all, p. 7.
T Sequeira, Adams and others have shown that the syphilitic pregnant
woman and syphilitic newly-born infants can be treated satisfactorily.

63

hands of midwives (varying at present from 30 to 95 per cent. of
total births) ; midwives are as a whole insufficiently trained to do
justice to the onerous responsibilities which devolve upon them;
and, moreover, the competent practising midwives are too few in
number and not appropriately distributed geographically.* Nor
is the training of the medical student in practical obstetrics entirely
satisfactory. In every medical school there is need for reform in
this matterff particularly in regard to teaching ante—natal physiology,
hygiene and pathology; the management of normal pregnancy;
the more careful and systematic application of the principles of
antiseptic surgery to obstetrics ; supervision during the post—natal
and nursing period; the management of the newly-born child ;
the prevention of conjunctivitis and ophthalmia (which together
with pelvic or vaginal infections may be due to the gonococcus,
suppurative cocci or the bacillus coli).

72. In the last few years great progress has been made in this
country in all these directions. In the new medical curriculum
issued by the General Medical Council, provision is made for in—
struction in ante-natal conditions and infant hygiene. Each
student is also required previous to graduation to undertake the
duties of an interne in a Lying-in Hospital, The developments in
obstetrical education have been set out elsewhere}: and there can be
no doubt as to the improvements which have taken place. A series
of special reports by Dame Janet Campbell on the training of the
midwife, the education of the medical student, and the wider subject
of maternal mortality were published by the Ministry of Health
in 1923—24§ and a Scotch Departmental Committee enquired into
similar matters in Scotland. In 1924 the Ministry of Health issued
Circular 517 setting out the practical administrative steps which
should be taken by Local Authorities, and in the following year the
Central Midwives Board extended the period of training for the
midwives certificate from six to twelve months, making the course
of study more thorough and practical. Lastly, in 1925, the Royal
Society of Medicine, appointed, at the suggestion of the Ministry of
Health, a special Committee to consider the redefinition of “ puer-
peral fever.”

73. The first steps, therefore, in the systematic and national
organisation of the supervision of maternity have now been taken,

 

* Report on Physical \Nelfare of Mothers and Children (Carnegie United
Kingdom Trust), 1917, vol. 2 (Janet M. Campbell).

1' Procs. of Royal Society of Medicine, 1919, vol. xii, No. 4, pp. 35—74, and
pp. 108—134.

1 Recent Advances in Medical Education in England, 1923, pp. 112L121.

§ (i) Notes on the Teaching of Obstetrics and Gynaecology in Medical Schools,
by Janet M. Campbell, M.D., H.M. Stationery Office, price 15. 6d.

(ii) The Training of Midwives, loc. cit., price 15. 3d.

(iii) illalernal Mortality, Ioc. cit., price 15.

64

and they should speedily result in the adequate training of midwives
and doctors for this work, thus bringing skill and experience to the
bedside of every woman in labour. Even before the event of child-
birth much may be done at Maternity Centres (the number of which
is happily increasing) in the direction of securing ante-natal hygiene,
domestic assistance, proper instruction, nutrition, and so forth.
Maternity homes, hospitals and lying-in institutions are also
urgently needed in all parts of the country—urban and rural—for
normal cases which cannot properly or safely be dealt with in crowded
tenements or inconvenient cottages, and for abnormal cases which
need skilled nursing and medical treatment. Since the Ministry
of Health was organised in 1919, upwards of 140 maternity homes
have been established providing 2,169 beds. A complete maternity
scheme thus includes :— -

a) an adequate medical, midwifery and nursing service ;

b) the satisfactory and sufficient nutrition of the mother ;

c) maternity centres providing ante-natal supervision ;

d) maternity home and hospital accommodation;

5) domestic aid before, at the time of, and after child-birth;

(j) maternity benefit and other financial aid in certain cases ;
and

(g) early notification of births and still-births.

(
(
(
(
(

That seems to be the wise policy, and it should be made applicable
in every district. But it raises, of course, large questions of social
administration and amelioration, which will take much time and
thought to work out satisfactorily in local areas.

iii.
Infant Welfare .

74. It is estimated that on the average, taking country and
town together, approximately 80 per cent. of all infants are born
free from obvious disease.* There would appear to be a “ mean
physical standard ” which is the inheritance of the people as a
whole, and no matter how far certain sections of the people
deviate from this standard by physical degeneration due to habit,
poverty or insanitary environment, the tendency of the race as a
whole appears to be to maintain the inherited average standard,
of health at the time of birth. But there is loss of ground immediately
after birth in the form of a high death rate among infants under one
year of age per 1,000 born, known as the infant mortality rate. The
death-rate of infants is the most sensitive index we possess of physical
welfare and of the effect of sanitary government. A high infant
mortality rate implies (a) the loss of many infants ; (b) the maiming

 

* In 1906 an inquiry in Finsbury showed that even in that central metro-
politan area 73 per cent. of infants were born healthy.

65

of many surviving children, for conditions which kill some, injure
others; (0) a high death rate in the next four years of childlife ;
(d) the existence of unhealthy conditions in the mothers and in the
home life of the people.

75. It is sometimes urged that the State would be wise to let
weakly infants die, thus giving free operation to what is called “ the
survival of the fittest.” But if this be wisdom, why restrict such a
beneficent principle to infancy? Would it not also be expedient
to let the weakly or diseased parent die, and those who may become
parents ? If disease or defect be permitted by the State to be
“ selective” in infancy, why not at all ages P There is in fact no
end to the application of such a doctrine.

But apart from the principle of saving and fortifying, there are
insuperable, practical and administrative difficulties to the alter-
native. Who is to determine which infant shall die? Is it to be
the parent or the doctor or the Local Authority? and on what
data is its fate to be determined ‘3

~76. In order to obtain a perspective View of this question the
principal returns since 1871 may be tabulated thus :—

 

 

 

England and Wales. London.
Birth Rate Death Rate Birth Rate Death Rate
per 1,000 per 1,000 I.M.R. per 1,000 per 1,000 I.M.R.
of Pop. of Pop. of Pop. of Pop.

1871—80 . . 35-4 21-4 149 35-4 22-5 158
1881—90 . . 32-4 19-1 142 33-2 20-5 152
1891—00 .. 29-9 18-2 154 33-2 19-6 160
1901—10 . . 27-2 15-4 127 27-5 15-6 126
1911-20 .. 21-8 14-3 100 22-1 15-1 100
1924 .. 18-8 12-2 75 18-6. 12-2 69

 

 

 

- It is evident therefore that a substantial decline in infant mortality
is taking place, a decline probably due, not so much to climatic
change or sanitary improvement, as to ” the quickening of the public
conscience upon the subject of late years,” a quickening which has
expressed itself in wider knowledge and greater care of child life.
To secure that advance and to maintain, or even accelerate it, is
the duty of the community, first by an understanding of the problem,
and then by a steady and continuous application of preventive
measures.

77. A correct understanding depends upon a knowledge of
the principal facts concerning infant mortality, which are these:
(B 32 /931)Q c

66

that its incidence falls chiefly in the first three months and in
the first week of the first three months; that in this country it
is higher in urban than rural areas; higher in the north than in
the south; that it is higher among illegitimate than legitimate
children; that its incidence is dependent not' upon density of
population but upon local and domestic conditions characteristic
of industrial areas or social classes of the community; that it is
high among the poor and low among a better social class (in 1911
in England and Wales the infant mortality of all classes was 130
per 1,000 births, of unskilled workers 152, of the intermediate
class 106, and of the middle and upper classes only 76)* ; that the
three chief causes of death in infancy are developmental conditions
(immaturity, prematurity, debility, wasting and atrophy), respiratory
disease and diarrhoeal disease; that since 1901—10 there has been
a significant decline affecting the whole of the first year but particu-
larly in regard to deaths due to diarrhoeal disease, then to respiratory
disease, and only much less so in respect of developmental disease.T

78. It is these facts which indicate appropriate measures of
prevention. Improved sanitary circumstances, attention to domestic
and municipal cleanliness, education of girls and mothers in
personal hygiene, sound and effective midwifery, the care, manage-
ment and feeding of infants,3,‘ avoidance of the racial poisons, and
above all attention to the physique of the mother—these are the
essential steps. It is significant, and indeed remarkable, that the
Registrar-General is able to report that the decline in infant mortality
during the first seventeen years of the present century has been
27 per cent. in the first'three months (as compared with 1898—1902),
50 per cent. at 3—6 months, and 43 per cent. at 6—12 months ; that
in the first twelve years of the century it has been 50 per cent. in
the last nine months of the year ; and that it is in the first month
only that the methods just named have not met with conspicuous
success. This one narrow period of relative failure is probably
due to inherent conditions, to shortness of the period of the appli-
cation of preventive medicine, and to unsatisfactory midwifery.
The improvement of the environment is always desirable, but broadly,
the problem of infant mortality will be solved only in so far as the
whole function of motherhood is fulfilled under favourable conditions.
Hence, each local authority will do well to consider for its own area,
in particular, the adequacy of the existing arrangements~

(a) for a proper maternity service, including ante-natal care,
(see p. 61) ;

 

* Recent investigations, still in progress, indicate that the several social
classes occupy the same relative positions as regards infant mortality, although
there has been a considerable fall of mortality in all classes.

T On the State of the Public Health, 1924, pp. 10—29.

1 Particularly breast-feeding, but not over-feeding. Regular feeding
every four hours is best for mother and child. (Minutes of Discussion on
Pediatrics, 1919.)

67

(b) for infant welfare centres (for consultations, home visiting
and the education of the mother) ; for the supervision
of infancy and childhood up to five years of age ;

(c) for infant treatment clinics ;

(d) for health visitors ; and

(e) for suitable accommodation in infant homes and hospitals.*

79. The mortality among little children aged 1—2 is from a
third to a quarter less than under twelve months of age, and from
2—5 is still further greatly reduced (in spite of the mortality due to
measles). The following is an instructive Table :—

Number of deaths in certain periods under one year and during next
4 years: England and Wales, 1924. .

 

 

 

Number of Death Rate
deaths. per 1,000 births.
Under one day . . . . . . 7,751 10-62
l—7days .. .. .. i. .. 8,165 11'19
1—4 weeks .. .. .. .. 8,224 11-27
4 weeks to 3 months .. .. .. 9,117 12-49
3—6 months . . . . . . . . 7,959 10-90
6-9 ,, .. .. .. .. 6,957 9-53
9—12 ,, .. .. .. .. 6,640 910
Death Rate
per 1,000 living.
1—2 years .. .. .. .. .. 15,419 22-04
2—3 ,, .. .. .. .. .. 6,356 8'54
3—4 ,, .. .. .. .. .. 4,089 546
4—5 ,, .. .. .. .. .. 3,055 3-79
Total under 5 .. .. .. 83,732 I 22 -64

 

 

 

Deaths at all ages . . . . . . 473,235 12- 18

 

In this pre-school age period there is, however, great need for
preventive measures dealing with measles and whooping cough,
rickets, mouth-breathing, squint and certain special children’s
maladies, particularly catarrhal and glandular conditions (due to

 

* A clearly defined policy should also be framed for dealing with the
mortality of illegitimate infants, including registration and inspection of lying-
in homes, rescue homes, and other institutions receiving unmarried mothers,
the provision of education and training under satisfactory conditions for the
mothers, registration and supervision of foster mothers, and a review of the
means by which unmarried mothers and their infants are dealt with under
the Poor Law.

(a 32/931)Q c 2

68

overcrowding, airless rooms, contact, infection, faulty diet, &c.).
A rich harvest will reward careful supervision and nurture at this
age period.

iv.
The School-Child.

80. The Industrial Revolution in England was little short of
a tragedy in respect of child life. Hardship, cruelty, disease, and
early death placed their gross and indelible mark on the English
child of a hundred years ago in a way and to a degree unknown
to-day.* All that is past. Yet to—day, also, there is a problem
of child life, and it is this. If we would rear a strong and virile
race of people we require more children and healthier children
as its foundation. Healthy maternity and healthy infancy are
essential preliminary conditions ; but until recently we have failed
at this third, or childhood stage, to protect the child from diseases
which arise from neglect of its body, to build up its physique, and
to provide it, as part of its education, with an understanding and a
practice of the laws of health.

81. The national system of the School Medical Service of
England and Wales was instituted in 1907. An ancestry of causes
and circumstances led up to the legislation which brought it into
being. First, there were the impelling and cumulative lessons
resulting from the growth of knowledge of the relation between
the physique of the child and its education, a principle appreciated,
though not always acted upon, since the days of John Locke;
secondly, there was the experience which had been gained under the
two Acts providing for the care and education of defective children ;T
thirdly, there were two official reports of investigations into the
physical condition of children of school age and their premature
employment ;1 fourthly, there was a report on the physical condi-
tion of the people which revealed the now obvious fact that the
foundation of the public health rests upon the health of the child-
population ;§ and, lastly, this report was followed by an inquiry
instituted by the Board of Education into the administrative
issues and requirements of a system of school—feeding and medical

 

* Select Committee (Sir R. Peel) on State of Children employed in Manufac-
tories, 1816 ; Select Committee on Employment of Boys in Sweeping
Chimneys, 1817 ; House of Lords Committee on State of Children in
Cotton Manufactories, 1819, &c.

1' Elementary Education (Blind and Deaf Children) Act, 1893, and the
Elementary Education (Defective and Epileptic Children) Act, 1899.

iReport of Inter-Departmental Committee on Employment of School
Children, 1902 ; Report of Royal Commission on Physical Training in Scotland,
1903.

§Report of Inter-Departmental Committee on Physical Deterioration,
1904.

l

69

inspection.* The data thus collected furnished an overwhelming
mass of evidence which, taken together, presented a convincing
case both of the physical needs of necessitous and underfed school—
children and of the administrative means necessary for the intro—
duction of a system of medical inspection and supervision. Hence,
in 1906, the Education (Provision of Meals) Act was passed to give
power to Local Education Authorities to take certain prescribed
steps for providing school-meals for necessitous children, and in the
following year a clause was included in the Education (Adminis-
trative Provisions) Act of 1907 which imposed a duty of medical
inspection and a power of treatment on the same Authorities.

, 82. From these beginnings has been built under the Board of

Education a national system of health supervision of the school—
child, further extended by the Education Act of 1918 (consoli—
dated in the Act of 1921), and now comprising the following func-
tions, undertaken by Local Education Authdrities :—

(1) The medical inspection and treatment of the child (5—14
years) in all grades of schools (including medical, dental
and orthopadic treatment clinics).

(2) The sanitation of the school premises, the hygiene of
education, and the control of infectious diseases.

(3) Systematic physical training.

(4) The provision of school-meals. ‘

(5) Special and open-air education for defective children
(blind, deaf, cripple, mentally deficient, diseased, and
debilitated).

(6) Supervision of juvenile employment in relation to physique.

The School Medical Service has been designed as part of the
public health service of the country, and is now available for all
children and adolescents in schools of all classes. There are up-
wards of 1,800 medical men and women and 4,300 school nurses
engaged in this work ; there are 1,190 school clinics for treatment,
and in London alone upwards of 220,000 children receive medical
treatment in the year ; there are 540 special schools for the educa—
tion and care of the 40,000 defective children.

83. This national system is not yet 20 years old, but already
great masses of disease and disablement are prevented or remedied,
and organised medical assistance has become an integral part
of the public duty of all Local Education Authorities and of their
school doctors and school teachers. Hundreds of thousands of
children annually are now receiving attention to their physical needs.
The result has been an increase in the sense of responsibility of the

 

‘ Report of Inter-Departmental Committee on Medical Inspection and
Feeding of Children attending the Public Elementary Schools, 1905.

(B 32/931»; c 3

7O

parent—" the increased work undertaken by the State for the in-
dividual will mean that the parents have not to do less for themselves
and their children, but more ”—a fuller appreciation of the individu-
ality of the child, and a larger understanding of the method and
purpose of education. Above all, the School Medical Service has
proved itself a branch of Preventive Medicine:

(a) by giving a new emphasis to the importance of the
beginnings of disease ;

(b) by reducing the results and disabling effects of disease in
childhood;

(c) by providing physical care and training in the age period
between infancy and adolescence, and so laying the
foundation for health in adult life; and

(d) by establishing the fact that the health of the child is the
foundation of the national health.

If the child be left the prey of neglected measles, scarlet fever,
rheumatic fever, malnutrition, or dental decay, the results in
adolescence and adult life are certain and inevitable, namely,
tuberculosis, nephritis, cardiac disease, anaemia and debility or an
early loss of the teeth. The law of cause and effect operates uni-
versally and with precision. We suffer much of the disease and
premature death which occurs between the ages of 18 and 58, first
because we neglect to deal with .the origins of disease in childhood,
and secondly, because we fail in that period to sow the seeds of
hygiene and healthy living—the insistence upon the essential elements
of health, viz., fresh air, exercise, warmth, nutrition, cleanliness,
habit. Thus. childhood is the time for the prevention of disease,
the nipping of it in the bud, as well as for a sound education in a healthy
way of life. The final issue of a comprehensive system of physical
welfare before school life, during school life and in adolescence, is
a citizen educated in hygiene, possessing a health-conscience, and
trained in personal and social habits to avoid infection, to remove
or ameliorate the conditions predisposing to disease, to live in
accordance with the laws of health, and to understand that the
individual body in health is the first line of defence against disease.

84. The findings of the medical inspection of school-children
are recorded elsewhere*. They show, happily, many healthy children,
a good promise for the future ; but they show, also, much unneces-
sary impairment, which creates for the State expensive problems.
Each Local Education Authority should have continually before
.them a clear View of the steps which are necessary from a medical
point of View in order to secure the full value of the School Medical
Service to every child of school age in their area. It cannot, I

 

* See Reports of Chief Medical Officer of the Board of Education, 1908—24.

71

think, be doubted that the irreducible minimum which will yield-
the results that the nation requires is as follows :—

(i) That every school-child shall periodically come under direct
medical and dental supervision, and if found defective
shall be “ followed up.”

(ii) That every school-child found ill—nourished shall, some-
how or other, be properly nourished, and every child
found verminous shall, somehow or other, be cleansed.

(iii) That for every sick, diseased, or defective child, skilled
medical treatment shall be made available, either by
the Local Education Authority or otherwise.

(iv) That every child shall be educated in a well-ventilated,
sanitary schoolroom or classroom, or in some form of
open—air schoolroom or classroom.

(v) That every child shall have, daily, organised physical
exercise of appropriate character.

(vi) That no child of school age shall be employed for profit
except under approved conditions.

(vii) That the school environment and the means of education
shall be such as can in no case exert unfavourable
or injurious influences upon the health, growth, and
development of the child.

These are simple propositions, but together they constitute a
Minimum Standard of the physical claim of the individual child—
of the child of the poor equally with the child of the rich—
toward which the more enlightened Authorities are year by year
making substantial progress.

V.

The Influence of Environment.

85. Long ago the Darwinian biologists following Weismann
pointed out that there are two main factors in organic evolution,
the nature of the organism and the nature of the conditions affecting
the organism. The early exponents of Preventive Medicine laid
their emphasis upon the latter. If we take up their writings we
find them full to overflowing of this doctrine. In 1869 the Royal
Sanitary Commission, on which sat the foremost physicians of the
day, defined the scope of public health requirements—“ the ordinary
supply of what is necessary for civilised social life ”—as concerned
with water supply, sewerage, streets and highways, housing, removal

(B 32 mm c 4

72

of refuse, smoke abatement,* public lighting, inspection of food,
provision for burial of the dead, registration of death and sickness.
That was the advanced programme of Preventive Medicine half a
century ago. Twenty-five years later a standard text book in-
cluded all these subjects with the following significant additions—
the study of meteorology, animal and vegetable parasites, infection
by bacteria, disinfection and the causes of specific disease. To-day,
another twenty—five years later, the latest edition of that same
textbook adds infantile mortality, school hygiene, tropical disease,
industrial hygiene, venereal disease and immunity. Now, here is some-
thing more than environment in the old sense of the term. Further,
the conception of environment itself possesses a new meaning,
more personal, intimate and integrated. In other words, Preventive
Medicine is entering into its biological setting, which comprehends
the nature of the organism, the nature of the environment and
their inter—relationship. That inter—relationship, action and reaction,
calls for much more research and investigation. Thus far we have
merely learned some of its elements. We must not now allow the
swing of the pendulum in favour of a fuller understanding of the
nature of the organism to lead us to disregard the effect of the
environment or think less of it, but, rather, to think more correctly
of it and to study its operations more minutely. For in many cases
it still remains the predominant factor. Three examples of the
influence of environment upon health and disease may be named
as illustrations of its relation to Preventive Medicine, a wholesome
and sufficient water supply, adequate and healthy house accommo—
dation, and the food supply.

Water Supply.

86. While polluted water has often been used by individuals
with impunity, the question of its importance in relation to health
and disease came to be more fully recognised as the relation of
uncleanliness to disease came to be understood and public water
supplies were introduced. Formerly a sporadic case of disease,
or death due to drinking contaminated water, was not recognised,
but when epidemic disease followed the wide distribution of a
water supply, attention was drawn to the importance of its purity
in regard to the health of communities. For instance, Corfield
collected particulars of more than 50 water-borne epidemics of

 

* The problem of smoke abatement still remains one of the most formid-
able in the field of environmental hygiene. It is true that during the last
20 years a considerable reduction of this nuisance has taken place in the
larger towns, particularly as a result of the more stringent administration of
the law in regard to factories, but mainly as a result of the substitution of
gas fires, and other means of heat production, for the open fire in the home.
Progress is slow, however, and the question is complicated by technical and
economic considerations of great difficulty.

73

typhoid fever between 1864 and 1902, and we now know that the
first of preventive methods is to secure for a community a sufficient
and wholesome water supply. ” Among the circumstances which we
find associated in outbreaks of typhoid fever,” wrote Sir John Simon
in 1869, “ there is none of more frequent occurrence, none which we
are more entitled to consider directly causative of the disease, than
the consumption of polluted water. It has been one of our most
familiar experiences that excremental fouling of wells is, in this
respect, among the worst dangers which can threaten the health of
a community.” Some typhoid outbreaks have been traced to
pollution of shallow wells, as at Guildford in 1867, in the Uxbridge
Rural District in 1882, at Hitchin in 1883, at Beverley in 1884,
and so on ; others have been due to pollution of deep wells, as at
Caterham in 1879 or at Watling in 1893 (1,315 cases). Other out—
breaks have been due to pollution at the spring, as at Maidstone
in 1897 (1,847 cases) ; or pollution of streams and rivers, as in the
Tees Valley in 1890, at King's Lynn in 1892, at Lincoln in 1905
(900 cases) ; or, again, contamination of the ground water, as at
Munich, at Terling, in Essex, in 1867, and at various places in
America; or, once more, to pollution of the water in the mains,
as in the famous case of Caius College, Cambridge, in 1873. The
illustrations are innumerable, the devastations in the early years of
public supplies extensive; a polluted supply brought disease, a
pure supply brought health. “ Many of the public improvements
have coincided with reduction of typhoid,” wrote Sir George
Buchanan as long ago as 1866. “ Though not with absolute con—
stancy, drying of the soil of a town and reduction in the crowding
of houses have been followed by reduction of fever. Much more
important appears to'be the substitution of an ample supply of
good water for a scanty and impure supply; other things being
equal, the towns in which this substitution has been completed have
made most improvement.” The improvement has occurred in the
reduction of cholera, epidemic diarrhoea and dysentery, as well
as typhoid; the deaths from typhoid have declined from 370 per
million in 1875 to 12 per million in 1924. Effective supervision of
water supplies includes control of the sources, gathering grounds
and catchment areas, of methods of filtration and storage, and of
distribution adits and house cisterns, and to this end topographical,
bacteriological and chemical examinations should be made regularly
of all public water supplies. Happily there is now widespread
recognition of this primary public health requirement, a wholesome
and sufficient water supply.

\

Public Health and the Dwelling-house.

87. The Housing Problem is two-fold in its relation to disease,
namely, the lnsuficlency and unsuitabllity of the house accom-

74

modation available.* Insufficiency leads to overcrowding; un-
suitability may be due to inadequate cubic capacity, absence of
ventilation or insanitation.. In the train of overcrowding, ill.
ventilation or insanitation follows a mass of trouble, incapacity,
disease and death. There is no subject in the whole range of Pre-
ventive Medicine in which the evidence is so general and incon-
trovertible as in regard to the ill effects of bad housing upon the
human organism. Commission after Commission, and report after
report, fora hundred years prove the case. If any further docu-
mentary evidence were needed in our own time it may be found
in that masterly and terrible chapter of evidence, the Report of
the Royal Commission on the Housing of the Industrial Population
of Scotland, 1917. The reference to the matter in these pages may
be brief. There are, broadly speaking, three evils of bad housing.

(0) There is diminished personal cleanliness and physique leading
to debility, fatigue, unfitness and reduced powers of
resistance. The Royal Commission on Housing of
1885 reported that in districts characterised by bad
housing, work-people lost on an average “ about 20

days in the year from simple exhaustion. . . . That
overcrowding lowers the general standard, that the
people get depressed and weary. . . . The general

deterioration in the health of the people is a worse
feature of overcrowding even than the encouragement
by it of infectious disease. It has the effect of reducing
their stamina and thus producing consumption and
diseases arising from general debility of the system
whereby life is shortened.”'}' The Glasgow School Board

 

* After the war years, 1914—1918, during which house building was in
abeyance, the State intervened to make good the shortage in houses. The
most recent official return (1926) is as follows :—

 

 

 

N umber of State
subsidised Houses
(1920—1925).
Statute.
Authorised. I Completed.
|

Housing, Town Planning, &c., Act, 1919 . . 174,588 173,325
Housing (Additional Powers) Act, 1919 . . . . 39,186 39,186
Housing, &c., Act, 1923 . . .. .. , .. 250,125 131,302
Housing (Financial Provisions )Act, 1924 . . 100,618 19,800
Total subsidised houses . . . . . . 564,517 ‘ 363,613

 

In addition, approximately 222,500 houses have been erected since the
Armistice by private enterprise without State aid in the form of subsidy.

TFirst Report of Her Majesty’s Ccmmissioners for inquiring into the
Housing of the Working Classes, 1889. (Cd. 4402), p. 25.

75

found that the children coming from one—room homes
were the lowest in height and weight. The very ex-
pectation of life is reduced in badly-housed as compared
with well-housed communities.*

(1)) A second result of bad housing is that the sickness rates
are relatively high, particularly for infectious, contagious
and respiratory diseases. Sir Shirley Murphy showed in
1898 that in districts of London where overcrowding
(more than two persons in one room in tenements of
less than five rooms) was under 10 per cent. the death
rate from pulmonary tuberculosis was 111 per 100,000
people; but where the overcrowding was over 25 per
cent., the corresponding death rate was 209 to 259 per
100,000. In Glasgow the death rate from measles,
whooping cough and diphtheria was shown by Dr.
Chalmers to be four times greater in one-apartment
homes than in four-apartment homes and upwards.
But the experience is universal. Bad housing increases
the incidence of all infections, contagious and verminous
conditions, of respiratory disease, and of anaemia, debility
and constitutional maladies.

(c) Thirdly, the general death mtes are higher and the expectation
of life is lower. The evidence is overwhelming, and
it comes from all parts of the world—the worse the
people are housed the higher will be the death rate.
For example, in London, in 1906, the total death rate
was 15-6, but in Finsbury it was 20-7, and in Hamp-
stead 13-5. Further, in six of the sub-registration
districts in Finsbury, it was under 12, and in five others
it was over 30. There is not only a difference between
central London and the suburbs, but between different
districts of central London there is this marked diver-
gence. Again, the infantile mortality rate (1891-1900)
in London was 142 per 1,000 births in districts with
under 10 per cent. of overcrowding (more than two in a
room), but in districts with over 25 per cent. of over-
crowding, it rose to 210—223 per 1,000 births. In 1906
the infantile mortality rate of London was 129 per 1,000
births ; but in Finsbury it was 137, in Hampstead only
79. Even in Finsbury it varied widely, seven sub-
divisions were under 70 per 1,000, but 19 sub-divisions
were over 200 and four were over 300. Once more, the
general death rate in Finsbury in that year (which was
20-7 for the whole borough) was 6-4 in homes of four
rooms and upwards, but 39-0 in homes of one room.
The following figures reported by Sir John Robertson,

 

* Report of Medical Officer of Health for London, 1902, pp. 19—20.

76

of Birmingham, further illustrate the case.* They
refer to two artisan areas in Birmingham: (1) with bad
housing, (2) with fair to good accommodation, and the
returns are for 1912—1916:—

 

—— l (1) l (21

 

 

Population . . . . . . . . . . . . 154,662 133,623
Area (in acres) . . . . . . . . . . 1,921 2,998
No. of Houses . . . . .. .. . . 33,471 30,172
Birth Rate .. .. .. .. 32-8 24-0
General Death Rate (1912- 16) .. 21-1 12.3
Infantile Mortality Rate (per 1,000 births) 171 -0 89-0
Consumptive Death Rate . . . . . 1'93 1 - 11
Measles Death Rate . . . . . . . . 0-83 0-24
Diarrhoea Death Rate . . . . . . . . 1-46 036

 

It is, of course, obvious that many factors and in-
fluences operate to create these immense differences,
but the principal is housing and all it entails for good
or evil. When we come to examine these death rates
we find (a) that they are due principally to an excess
in the common infectious diseases, epidemic diarrhoea,
and respiratory disease, and in infantile mortality,
and (b) that they are highest where the density of houses
is greatest, where overcrowding is excessive, where
there IS a poor class of tenement house, where the house
property is damp, dilapidated and insanitary, and where
there is a high percentage of poverty and a low standard
of him“

88. What is it in the house accommodation which leads to
these results? One factor no doubt is the gravitation to the
lowest stratum of housing of the physical and mental cripples and
invalids of our civilisation. But this is not a complete explanation ;
such an environment will injure the best naturally endowed
organism, and for the following reasons : First, it is the limited cubic
capacity per person which exists in conditions of overcrowding. At
the last Census in 1911 it was found that one-tenth of the population
lived in overcrowded tenements. In night inspections in central
London I have myself found that in one street in 1901 the over-
crowded tenements, as measured by the lenient standard of the
by-laws, formed 73 -4 per cent. of the whole. It requires no argument
to prove the evil effect of such conditions, physical, mental and moral.
“ The one—room system,” said Lord Shaftesbury, “is the one-bed

 

* Housing and Public Health, 1919, p. 14.
1 Report on the Public Health of Finsbury for 1906, pp. 17—32.

77

system.” Secondly, there is the absence of effective through
ventilation—cool, fresh, moving air. Tatham, Darra Mair and many
other observers have shown that the general death rate in back—to-
back houses (which have no through ventilation) is higher than in
through-ventilated houses by 15 per cent, and that the phthisis
death rate is increased by 12 per cent. There can be little doubt
that airless rooms, changes of temperature, dust and contact in—
fection bear an intimate relationship, possibly causal, to the whole
group of catarrhal and bronchitic diseases which contribute so heavily
to invalidity and mortality. Lastly, there is insanitation—outside
the house, ineffective methods of excreta disposal, insufficient
scavenging of refuse, unpaved yards or streets ; inside the house or
curtilage, back—to—back houses, insanitary ashpits, privies or cess-
pits, damp walls, bad drainage, dilapidated structure and domestic
insanitationfli Thus filth, dust and effluvium contaminate every-
thing and “ breed infection.” What can be hoped for in family
health with one water tap or one closet to half a dozen houses or
tenements? In brief, the evil is one of gross uncleanliness and
overcrowding, and in their track health rarely follows.T

Public Food S'lrtjlply.

89. A third example of the effect of environment on health may
be found in the food supply. That the consumption of unwhole-
some food may prove deleterious every school-boy knows after his
first experience of unripe apples. That side of the question has
been the common knowledge of humanity from primeval times.
But three new factors have arisen, namely, the handling, pre-
paration and transport of food supply for vast communities, the
conveyance by means of food of bacterial or toxic infection and
metallic poisons, owing to contamination with infective or poisonous
agents, and the new knowledge regarding tuberculosis and other
specific diseases of animals communicable to man. For instance,
in the middle of the last century, Dr. Michael Taylor, of Penrith,
demonstrated milk—borne disease derived from disease in the cow

 

* A sanitary house should be (i) free from serious dampness, (ii) satisfac-
torily lighted and ventilated, (iii) properly drained and provided with adequate
sanitary conveniences, and with a sink and suitable arrangements for dealing
with slop water, (iv) in good general repair, and should have (v) a satisfactory
water supply, (vi) adequate washing accommodation, (vii) adequate facilities
for preparing and cooking food, and (viii) a well-ventilated store for food.

1' The essential points to be considered in estimating the quality of house
accommodation include (a) number of houses per acre, ([7) width of street and
height of buildings, (a) relation of houses to each other, (d) suitability of soil
and outlay, (3) general water supply, (f) drainage and sewerage, (g) paving
and condition of curtilage, (h) the condition of the house itself, cubic capacity,
and height of rooms, lighting, ventilation, dryness, repair, &c., (i) sanitary
accommodation, (j) house water supply, (k) arrangements for disposal of
refuse and ashes (see Housing (Inspection of District) Regulations, 1910,
No. 919). As in factories differentiation should be made between mums
provided and maimenance and use of the means by occupier.

78

or from contamination.* Again, during the last 70 years evidence,
has accumulated implicating oysters, cockles and other shell-fish,
cheese, ice-cream, beer, hams, sausages, meat pies, potted meat,
and many prepared and manufactured foods. Sometimes the
poisoning is due to lead or arsenic, sometimes to bacterial infection ;
the infection may be of human or animal origin. Hence arises the
need for control, for hygienic preparation, and for an effective
protection.1‘ But that is not all. Far more important to the
health of a community than ideally sound food is sufficient food,
adequate in quantity and suitable in quality and nutritive value.
Malnutrition is wider in incidence and more devastating in issue to
a community than food-borne disease. For proper nutrition lies at
the foundation of a healthy and resistant body. The first funda-
mental fact concerning the relation of food to Preventive Medicine
is therefore this of nutrition ; which, though it finds its principal
factor in food in appropriate quantity and quality (proteins, car-
bohydrates, fats, salts, vitamins) to repair the waste of the body,
furnish energy and heat, and provide for growth, is also dependent
upon other conditions. There must be healthy physiological pro-
cesses of digestion, absorption, assimilation, which in their turn
require an adequate standard of cooking and preparation of the
food, a due proportion of rest and exercise, of oxygenation of the
blood, and of excretion. Food is but one factor in metabolism, and
the task of the worker in Preventive Medicine is not merely to
keep the people alive, but to secure and maintain well—balanced
nutrition. In order to do this it is necessary to safeguard the
whole external and internal environment relative to food.

90. The second fundamental principle is the protection and
control of the food supply. The form of control which is necessary
in respect of food varies widely in respect of the article itself,
liability to infection, contamination and deterioration, and its
market. For example, milk for human consumption should be pure,
clean, whole milk, unsophisticated and unadulterated, derived from
healthy cows living under sanitary conditions ; it should be obtained
by clean methods of milking ; strained, cooled and protected at the
farm, in transit and in the home from all forms of infection or
contamination, whether conveyed to it by the cow, the milker, the
utensils or by external circumstances. Such control can be ex ercised :—

(a) by the consumer, if he demands pure milk and himself
protects it from uncleanliness;

(b) by the dairy trade, if it conducts its business properly and
in a clean'and scientific way;

 

* It has been estimated that 30 per cent. of the cattle in this country
are tuberculous and that 2 per cent. (including those giving milk containing
tubercle bacilli) are in an advanced and dangerous stage of the disease, such
as would bring them within the provisions for slaughtering under the Tuber-
culosis Order.

1' Food Poisoning (Savage and White), Medical Research Council Special
Report, No. 92, 1925.

79

(c) by the sanitary authority, if it puts into force its legal
powers of control over adulteration, uncleanliness and
infection.*

91. The milk question is an excellent illustration of the kind of
action that is necessary in regard to food control. Although there
have been signs of progress in certain aspects of this matter, largely
inspired by the system of grading established under the Milk
(Special Designations) Order, 1923T, much milk now sold is dirty,

"' See Sale of Food and Drugs Acts, Milk and Dairies (Consolidation) Act,
[915, Milk and Dairies (Amendment) Act, 1922, Milk, (Special Designations)
Order, 1923, Milk and Dairies Order, 1926, &c.

T The various grades now established by the Milk (Special Designations)
Order, 1923, may be summarised as follows 2—-

(1) Certified Milk must be produced from cows which have passed a
prescribed tuberculin test and veterinary examination. _ The whole
herd must be submitted to the test and veterinary examination at
intervals of six months, and every animal added to the herd
must be tested immediately before admission. The milk must be
bottled on the farm and must not at any time contain more than
30,000 organisms per c.c. or any coliform organisms in 0 -1 c.c.

(2) Grade A (Tuberculin Tested) M ilk is subject to the same conditions
as Certified Milk as regards the testing and examination of cattle.
The milk must be, bottled before distribution and must not at
any time contain more than 200,000 organisms per c.c. or any
coliform organisms in 0-01 c.c.

“(3) Grade A .Milk must satisfy the same conditions as Grade A (Tuber-
culin Tested) Milk, with the exception that the tuberculin test
is not required and that veterinary examinations of the c0ws in
the herd are made at intervals of three months instead of six
months.

(4) Pastemlsed Milk is milk which has been pasteurised by the holder
process as defined in the Order, l.e., it must be held at a temperature
of 145° F. to 150° F. for at least half an hour and then cooled to
55° F. It must not be heated more than once and it must not
contain more than 100,000 organisms per c.c. If the milk so
treated is Grade A milk the number of organisms must not exceed
30,000 per c.c. and there must be no coliform organisms in 0 -1 c.c.
Pasteurisation or heating of Certified or of Grade A (Tuberculin
Tested) Milk is not allowed.

The Order provides for the payment of a small annual fee by licensees
in each of the grades named which is intended to cover the extra cost involved
in administration of the scheme. Licences for the production and sale of
Grade A and Pasteurised Milks are granted by local authorities as are also
the retail licences required for the sale of Certified and Grade A (Tuberculin
Tested) Milks. The collection and despatch of samples of all grades of milk
for bacteriological examinations are also undertaken by these authorities.
In the case of Certified and Grade A (Tuberculin Tested) Milks the granting of
licences to producers remains under the direct control of the Ministry to whom
reports are made on the tuberculin testing of the herds in question and on
the results of their periodic veterinary inspection by veterinary surgeons
approved for the purpose. Reports upon the bacteriological examination
of all Certified Milk and of Grade A (Tuberculin Tested) Milk sold retail by
the producers, are also received by the Ministry and dealt with in the food
department. A small staff of specially trained milk inspectors make periodic
v151ts to the farms and dairies of producers holding direct licences from the
Ministry to see that the conditions laid down in the Order are being complied
With and in ascertaining that suitable arrangements have been made by
applicants for new licences in these grades.

 

80

tuberculous or adulterated; it is produced too largely under un-
wholesome conditions; the regulations controlling it are still too
largely permissive and unsupervised ; and there is need for consider-
able “ speeding—up ” all round. Broadly, the solution, here as else-
where, is to be found in (i) more effective laws and regulations,
(ii) a firmer administration in every area, (iii) the education of the
public, and (iv) realisation by the trade that good and careful milk
production and distribution is profitable business. There are com-
parable means of dealing with unsound food and with polluted shell-
fish. Again, the whole business of the meat supply calls for
supervision. Public abattoirs, thorough and uniform meat inspec-
tion, and the control of imported meat are necessary steps. Hence,
though the Local Authority is interested, far more directly than it
has hitherto recognised, with the nutrition of the population in its
charge—for nutrition is the basis of health—-it is directly and imme-
diately responsible for the protection of the community from every
form of poisoning, malnutrition or physical degeneration having its
origin in an uncontrolled food supply—unsatisfactory meat, poultry,
game, fish, fruit, vegetables, corn, bread, flour or milk exposed for
sale, or deposited in any place for the purpose of sale or of pre-
paration for the food of man.* This means, of course, adequate
inspection and the seizure of bad food, including control and
local supervision of imported food. But, as every medical officer
of health knows, such a proposition raises far—reaching issues of
the production or growth of the raw material, slaughtering and
slaughterhouses, public abattoirs, a uniform system of meat exami-
nation, the control of imported meat, the transport of meat, the
detection of unsoundness and disease of animals communicable to
man, and so on.T Further, there are other conditions which must
be considered, such as the manufacture of prepared foods, curing,
canning, drying, the control of preservatives in food ; its contami-
nation with metals or agents of decomposition, its storage and its
cooking. Lastly, there is the whole wide question of food poisoning
and food-borne disease, its character, incidence and prevention,
and its relation to food premises, food industry and the national
increase of a good and cheap food supply.

vi.
Industrial Hygiene.

92. Though for the majority of the population life seems to be
a more or less ceaseless round of labour, it must not be forgotten
that men labour to live and both their life and their labour are

 

* Public Health Act, 1875, S. 116.

T See Public Health (Regulations as to Food) Act, 1907, and the particular
Regulations of 1924 as to meat, of 1915 and 1925 as to imported food and
shell-fish, and of 1925 as to preservatives in food.

81

restricted if the conditions of labour be not satisfactory. The
Industrial Revolution in England took men, women and children
from the fields to the towns, from the chamber workshop to the
mill, from an evil environment to a worse. It turned the dis—
comforts and limitations of the poor into a rigid system, a system
which left indelible marks upon the physique of the people. In
the early part of the nineteenth century the State found that its
children were being ruined in body and mind by the conditions
and circumstances of their employment. “ Working young children
during the same stages as adults,” said Sir Edwin Chadwick, ” is
always injurious overwork for young and growing children, whether
the work be mental or moral.” Official reports in 1816, 1819, 1832,
and subsequent years furnish overwhelming medical evidence of the
gravity of the physical injury due to the premature, prolonged or
unsuitable employment of children. There is now a century of
proof. Nor was such employment affecting children only. The adult
labourer was being injured also. “ We manufacturers,” wrote
Robert Owen long ago, “ are always perfecting our dead machinery,
but of our living machinery we are taking no care.” All through
the first half of the nineteenth century evidence was accumulating
in confirmation of that proposition both as regards men and women.
“ To use up or damage its women by setting them to hard wage
labour in mill and workshop,” wrote Mr. Hobson in 1914, “is
probably the greatest human waste a nation can practise or permit.”
But everything depends on the conditions. In 1832 Dr. Turner
Thackrah, in 1852, Mr. Finlaison the actuary, in 1857 Dr. Greenhow,
and in 1862 the Medical Department of the Privy Council, investi-
gated and reported upon the effect of occupation upon health,
and through the agency of the Factory Department of the Home
Office and otherwise such inquiries have continued and increased.
Every industry indeed was found in greater or less degree to
affect the death rate. Tatham showed that if the comparative
mortality figure for the agricultural worker be 602, that for the
shoemaker is 920, for the hairdresser 1,099, for the chimney sweep
1,311, for the glassmaker 1,487, for the leadworker 1,783, and for the
filemaker 1,810. And the contrast is even more marked for sickness,
disablement and accident. It also has its relation to economy and
output. “ The most economical production is obtained by employ-
ing men only so long as they are at their best,” wrote Sir
William Mather in 1894, “ when this stage is passed there is no true
economy in their continued work.” Thus the actual conduct of
business is primarily dependent upon physical health.* For the
simple fact is that without health there is no energy and without

 

* “ Economic processes are primarily physical in the efforts they evoke
and in the needs they satisfy ; the expenditure and recoupment of physical
energy constitute the first and most prominent aspect of industry.” (Work
and Wealth, J. A. Hobson, 1914, p. 13.)

82

energy no output ; and more important than output are the vigour,
strength and vitality of the worker.*

93. The movement for reform began with the enlightened
action of individual employers, and was continued by the State.
It began with the control of the hours of labour, and it has com-
prehended within its purview the whole wide compass of industrial
betterment and the welfare of the worker :

(a) the careful selection of workers on engagement, and periodical
medical supervision (including observation as to output,
lost time, sickness, physiological requirements, &c.);

(b) the hours of employment—shifts, breaks, spells, pauses,
holidays, Sunday work, night work, overtime;

(c) the factory or workshop environment—design, structure,
sanitation, cleanliness, heating, temperature, ventilation
(including the removal of dust and fumes by “ exhaust
ventilation ”), lighting, sanitary accommodation, washing
facilities, cloakrooms, seats, rest rcoms, surgeries;

(d) the personal well—being of the worker—the industrial employ-
ment of women,1‘ incentive, food supply and drinking
water, canteens, protective clothing, lifting weights,
welfare conditions, first—aid boxes, rest, recreation, dental
treatment, educational classes, physical education, sports’
grounds, recreation halls, appointment of psychologists
and welfare supervisors ;

(e) the efiect of occupation upon health—fatigue (due to excess
in duration of labour, specialisation, repetition, strain
or speed), sicknessI, injuries, accidents, industrial disease
(poisoning by lead, phosphorus, arsenic, mercury,
anthrax, dust, fumes, &c.).

With reasonable care and attention to speed, strain, lighting,
mechanical contrivance, &c., accidents can be reduced by 40 to 80
per cent. Considerable progress has already been made in the
reduction of accidents by additional fencing of dangerous machinery
and the education of the workers by means of Safety Committees,
and the publication of pamphlets and posters. These matters
concern 133,000 workshops and 142,000 factories, in which twelve
million people spend a third of their lives. It cannot be otherwise

* See also Industrial Health and Efiictency, 1918 (Final Report of the
Health of Munition Workers Committee, 1915—1918, Cd. 9065).

f See Report of the War Cabinet Commission on Women in Industry, 1919
(Cmd. 135), pp. 218—253 (Dr. Janet Campbell).

1: In 1925, out of a staff of nearly 1,000 girls employed by a large firm in
the Midlands in their general offices, 3,124 working days (:81); years) were
lost through absenteeism caused by the common “ cold ” (exclusive of
bronchitis and influenza).

83

than that this vast enterprise of industry must profoundly affect
the health, physique and capacity of the whole body of workers.
The administration of hygiene carried out by medical officers,
inspectors, certifying factory surgeons, and welfare workers on the
one hand, and by proprietors, managers and employers on the
other carries with it therefore a responsibility which if undischarged
or disregarded incurs heavy damages.* Whatever was the case
before 1914, the experience of the war has demonstrated beyond
all question that industrial hygiene forms an integral part of the
practice of Preventive Medicine.1‘ Finally, it may be added that,
apart from other considerations, well-organised industrial “ welfare ”
is found by those who have tried it, to be a sound economic
proposition.

vii.
The Prevention and Treatment of Infectious Disease.

94. The glory of Preventive Medicine in our own time has been
its victories over infective disease. The cause of a dozen forms
has been discovered and the new knowledge applied. We have
witnessed the .isolation of some pathogenic bacteria, made possible
by the Koch method of the solid culture medium, in which
Robert Koch’s pupils and fellow workers—Loffler, Gaffky, Pfeiffer—
participated ; the study of protozoa, which started from Laveran’s
discovery of the germ of malaria ; the discovery by Loffler, Frosch,
Roux, Nocard, and others of the viruses which pass through filters ;
and the recognition of insects as intermediate hosts and transmitters
of infectious diseases. Then there has been the study of the immunity
theory first inaugurated by Metchnikoff, and which received a new
impetus from the discovery of antitoxin by von Behring, through
which a Wide field of immunity and the investigation of serums
was opened up, on which Pfeiffer, Bordet, Widal, Wassermann,
Ehrlich, Wright, and others have worked with successful result.
Some of the most valuable fruits of these labours from a practical
point of view have been the diagnosis of diseases, first in the form
of the Widal—Griiber reaction, and later the Wassermann syphilis
reaction. Lastly, there has been the new work in prophylaxis,
vaccination and serum therapy of infective disease and the control
of tropical scourges. Malaria is coming steadily under command ;
yellow fever can be restricted. “ The effects of these two dis-
coveries” (the transmission of malaria by the anopheles and of
yellow fever by the stegomyz'a) wrote Gorgas of the Panama Canal,
“ will be as far—reaching as those of any discoveries ever made in
medicine, not even excluding the immortal works of Jenner and
Lister. These discoveries enabled us to control entirely "health

 

* Now required under the W orkmen’s Compensation Act.
1' See The Health 0] the Induslrial Worker, by Dr. Major Greenwood and
Professor E. L. Collis, 1921 (J. and A. Churchill).

84

conditions at Panama. . . . I believe we are on the eve of
the occupation of the Tropics by the white man. If this be so,
then great civilisations, in the course of time, will develop in tropical
regions.” If we pursue, in the same spirit, the cause and control
of infection in Britain and in the West the temperate climates
may show even greater advance. When Lord Macaulay compared
the state of England at the death of Charles II in 1685 with the
middle of the nineteenth century, he wrote: “ Some frightful
diseases have now been extirpated by science and some have been
banished by police. The term of human life has been lengthened
over the whole kingdom, and especially in the towns. The difference
in salubrity between‘the London of the nineteenth century and
the London of the seventeenth century is very far greater than the
difference between London in an ordinary year and London in a
year of cholera.”

95. The common infectious diseases in England are notifiable,
and include smallpox, cholera, diphtheria ; typhus, enteric, relapsing,
scarlet, continued, cerebro-spinal and puerperal fevers; all forms
of tuberculosis, poliomyelitis, ophthalmia neonatorum, pneumonia,
influenza and malaria (see p. 30). Rheumatic fever and venereal
disease are not notifiable. Rabies, anthrax, glanders, and certain
exotic diseases are notifiable on occasion. But the true toll of
the infective diseases is not only their immediate incidence and
death rate, but their remote results which incapacitate and lead to
invalidism. The application of the scientific method to their control
has built up a national system of Preventive Medicine which is
represented briefly in the following steps :—

(i) The study and investigation of the causes and conditions
of infective disease and its accurate and early diag-
nosis ;

(ii) The application of prophylactic methods (inoculation,
vaccination, &c.) ;

(iii) The notification and registration of sickness ; its character,
incidence and distribution ;

(iv) The isolation of the case from the community, and its
effective treatment ;

(v) The disinfection when necessary of the premises ;

(Vi) The control of ” carriers ” and “ contacts” ;
)

(vii The adoption of special methods of prevention varying in
different diseases.

96. These well—tried and orthodox measures should be practised
as in the past, but, I venture to suggest, less spasmodically and
with a more thorough application than heretofore in the area of
every Local Authority. My reasons for this submission must be

.85

briefly presented. In an earlier section of the present Memorandum
the fundamental principles concerning the nature of disease are
sketched in outline. They seem to me to call for close application
to the prevention of infectious disease, particularly as regards the
whole question of variation and the factors which produce it. The
bacteriologist finds that each type of bacillus is accompanied by
a zone of atypical forms associated with it ; and it is the atypical
form produced by differences of condition, environment, specificity,
virulence, culture, age, or animal passage which creates the
bacteriological problem. The clinician meets with an atypical case
in a patient presenting some typical signs and symptoms in accord-
ance with previous standards, but other quite exceptional characters.
The epidemiologist finds surrounding his group of typical cases
of scarlet fever, typhoid or influenza a zone of atypical cases, even
a separate outbreak, produced by differences of seed or soil, and it
may be that these aberrant cases, these atypical epidemics, present
exceptional signs and symptoms, and differing degrees of virulence
and mortality. Happily, also, they may serve to solve the problem.
Facts such as these should lead us to hesitate before we proclaim
every fresh manifestation of infectious disease to be a “ new ”
disease, botulism, alastrim, or what not. They should lead us to
suspect “ the track of the many into the one.”

97. What are the fundamentals upon which we must build
in grappling with infection P Let me recall them in simplest form.
First, there is the vera causa of the bacteriologist, the infecting germ.
We must know it and its ways biologically; we must learn of its
atypical forms, whether parasitic or saprophytic; and we must
discover the relation of the type and its allies to the normal microbic
flora of the human body. If and when we know our enemy and his
relation to our friends, we can proceed to the second fundamental
issue, namely, the discovery of, and eventually the control of, the
conditions which create or favour the pathogenicity of the invading
bacillus. How various and diverse they are no one yet knows, though
slowly we are learning to piece together the indictment against them.
Thirdly, we must investigate the typical clinical manifestations of
the infection and their atypical modifications or variants—all those
concurrent, or ante or post, morbid conditions, however minute and
transient, they may appear, which accompany the outbreak and show
similarities, correlations or affinities with it—not hastily concluding
that such variants are “ new” or different diseases, but seeking to
learn the grounds of their alliance or concurrency. Fourthly, we
must endeavour to learn of and then remove all predisposing con-
ditions which favour the susceptibility of the individual or which
weaken his natural defences.* The resistant body of the patient is

 

* One of the best practical examples of such aetiology and control is that of
the diphtheria bacillus, the clinical disease of diphtheria, and the application
of the principles of the Schick test (see Special Report on Diphtheria, its
bacteriology, pathology and immunology, by the Medical Research Council, 1923).

86

of no small account in our struggle with the invader, yet it is
frequently neglected by the worker in preventive medicine. Ulti-
mately, it may prove that the fortification of the host is, in the long
run, the best means of defeating the enemy. In any case, it is
certain that our efforts must always be directed to the removal of the
conditions, in seed or soil, which make for disease. It is that, and
not a frontal attack against an enemy in unknown strength, which
is the sound strategy. Lastly, there is another point not to be for-
gotten. We must deal with the disease itself and its sequelae. What
is required in the future effectually to remove the damage done by
these diseases is a fuller recognition of the fact that each infective
disease must be dealt with in regard to its particular and specific
effect. Notification and isolation, on which attention has hitherto,
quite properly, been concentrated, are mere preliminaries to the real
attack upon the stronghold of these diseases. The essential step is
to address ourselves to the vulnerable point of each malady and to
apply to it the direct and indirect means of preventive treatment
appropriate to its character or site in the body.

Measles.

98. Let us consider how these principles work out. Measles
is so universal in this country that few children escape it ; certainly,
between 80 and 90 per cent. of all children of 15 years of age have had
an attack of the disease. The number of “ first ” notifications in
England and Wales in 1918 (when the disease was notifiable) was
414,000, which is substantially more than all the other notifiable
diseases put together, and the deaths in the same year returned as
due to measles were 9,787. In itself, it is not a highly fatal disease,
but in its complications and sequelw it is one of the most damaging
and mortal of all the infectious diseases. In brief, it is not simply
measles as such to which we must give attention, but to all it
portends. Principal among the conditions which follow in its train
are bronchitis, pleurisy, pneumonia and empyema, tuberculosis,
malnutrition and retarded growth. ” A very common result of
measles is cheesy degeneration of the mediastinal glands and a
subsequent tuberculosis of the lungs ” (Goodhart and Still). Whether
measles chiefly produces conditions favourable to subsequent tuber-
culous infection or whether it acts chiefly by causing latent or pre-
existing tuberculosis to flare up and become active is immaterial to
the issue. Measles, whooping cough, diphtheria, scarlet fever and
influenza are the chief diseases cited by Holt as responsible for
deaths from broncho-pneumonia, either as a primary disease or
secondary to bronchitis of the larger tubes. By far the commonest
form of death certificate is “ Measles, broncho-pneumonia.” In
1911, when this question was specially investigated by the Registrar-
General, no less than 68 per cent. of the total deaths from measles
are stated to have been complicated by some form of pneumonia.

87

Here we have, in any case, one of the most fertile forerunners of
subsequent grave disablement.*

99. But there are other examples. The materies morbi of
scarlet fever is particularly obnoxious to the kidneys, and thus an
acute or chronic nephritis may ensue ; rheumatic fever may leave
behind it an infective valvular disease of the heart ; influenza leaves
pneumonia, cardiac dilatation, and conditions arising from mixed
infection ; diphtheria may be followed by paralysis due to degenera-
tion of the nerve fibres, and by insufficiency of the heart; and
whooping cough by collapse of the lung. And what are we to say of
the progeny of an attack of those universal and protean diseases,
influenza, malaria, syphilis, or tuberculosis ? They affect the whole
body and, unless controlled, mark it for the rest of its days and not
seldom with disablement and devastation. It is these products of
infective disease which we must have in mind, and to remove them
we must so deal with the whole nature of the disease as to extract its
sting. In a word, this implies the practice of a curative medicine
which is preventive in effect. Measles, scarlet fever, rheumatic
fever, influenza, diphtheria, and whooping cough may be so treated,
and are so treated under favourable circumstances and with sufficient

 

* The Registrar-General’s Return shows, for the year 1923, that 71,711
deaths at all ages were recorded from,diseases of the respiratory system.
18,531 of these deaths occurred in the age period 0—5 years, so that the incidence
of these diseases (pneumonia, broncho-pneumonia and bronchitis) on child
life is still a heavy one.

What are the causes of these wide-spread and prevalent forms of disease,
and how far are they preventable ?

Famine, fatigue and exposure to cold have long been regarded as the
cardinal :etiological factors. Improved social conditions will ensure that the
body is adequately and suitably nurtured; the danger that an excess of
carbohydrate diet may produce the “ catarrhal child " is to be noted ; over-
fatigue can be guarded against, and care can be taken to protect persons,
especially susceptibles and young children, against exposure to low extremes
of temperature. Sometimes an individual may constitutionally have an
undue susceptibility to respiratory disease. Again, the statistics of the
Registrar-General show that mortality from respiratory diseases in urban
districts is much greater than that of rural districts, although the county
boroughs of the south of England suffer less than the rural districts of the
north.

The prevention of respiratory diseases begins in infancy. Colds should
never be neglected. If made light of in childhood bronchitis is a common
sequel, and this may be followed by broncho-pneumonia; even if the child
escapes or survives pneumonia, chronic infective conditions of the mouth,
nose and throat frequently persist, and are often associated with adenoids
and enlarged tonsils, with constant liability to severe complications.

Lastly, prophylactic vaccine treatment is to be encouraged. At Brampton
Hospital a regular clinic has been established for this purpose. It is found
that the administration of a reliable stock vaccine does diminish the tendency
of patients to suffer from winter colds, influenza and bronchitis.

88

skill, as to reduce, and in many cases remove, the very sequelae
which are their continuing and intrinsic evil for the great mass of
the people.* Hence, we need to make available for all that better
nursing, that higher degree of medical skill, that closer home attention,
which has hitherto been the lot of the favoured few. It is a long
task and a complex one, but it must be attempted, and much more
careful attention should be given to it by medical practitioners and
by public health officers and school doctorsrf'

Tuberculosis.

100. Tuberculosis is insidious but invasive. As Sir Samuel
Garth said in rhyme :—
" While meagre Phthisis gives a silent blow,
Her strokes are sure, but her advances slow ;

No loud alarms nor fierce assaults are shown,
She starves the fortress first, then takes the town."

Whilst tuberculosis remains one of the principal national scourges, it
is important to recognise that it is steadily declining. The fall
in the mortality of tuberculosis of the respiratory system in England
and Wales is set out in the following significant standardised death
rates per million living (1847—1924) :—

 

 

Year. Male. Female. Persons.
1847 . . . . .. .. . . 3,065 3,306 3,189
1867 . . . . . . . . . . 2,669 2,638 2,653
1887 . . .. .. . . . . 1,809 1,568 1,685
1907 . . .. .. .. .. 1,315 948 1,125
1924 .. .. .. .. .. 904 708 801

 

 

 

Such a long series of years cannot be quoted for non-pulmonary
tuberculosis, but that also in recent years has shown steady reduc-
tion. The past history of the decline of this disease is not only full
of encouragement as regards its relative conquest, but also of
instruction as to the factors which have played a chief part in its

 

* Reference may in this connection be made to the Report on the Preven-
tion of Mortality and Disablement due to Measles and Pneumonia in Children
by Dr. A. S. MacNalty (Reports to the Local Government Board on Public
Health and Medical Subjects, New Series, No. 115, 1918) in which the avail-
able information bearing on the pathology, clinical features and treatment of
measles and pneumonia, on the circumstances determining death from
these diseases and on practical measures for rendering them less fatal was
collected and analysed, and also to Circular 35 of the Ministry, issued on the
28th November, 1919 (Measles and German measles), in which the practical
measures which are desirable in dealing with outbreaks of measles were.
summarized.

1' See On the State of'the Public Health, 1922, pp. 59—65.

89

defeat. First among these is the increase in the powers of resistance
of the individual by sound nutrition, the practice of hygiene and the
immunisation of the people. Social amelioration and cheap food
have played an important part. Secondly, there has been an
improved practice in prevention of the spread of infection from the
diseased to the healthy, and by the control of tuberculous milk or
meat. It is, however, still true to say that the proportion of bovine
to human infections is relatively high in children under five years of
age, and in those forms of tuberculosis which are primarily in the
alimentary tract. Results obtained by Dr. Stanley Griffith show
that of the species of B. tuberculosis isolated from certain sites,
chiefly in children, bovine strains were found as follows: 46-5 per
cent. from glands of the neck; 18.3 per cent. from bones and
joints ; 50-8 per cent. from the skin (lupus) and 38-4 per cent. from
scrofulodermia; 1 -31 per cent. from lungs (pulmonary tuberculosis) ;
and 41 - 3 per cent. from alimentary and mesenteric infection in children
under 10 years of age. The third great line of defence is the care
of the general health, including improved housing, less overcrowding,
industrial welfare, the open-air life, and adequate infant and child
welfare service. Fourthly, there is the education of the people in
the practice of health, and the formation of sound habits of hygiene.
Lastly, there is the direct attack by particular methods on this
particular disease—(i) prompt and early notification, (ii) domiciliary
and dispensary treatment, (iii) the sanatorium, (iv) the hospital,
(v) the village settlement, and (vi) proper and effectual means of
after-care. In 1924 there were in England 360 tuberculosis officers
working under the Local Authorities, 457 dispensaries, and 460
institutions (including sanatoria) with accommodation for 20,750
persons. The two “ Village Settlements,” at Papworth in Cam-
bridgeshire and Preston Hall in Kent, both of them under the
direction of Dr. Varrier—Jones, are admirable illustrations of what
can be accomplished by this means.

101. Whilst the sanatorium principle is perfectly sound, and has
behind it an unanswerable body of experience, unfortunately it
remains true to say that the sanatorium system is not seldom
inefficiently practised. The true principles of the sanatorium treat-
ment of tuberculosis are these :—

(a) That the cure or continued arrest of tuberculosis is a matter of
prolonged and persistent endeavour, in which success can only
be obtained by maintaining patients under satisfactory hygienic
conditions of life for a long period, and in which the willing
co-operation of the patient is secured in the persistent carrying
out of the rules of a healthy life laid down for him.

((1) That an essential factor in obtaining permanent arrest of tuberculosis
is to secure the commencement of treatment in an early stage of
the disease, before destruction of tissue has proceeded too far
(and not at a stage when permanent arrest is hopeless or at least
unlikely) and continued for a sufficiently long period.

90

(c) That satisfactory conditions include appropriate therapeutic treat—
ment, suitable dietary without overfeeding, an open-air life, rest,
graduated exercise and occupation—all under direct medical
supervision.

((1) That full regard is bad to education and prevention ; and

(e) That in all cases there is an effective system of after-care.

Whilst the too sanguine hopes of those who expected impossi-
bilities from sanatorium treatment were naturally doomed to
disappointment, it is certain that the principles for which the
sanatorium stands must remain an essential and integral part of
the national practice in the struggle against tuberculosis, even if a
vaccine or therapeutic serum be forthcoming. But a sane and
measured View must be taken of what the sanatorium can do for the
various classes of patients committed to its care, and what it cannot.
It is only a part of a national scheme.

In a word, the essential element of sanatorium treatment, as
now conceived and as practised in the past by successful sanatorium
superintendents, is a carefully calculated balance of rest and exercise
under constant and watchful medical supervision, and under
conditions which permit of abundance of fresh air and sunshine,
adequate and nutritious diet, appropriate occupation, and quiet
and restful sleep. Such are the conditions which seem best calcu-
lated to increase the natural resistance of the patient, to promote
the healing of lung lesions, and to pave the way to more or less com-
plete arrest of the disease.* In certain cases these advantages can
be better provided in the home or elsewhere than in a sanatorium.

 

’* A special report was prepared by the Medical Research Council (No. 85)
in 1924 showing the following result for patients who had attended the Frimley
Sanatorium.

Survivors per 1,000 patients ten years after discharge from the Sanatorium.

Cases in Males. Females.
Early stage . . . . . . 782 887
Middle stage . . . . . . 382 497
Advanced stage . . 104 108

A similar inquiry has been made in Lancashire of patients with pulmonary
tuberculosis commencing sanatorium treatment in 1914—15, who were alive
ten years later.

 

Number of Survival
Cases. Number. patients known rate
to be alive. per 1,000.

 

 

Patients with positive sputum . . — 107 224
Patients with negative sputum . . —— 201 635
Total . . . . 763 308 403

 

 

 

 

In Birmingham, out of 946 patients treated in the Sanatorium in 1913,
618 were alive ten years later, giving a return of 653 per thousand. One
other example is from the Shirlett Sanatorium, Shropshire, where the number
of patients surviving after ten years was 402 per 1,000.

91

102. Speaking generally, the experience in this country and in
Germany and America suggests that the causes of failure of the
sanatorium system, or of any particular sanatorium, are :—

(a) The admission and retention of the unsuitable.

(b) The unwillingness of the ill-informed patient to enter the sanatorium
and remain sufficiently long for sound treatment.

(0) A lack of reasonable and available facilities for early diagnosis, and
the proper early selection of cases for admission.

( The unwitting or careless mismanagement of the sanatorium itself.

(e) Inattention to, or misapplied, after-care.

It is obvious that the mere existence of a comprehensive national
organisation designed to deal with this disease is not of itself suffi-
cient. There must be a close and effectual co-operation between all
the persons concerned—the patient, the practitioner, the school
doctor, the tuberculosis oflicer, the superintendent of the sanatorium
—as well as a close co—ordination between the various agencies and
facilities provided, in order to secure the complete control of this
disease. The infection of tuberculosis is probably almost universal,
and the fact that the majority of persons infected recover and live
long and useful lives is the most substantial of all evidence that the
disease can be arrested and even cured. The results of the action
taken in the last twenty-five years are full of hope and encourage-
ment as to its final defeat.

Influenza.

103. Influenza has been identified historically for several
centuries, appearing and causing great havoc in many countries,
at intervals which may have been so prolonged as to create the
impression on its reappearance that a “ new ” disease had emerged.
It has been associated with the English Sweats of 1485—1551, and was
undoubtedly met with by Sydenham, Willis, and the seventeenth-
century epidemiologists, as one of a group of correlated infections,
prevailing epidemically in successive years. In the nineteenth
century came pandemics of influenza.* Prior to 1890 few deaths
had been registered as due to influenza since 1848 ; in the three years
1890—92, 4,523, 16,686 and 15,737 deaths successively were ascribed
to this cause.1‘ Since then influenza has continued to be returned as
a common cause of death each year, the lowest number of deaths
returned under this heading in England and Wales in any year
being 3,753 in 1896 and 4,334 in 1911, as compared with 12,417 in
1899, 16,245 in 1900, and 104,738 in 1918. In 1924, the number of
deaths from influenza was 18,986.

 

* The question of the inter-relationship or identity of this disease with its
allies was ably discussed by Sir William Hamer in an official report on
Influenza to the London County Council, 1919, No. 1963.

1' For an exhaustive account of the epidemic of 1889—92 see Dr. Franklin
Parsons’ two Reports to the Local Government Board. (Cd. 6387 and
Cd. 7051.)

92

104. The disease, in its initial stages, often affects the lungs with
small heemorrhages and infiltration of the lung substance. leading
on to various degrees of pneumonia, pleurisy, and purulent bronchitis.
The whole process is septicaemic with various secondary infections
and complications. Hence arise differing clinical forms, 'toxic or
typhoid, cerebral or mental, rheumatoid, gastro-intestinal, pneu-
monic. The symptoms differ accordingly, fever, respiratory mani-
festations from bronchitis to pneumonia, nervous, cardiac and
mental symptoms being predominant. Towards the latter part of
the pandemic of 1889—92 Pfeiffer described a bacillus which he had
discovered. The fact that this bacillus, if it be not the causal
micro-organism of influenza, produces much of the mischief in this
disease, is confirmed by its presence in large numbers in immediate
relation to minute lesions occurring in the lung and the excretions.
It is occasionally discovered in bronchial secretions and elsewhere
when there is no suspicion of influenza, and in a considerable number
of outbreaks, indistinguishable clinically from influenza, the Pfeiffer
bacillus has not been found, or in only a small minority of the total
cases. The predominant organisms recently (1915—1919) fOund in
influenza have been diplococci, micrococcus catarrhalis, the pneumo-
coccus, or a- haemolytic streptococcus. Our knowledge of the modes
in which the infection of influenza is spread is very imperfect.
We only know that, especially during the febrile stage, the saliva
and the nasal and bronchial mucus contain elements contagious to
man and virulent to certain animals, such as monkeys. Certain
facts have been reported, from which it would seem that not only
monkeys, but also domestic animals, particularly cats, dogs, and horses
were attacked by influenza during epidemics among human beings,
and might have been vehicles or agents in the diffusion of the virus.
The risk of infection depends on close personal contact and possibly
“ drop infection,” whilst the severity of infection seems related to
lowered resistance and possibly increased virulence. It would seem
that influenza confers on man an immunity of only slight degree and
short duration. Trials in preventive vaccination, bacteriotherapy
and serumtherapy made by various experimentalists have as yet
given only imperfect results. It cannot be otherwise, since (the
specific virus of influenza being unknown to us) these trials could be
carried out only with various non-specific organisms, such as the
bacillus of Pfeiffer, pneumococci, streptococci, &c. Vaccines or
sera prepared from those organisms appear to act only on the
secondary bacterial conditions associated with influenza.

105. The post-war pandemic presented itself in three waves,
affecting persons, in the main, between 16 and 40 years of age.
The first wave reached its maximum in June and July, 1918, the
second in October and November of the same year, and the third
in February and March of 1919. In London alone it carried off
18,000 persons, and in India six millions. The disease spread

93

rapidly throughout Europe, Asia, Africa, and Australia, and though
most fatal in its second wave, had, on the whole, a fatality relatively
slight compared with its severity of incidence and attack. No
doubt, the excessive mortality of the second wave was in part due
to seasonal conditions, shortage of food and fuel, and aggregations
and movements of population. Whilst, therefore, certain conditions
affected the epidemic which lie beyond human control, a significant
feature of influenza, as also of epidemic pneumonia, is the dependence
of its prevalence on personal infection due to (a) aggregations of
susceptible persons ; (b) in ill-ventilated and overcrowded conditions ;
and (c) of relatively low resistance. It is also significant that simple
measures, when practised, were effectual in avoiding or reducing
the degree of infection. Fresh air, “ nasal drill,” antiseptic appli-
cations to the nose and throat, physical exercise, ample food supply,
segregation, and avoidance of fatigue, chill, and alcoholic excess,
probably sufficed in many cases to prevent attack from the disease.*

E 15 idem ic Nervous Diseases.

106. The chief diseases which fall into the category of epidemic
nervous diseases are cerebro—spinal fever, poliomyelitis with its cere-
bral form, polio-encephalitis, and that disease of comparatively
recent recognition, encephalitis lethargica. It is only within the
last few years that the epidemiology of these diseases has been
intensively studied. Probably, the reasons for this are the impres—
sion of earlier teaching that nervous diseases should be regarded
as due to a chronic process, a thrombosis, arterial affection,
or some other degenerative change giving rise to sclerosis of the
nervous tissue quite apart from* any question of infectivity ; the
sporadic character assumed by types of epidemic nervous disease;
and the failure to recognise mild and abortive forms as connected
with the same disease.

With the exception of cerebro—spinal fever, which made a heavy
epidemic visitation in this country during the war period and the
incidence of which has now returned to pre—war figures, these
epidemic diseases of the nervous system show some tendency to
increase. The evil wrought by poliomyelitis and encephalitis
lethargica frequently does not pass with the subsidence of the acute
attack. It has been‘asserted that over half the patients who
survive an attack of acute poliomyelitis remain crippled to a greater
or less extent throughout life, while the mental and physical sequela:
of many cases of encephalitis lethargica, especially in children, are
severe, distressing, and often fatal. Cerebro-spinal fever is due to
a specific meningococcus ; poliomyelitis and encephalitis lethargica
are provisionally ascribed to filter—passing viruses. It may be

 

* See also Report on the Pandemic of Influenza, 1918—19, Ministry of
Health Series No. 4.

94

assumed that in epidemic periods the Viruses of all three diseases
are wide—spread among the population of the area affected. This
has been proved for cerebro-spinal fever and poliomyelitis, and
although at present bacteriological proof cannot be adduced in the
case of encephalitis lethargica, the epidemiological behaviour and
probable channels of infection of this disease resemble so closely
that of the other nervous diseases that the assumption appears
true for it also. These diseases appear to be disseminated by case-
to—case contact, but the links in the chain of infection are broken,
first, by the fact that the causal organisms die out quickly; and,
secondly, because many persons infected do not contract the disease
owing to lack of that mysterious catalytic agent of infection which
is termed susceptibility. “ Carriers” may transmit epidemic
nervous disease to others or may more rarely themselves develop
a declared type of nervous illness. All three forms of nervous
disease resemble one another in that they give rise to mild and
abortive types which often, pass unrecognised and yet have all the
potentialities of disseminating the epidemics in their gravest form.*

107. Cases should be promptly notified, an alert watch kept for
abortive and mild types, and ” contacts ” supervised. In View of
the severity of epidemic nervous diseases, and the value of good
nursing for the patients, it is important to secure hospital and
nursing service as far as possible. Those in contact with the case
may be advised to use antiseptic nasal sprays or douches and
gargles for the throat. Any person in the infected household
who suffers from symptoms suggesting an abortive attack should
be treated from this point of view and isolated until recovery takes
place. After-care, particularly of mental cases, is essential. With
regard to cerebro-spinal fever, overcrowding and the avoidance of
fatigue are predisposing conditions to be guarded against. Pro-
phylactic doses of anti-meningococcic serum have proved dis-
appointing; but, as Sir Humphry Rolleston has shown, experience
in the Navy during the war testified to the beneficial influence of
the serum in the direction of diminishing mortality. If paralysis
occurs in poliomyelitis, permanent crippling can only be avoided
by prompt and long-continued orthopaedic treatment and super—
vision. The activities of the Maternity and Child Welfare Centres,
the School Medical Service and Orthopaedic, Schemes should all be
co-ordinated with other branches of the Public Health Service in
' preventing, treating and investigating epidemic nervous diseases.

viii.
The Prevention and Treatment of Non-Infectious Disease.

108. For many years the administration and practice of‘
Preventive Medicine has been confined, largely, to two principal

 

* A. S. MacNalty :' Milroy Lectures on Epidemic Diseases of the Central
Nervous System. The Lancet, 1925, I. 475, 532 594.

95

spheres—that of the environment and that of infectious disease.
The time seems to have come for including all disease which is
preventable within the conception of Preventive Medicine.

We have already seen that the ordinary infectious diseases
contribute only a fraction of the disablement and invalidity which
are undermining the public health, and that the real battle lies
elsewhere. Looking over the world generally, the modern infective
scourges of the human family are tuberculosis, malaria, plague
and influenza. Yet even so, the vast bulk of invalidity is due to
other morbid conditions. Abortion, miscarriage and still—births are
due principally to conditions other than these infective scourges.
Infant mortality is caused, in the main, by prematurity and atrophy,
by respiratory disease and by digestive disorders. The bulk of
the disabilities of child life are due to measles. rickets, catarrhal
conditions, defects of the senses, dental decay and malnutrition.
The war revealed that the physical defects of recruits were general
impairment, dental decay, flat-foot, poor eyesight and indigestion.
Sickness benefit under the Insurance Act is principally among men
for bronchitis and indigestion, for' diseases of the nervous system,
for debility, neuralgia and neurasthenia, for skin disease, anaemia
and a dozen forms of sepsis; and among women the disabling
conditions are anaemia, intestinal stasis, catarrhal and gynaecological
maladies, and dyspepsia. Even when we come to the hospital
categories and the death returns we find we have to deal not with
infectious diseases chiefly, but with disorders of the heart and kidney,
cancer, and injuries. It is, of course, true that many of the
conditions here named find their origin in infective processes, but
it is clear that a comprehensive understanding of Preventive
Medicine must include much disease not classified as infectious,
and all disease which is preventable. For it is such conditions which
are undermining the health of the people, for which vast numbers
of recruits have been rejected, and which lead to an appalling waste
of time, capacity and production. As types of diseases which hitherto
have been conceived as non-infectious (though infection cannot
always be excluded, and may indeed be causal), and yet which
present knowledge justifies us in considering, in part at least, to be
preventable, we may briefly consider rheumatism, heart disease,
rickets, mental disease, dental caries, certain forms of indigestion,
diabetes, and some surgical conditions. This group is by no means
exhaustive, but it illustrates both some of' the great systems of
the body in respect of pathology and some of the principal disabling
or mortal diseases which are more or less preventable.

A cute Rheumatism.

109. There is still much confusion in the medical profession,
as well as among the lay public, on the subject of rheumatic

96

affections. Acute rheumatism, sometimes termed “ rheumatic
fever,” is a general acute disease of childhood and adolescence,
the result of infection by some unidentified organism which causes
acute inflammation of certain serous membranes. This disease
usually displays fever, pursues a definite course, and may attack
certain organs of the body, the most serious effects being heart
disease and chorea ; it does not give rise to chronic changes in the
joints. The term “ sub-acute rheumatism” is frequently used for
a milder form of the disease; this use has to be accepted as a
current term in Medicine; it is open to academic objection as
it so often relates to a fever in which the joints are less acutely
inflamed ; but the cardiac inflammation may be as serious in this
form as in those with more pronounced fever and synovitis. Acute
rheumatism is a clinical condition to be differentiated from the
composite group of derangements conventionally termed chronic
rheumatism which occur in adults, causing considerable invalidity
and diminution of working power, but without heart disease or
serious mortality.

110. In my reports to the Board of Education for 1912 and
1924, I dealt somewhat fully with the question of heart disease
and rheumatism in children of school age. The evidence seemed to
indicate that rheumatism is the main cause of organic heart disease
in children, though a certain proportion of it could be traced
to infective diseases, such as scarlet fever or diphtheria. In 1924
the Ministry of Health issued a special report on the Incidence of
Rheumatic Diseases, 8. record of an inquiry into the prevalence of
rheumatism among that portion of the working population which
is insured under the Health Insurance Act. In acute rheumatism
nearly 50 per cent., and in so-called sub-acute rheumatism nearly
25 per cent. of persons showed signs of recent or old inflammation
of the valves of the heart. In regard to causation, the Report
indicated that in acute rheumatism tonsillar sepsis may be an
important aetiological factor.

The extent of the evils wrought by aCute rheumatism can be
gauged to some extent by studying the mortality due to heart
disease. The total number of deaths in England and Wales in
1924, attributed to diseases of the heart, was 60,650, yielding the
highest proportion per thousand (128) deaths from all causes. If
diseases of the circulation be added to those of the heart, 168 deaths
per thousand were attributed to these conditions. Many of these
deaths are due to other causes, especially syphilis ; but it is incon-
testable that most of the deaths from heart disease in children,
congenital heart disease being excepted, as well as a heavy
proportion of the adult deaths, especially those in the earlier
age groups or before middle life, are due primarily to acute
rheumatism.

97

l l 1. The following lines of action, which I have discussed in more
detailin my annual reports on “ The Health of the School Child ” for
1924 and 1925, may be advised for the prevention of acute rheumatism
and its formidable consequences.

(1) First of all intensive and organised research is required. A knowledge
of the exact cause of acute rheumatism must be sought for. Bacteriological
investigations of the disease and its behaviour must be co-ordinated with
clinical and epidemiological inquiries.

(2) Following-up.—The School Medical Officer should establish a register
of all the children suffering from the principal manifestations of acute
rheumatism, especially heart disease and chorea. Such children should be
individually studied and kept under observation.

(3) Dissemination of Information—Parents and teachers should be
informed of the significance of acute rheumatism and its early symptoms.
The dangers of neglecting “ growing pains,” sore throats, anaemia, the early
signs of chorea, &c., should be impressed upon them and steps should be
taken to familiarise them with the symptoms which indicate the possible
onset of acute rheumatism and with the means which may be taken to guard
the child from conditions such as damp rooms, damp boots or clothes, which
may predispose to the disease.

(4) Exclusion from School.—Exclusion from school or otherwise of children
suffering from the effects of acute rheumatism should be determined by the
activity of the disease, the state of the patient, and the conditions of its home
life and circumstances. A modified curriculum may be desirable.

(5) There should be medical and surgical treatment suited to the case, in
school, home, clinic or hospital, and particular care should be taken to remove
any focal infection in teeth or tonsils.

(6) The School Medical Ofl‘icer should also advise in regard to the home
and social environment of the rheumatic child, its after-care, its upbringing
and employment.

(7) Children suffering from acute rheumatism require early hospital
treatment and there is need for more institutional accommodation for such .
children. Preferably they should be treated apart from other invalid
children and accommodated in separate open-air hospitals or residential
recovery schools, where " team " and co—operative research can be made
into differential diagnosis and causation, and where suitable treatment, training
of the body, and education of the mind are available, and where rest and
convalescence may be prolonged. Where hospital accommodation is not
available, children should be kept under regular supervision at the Child
Welfare Centre, at the School Clinic or at special Cardiac Clinics. There
should be active and close co-operation between such work and the hospital
service of the area, and between hospital almoners and Care Committees.

(8) Finally, it must not be forgotten that while acute rheumatism is a
disease of childhood and adolescence, its cardiac manifestations are often
prolonged into adult life. The prevention and treatment of heart disease in
the adult requires, therefore, consideration, planning and systematisation-

Chronic Rheumatism.

112. Quite apart from Acute Rheumatism, considered in the
preceding section, there exists a number of changes which in adult
life, and especially after middle age, affect muscles, tendons and
joints ; these are associated with pain, deformity and impairment of
motor function; sometimes acute in onset (acute rheumatoid

(B 32/931)Q D

98

arthritis) and then often confounded with or mistaken for acute
rheumatism. They usually have an insidiously progressive course,
but are liable to exacerbations and remissions. The classification
of this composite group of derangements, known collectively as
" chronic rheumatism " in the Special Report of the Ministry of
Health, 1924, is divided into two groups as f0110ws :—
Group B.*—Non-articular manifestations of so-called ” rheumatism."
Muscular rheumatism (fibrositis), lumbago and sciatica with
brachial neuritis. Lumbago is separated from muscular rheu-

matism as being a clinical entity easily distinguishable, of occupa-
tional interest and of special incidence upon males.

Group C.T——-Is divided into four ; rheumatoid arthritis (including infective
peri-arthritis), osteo-arthritis, gout and unclassifiable chronic joint
change disease.

113. These diseases have been attributed to a variety of causes,
e.g., to changes due to poisons produced either by local or by systemic
invasions by bacteria, such as septic poisoning from dental disease;
to an unsuitable dietary; to age-influences; to disorders of the
endocrine glands ; to environmental influences ; to lack of or excess
of exercise ; to defective hygiene and to climatological factors, such
as humidity, actinic power of the sun, altitude and so forth. It is
obvious that a number of diseases are included under this so-called
Chronic Rheumatism. Sir William Osler remarked that there was
no disease entity to which the term could be applied and that it
would be an advantage to give it up entirely. Although as yet
positive bacteriological proof is lacking, chronic infection, either
with a specific organism or with various types, seems to afford a
reasonable explanation of the non-articular manifestations, such as
fibrositis, and of the chronic joint affections (rheumatoid arthritis
and osteo—arthritis). The acute onset with fever in many cases of
rheumatoid arthritis and polyarth‘ritis, the resemblance of the joint
lesions to those of gonorrhoeal arthritis, and the association of the
arthritis with definite foci of infection in certain cases are all in
favour of an infective theory of origin. The sources of such infection
may be many : apical dental abscess, pyorrhoea alveolaris, tonsillitis,
suppuration in the nasal sinuses, chronic bronchitis, pelvic disease
in women and prostatic disease in men, chronic infection from the
intestinal tract, &c.1 As the Ministry’s Report on the Incidence of

 

"‘ Group A comprises Acute and Subacute Rheumatism in the Ministry’s
classification.

TThe division between rheumatoid arthritis and osteo-arthritis in the
group was defined on the lines of Hale White’s symptomatology as given in
French’s " Index of Differential Diagnosis.’

1 For purposes of completeness gout has been included in the Ministry’s
classification of chronic rheumatism. But gout is a definite disease of meta-
bolism, though a septic focus may be present, and a disease distinct from the
chronic joint affections here considered. Heredity, alcohol, over-feeding and
lead are the chief causes of gout, and increased temperance in food and drink
and the prevention of chronic lead poisoning are mainly responsible for the
comparative rarity of gout in the present day. Its decline is a notable
instance of the value of preventive medicine

99

Rheumatic Diseases indicated, each year these diseases are costing
the Approved Societies nearly 7£2,000,000 in sick benefit, and the
nation over 3,000,000 weeks of lost work, for the insured population
alone. Half this loss, both of money and of time, is due to chronic
joint diseases. With regard to non-articular manifestations, as I
stated in my introduction to the Report :——

" The great importance of any steps which will diminish the incidence
of these non-articular " rheumatic ” diseases will be appreciated when
it is, considered that supposing the sample population here taken to
be a fair one, there must be approximately 56,000 cases of muscular
rheumatism, 90,000 cases of lumbago, and 27,000 cases of sciatica and
brachial neuritis occurring each year in insured men in England and
Wales. In addition, each year there will be some 52,000 cases of
non-articular ” rheumatic " cases amongst insured women."

114. In the prevention of these complex affections, we can
endeavour to remove the conditions in the individual, assigned as
probable sources of infection, but our campaign will be all the more
effective when we are acquainted with their causes. To this end
encouragement should be given to all forms of research in connection
'with these diseases. Much might be done for the treatment of
chronic rheumatism by the formation of arthritic hospitals, special
clinics (such as the Pilkington Hospital at St. Helens, Lancashire),
or by the further development of suitable spas, at some of which
enlightened medical practice is steadily gaining ground in the
treatment of chronic rheumatic conditions. '

H eart Disease.

115. Of Harvey’s discovery of the Circulation of the Blood,
Sir John Simon said : ” To medical practice it stands much in the
same relation as the discovery of the mariner’s compass to naviga-
tion; without it the medical practitioner would be all adrift, and
his efforts to benefit mankind would be made in ignorance and at
random. . . . The discovery is incomparably the most import-
ant ever made in physiological science, bearing and destined to bear
fruit for the benefit of all succeeding ages.”*

116. One of the largest contributors to the death rate between
the years 40—60 is heart disease. In 1924 it was reported that
79,428 persons died of diseases of the heart and circulation, of
whom 15,660 died between 40 and 60. Yet cardiac disease under
60 years of age is, in large measure, a preventable disease. In

 

* Harvey Tercentenary Memorial Meeting, Folkestone, 1871. His discovery
created a new understanding, a fresh orientation, of the whole part played.
by the heart and circulation in both physiology and pathology. = ‘

(B 32/931)q D 2

100

childhood and youth the undeveloped circulatory system is
unstable, in both the heart itself and in the nervous control
of the heart ; there is a low and inequable vaso-motor tone, easily
disturbed, and there is a considerable range of physiological
variation which must not be mistaken for evidence of disease.
At and after the age of 4 or 5 years rheumatic fever, scarlet fever,
pyaemia and pneumococcal infection begin to exert effects on the
circulatory system which, if neglected, may readily become per—
manent. In adult life, there must be added fatigue, degeneration
of the arteries, chronic bronchitis, emphysema, renal disease,
alcoholism, syphilis, and the direct effect of bodily and mechanical
strain on a heart enfeebled by infection. “The dominant factor,”
says Sir Thomas Lewis, “ is invasion of the heart by infective
organisms or their product, and a consequent weakening of the
myocardium. . . . When it is thoroughly grasped that infec-
tion has more to do in heart failure than has strain or a mechanical
defect in the heart itself, at all stages of the disease, in its initiation,
in its development and in its progress to immediate circulatory
embarrassment and death, then and only then is the natural history
of heart disease understood.”* The symptomatology of heart
disease has been defined with equal precision by Sir James Mackenzie.
“ The heart’s efficiency,” he says, “ can be ascertained by recog-
nising the manner in which it responds to effort. The first sign of heart
failure is shown by a sensation of distress on the individual under-
taking some effort he was accustomed to perform in comfort. The
chief sensations of distress produced by the exhaustion of the
heart are breathlessness or a sense of constriction across the chest
or pain.”1‘

117. Thus, in our own time, we have seen the knowledge of the
heart in disease revolutionised almost as completely as was its
physiology by Harvey. The work of Gaskell and of Engelmann on
the functions of the heart muscle and the clinical studies of the late
Sir James Mackenzie, Sir Thomas Lewis, Wenckebach and others
have not only altered former conceptions of heart disease, but have
replaced empirical remedy by treatment at once more scientific
and more effectual. The old views of the neurogenic cardiac
mechanism with its musculo-motor nerve centres, controlled by the
higher centres through the vagi and sympathetic nerves, first gave
place to Gaskell’s discovery of a myogenic source for the action of
the heart. With the aid of well-devised instruments, the polygraph
and the electro-cardiograph, physicians are enabled to study the
clinical disturbances of the heart and a whole science of cardiac

 

* The Soldier's Heart and the Effort Syndrome, 1918, p. 37.
1' The Future of Medicine, by Sir James Mackenzie, M.D., F.R.S., 1919,
p. 116.

101

irregularities has been evolved in less than a decade. Here, again,
laboratory work underwent prompt clinical application, although
in many cases the process was reversed and the polygraph studies
of Sir James Mackenzie, 'done at the bedside, amid the stress of an
arduous general practice at Burnley, revealed hitherto undiscovered
physiological truths.

118. Heart disease may thus be a form or expression of an
infective process. And the heart so infected fails because the
heart muscle is weakened and unhealthy, and its capacity to pump
is reduced. Murmurs, enlargement, irritability, irregularity, even
alterations in blood pressure, as well as many of the symptoms of
heart trouble, are in large degree due to mechanical effects of
myocardial involvement. Heart disease is, broadly, disease of the
heart muscle and its nervous mechanism of control, and it is caused
by conditions which are in the main preventable, at least in the
earlier years of life. For over and above infection, there is the
large group of secondary conditions of the heart following on primary
lesions elsewhere in the body. There is the mechanical strain on
the heart resulting from high arterial tension due to certain occu—
pations, strain, the plethoric habit, or gout or renal disease ; great
vicissitudes of temperature and exposure to weather may tax the
accommodating power of the heart ; violent or exceptional exertion,
and unfavourable hygienic conditions tend to malnutrition and
degeneration of the heart muscle; excessive use of alcohol or
tobacco; a dietary and a sedentary habit which lead to obesity
and chronic renal trouble lead also to cardiac disease. The
prevention of organic heart disease thus becomes partly the escape-
from the sequelee of infection, and partly the avoidance of mechanical
and vital strains cast on the circulatory system by secondary
conditions due to pathological processes in the body, accentuated.
not seldom by the habit or occupation of the patient ; for whilst
the modern understanding of heart disease lays its chief emphasis.
on infection and the condition of the myocardial muscle, the effect
of these collateral conditions cannot be ignored.

All this new knowledge helps in the prevention and treatment
of heart disease. Irregularities of the heart, which if untreated
and unchecked might lead to permanent disorders, can now be
recognised in their early stages and effectively treated. The
administration of cardiac drugs has been placed for the first time
on a rational therapeutic foundation. A new and important drug—
quinidine—is now coming into general use, which by abolishing
auricular fibrillation, will often postpone or prevent the onset of
heart failure, in the treatment of which digitalis still holds its
premier place. It is now largely realised by medical practitioners
that a mitral systolic murmur may be compatible with a useful

(B 32/931)Q D 3

102

and active mode of life, and that the existence of congenital heart
disease does not necessarily imply the early death of the patient.

119. Preventive medicine suggests, first, the prophylaxis of
infection and reduction of the factors inimical to the heart ; secondly,
the avoidance of the ill-effects of dilatation and irregularity due to
pressure on an organ upon which an infective process has already
set its mark, in other words, to relieve its burden; and, thirdly,
what may be described as the physiological treatment of early
cardiac 'disease and high blood pressure (hyperpiesis), to ward off
untoward results, by supervision, in youth and adolescence, of
cases of infectious disease, rheumatic fever, and disordered action
of the heart ; by rest, fresh air, exercise and hygiene treatment;
by elimination of toxic influences; and by increasing natural resist-
ance. Judicious exercise up to the point of discomfort, breathless-
ness, or pain is one of the most useful forms of treatment. Both
organic and functional pathological conditions of the heart afford
striking illustration of disease as a process.

The patient seeks medical advice always at a given stage, almost
invariably at a late stage, and what is necessary in order to reduce
the heavy tax now made both on the capacity and on the vitality
of a community in respect of heart disease is something of a new
attitude ]towards it. Such an attitude seeks to understand (a) the
origin, (b).'the differentiation between organic and functional factors,
operating‘often in the same patient, (0) the relationship of the heart
condition‘to the whole morbid process going on in the body, (d) the
bearing which the habit and occupation of the patient have on these
factors, and the beneficial effect of a hygienic régime and a course
of prophylactic treatment upon them, and (6) above all, the proper
following up and “ assessment ” of the case. Here, however, I am
pleading, not for any particular form of specific treatment of heart
disease, which is not my concern at the moment, but for a new
bearing towards it which shall be etiological and prophylactic in
spirit, a comprehension which shall embrace a larger appreciation of
its preventability and a wider understanding of the relations of
social, domestic and industrial life to its occurrence, and which shall
apply and adapt the new methods of estimation and assessment
which have proved so valuable duringand since the war.

Rickets.

120. Rickets is another example of a non-infectious malady
which may be in large degree preventable. Its anatomical, clinical
and pathological characters were first authoritatively described in
England by Francis Glisson in his Tractatus d5 Rachitide in 1650.
The disease has been long prevalent in this country, and though

103

relatively non-fatal, is one of the most fertile of the crippling and
disabling diseases of early childhood. In 1911, in England and
Wales, 954 deaths of children under five years of age were ascribed
to rickets as the primary cause ; for the year 1924 only 455 deaths
were so ascribed. Yet rickets is a serious factor in national ineffi~
ciency, for it often leads to structural malformation of bones and
teeth, to a lowered power of resistance, and to the occurrence of
respiratory complications. Holt observes that the encroachment
upon the lungs by a thoracic deformity may in itself be enough to
keep a child in a delicate condition and retard its growth, while
such a condition is a constant invitation to acute attacks of
bronchitis and pneumonia.

Rickets is a constitutional condition, though the hypertrophy of
cartilage and the defective formation of osseous tissue is its out-
standing manifestation. The important researches both in the
laboratory and the hospital conducted in England and America
have made rickets not only preventable but prevented. Some.
difficulty is now experienced in finding a typical case of rickets for
demonstration to medical students in the practice of the London
hospitals. The studies of Professor Noel Paton, Dr. Leonard Hill,
Professor Mellanby, Dr. Findlay, Dr. Harriette Chick and a band
of fellow—workers have already greatly affected our practice in this
country in the feeding of children and the control of rickets. This
recent work has proved that there are two outstanding factors
involved in the etiology of rickets :——

(l) The amount of a substance (anti—rachitic vitamin) in the
diet having similar physical properties and distribution
to vitamin A. ‘

(2) The degree of exposure to sunlight.

In addition, the American school of workers, as the result of
work with rats, has laid stress on the absolute and relative amounts
of calcium and phosphorus in the diet. Mellanby attaches much
importance to the amount and type of energy-bearing food-stuffs,
and more particularly the amount and type of cereals eaten.*
Whilst the exact cause of rickets is not yet clear, it is a disturbance
of metabolism brought about by many factors, of which deprivation
in the child’s dietary of anti-rachitic vitamin (Fat' Soluble A) and
lack of sunlight are the most important.

 

* For a useful summary of the modern work on Rickets see Medical
Research Council, Special Report Series, No. 38 (revised) “ Report on the
present State of Knowledge of Accessory Food Factors (vitamins).” Second
Edition. London, 1924. Price 45. 6d. net. Also Experimental Rickets
(Mellanby), No. 93, 1925.

(B 32/931)g D 4

104

121. The means of prevention are proper housing, sunlight in
the open-air,* adequate parental care and a suitable dietary. Cod-
liver oil, the richest known source of the anti-rachitic vitamin,
has been proved by laboratory and clinical experiments to have a
specific prophylactic and curative value; milk, eggs, butter, and
green vegetables have also definite anti-rachitic action (though
milk and butter show great variation in this respect).

Mental Disease.

122. “ Soundness of mind,” wrote Sir Thomas Clouston, of
Edinburgh, “ is the master key to all human effort and progress.”
That surely is the proper view point from which to consider the
work of preventive medicine in relation to lunacy and mental
disorder. First, we must seek to maintain the mental health and
capacity of the people; secondly, the whole problem of mental
inefficiency must be handled from the preventive side; thirdly,
more attention must be given to early mental disorder, to intermit-
tent and recurrent cases, and to mental aberration associated with
other disease; and, fourthly, the prevention and treatment of
mental disorder must be pursued along the lines of psychology and

physiologyxl'

123. The primary causes of insanity may be grouped under the
headings of heredity, environment, physical or bodily conditions,
and mental or psychological states. The relative appreciation of

 

* The beneficent influence of the rays of the sun in maintaining health
and in the prevention of disease has been recognised from the days of the early
civilizations. The action of sunlight is twofold. There is a direct effect
shown vividly on the exposure to the sun's rays of the body of a child suffering
from rickets; changes are brought about in the blood serum aflecting
particularly the quantity and distribution of calcium and inorganic phosphorus
which lea'd to the healing of the rachitic condition. There is also an indirect
effect shown by the feeling of comfort and well—being associated with the
warmth produced by sunlight.

These health-giving properties of sunlight are, for the most part, due to
the ultra-violet rays, which are found at their maximum at high altitudes
where appr0ximately three-quarters of the sun energy is available. At sea
level the proportion becomes reduced to about one-half, and in the smoky
atmosphere of a large city, to a quarter or less. Passage through glass almost
completely arrests the ultra-violet rays. The maximum advantage is obtained
from sunlight when the warmth of the sun’s rays is associated with a breeze.
The movement of the air leads to evaporation and a consequent cooling of
the surface, circulation of blood and lymph and the processes of metabolism
being increased. Some of the value of sunlight in the prevention of rickets is
obtainable by forms of light radiation (carbon-arc lamp, mercury vapour
lamp), which, like cod—liver oil, exert preventive and curative effects on
rickets. Artificial light is likewise useful in other conditions.

1‘ In Pinel‘s classification there were four groups of insanity, melancholia,
mania, dementia and amentia. Since his day there have been suggested
numerous subdivisions and diflerentiations of these classic terms, various
forms of insanity (confusional, maniacal, delusional), amentia, dementia,
psychoneuroses, &c.

105

these factors in the production of insanity still depends to a large
extent upon their protagonists. The hereditary tendency towards
insanity may be latent, and may not even appear in the individual
until some stress as an exciting factor is brought to bear upon the
psychopathic predisposition. The exciting factors may be (1)
physical, e.g., trauma, infection, toxic factors, unhealthy environ-
ment, unsuitable diet or (2) psychical, e.g., worry, emotional stress,
overwork. These exciting factors may also give rise to mental
disorders in individuals without a family history of insanity. In
a sentence, the causes are heredity and stress. The'Board of Control
found that the aetiological factors of 12,605 cases of first attack of
insanity showed in men the principal causes in order to be alcohol
(25-4 per cent); heredity, mental stress, syphilis, and senility
(11 -6 per cent.) ; and in women the principal causes in order were
heredity (28-0 per cent), mental stress, senility, puberty and the
climacteric (15-9 per cent), and alcohol (10-3 per cent.). Whatever
may be said of some of these, it is certain that alcohol, syphilis
and mental stress are within man’s direct control. U The hope of
reducing the amount of insanity in the country lies more in the
steps which may be taken for preventing the occurrence of the disease
and for its treatment in the initial stages than in improved methods
of treatment when the disease has become confirmed.”* According-
to Carswell, hereditary taint manifests itself earlier in life than do
mental disorders due solely to toxic, infective or physical stresses ;
he estimated that while 43 per cent. of all cases have a constitutional
basis, 67 per cent. of cases arising between the ages of 15 and 45.
years are explained by inherited predispositionxf

124. Day by day medical research is demonstrating the increasing
importance of chronic toxaemia in the production of mental disorders.
Such infective foci diminish the resistance of the body, and by
producing degenerative changes in the nervous and endocrine systems,
dispose to and even determine mental disturbance. Insanity due
to syphilis, tuberculosis, alcoholism and the puerperium has long
been recognised. It is now substantiated that focal infections of
the teeth, tonsils, accessory nasal sinuses, alimentary tract and its
appendages—the gall-bladder and appendixfland of the genito-
urinary organs are'of importance in the causation of mental disorders.

 

* Fourth Annual Report of the Board of Control for Lunacy and Mental
Deficiency, 1917, (102), Part II., p. 7.

TCarswell, ]., Journ. Mental Science, London, 1924,1xx., p. 347. For the
prevention of hereditary insanity, systematised eugenics, sterilization of
defectives and measures of birth-control have been advocated. It may be
said at once that public opinion in this country is by no means ripe for the
compulsory enforcement of such drastic methods ; while it cannot be shown
that they rest on firm scientific foundations or are practicable and equitable in
application. The segregation of mental defectives is provided for in the Mental
Deficiency Act (1913), and this tends to diminish the propagation of the
individual so affected.

106

At the New Jersey State Hospital, Trenton, the number of discharges
increased from 37 to 85 per cent. after removal of oral and tonsillar
infections (H. A. Cotton, 1923). Encephalitis lethargica and endo-
crine deficiency are other factors newly recognised as calling for
attention. One of the most promising methods of treatment, as
war experience and American workers have demonstrated, lies
in the establishment of psychiatric clinics for dealing with early
cases of mental disorder, preferably attached to general hospitals,
in order that the physical causes of insanity may be treated currently
with the psychogenic causes. The clinics should be for in—patients
as well as out—patients; they should be equipped with a special
medical and nursing staff with facilities for consultation and free
from powers of detention. Hospitals, other than asylums or Poor
"Law infirmaries, are likewise needed for mental diseases, such as the
Maudsley Hospital in South London. Both at clinics and hospitals
there should be facilities for medical investigation, diagnosis and
education in addition to treatment.

That is the case for Preventive Medicine, but it must apply to all
grades and degrees, from mental retardation to insanity, from
mental disease which is nervous in origin to nervous disease which
is mental in origin. The whole field of pathological psychology
must be viewed as one problem, from childhood to old age, and
we must no longer wait for mental disease to be both created and
brought to maturity before action is taken. Hitherto, it would
almost appear that we permit conditions of life and labour which
tend to create lunacy—at an average rate of 21,000 certified cases
per annum—and then when lunacy has matured, and become
‘certifiable, we incarcerate the lunatic (130,000 notified insane
persons being under care in England and Wales) at an annual
cost of approximately £7,000,000. In addition to the certified
lunatics we have, it has been estimated, 150,000 persons (including
48,000 children) who suffer from feeble-mindedness,* and probably
not less than 10 per cent. of the child population are “ dull
and backward” as judged by educational tests.1' To these
formidable figures must be added a great mass of minor mental
affliction, psycho—neuroses and neurasthenia. Taken in sum total
mental disease and incompetence is a serious drain on the capacity
of the nation. Yet much of it is directly preventable. It is not
only a medical problem which thus faces us, but a social one.
Alcoholism, prostitution, venereal disease, neglected environment
and evil habit must receive attention. And in the wider sphere of
practical medicine we must detect, by the newer methods of
psychology, incipient mental disability and disorder, whether
associated with bodily disease or not—sensory and motor symptoms,

 

* Report of Royal Commission on the Feeble-minded, 1908.
TReport of Chief Medical Officer of Board of Education, 1922, pp.
107—110.

107

neurasthenia, hysteria, psychoneuroses, depression, and all the
borderland signs of degeneracy—and having detected these signs
we must act with the vigilance we should apply in incipient tuber-
culosis or heart disease, and with ample appreciation of the benefits
of open air, exercise and the hygienic way of life.

Dental Disease.

‘ 125. The School Medical Service has demonstrated beyond all doubt
wide—spread dental defect among children of school age, 67 per cent.
of whom require immediate dental treatment. The Departmental
Committee on Sickness Benefit claims under the National Insurance
Act pointed out the prevalence of dental caries among insured
persons, which produces “ much sickness of various kinds, resulting
in a drain on the sickness benefit funds.” The Prudential Approved
Societies have stated that “ neglect of teeth trouble is the cause of
quite half of the ill-health found among the industrial classes.” The
Army Medical Council have reported on the loss of man power to the
State owing to defective dentition. In the Scottish Command it was
estimated that " 44 per cent. of the men are dentally unfit, i.e.,
they lack the minimum of dental efficiency which will ensure effective
mastication of food.” In the Western Command, from April, 1917,
to March, 1918, between 80-90 per cent. of the recruits were in need
of dental treatment. (Recruits, aged 18-19, 83 per cent., recruits,
aged 19-44, 93 per cent). In the Northern Command, 84 per
cent. of recruits, aged 19—24, were suffering from decayed teeth.
In the general population it was found that the condition of the teeth
of the women was worse even than that of the men.*

There can be no doubt, therefore, of the prevalence of dental
disease. Some of it is of minor importance, but much of it is so
serious in degree that it leads to subsequent disease. Toothache,
pyorrhoea, and oral sepsis are the earliest local manifestations,
but they are not terminal conditions. The glands of the neck become
affected, mastication is interfered with, anamia and toxaemia occur,
and they are followed by general maladies in different parts of the
body, gastro-intestinal trouble, arthritis, and neurasthenia. The
tale of trouble which follows dental disease may be long and grave.
Yet it is a directly preventable condition.

126. The causes of dental disease are not yet fully understood.
It is generally agreed that the immediate cause is the erosion of enamel
by acid produced by bacterial action, but teeth vary greatly in their
susceptibility to such action. Professor J. McIntosh regards
Bacillus acidophilas odontolyticas as the causal agent of dental
caries ; he has produced artificial caries in vitro with pure cultures of

 

* Report of Departmental Committee on Dentists Act, 1919, Cmd. 33,
pp. 17—23.

1C8

this organism and support is given to his contention by the confirma-
tory work of Rodriguez (1922), Bunting and Palmerlee (1925) and
others.*

There should be little need in this age to emphasize the importance
of care of the temporary and permanent teeth and periodical visits
to the dentist. An investigation has been made under the auspices
of the Medical Research Council (by the Committee for the Investi-
gation of Dental Disease, Report No. 97, 1925) on the incidence of
dental disease in school children which reveals many interesting
facts as to the origin and course of juvenile dental caries. Caries
is a progressive disease ; arrest is uncommon, occurring in less than
1 per cent. of diseased permanent teeth. Of all these the six-
year molars decay most rapidly after eruption, 6-8 per cent. showing
signs of decay during the sixth year, 12-2 per cent. during the seventh,
23-5 per cent. during the eighth; and this proportion rises to 44
per cent. at ten years and 56-5 at 13, in the absence of treatment.
The second molars, which erupt at about 12 years of age, if uncared
for, decay with almost equal rapidity. It is important to educate
parents and older children concerning these three fundamental
'truths :—

(i) that the permanent teeth are worth preserving;
(ii) that neglect of the temporary teeth causes decay of the
permanent; and
(iii) that decay, once it has started in a tooth, will inevitably
end in the loss of the tooth unless the necessary treatment
is undertaken.

Suppurative periodontal disease, commonly known as pyorrhaea, is
one of the most wide-spread ailments of the present day: starting
usually in early adult life, its progress is slow and insidious,‘and
owing to the common absence of pain, it may remain unsuspected
by the individual affected. It may be local or general. Pyorrhoea
is responsible for general depression of health, for anamia, rheu-
matism and other indications of the absorption of septic material
into the body. The causes of the disease are not yet fully under-
stood, and are at present the subject of careful investigation by
several skilled workers. It is, however, known that certain local
conditions, such as spacing of the teeth, abnormal articulation, and
accumulations of tartar are predisposing causes, and that Bright’s
disease, diabetes and other general conditions have a similar tendency.
But whether the disease is primarily infective in origin, or the infection
is secondary to anatomical changes, is not yet established. That the
condition will ultimately be found to be preventable may be regarded
as assured.

 

‘ J. McIntosh, W. W James, and P. Lazarus-Barlow (1922) Brit. Journ.
Exp”. Pathol., 111, 138 ;——(1924) V, 175 ;—(1925) VI, 260.

109

127. Improvement in the health and physique of the nation
depends to a large extent upon the prevention of dental disease.
This fact has recently been illustrated in the records of an Approved
Society, which shows a reduction of over 40 per cent. in the number
of sickness claims for such ailments as anaemia, gastritis, dyspepsia,
and chronic rheumatism since the institution of dental treatment for
its members.*

In the present state of our knowledge, the means at our disposal
for preventing dental disease are four—fold: (1) education of the
people as a whole in the value of good teeth and the disadvantages
of diseased teeth; (2) the supply of an adequate diet to promote
the growth of perfectly formed and regular teeth; (3) instruction
in the daily practice of oral hygiene (in order to reduce fermentation
and infection) by means of a detergent dietary and the use of the
tooth-brush; and (4) periodical dental inspection with treatment
of the teeth by conservation, and where necessary by extraction,
restoration or regulation.

Indigestion and Alimentary Disease.

128. “ Defects and derangements of digestion,” said Sir William
Roberts more than 30 years ago to his class of medical students
in Owens College, Manchester, “ are among the most common of
human ailments. They not only complicate almost every variety
of disease, but they constitute by themselves a serious torment
to a large number of otherwise healthy people. Not a few of
those who bear a large and vigorous part in the world’s work, and
mayhap reach a green old age, are plagued half their days with
dyspeptic troubles.” The facts presented in a previous section of
this memorandum fully confirm this opinion. Whether we select
the insurance patient, the hospital patient, or the cause of the final
event, it will be seen how large a proportion of the sickness and
death there recorded is due to some form of indigestion or alimentary
disease. Yet, hitherto, Preventive Medicine has had little or
nothing to say in respect of this enormous and so largely preventable
group of diseases.

129. The process of digestion is physiological. Man must take
daily a certain amount of food in order to furnish heat, energy
and the repair of waste of tissue, the value of the food being measured
not by that consumed but by that assimilated. The degree of
assimilation will depend on the nature of the diet and the power of
digestion of the body. By the process of digestion in the mouth,
the stomach, and the intestine, the food—stuffs are altered to fit

 

* See “ Memorandum submitted by the United VVomen’s Insurance Society
on the first 91} years’ experience of the Society's Dental Scheme," issued fer
the Royal Commission on National Health Insurance.

110

them for absorption, by which they may ” become blood ” and
replenish all parts of the body and become also its framework.
What cannot so be used is, with other waste products of metabolism,
cast out of the body. The process is part of all animal life, and with
one exception is the most universal of all natural functions. But
there is this difference between supplying the body with food and
the lungs with air, that man has a wider freedom of choice as to
time, occasion and material in supplying food to his body than air,
and this is one of the reasons why the alimentary system is more
unfairly treated than the respiratory. For unfairly treated it is;
and many, perhaps most, of the ills which men suffer from disordered
function or disease of the alimentary system are due to ignorance
or neglect. They are conditions which are therefore avoidable.
" Prevent indigestion,” said Sir Lauder Brunton, “ rather than
cure it.”

130. Acute dyspepsia or acute gastritis usually follows some
error in the quality or quantity of the food taken. The principal
digestive derangements, however, are due to chronic dyspepsia, a
collective term embracing many complex conditions which at present
do not lend themselves to orderly classification. Some are disorders
of gastric secretion, like deficiency or excess of the gastric juice ; in
others there are derangements of the motor power of the stomach,
as in atomic dyspepsia and peristaltic unrest. Some forms of
dyspepsia are due to repeated attacks of acute gastritis or to
slow poisoning by a septic focus in the body; in many cases a
septic condition of the teeth and gums is responsible, whilst others
have a functional origin, “ nervous dyspepsia.” Chronic dyspepsia
is responsible for much ill—health, mental depression, and sometimes
for gastric ulcer and cancer.

Organic trouble of the nature of gastric or duodenal ulcer,
malignant or other disease, is often due to an infection, obstruc-
tion or imitation in some other part of the alimentary canal, with
or without absorption of toxins.* They are, not seldom, secondary
conditions, which began with a relatively mild, transient and re-
current but entirely preventable disturbance of the digestive process
—-in the stomach, in the intestine or in the appendix. The vast
bulk of disabling indigestion which brings patients in tens of
thousands daily to the doctors and to the hospitals consists of

 

* The recognition of such conditions has been aided to a great degree by
modern technique, for example, the use of X—rays combined with barium
test-meals, methods of gastric analysis, the gastroscope, and the determination
of basal metabolism. Organic causes of indigestion can now be differentiated
from functional ones ; the diet can be so planned and arranged by the physician
as to eliminate the indigestion-provocant in the individual. It remains true,
however, that once indigestion is established it is very difficult to remove it;
and that as with most diseased states the earlier medical advice and treatment
are sought the more hopeful is the prospect of cure.

111

dyspeptic indisposition of a functional nature. But owing to
neglect of treatment, incorrect treatment, ignorance of hygiene or
persistence in faulty habits, the bulk of it continues to be more or
less a disablement throughout life, and some of it, more of it than
we generally assume, leads to secondary and ultimately fatal disease.

131. But the problem is not as simple as it looks, and if Pre-
ventive Medicine is to play its part there must be a fuller under-
standing of the two—fold issue which it raises. For, first, there is
an issue concerning the dietary of man; and, secondly, there is
the question of the functioning and habit of his body.

The first issue concerns the food customs of mankind which are
an outcome of profound instincts and century-long experience——
dependent upon the fruits of the earth, temperature and tropical
climate, social conditions, religion, predilection, a score of factors,
habits and tastes. The consumption of rice, oatmeal or meat varies
nationally. In this country we eat more meat than most other
nations, and our meat and fish consumption is probablyincreasing ; in
recent years also the use of fruit foods has enormously developed;
sweets, jams, sauces, pickles, spices and prepared foods have also
increased in consumption; and fine-milled flour bread is used in a
variety of forms. Again, our food is subjected to elaborate cooking
processes, though not equally thorough in action or degree. Perhaps
the most remarkable development is the addition to our cereal,
farinaceous and flesh diet of innumerable articles and beverages
commonly assumed to be “ stimulant ” in action, such as tea, coffee
and alcohol. These articles are not in themselves nutritious, but
they dilute and change the food with which they are mixed in diet,
and they exert effects on the alimentary tract itself. Indeed, the
excessive consumption of tea and alcohol may prove to be causes
of dyspepsia.

We are now learning more about food-values. Food is not merely
a question of proteins, fats and carbohydrates, or even of calories.
Sir F. Gowland Hopkins’ discovery of vitamins has compelled us to
adjust our diet—tables. More than ever it behoves us to cherish
the fruits of the earth so that in due time we may enjoy them.
Green vegetables, salads and fruit play an important part in nutri-
tion, and their increased consumption of late years in this country
is a sign of health. Excess of starches and sugars in the diet is
to be avoided. Whole-meal bread is better than white fine—milled
flour bread. Tinned and canned foods should not bulk too largely
in the daily bill—of-fare. Deleterious preservatives in food are
indubitably responsible for some indigestion, and this problem is
now being controlled by- the State. Lastly, food should be
properly cooked, and in this matter, and in a knowledge of food-
values, the British housewife, often entering as a bride upon a

112

highly—skilled occupation without previous training. lags behind
her continental sister.

Here, then, we have the subject of dietary as it affects health.
“ As much mischief in the form of actual disease, of impaired vigour
and of shortened life, accrues to civilised man,” said Sir Henry
Thompson, the surgeon, ”from erroneous habits in eating as from the
habitual use of alcoholic drink, considerable as I know the evil of
that to be. . . . More than one-half of the chronic complaints
which embitter the middle and latter part of life is due to avoidable
errors in diet.”

132. The second issue is the functioning and habit of the indi—
vidual. The normal physiological action of the digestive system
depends upon health, exercise, rest, taste and idiosyncrasy—“ One
man’s meat is another man’s poison ”—and the diet must be re—
vised to meet the changes in the type of nutrition which naturally
takes place as the individual travels from youth to age. Sir W.
Roberts laid down as a rule in regard to regulation of diet the
two-fold question: Do you like it, and does it agree with you?
There is much to be said for it as a combined question, though
knowledge and experience are necessary for its answer. “ The
palate,” he used to say, “ is placed like a dietetic conscience at
the entrance gate of food, and its appointed function is to pass
summary judgment on the wholesomeness or unwholesomeness
of the articles presented to it. It is, of course, not infallible—
no instinct is—but so close and true are the sympathies of the
palate with the stomach and the rest of the organism, that its
dictates are entitled to the utmost deference.” Even here tradition,
upbringing, habit and cultivation play their part. The more
important question is, does your selected food agree with you P
Does it produce energy, heat and well-being ? and is its use accom—
panied by any ill results to body or mind? There are other
aspects of habit which must not be forgotten, and which unquestion-
ably have a large share in the production of disease. For instance,
(a) the irregularity of meals and the consumption of food in between
them, (b) the unvariated monotony of the regular meals, (0) the
failure to masticate, owing to defective teeth or other cause,
(d) the habit of drinking with meals and washing down food, (e) the
habit of bolting food, like posting letters, (1‘) over—eating, (g) chronic
constipation, (h) swallowing air at the time of eating, and (1') the abuse
of alcoholic beverages. This list of plain and obvious practices seems
hardly worthy of formal mention, but it records the eating habits
of vast masses of the people, habits which, though they may appear
to be trivial, lead unquestionably to a great and unnecessary burden
of disablement and disease.

A

133. The office of Preventive Medicine in regard to disease of
the digestive system is to adjust the national standards of diet to

113

the special peculiarities and changing needs of the individual; to
deal with the beginnings of ill—health, and so diminish that heavy
burden of suffering and death which follows upon organic disease
of the alimentary canal ; and to educate in the hygiene of dietetics
and digestion, with a view not only to preventing the “ deficiency ”
diseases, dyspepsia, alcoholism, intestinal stasis and infective
processes in the alimentary canal, but to building up a well—nourished
and resistant body.

Diabetes.

134. A word may be added upon Diabetes Mellitus, an example
of a non-infectious disease the serious effects of which have been
greatly minimised by recent advances in medical science. The
modern study of diabetes dates from Claude Bernard’s demonstra-
tion of the glycogenic function of the liver in 1857. It was early
appreciated that the application of ordinary hygienic principles with
special methods of diet could diminish or abolish the sugar output
in mild types of diabetes, particularly in the forms to which the term
Glycosuria would be more strictly applicable. Rollo, for instance,
in 1797, recommended the use of a meat diet. But the prognosis
in true diabetes remained grave and the younger the patient the
less likely was recovery. The tendency for the diabetic patient
to contract a rapidly progressive form of tuberculosis augmented the
gravity of the case. The first important therapeutic advance was
made by Allen, who introduced the starvation treatment of diabetes
in 1913. Then work on the biochemistry of the pancreas culminated
in 1922 in the isolation of insulin by Banting and Best at Toronto.
This substance was made by an alcoholic extract of the pancreas
which, when injected subcutaneously, lowered the sugar content of
the blood and urine. The application of insulin to the treatment
of persons suffering from diabetes soon followed. The isolation of
insulin thus constitutes a therapeutic landmark, but the results
obtained by its use are variable, sometimes disappointing, and in
every instance its use must be combined with considerable dietetic
restriction. (Beaumont and Dodds.)

Preventive Surgery.

135. Let me say at once that, from my standpoint, whilst I
regard Surgery as one of the foremost means of Preventive
Medicine, I recognise that it is, in the main, primarily individualistic
and curative. Yet one of its purposes is to prevent or remove the
causes and conditions of disease and disablement, and that is the
purpose also of Preventive Medicine. In a sense, no branch of
Medicine has done more to prevent disease within the last two
generations than surgery. First, the whole principle of modern
surgery is the prevention and abolition of sepsis. The object of
surgical intervention is not infrequently the removal of a focus of
suppuration or infection, and its method and spirit are directed to

114

the abolition of the septic process. “ The antiseptic system of
treatment,” said Lister in 1869, “ consists of such management
of a surgical case as shall effectually prevent the occurrence of
putrefaction in the part concerned ; ” and fifty-six years afterwards
Mr. Rutherford Morison is able to say that “instead of fearing
sepsis and peritonitis, surgeons now recognise that their most
important operations are for the prevention and arrest of them.”
Secondly, the direct action of surgery is often an exploration of the
origin and nature of the conditions of disease, and its history in
various directions marks it out as a truly experimental science, a
method of research, by which new knowledge is acquired of the
expression of disease and the means of its prevention. Thirdly,
the object of surgery is the removal of diseased tissues and the
prevention of malpositions, malformations, or disability. And this
prevention is associated with re-education of function. Lastly,
the surgeon, like the physician, follows the great teaching of Hippo-
crates in the ancient world and of John Hunter in the modern
world, that restoration and healing in the human body are effected
by powers inherent in the living organism.

136. The surgeon, like the physician, can only serve and assist
Nature by placing the body and its organs at her service, by removing
obstructions from her path, by supplementing and aiding her
processes, and by fortifying the body defences against the on-
slaughts of infection or trauma. In my view all this is of the essence
of Preventive Medicine. It is an alliance with Nature against
dysgenic forces—it engages the enemy, and indirectly, at least
in some of its aspects, it strengthens the defences of the citadel.
The occasions when surgery fulfils these purposes are numerous.
Abdominal surgery has proved its case as a preventive possibility
in various conditions, indeed it has altered our conceptions of the
origin of gastric and intestinal trouble and of its means of cure;
genito-urinary surgery has become more and more preventive in
purpose ; gynwcology has done much to correct the results of the
negligence, hazards and accidents of midwifery and the effects
of venereal disease; a fuller application of surgery to obstetrics
is steadily removing the dangers of child-birth and its maternal
sequelae; the ancient operation of circumcision is clearly pre-
ventive in aim, and so is the radical cure of hernia, particularly
its congenital form ; many minor surgical interventions, for hydro-
cele, varicose veins, septic wounds, flat foot, &c., are also preventive ;
the prevention of industrial accidents has been mentioned as a
branch of preventive surgery; the removal of fibrous adenoids
has prevented physical and mental impairment in the school child,
and of tonsils the spread of sepsis in ear, nose and throat ; the new
treatment of fractures and dislocations has returned many disabled
men to the ranks of industry in full efficiency ; the surgical treat—
ment of tuberculosis, infant paralysis and rickets has opened a new

115

life to the cripple; the surgery of the eye and the prophylaxis of
ophthalmia neonatoram have prevented blindness; and the work
of the modern orthopaedist has revolutionised our ideas of what
repair may be made to mean.

137. Perhaps no more hopeful example of the value of preventive
measures can be cited than their application in cancer. Surgical
removal of chronic ulcerated conditions of the skin, lips or tongue,
of moles, warts or gall-stones, are all examples of treatment of
conditions which, innocent in the first instance, may result in a
malignant growth at a later period. It is true that the number
of conditions to which this principle is applicable is at present small,
but itis permissible to hope that as knowledge grows it will increase.
The dividing line between innocency and malignancy is ill-defined
and the more that is learnt of the preceding local conditions the
more widely may the principle be applied. Even when cancer
itself has appeared, early operation affords the best chance to the
patient, although all risk of recurrence is not necessarily removed.
Many instances occur in which after a cancerous growth has been
removed, especially at an early stage, the patient has ultimately
died from an entirely different cause. There is, moreover, in-
dubitable evidence that removal by operation, even if it is followed
by recurrence, enables many patients to live natural lives in comfort
for considerable periods, while even in advanced cases removal may
relieve or prevent suffering. It has been shown that, judged by the
limited test of survival to three years, the results of the modern
operation for cancer of the breast are almost 50 per cent. better than
those of the older operation ; and that if this operation be done in
an early stage of the disease the percentage of survivors for that
period is from 65 to 80. Later and more detailed investigations
indicate that under such conditions the saving and prolongation of
life is greater still.*

Though at several other sites surgery cannot claim results
comparable to these, it is, through the aid of anxsthetics and
antiseptics, constantly extending its sphere and is responsible for
preventing much suffering and premature death. Within recent
years, too, surgery has availed itself, especially in respect of cancer,
of the newly-discovered and powerful agents, radium and X-rays.1'
Direct prevention of cancer obviously cannot be envisaged or
attempted on a large scale until more is known of its mode of
causation, and it is greatly to be hoped that recent researches will

 

* Reports on Public Health and Medical Subjects, N0. 28, Cancer of the
Breast and its Surgical Treatment, by Janet E. Lane-Claypon, M.D., D.Sc.,
Ministry of Health, 1924; also A further Report on Cancer of the Breast,
with Special Reference to its Associated Conditions, No. 32, 1926 (H.M,
Stationery Office).

T IWedical Uses of Radium, Med. Res. Council Rept. No. 90, 1924.

116

open the way to this much-desired goal. In the meanwhile such
preventive measures as are available are of a personal and individual
nature and are applied mainly through the medium of surgery.*

138. A modern instance of the association of preventive and
curative medicine is found in the recent advances in Orthopaedics
(@969, " straight ” and wat3iou, " a little Child "). Sir Robert
Jones, Sir Henry Gauvain, and others have been the pioneers
in this work. They have built up a new craft of conservative surgery
in which the knife is held in abeyance; by careful methods of
immobilisation and physical education the cripple is made straight,
and many a limb which under the older teaching would have been
lopped from its trunk is now preserved and made a useful member.
The chief causes of crippling are :—Congenital defects, Rickets,
Acute Poliomyelitis (Infantile Paralysis), and Tuberculosis. Pre-
vention of crippling, due to the last three of these causes, primarily
lies in the measures of prevention already discussed in regard to
rickets, epidemic nervous diseases and tuberculosis. If crippling
be established, early orthopaedic treatment is demanded. Only a
small proportion of crippled children suffer from congenital defects
and these, if properly treated soon after birth, are often easily rectified.
The considerations to be met in formulating a complete scheme of
orthopaedic treatment are referred to in detail in Sections VIII and
VII respectively of my Reports to the Board of Education for 1922
and 1923. Briefly, they may be summarized as follows :—

(1) Crippling defects—Steps which should be taken to prevent tuber-
culosis, rickets, infantile paralysis, &c.

(2) Ascertainment of the number of cripples in the area and the nature
of their defects. All public health officials, teachers, voluntary bodies,
&c., should assist in securing early detection of defective children.

(3) Provision of remedial facilities—

(a) Art orthopaedic hospital should be available to serve the needs
of an area. Local Education Authorities should secure by
arrangement with the hospital the services of an orthopaedic
surgeon for the examination and treatment of crippled
children.

(1)) The establishment of Orthopaedic Clinics at which children can
be seen at regular intervals for examination and treatment
by the orthopaedic surgeon and nurses acting under his
direction. These clinics should be open at least once a week
and more frequently if special treatment is given.

(c) The provismn of facilities for the supply of surgical appliances.

(d) The establishment of effective arrangements for the following-up
of the children by health visitors and school nurses, to ensure
regular attendance at the clinics and the utmost co-operation
of all concerned in the remedial activities provided.

 

"‘ Vide Memoranda prepared by the Ministry of Health Departmental
Committee on Cancer—(i) Etiology and Incidence, Circ. 426; (ii) Efiects of
Radium and X-Rays, Circ. 476 ; (iii) Cancer of the Breast, Circ. 496 ; (iv) On
Experimental Cancer Research, Circ. 516; (v) Cancer of the Breast, Circ. 716.
Price 1d. each (by post, 11}d.).

117

(4) Provision of efiiciemfi after—care facilitzes.—Re-educative and
remedial exercises may have to be provided after the crippling defects
have been remedied so far as to enable the children to attend regularly
the ordinary public elementary school.

The fundamental principles to be borne in mind are two : first,
reconstruction, and secondly, re—educatz’on. The reconstruction is
commenced by the anatomical restoration, the re-apposition of
the ends of the broken bone, repair of the damaged part and replace-
ment of the functioning organ; secondly, the true axis of the
limb must be obtained to correct the error in alignment ; thirdly,
there must be indirect fixation to secure rest and in such a position
as to retain the best functional attitude; and lastly, when all
inflammation, pain and reaction have disappeared, re—education of
function may commence. Re—education of function is partly
physical and partly mental. It begins with massage and faradisation
to stimulate circulation and nutrition in wasted muscles; then
voluntary movement, physical drill, gymnastics and hydrotherapy ,
and lastly, re- e—ducation by co-ordinative and purposive movement
in the workshop or at the orthopaedic centre.

139. Preventive Surgery may thus be illustrated in a general
way as follows :—

(a) Surgery in children’s conditions—enlarged tonsils and
adenoids, phimosis, hernia, ophthalmia.

(b) Orthopaedic surgery in deformities—rickets, tuberculosis,
paralysis, scoliosis, talipes, flat foot, hammer toe, fractures.

(0) General surgery—sepsis, tuberculosis, varicose veins, hernia,
venereal disease, malignant disease, tumours, thoracic
conditions, abdominal and genito-urinary surgery,
gynaecology, dental caries.

((1) Industrial surgery—wounds, fractures, injuries, poisons,
fumes, anthrax, tetanus, etc.

140. Thus, as it seems to me, we have here a further extension of
the spirit of Preventive Medicine—curative, preventive, re-con-
structional, educational. It begins with the beginning of disease
and not with its end results, and it prevents deformity and dis-
ability; it is the restoration of function. Moreover, it is a model
of “ team ” work, and the complete integration. Chemistry,
physics, electricity, biology; anatomy, physiology, pathology,
and pharmacology; medicine, surgery and therapeutics—they
are all here, interdependent in proportion as they are perfect, all
brought to the crucial point and transmuted into redemptive
power of educational and economic value. This sort of reconstruc-
tional medicine now awaits application to some of our great civil
problems of disablement and of crippling. It marks an epoch in
British Medicine.

118
. ix.
Public Education in Hygiene.

141. An essential part of any national health policy is the in-
struction in the principles and practice of hygiene of the great
mass of the people. In this as in other spheres of human affairs
ignorance is the chief curse. We are only now, as knowledge
grows, becoming aware of the immeasurable part played by igno-
rance in the realm of disease. It is hardly too much to say
that in proportion as knowledge spreads in a population, disease
and incapacity decline; and this becomes more evident as the
gross forms of pandemic disease are overcome. As in the indivi-
dual so in the community, knowledge is the sheet anchor of pre—
ventive medicine—knowledge of the way of health, knowledge of
the causes and channels of disease, knowledge of remedy. The
great reforms to which reference is made in these pages are depen-
dent for their achievement upon an enlightened and responsive people.

142. One of the characteristics of the Dark Ages was the pre—
valence of fatalism. Men felt crushed by circumstances; they
seemed helpless in the presence of pestilence and misery, and for
centuries they existed under a sense of impending disasters which
they could neither foresee nor prevent. Disease seemed to them
something occult, supernatural, beyond their understanding or
control. The cataclysm of the European War and the scourges
of influenza and plague which have swept through the Empire
have, in their degree, exerted in our own time a somewhat similar
effect. Let men once feel that external circumstances control
their fate, and their attitude to reform and progress is one of despair.
Let them once recognise, on the other hand, that in large and in-
creasing measure they are masters of their own destiny, and their
life takes on a new, more hopeful and purposive aspect. Education
is then seen in its true light, its true potentiality. It becomes the
instrument of reform, and in no sphere of national well-being is
this more necessary than in relation to Preventive Medicine. We
now have a compulsory and universal national system of education ;
an essential part of it should be a knowledge of the principles of
health. We have already neglected this subject too long, and we are
paying the heavy price of neglect. It is desirable to give to the
whole child and adolescent population, of all social classes and
grades, first, a body of facts concerning personal health, and secondly,
an experience of the practice of hygiene. The two elements should
be taught together, for only thus can a working and practical
knowledge be acquired. The teaching of theory only will avail
nothing; from the earliest age the individual should be trained in
the habit of healthy living. Whilst the primary need is the educa-
tion of the child and adolescent, the education of the whole people
in hygiene is necessary, and considerable progress is being made in

119

this direction.* “ In order to live well, it is first necessary to live ;
and in order to live, it is necessary to observe certain elementary
rules for the conduct of our physical existence.”T

143. Four illustrations of the method of instruction may be
named :—

(l) the general practice of hygiene ;

(2) the teaching of mothercraft to elder girls;
(3) physical education; and

(4) the method of open-air education.

, In the use of these methods, medical terminology and technique
should be avoided, and little direct instruction should be attempted
in the details of the signs, symptoms or treatment of disease. The
instruction should be simple, positive and practical.

(i) The Practice of Hygiene.

144. At the present time hygiene is taught in the elementary
schools, and, therefore, fomis one of the subjects of training for
the student entering the teaching professionj; In the school itself
the subject, whether taught incidentally or in the form of set lessons,
should be undertaken in a practical way. To inculcate cleanliness,
the practice of cleanliness is necessary—clean heads and bodies,
the use of the toothbrush and the school bath, a clean alimentary
system, the avoidance of verminous conditions, a clean schoolroom,
and so forth ; the value of fresh air must be taught by the regular and
continuous ventilation of the schoolroom, life in the open air, proper
breathing exercises, &c. ; the same applies to, the value of exercise,
food. rest ; each subject must be as far as possible practised by the
1earner.§

But much more than this is needed. “ A man’s real education
begins after he has left school," says Henry Ford; ”education is gained
through the discipline of life.” Therefore, in the first place, the
adolescent and adult population require a training in hygiene, in
continuation schools and voluntary institutions for the extension
of university and technical education or elsewhere: in the second

 

* See Public Education in Health, 1926 (H.M. Stationery Office, 6d.).

T The Common Weal, by the Right Hon. H. A. L. Fisher, 1924.

i; The official syllabus issued by the Board of Education in 1919 consists of
eight sections, dealing with the condition of health in childhood, the senses
and their training, the practice of hygiene, the common ailments of school
children, the physically or mentally defective child, the welfare of infants
and young children, the work of the school medical service, and the school
building and its surroundings. There is also a separate syllabus for the
teaching of the hygiene of food and drink (1922) ; see also The Practice of
Health, issued by Headmaster’s Conference (Warren & Sons, Winchester)
1924, price ls. (post free).

§ See The Health of the School Child, 1925, pp. 108—129.

120

place, the instruction thus provided must be Applied Hygiene,
including information on the daily practice of health, physical exer-
cise, clothing, rest, food and dietetics, sex-hygiene, the protection and
use of milk, the prevention of indigestion, bronchitis, tuberculosis or
venereal disease, domestic sanitation, and the importance of the
treatment of disease at its beginnings, e.g., indigestion, bronchitis,
dental disease, tuberculosis, venereal diseases, cancer.* To be
effective, this means that the people should seek medical advice at
the earliest rather than at the latest stage of these and other maladies.
Thirdly,all through the country, in almost every home and in ahundred
thousand factories and workshops, there is urgent need of education
in regard to health and physiological efficiency. A representative
employer (of 7,000 persons) writes that “ the effect of the teaching
of hygiene in relation to industrial life has unquestionably been
beneficial in two respects, first, it has tended to better health in the
persons selected and in the maintenance of a higher standard of
health in the factory, and secondly, it has helped to reduce indus-
trial fatigue, and through limiting loss of work through illness has,
without doubt, increased output. I attribute the improved physique
of the boys,” he adds, ” to systematic physical training provided
in the factory, to adequate facilities for regular meals, and to the
development of camp life. I am convinced that the proper- physical
care of the worker is not only called for from humanitarian motives,
but is a sound commercial proposition, and I hope that there will be
enormous development.”

(ii) The Teaching of M othercmft.

145. The health and proper care of the child depend primarily
upon Motherhood. ‘If the school girls of this generation are to
become the wise mothers of the next they must be taught the elements
of Mothercraft. That seems a simple and self-evident proposition,
but its truth does not appear to be generally accepted. Yet it
would be difficult to exaggerate the importance and even necessity
of the teaching of Mothercraft to girls and young women. If every
woman understood the ordinary care and management of herself
and her baby, much discomfort, malnutrition, sickness and even
premature mortality would be avoided, and the burden of maternal
suffering would be immensely relieved. The more unsatisfactory

 

*The principal routine work of educating the public in hygiene and
domestic sanitation falls to the Local Authorities (Public Health Act, 1925,
S. 67), but valuable supplementary and propaganda work of this nature is being
carried out at the present time by certain well known voluntary associations
established for the specific purpose, such as the British Social Hygiene
Council, the National Association for the Prevention of Tuberculosis,
the National Clean Milk Society, the People’s League of Health, and the
various societies leagued together in the Central Council for Child Welfare-
Closely akin is the health work of the Boy Scouts and Girl Guides movement.
All this educational enterprise and organisation form an invaluable and
integral part of national Preventive Medicine.

121

and unwholesome the housing conditions the more necessary is it
for a working mother to know how to keep her baby in reasonably
good health, partly for its personal well—being, but also for her
own sake, so that in her over—full life she may be spared the
avoidable anxiety and trouble caused by sickness due to improper
care of herself and her child. It may be admitted at once that a
knowledge of Mothercraft is not a cure for all evils associated with
infant mortality ; but when one observes what sound common—sense,
well-informed understanding and methodical care can do for the
mother and baby in the most unpromising surroundings, it seems
deplorable that any mother should lack the elementary knowledge
and equipment necessary to enable her to give herself and her baby
the best chance of life and health. We cannot compel her to put
knowledge into practice, but we can at least see that she has had
ample opportunity of learning the first principles of maternity and
of realising the suffering to herself and her children which neglect
of certain Observances may cause. “ The infant cannot indeed
be saved by the State,” wrote Sir Herbert Samuel, when President of
the Local Government Board. ” It can only be saved by the mother.
But the mother can be helped and can be taught by the State.”

146. The health, and even the life, of the infant is dependent
primarily upon its mother,—upon her health and strength, her
capacity in domesticity, her knowledge of the care and management
of infancy, and her control of its food and environment. There can
be no doubt or question about this. The fundamental requirement
in regard to healthy infancy, which is the door of childhood and
school life, is healthy motherhood combined with the art and practice
of Mothercraft. The teaching of Mothercraft may be divided
conveniently into three periods : (1) Instruction to elder girls at the
elementary schools (12 to 14 years of age), (2) to girls from 14 to 18
years of age in secondary and continuation schools, and (3) to the
expectant and nursing mother at maternity centres. In each of
these periods the two main issues must be kept in mind, namely,
the health of the girl herself as a future and potential mother, and
her knowledge and practice of infant care.*

147. Whilst there is need for various types of institution for
promulgating this gospel of healthy infancy—infant welfare centres,
children’s clinics, schools for mothers, maternity centres, and the
School Medical Service—the evidence is accumulating, in spite of
prejudice or ill—informed criticism, in favour of the application of
educational methods and the spread of knowledge. Ignorance——

(a) of the principles and practice of maternal hygiene,
(b) of the common causes of disease,

 

* The Teaching of Infant Care and Management to School Girls. Board of
Education Circ. 1353. (Dame Janet Campbell, MD.) 1925.

122

(c) of the means of prevention, and
(d) of the adaptation and adjustment of conditions of environ-
ment to the individual child,

remains the principal operating factor, in the vast majority of cases,
in the production of preventable disease. Many an illiterate and
poverty—striken mother is, in a domestic sense, competent and well-
informed in these matters ; many a mother in highly civilised circum-
stances is incompetent and ignorant. Competent maternity wherever
it occurs is generally a remedy, though not the only remedy ; incom-
petent maternity is always a disability. But to say that maternal
ignorance is thus a fundamental issue is not to condemn the mother
or allocate culpability ; the culpability probably lies elsewhere.
Nor does it ignore the manifold influences of environment. It states,
what cannot be gainsaid or denied, that education in maternal hygiene,
a homely capacity to control domestic influences and circumstances,
and the growth and spread of a knowledge of health lie at the root of
the matter.

(iii) Physical E dncation.

148. Physical education in schools as we now understand it dates
from the issue of a Syllabus of Physical Exercises by the Board of
Education in 1909. This syllabus was revised and amplified in 1919,
and physical education in all elementary schools is based upon the
exercises and games set out in this book.

Provision is made for a nucleus of free—standing gymnastic exer-
cises from the Swedish system, designed to develop all parts of the
body harmoniously and in proportion, and also to exert a corrective
influence upon minor or incipient physical defects, such as round
shoulders, flat feet, bad standing positions, &c. These exercises
are supplemented by others of a more active and vigorous character,
“ general activity exercises,” by playground and team games, by
folk and country dancing, and, in the summer months, by swimming.
Much attention has been paid to the method and technique of teaching
this subject with a View to getting rid of the old conception of the
“ drill” lesson with its formality and dulness, and to replacing it
by a period of active exercise full of un—anticipated yet disciplined
movement, which retains the interest and attention of the class,
and serves to promote healthy circulation and respiration, and which
sends the child back from the playground to the class—room refreshed
and invigorated mentally and physically.

149. It is desirable that every child should have a daily period of
exercise in the open air whenever possible and many schools now
make such provision. A lesson of 20 minutes three times a week,
with a longer period once a week for organised games and swimming,
is also common. Playing fields as well as playgrounds are now

123

provided in connection with many schools to the great advantage
of the children. But more of them are needed.

Physical ,exercises are taught by the class teacher, who is given
special instruction during the training college course, and subse-
quently often attends evening classes or vacation schools. Many
Local Education Authorities have appointed Organisers of Physical
Training, men and women who are experts in this subject, and whose
duty it is to assist the class teachers by means of advice, demonstra-
tion, training courses and so forth. Great improvement has taken
place in the standard of teaching physical exercises during the past
10 or 12 years, and for this the Organisers are to a large extent
responsible.

150. Physical education in secondary schools should follow the
same. general principles as in elementary schools, but here the better
conditions. including smaller numbers, more adequate indoor and
outdoor accommodation, and specialist teachers, as well as the greater
age of the pupils, permit more advanced training in gymnastics and
games, and a closer co—ordination with the outdoor pursuits and
hobbies of the young man and woman.* '

(iv) Open-Air Education.

151. “ I would make a shed on the roof and take it there for
fresh air,” said Dr. Johnson, when Boswell asked him what he would
do with a new-born child. Fresh air is good for everybody as well
as infants. During the war the nation had a valuable object lesson
of the benefits to be derived from an open—air life. Thousands of men
withdrawn from the urban areas of the country to undergo cam‘p
training in the Army manifested an obvious and substantial improve-
ment in their physical condition. No one can measure the national
gain that accrues from such increased physical well-being, even as
no one can estimate the loss in defective and devitalised man-power
which the nation has sustained for many years, due to the lack
of appreciation, and even systematic neglect, of the value to the
human body of fresh air and sunlightt The open—air school is a
simple and economical way of applying a method of natural education
to the susceptible body and mind of the child, who is also insensibly
taught under such favourable conditions to recognise and value some
of the fundamental principles which underlie a hygienic way of life.

 

* The Board of Education Syllabus of Physical Training for Schools, 1919 ;
Physical Exercises for Children under Seven Years of Age, 1919 ; Suggestions
in regard to Games, 1920 ; Physical Exercises for Rural Schools, 1924 ; The
Team System (Supplementary Suggestions), 1924.

1' Science of Ventilation and Open Air Treatment, by Leonard Hill, F.R.S.,
Med. Res. Council Rept. No. 52 (1920).

124

Fresh air, exercise, cleanliness, rest, regular meals, careful supervision
form a series of conditions as certain in their beneficial physical effect
as they are conducive to the creation of a mental atmosphere favour-
able to the opening mind. As Walt Whitman sang in the Song of
the Open Road, " '

“ Now I see the secret of the making of the best persons.
It is to grow in the open air.”

152. Every elementary school has its quota of dull or backward
children, debilitated and anmmic, malnourished, stunted and weakly
children. handicapped by a physical infirmity which renders them
unable to derive reasonable benefit from their schooling, and for
whom the best possible treatment is an open-air school. It is im-
possible to say how many such children exist, but it is estimated at
not less than 10 per cent. or 600,000. The present provision supplies
accommodation for less than 6,000. The need for the extension of
open-air education is, therefore, urgent. In a large number of cases
some adaptation of the existing premises would suffice, in others
playground classes could be started. Elaborate and expensive
buildings are not required, provided that suitable arrangements are
made whereby the children are kept warm, dry, and well fed. The
essential point is life in the open air—a new way of living, the practice
of hygiene, the restoration to the town child of the wholesomeness
of life.*

153. These four methods of education in hygiene are submitted
for the consideration of local authorities. They are, of course,
only illustrations, but in principle they are widely applicable.
Obviously, these principles of hygienic education apply to offices,
factories, workshops, homes, bedrooms, &c., as well as schools,
and to adults as well as children. One thing is certain, no substantial
advance can be made in this country in the practice of Preventive
Medicine apart from the will of the people, which can only be guided
rightly by knowledge and practice in hygiene. We have witnessed
a nation organised for war, we require a nation organised for the
purpose of national health.

 

" The application of the open-air method of education in schools takes the
form of—(l) Classes held in the playgrounds of schools, for the instruction
of children who are normal or suffering from malnutrition or other physical
defects; (2) Classes held in public parks or open spaces for children and
adolescents ; (3) " School journeys,” from one day to three weeks’ instruction
at the seaside or in the country ; (4) Holiday schools and camps for children
and adolescents; (5) Open-air class-rooms in schools; (6) Open-air Day
Special Schools; and (7) Open-air residential schools of recovery for the
treatment and education of children suffering from severe debility or other
disabling conditions.

125

X.
Investigation in Relation to Preventive Medicine.

154. Among the duties of the Minister of Health is included
“ the initiation and direction of Research.”* This sound proposi-
tion implies that no scheme of practice in Preventive Medicine
is complete unless it includes opportunity and provision for in-
vestigation and the acquisition of new knowledge. Such work
may be classified for the purposes of practical convenience in four
general groups.

(a) Analysis and the examination of sewage effluents, food,
milk, sputum, blood, &c.

(b) Research of a more elaborate kind principally under-
taken in well-equipped laboratories, arising in the
current administrative work of the Ministry.

(c) Clinical and personal study of disease in the individual.

(d) “ Field " and communal investigations of disease and
mortality.

(e) Publication of results under the previous four heads for
information of local authorities or the general public,
and the promotion of the practical application of the
knowledge thus made available.

On the one hand, chemical, physical, and bacteriological
analysis of specimens relating to Medicine, particularly in regard
to diagnosis and the determination of content, is being carried
out in laboratories throughout the country, and though its aims
are of necessity relatively narrow, practical and immediate, most
valuable knowledge might be derived from it if it were more closely
associated and jointly reviewed. On the other hand, elaborate and.
prolonged research work having for its object the advancement
of medical science, and a minute and extensive inquiry into first.
principles, is organised by the Medical Research Council in a great
variety of ways and places.1' This invaluable work which has
abundantly justified itself, and with which the Ministry cordially
co-operate, does not, however, cover the great field of investigation
which lies before us. There remain the two other groups of
inquiry which, though already partly the concern of the Medical
Research Council, call for development and continuation by another
kind of investigation, which, happily for the progress of Medicine
in this country, has always received attention. Speaking generally,
it is the third and fourth groups, (c) and (d), which seem to lie more
particularly in the province of Preventive Medicine—clinical

 

* Ministry of Health Act, 1919, Section 2. ,
1‘ Similar work is undertaken at the Pasteur Institute in Paris, the Koch
Institute in Berlin and the Rockefeller Laboratory in New York.

126

epidemiological, and communal; though such work is not and
cannot be wholly separable from the work of the Council, itself
an institution of Preventive Medicine.

155. One of the distinguishing and peculiar services rendered
by the Central Medical Department in early days was the “ field "
research and investigation work which it performed and inspired.
In 1839, in order that the Registrar—General might turn to scientific
use the vast stores of medical data flowing into his hands, Dr. William
Farr was appointed ” Compiler of Abstracts,” and from that time
onwards for forty years he rendered invaluable service to the State
by summarising the facts and deducing the conclusions to which
they led. In 1855 Dr. Simon was appointed Medical Officer of
the new Board of Health (1855—58), becoming in due course Medical
Officer of the Privy Council (1858—71) and eventually of the Local
Government Board (1871—76). For upwards of twenty years,
ltherefOre, these two great pioneers worked alongside each other,
the one nominally on the statistical, the other nominally on the
administrative side of State Medicine. The result was a remarkable
series of field investigations, the standard of which has not since
been surpassed.* The findings of these inquiries form a substantial
part of the foundations of the practice of Preventive Medicine in
England, though at first sight they appeared to have no practical
effect. That is a common characteristic of sound scientific work;
its value is not apparent, but latent. It is preparatory to action;
the seed must be placed in the ground if fruit would be obtained.
Systematic investigation, experiment, and disinterested epidemio-
logical inquiry is the life blood of Preventive Medicine. It extends
the boundaries of our knowledge of disease, and our knowledge
is still dangerously fragmentary and incomplete; it provides the
facts of the case for legislation and administration ; and it furnishes
assistance in the great business of education, of foresight and of
forecasting. Too often epidemics of disease in this country have
caught us unawares, unready and unprepared. Yet their course
follows the unvarying natural law of cause and effect. It is not
disease which is capricious ; that is rather the characteristic of the
observer. It is part of the purpose of a scientific scheme of national
health to reduce caprice, chance, and surprise to a minimum and
to establish in their place firm and growing knowledge. Workers
in Preventive Medicine must not find themselves unprepared with
their plan of campaign or an adequate survey of the terrain, until
the enemy has published his ultimatum and it is too late.

 

* There were Farr's “ Letters ” and decennial supplements to the Registrar-
General on the one hand, and on the other the reports of systematic investiga-
tions throughout England as to preventable disease and the “ necessaries
of health.” (Greenhow, Enchanan, Edward Smith, Whitley, Ballard, Rad-
cliffe, and others.)

- 127

156. Nor is the acquisition of new knowledge by research and
investigation alone a function of a central department. The prob-
lems of medicine arise where the patient lives, his home and work-
place are the fields in inquiry; and the medical practitioner is
the man to carry out partly or wholly the investigations which are
necessary. Harvey, Sydenham, Willis, Morton, Fothergill, Huxham,
Haygarth, and John Hunter were all practitioners; and in our
own day practitioners have repeatedly demonstrated both their
desire and capacity to undertake investigation work. In 1922—23, a
group of insurance practitioners co—operated together in a valuable
study of the incidence of Rheumatism.* The incidence of disease
of the heart or respiratory system, pathological fatigue, digestive
disorder, nervous maladies, the epidemic diarrhoea of infants, or
incipient mental disease can be best determined by the practitioner
or the school doctor; even yet we do not pay sufficient regard
to the causes of abortion, miscarriage, or still-birth; the almost
universally bad condition of the teeth remains largely unexplained ;
that vast mass of unnamed and undetected physical unfitness,
malnutrition, disablement and impairment which undermine the
capacity of a nation can be best investigated and handled in local
areas. There is also a large region of research into tuberculosis
lying before the Tuberculosis Officer ; a similar inquiry into syphilis
and venereal disease, their incidence, prevention and treatment
falls to the sphere of the Venereal Disease Officer or practitioner;
and the field of investigation lying before the Medical Officer of
Health is almost boundless. These are everyday problems of
Preventive Medicine, for investigation and research are no prero-
gative of the hospital ward or the laboratory.

157. For the purpose of illustration and suggestion some of
the 'wide channels of investigation may be mentioned. Take the
bills of mortality. They record the number of deaths in registration
districts per annum and the certified cause of death. Their validity
depends, of course, upon the accuracy of the diagnosis or of post
mortem findings, and hence in the last resort upon the skill and
knowledge of the medical man. But taking them as approximately
indicating the cause of death we may learn much from their study.
Instead of accepting a total of, say, 1,000 deaths and its resultant
death rate, in a given area, we must proceed to analysis and differ-
entiation in order to answer the following questions 2——

(1) What is the relation of the total number of deaths to the total popu-’
lation and the section of the population mainly contributing the
deaths ?

(2) What are the causes of death when fully classified P and how many.
of them are due to infection ? (The problems of cause and
infection form subsequent issues.)

 

“ Report on The Incidence of Rheumatic Diseases, Ministry of Health,
No. 23, 1924.

128

(3) What is their distribution in sub-districts, streets, courts, alleys,
slums ?

(4) What is their distribution in houses, tenements and rooms? and
what is the relation to soil or topographical situation ?

(5) What is the age incidence of death at all age periods, and, under one
year, in months and weeks? how many of the deaths may be
considered premature ? what is the number, incidence and distri-
bution of the still-births ?

(6) What is the sex distribution ? and what is its relation to different
diseases ? >

(7) What influence does overcrowding and domestic insanitation bear
to the deaths recorded P

(8) What influence is exerted on-the death rate by diet, alcoholism, and
social and economic conditions of the family ?

(9) What is the relation between occupation, industrial conditions and
fatigue and the deaths of a district ? and between the deaths and
the factories, workshops, workplaces and homes where the occu-
pation is followed P

(10) What is the influence of climate, season, month and date of death
upon the death rate P Why is it that infant deaths from overlying
and other causes have a tendency to occur at the week-end, when
there is most leisure and most wages in the home P

(11) What is the number and character of deaths due to conditions
originating in childhood, or to heredity, diathesis or disposition
of body P

(12) What is the number and character of the deaths which have occurred
in the area which appear to be due in large degree to inadequate
treatment P

Here there are a dozen points suggestive of the sort of inductive
inquiry which may be found to throw light on the causes and condi-
tions of a high death rate, But a deductive inquiry is also necessary
in all areas, in order not to miss the operations of general or even
universal conditions upon the particular and the local. Thus,
to understand its meaning to the community it is necessary to study
and differentiate the mortality to the utmost limit ; then to apply
to what Radcliffe 50 years ago called “ the constant foci of infec-
tion " the means of treatment. To state a mere general death rate
is of little more value in its sphere than to state in the sphere of
medical practice that a person is ill and that a patient stands
before us. Yet all over the country hundreds of official reporters
content themselves with the statement that the death rate of their
area is such and such a figure. But it is not sufficient to inform
the patient that he is a patient ; it is necessary to get down to the
minutest facts regarding his heredity, history and physical condition,
bringing to our assistance all the aids of diagnosis ; then to deduce ;
then to apply appropriate remedies. In other words, the com-
munity is a patient.

129

158. Somewhat similar and even more searching investigations
are necessary in other directions, of which the following may be
named as illustrations :—

(a) Infancy—Causes and conditions afiectin the birth rate.
Nutrition in relation to developmen disease.
Effect of congenital and infant disease on childhood.
Causes and conditions of infantile diarrhoea and other epidemic
diseases of children.
Maternal and infant mortality.
Morbid conditions of the mucous membranes (adenoids, tonsils,
intestinal catarrh, &c.).
(b) Nutrition—The foundations of nutrition (food, warmth, exercise,
nurture, hygiene).
Dietary in relation to nutrition and dyspepsia.
Dietary and energy~the food of the industrial worker.
Food poisoning : deleterious foods, forms of adulteration.
Relation of food to age, sex, climate, assimilation and deficiency
diseases (rickets, scurvy, &c.) ; relation to chronic disease such
as cancer.
c) Industrial health problems. (See page 82.)
(d) I Median—Causes of high, low and variable virulence and infectivity.
Factors affecting susceptibility or resistance of the individual.
The immunity of the individual.
The sequelaa of infectious disease.
Infection of the nervous system.
Mode of infection and means of treatment of influenza.
Tuberculous infection in childhood.
The carrier—acute, chronic, and intermittent.
Catarrh, “ common cold,” coryza—its cause and incidence; its
relation to other catarrhal diseases.
The normal bacterial flora of the nose and throat.
Prophylaxis of disease in the individual.
Social, industrial and environmental factors influencing infection.
(6) Epidemiology—Causes of recurring waves and cycles of infection.
Factors affecting susceptibility or otherwise of a community.
Age incidence of disease prevalence and its cycles.
Immunity of communities.
Seasonal fluctuations 1 age, distribution, incidence, fatality.
Field investigation of cholera, plague, malaria, dysentery, &c., in
Greater Britain and elsewhere.
Field investigation of coryza and influenza, cerebro-spinal fever,
poliomyelitis, encephalitis, smallpox, scarlet, enteric, diphtheria,
&c., and the inter-relationship of disease.
Field investigation of rheumatic fever.
Constituent factors in control of tuberculosis.

(f ) Dental caries—Incidence, cause, prevention.

(g) Non-infectious disease.—Beginnings of disease.

Physiological scope of various organs of the body.

The study of signs and symptoms: how produced, significance,
and prognosis.

Effect of drugs, modification by disease.

Study of the functional efficiency of organs.

Heart disease in the child and adolescent.

The incidence, causes, treatment and prevention of cancer, nervous
diseases, alimentary disease (duodenal ulcer, colitis, &c.),~
nephritis, bronchitis, &c. The relation of bronchitis to ill-
ventilation and the domestic habits of the people.

(B 32/931)g E

130

This is the sort of work which lies before us, the comprehensive
study of the facts as they are in daily life and environment and
not only as they are in the laboratory. It is in the field, in general
practice, in the study of epidemics, in the workshop, in the home as
well as in the laboratory that truth is to be found—in situ. It is
the great opportunity for “ group” or “ team ” work, for here
clinician and laboratory worker, social student and epidemiologist,
practitioner and specialist, statistician and administrator join
together in their quest. There is need for foresight, preparation,
co-operation. “ In the field of observation,” said Pasteur, “ chance
only favours the mind which is prepared.” In the spirit of such
investigation we get not only co-ordination of search but an even
more alert and keen practitioner, growing in mind and heart, with
an ever-expanding understanding of the width and greatness of his
calling.

159. By this means also we may foresee and forecast, and thus
lay the foundations of a Medical Intelligence Service, an instru-
ment so long desired and So long lacking in England. I desire with
the utmost emphasis to impress upon my colleagues the great
truth that the spirit of research, of investigation, of the finding
and following of new learning is the monopoly of none and the
inspiration of all. The dead hand of traditional authority stifled
freedom of thought in Medicine for fourteen hundred years. It
did so because in human nature the dislike of change, the fear of
the unknown, the avoidance of personal responsibility are deep
and strong. These instincts are still potent, they respond readily
to the suggestion that investigation is only an affair of laboratory
experts. Those who argue thus are the mediwval traditionalists
in new guise. The field of knowledge is so great that all cannot
be equally familiar with every part of it, and some specialisation
is inevitable. But the duty of the specialist is not to play providence
to the medical practitioner, not to take investigation out of his
hands, not to under-value the quest of truth in spheres other than
his own, but to suggest and advise how the problems confronting
the practitioner or the practical worker in Preventive Medicine
may be solved, or at least brought nearer to solution—to guide,
aid and supplement, and to look forward into the unknown. Such
I conceive to be a principal duty of a Medical Intelligence Service.
It will have its central officers no doubt, but it should be dependent
also upon the investigations, the acquisition and interpretation of
knowledge of the medical practitioner. It will investigate and
study epidemiology and correlate it with bacteriology; it will
collect data from all parts of the world; it will observe the operation
of epidemiological factors ; it will work through medical statistics ;
it will summarise the clinical findings of medical practice; and
it will be a means of public education. Only by some such wide
scheme of co—operative association can we hope to cultivate all

131

through the medical profession a true love of learning, the diffusion
of knowledge, and an extension of the frontiers of life.

Conclusion.

160. Thus, in brief outline, the provisional articles of a national
policy in Preventive Medicine, the principal elements in an ordered
sequence, may be named as follows :—

i. Heredity and Race.

ii. Maternity, and the care, protection and encouragement
of the function of Motherhood.

iii. Infant welfare and the reduction of infant mortality.

iv. The health and physique of the school child and adoles-
cent.

v. Sanitation of the environment, the control of the food
supply, and an improved personal and domestic life in
the home.

vi. Industrial hygiene, the health of the worker in the work-
shop. .

vii. The prevention and treatment of Infectious Disease.
viii. The prevention and treatment of Non-infectious Disease.

ix. The education of the people in Hygiene.

x. Research, inquiry and investigation; and the extension
of the boundaries of knowledge.

It is obvious that these ten subjects, though placed in ordered
sequence, overlap and overflow each other; it is equally obvious
that such interrelation is mutually valuable throughout. Further,
it is clear that preventive and curative medicine are here in intimate
association. We repeat, we are not, in the present memorandum,
concerned with a definition of one subject in the medical curriculum,
termed ” Public Health ” ; we are concerned rather with Preventive
Medicine, that is medicine which is preventive in purpose, and which
embodies the whole of medicine as regards disease which is pre-
ventable, especially in its beginnings rather than its end-results.
It includes racial problems, maternity and non-infectious diseases
as well as questions of environment and infection. It includes
the cure of disease in its early stages as Well as its avoidance. It
has for its aim not alone the postponement of death nor the defeat
of disease; its aim is the healthier and happier life of man, and
the growth and enlargement of his capacity and destiny.

A programme of this nature when accepted by the practitioner
of medicine may be of assistance in the codification of his thoughts
and aims, in bringing his mind in touch with the wide and national
purposes of modern medicine, and in making his practice more

preventive though not less curative. “ The prevention of disease,”

(B 32/931)Q E 2

132

writes the Editor of the Lancet, ” is as much the role of the practi-
tioner as is the cure and care of patients.”* When accepted by a
local authority as an expression of its understanding of the practice
of Preventive Medicine, such a programme can only find fulfilment
by degrees, must be modified in detail according to the character
of the area to which it is applied, and will be achieved by varied
means and differing methods and by numerous agents, unofficial
and voluntary as well as official and statutory. But whatever
be the diversities of administration this broad fact remains, that
until and unless the practice of Preventive Medicine be inclusive,
ccmprehensive, systematic and continuous, it is idle to expect to
.reap its full measure of benefit. Merely to deal with one of these
ten items, or indeed with half a dozen of them, and leave the others
disregarded is to court failure and deserve it. We must begin
at the beginning, which is education; then we must pursue our
course, without haste but without rest, with foresight and circum—
spection, with open—mindedness and forward-looking thought,
holding our problems in correct proportion and perspective, and
always with the consent and understanding of the community.
Only thus can we continually adapt and modify, within the compass
of a practical scheme, in accordance with new knowledge.

It is clear that such a policy as that which is here outlined calls
for an adequate medical service and the appropriate administrative
machinery, and to a brief consideration of these matters we must
now turn. The adequacy of a medical service depends primarily
upon the competency, technique and sphere of the medical man ; its
effectiveness of administration depends perhaps most largely upon
a proper appreciation of the knowledge, readiness and will of the
English people as expressed in Parliament, in our representative
institutions, and in our system of local government, its history,
statutory obligations and way of working, and the relation of
voluntary agencies to it.

 

 

* Lancet, August 2, 1919, p. 205.

o

133

SECTION VII.
AN ADEQUATE MEDICAL SERVICE

161. We have now seen in outline the purposes of Preventive
Medicine, the problems which await it and the principles of reform
and of their application. There remains the consideration of
the means of action, namely, the provision of an adequate medical
service and of the administrative machinery which is appropriate.
Here, too, we find much accomplished by those who have gone
before us ; here, too, the stage of evolution at which we have arrived
indicates that the next steps are co-ordination, re-adjustment and
development rather than revolution. Nor can they all be taken
forthwith or all together. The history of English medicine and
its institutions runs back over centuries. Its progress must be
slow and steady. There is no panacea for ills so complex; there
is no quick and short route to the ideal. We must walk with
circumspection, not forgetting the ancient traditions, yet not
confined by them.

(i) The M edieal Practitioner.

162. The foundation of a medical service is the medical practi-
tioner. He is its pivot, its anchor, its instrument. If he is com-
petent it has the first surety of success ; if he is ineffective or ill-
equipped, it must fail. His competency is not only his learning
and knowledge, but his practical capacity, his clinical skill and
experience, above all his resourcefulness, adaptability, common
sense, tact and imagination, firmly established and set in integrity
and high character. These are individual virtues, and the medical
practitioner is individualistic in upbringing and in purpose. He
should safely hold the secrets of his client, and he should have ample
opportunity of rendering the full personal worth of his counsel
to his patients. The social and individual relationship between
doctor and patient is invaluable in the treatment of disease. His
responsibility and his growth in individual worth are of first-rate
importance. ” Any change, whether effected from within or im-
posed from without,” wrote Sir John Tweedy, ” that restrains
the liberty or lessens the responsibility of a medical man, or
hampers the free play of his intellectual activities, will be detri-
mental to the authority and usefulness of medicine, and prejudicial
to the interests of public health and national welfare.”

It must not be forgotten that in addition to his private practice,
every medical practitioner has definitely prescribed duties to the
State. It is inevitable that these should increase rather than
decrease, for the communal value of the practitioner must expand
with the development of the solidarity and interdependence of

134

human society.* He performs also public medical servicesT Whilst
these developments constitute an enlarged relationship to the com-
munity, they do not (as some critics have suggested) “ abolish ” the
practitioner, nor do they absorb him in a whole time state medical
service. Neither of these eventualities is practicable or desirable.
The State should not take out of the hands of the medical practitioner
—whether in contract practice or otherwise—the patient whom he is
willing and competent to treat and on reasonable terms with which
the patient can comply. In other words, the-professional founda-
tion of any public medical service must be the medical practitioner,
but he can only make his full contribution,

(a) if he be adequately trained in preventive as well as curative
medicine ;

(b) if the necessary equipment and facilities for effective
practice be available ;

(c) if the practitioner be secure of a fair recompense for his
services; and

 

* A medical practitioner may be liable under statute in the following
respects :—

(1) He must certify births and deaths (Births and Deaths Registration
Act, 1874), and notify all births within thirty-six hours (Notification of
Births Acts, 1907—15) ; he must notify cases of infectious disease (Infectious
Diseases Notification Acts, 1889 and 1899, and special Notification Regulations
as issued), of industrial poisoning (Factory and Workshop Act, 1901), and of
verminous children (Children Act, 1908). He must also be ready to vaccinate
(Vaccination Acts, 1867—1907), and to certify the removal of infectious cases
to hospital (Public Health Act, 1875).

(2) He may be called upon to inspect and certify for house disinfection
(Public Health Act, 1875, and Infectious Disease Prevention Act, 1890),
and to issue certificates for the removal and burial of dead bodies (Ibid).

(3) He must be available to respond to the requirements of the local
sanitary authority for the provision of medical assistance and treatment
for the poorer inhabitants of the district in which he lives (Public Health Act,
1875, s. 133).

(4) He may be required to inspect and condemn in regard to nuisances
and insanitary house property (Public Health Act, 1875, or Amendment
Act, 1907) ; or inquire into unhealthy or insanitary areas, or be appointed
to act temporarily as Medical Officer of Health (Housing of the Working
Classes Act, 1890).

(5) He must know something of the ill-efiect upon health of dangerous
or offensive trades (Public Health Act, 1875), and of unsound food (Public
Health (Unsound Food) Regulations, 1908).

(6) He may be appointed medical attendant to a retreat under the
Inebriates Acts, 1879—1900.

(7) He must be competent to diagnose all forms of mental disease (Lunacy
Act, 1890, and Mental Deficiency Act, 1913).

(8) He may be appointed to carry out various duties under the Merchant
Shipping Acts, 1894 and 1906.

(9) He may be called upon to certify defective and epileptic children
(Education Act, 1921, Sections 55 and 56).

(10) He may be appointed as a Certifying Surgeon (Factory and Workshop
Act, 1901, s. 122) and would thereupon become liable for various duties
under that Act, particularly the detection of minor ailments and defects.

135

(d) if he and his patient be in possession of that mutual con—
fidence and freedom of individual action in relation to

the practice of medicine which are necessary to its proper
fulfilment.

There must always be a full recognition of this relation between
doctor and patient if the unique value of the medical practitioner
—both to the individual and to the community*is to be main-
tained. If the new association between the State and the prac—
titioner is to endure and be fruitful, there must be mutual under-
standing on this point.

163. Post-graduate Education—If the practitioner is to render the
service we have been discussing, means must be provided for him
to continue his education and keep himself well informed as to
the advances of medicine. His science must expand with his art.
So rapidly does medicine progress that unless a doctor continues
his medical education all through his years of practice he soon gets
out of date or fails to grow in capacity. The advance of medicine

 

(11) As Medical Officer of certain charitable and reformatory institutions
he may be appointed Certifying Surgeon of such institutions (Factory and
Workshop Act, 1907, s. 5).

(12) He is liable for a series of duties in regard to workmen’s compensation
(Workmen's Compensation Acts, 1906 and 1918), old age pensions (Old Age
Pensions Act, 1908, and Treasury Regulations as issued), superannuation,
and pension claims (Ministry of Pensions Act).

(13) He may undertake service as an insurance practitioner under the
National Health Insurance Act, 1924.

(14) He may be appointed as a member of a Maternity and Child Welfare
Committee (Maternity and Child Welfare Act, 1918, s. 2).

(15) He may be called in by a midwife to assist in cases of emergency
(Midwives Act, 1918, s. 14).

(16) He must observe the regulations affecting the issue and dispensing
of prescriptions containing such drugs as Cocaine, Morphine, &c. (Dangerous
Drugs Acts, 1920—25).

(17) He may accept appointment as Medical Officer of Health, School
Medical Officer, Specialist Medical Officer (Tuberculosis, Venereal Disease,
Maternity and Child Welfare, &c.), or under the Poor Law Medical Service,
the Post Office, or the Board of Education in connection with the Teachers
Superannuation Acts.

(18) Lastly, the medical practitioner may be required, from time to time,
to give certificates, reports, &c., for use in Courts of Justice or in connection
with the public services or ordinary employments.

T It is sometimes alleged that the public medical services are designed to
exclude the private practitioner. But the contrary is, in fact, the case.
For example, the Poor Law Medical Service has 4,000 medical officers for out-
door medical relief, practically all of whom are private practitioners; the
Post Office list of 3,500 medical men are all practitioners; out of 1,450
Medical Officers of Health, 1,100 are private practitioners, and only 350 are
whole-time officers; of the 1,800 medical men engaged by local education
authorities in the inspection and treatment of school children, 1,000 are in
private practice, of 1,770 certifying factory surgeons, all, hardly with excep-
tion, are private practitioners; and the whole of the national insurance
service is in the hands of private practitioners.

136

is continuous, and the practitioner should be provided with ever
enlarging facilities for the acquisition of knowledge and for the
carrying on of his practice, especially if the practice lie away from
a well-equipped hospital or large town. There are new drugs, new
methods of diagnosis and treatment, new means of prevention, an
ever-expanding differentiation of medicine and its allied sciences,
and new applications of old principles, which make it essential
that the practitioner should have ample opportunity of refreshing
his faculties, revising his methods and extending his knowledge.
Hence provision is necessary for various forms of post—graduate
instruction, associated with the medical schools (where they exist)
or with the local hospital.

Three points should receive attention in the organisation of
such post—graduate courses.* First, there are the subjects of study.
The general practitioner needs most of all a revision course in clinical
diagnosis and treatment—subjective symptoms, physical signs,
the use of a few necessary instruments of precision, some knowledge
of the extent and limitation of laboratory tests, radiography, above
all clinical integration and judgment—special tuition in tuberculosis
and venereal disease, the detection and management of early mental
cases, differential diagnosis in surgery, disorders of digestion,
ophthalmology, and the group of conditions known as “ war ”
neuroses.

164. Secondly, in organising post-graduate study for the prac-
titioner the arrangements must allow (a) for tuition apart from
the ordinary medical student, (b) for an appropriate association
of laboratory and clinical work in the courses proposed, and (c)
for the facilities provided to be conveniently accessible in respect
of time, place and fee. In the past the practitioner has not re-
sponded to the intermittent provision made for his further instruction
because these three points have not been sufficiently regarded.
They involve a local organisation in counties or similar areas,
associated with the local hospital, to which greater access should be
obtainable by practitioners of the district, at which clinical demon-
strations and conferences should be held by the staff (or visiting
consultants or practitioners), not on exceptional or curious cases,
but on the ordinary patients, on routine autopsies, and on clinical
methods. Such hospitals should also become organised centres
for providing clinical, bacteriological, pathological and radiographic
facilities for the practitioners of the neighbourhood. A local
hospital library and museum will add to the interest and value of
such work.

165. Lastly, attention must be given to the principles governing
the conduct and character of post-graduate courses. The courses

 

“ See Report of the Post-Graduate Medical Committee (Chairman, Lord
Athlone), 1921, H.M. Stationery Office. Price 8d.

137

should be comprehensive and well arranged, and taken by students
able to appreciate, understand and apply the teaching given. The
quality of the work should reach university standard in respect of
the teaching staff, the syllabus, and the sustained character and
homogeneity of the treatment of the subject. Perfunctory, irregular
or merely didactic instruction will fail, as it deserves. Above all,
such courses must be practical, providing each student with an
experience which is directly valuable to him in the better discharge
of his professional duty, enabling him to make fuller use of his own
clinical opportunities. There are now medical schools or facilities
for clinical instruction at 20 or 30 populous centres in England and
Wales, and in almost every county and in every large town arrange—
ments could be made with local hospitals for post-graduate work.

‘ ' What is necessary is the organisation of all the clinical work thus

represented on behalf of thousands of medical practitioners, having
its local centres in well—appointed hospitals, laboratories and clinics
in county and town. The benefit accruing to the practitioner
and to the patient by such a scheme of educational co-operation is
difficult to over—estimate, for its immediate effect would be better
treatment for the patient and improved medical equipment. The
fact is that owing to lack of foresight and organisation incredible
waste of opportunity is going on in regard to this field, and nothing
like full value is being derived for the practitioner. The nation
badly needs all the best medical work, both treatment and research,
and all the best medical education which is, or can be made, avail-
able. A great part of the population are submitting themselves
to medical treatment by professional men trained 20 or 30 years
ago, many of whom, though they have experience, lack suitable
opportunity of revising their knowledge and equipment.

166. Increased Practitioner Facilities—The second urgent re-
quirement of the medical practitioner is increased facility for
practising his profession adequately in regard to (a) laboratory
equipment, (b) consultant advice and assistance, and (c) co-operation
with medical colleagues in the vicinity. in the form commonly
described as “ team ” or ” group ” work. Laboratories are now
established by many county councils and municipal bodies, and
also of course exist at all medical schools and well-equipped hospitals.*
But work at pathological laboratories should be carried out in close
partnership with the clinician, and therefore clinical laboratories
must be sufficiently numerous and local for ready reference and
frequent consultation. Such local or branch laboratories should
be associated with larger central laboratories, but the particular
need at present is laboratory provision and consultation within
reasonable reach of the practitioner. Again, the fact that the advance
of Medicine has not only carried the range of its science and art

 

"‘ See Report of Departmental Committee on Tuberculosis, 1912, Cd. 6654,
pp. 126—136.

138

beyond the capacity of the individual mind and the individual hand,
but has demonstrated that the accurate diagnosis or adequate
treatment of disease is dependent upon a series of studies or inquiries
which cannot always be performed by one busy practitioner, makes
it necessary to provide for consultation and co-operation. “ No
man, be his faculties what they may,” wrote Sir Clifford Allbutt,
“ can be at once physicist, biochemist, pathologist, practitioner and
sanitarian.” Take the case of disease in the alimentary system.
There must be, even for its diagnosis, careful clinical examination,
radiography, chemical and also pathological analysis of the gastric
or bowel contents, the use of special instruments, test meals, and
so forth. Its adequate treatment may require prolonged medical
attention or surgical intervention and in any case competent nursing.
Clearly the case cannot always be handled by one man ; laboratory
investigation, consultation and “ team” work are all necessary.
But the practitioner must not on that account lose interest in his
case. Such team work should be the supreme opportunity of
education.*

167. There is no way of continuing the education of a medical
practitioner better or more effectively than by providing him with
the means to help himself. For too long he has struggled on against
desperate, indeed almost hopeless, conditions—without assistance,
guidance or co—operation which is readily available, without labora-
tory facilities, without nurses, without ample clinic and hospital
accommodation. It is difficult to exaggerate the importance,
both to Medicine and to the State, of the position of the practitioner.
No imposing institutes or hospitals will bring the healing art into
the homes of the people ; that can be done only by the practitioner.
No philosophy will of itself integrate, simplify and unify Medicine ;
that can be achieved only in the person of the practitioner. In-
cipient and early disease comes only to him and to the school doctor.
If it is to be diagnosed before structural change occurs, they must
do it—by the careful observation of subjective symptoms and
their meaning, by the use of laboratory methods as aids to their
own clinical labours, and by the study of the whole art and science
of prognosis and prevention. “ The general practitioner’s outlook
needs to be more comprehensive,” states Lord Dawson. ” In him
should be realised the correlation of preventive and curative medi-
cine. He should concern himself with measures for the maintenance
of health as well as the curing of disease ; he must be brought into
the position of a rightful leader and skilled adviser in all that apper-
tains to the social service and welfare of his district ; in matters of
health he should be the father of his people.”T

 

* See Report of Royal Commission on National Health Insurance, 1926,
Chapter V, pp. 28—66.
'|' The Nation’s Welfare (1918), p. 17.

139

(ii) Auxiliary Services.

168. In the adequate practice of Medicine the private medical
practitioner is not the only agent. Closely associated with him are
the dentist, the midwife, the nurse, the health visitor, the sanitary
inspector, the dispenser, and the expert workers in electric treatment,
massage and remedial exercises. In all parts .of the country many
thousands of cases of illness require for their adequate treatment
'the services of a nurse or expert masseur. The proper training,
registration, employment and distribution of these invaluable
coadjutors calls for consideration in any national scheme of pre—
ventive and curative medicine. These professions ancillary to
medicine have of course been well represented for many years, but
there is need at the present time for more thorough co-ordination.

(iii) Clinics and Dispensaries.

169. The Poor Law Act of 1601 was designed to provide for
'the relief of the “lame, impotent, old, blind, and such other among
them being poor and not able to work,” and when in 1834 the Poor
Law Commissioners inquired into the public medical services they
’found that a system of medical relief had grown up throughout the
country providing medical aid through district medical officers and
at dispensaries.* Provident dispensaries, contract practice and
medical clubs also arose, and all these agencies were at work, un-
equally but widely, when the National Insurance Act was passed in
191 1. Many of them of course continue, but a new kind of dispensary
was introduced in the advent of the “ School Clinic” under the
Education Act of 1907, and the yet earlier Tuberculosis Dispensary
"for dealing with persons suffering from that disease.

170. The Clinic, as generally understood, is an out-patient depart-
ment, with or Without beds, established ad hoc for the diagnosis or
treatment of diseaset It possesses a medical staff (part or whole time),
a nursing staff, competent, trained assistants, and suitable special
equipment. At the present time the following examples of this
institution may be named :—

(1) General and Provident Dispensary (I30).

2) Tuberculosis Dispensary (450).

3) School Clinic (medical and dental) (1,190).

4) Maternity and Infant Welfare Centre (2,200).

5) Venereal Disease Clinic (190).

6) Other Special Clinics (mental, dental, orthopaedic, artificial
light, &c.).

* For an historical account of the treatment of the sick poor in England see
English Sanitary Institutions (Sir J. Simon) and English Poor Law and The
State and the Doctor (Sidney and Beatrice Webb). The dispensaries were
instituted in the eighteenth century mainly by medical practitioners.

T It should be distinguished from the " clinics " in medical schools, the
:prime purpose of which is education or demonstration.

(
(
(
(
(

 

140

It is evident that the practice of these institutions is not always
identical. In some, educational work is predominant; in others
examination, consultation and observation; in others direct treat»
ment is the principal purpose. All these clinics serve, however,
to furnish types of assistance and advice which cannot usually be
rendered by the general practitioner; they all provide for such
“ team ” work as may be found practicable both between doctors.
and between doctors and auxiliary officers ; they all act as receiving
house and centre of diagnosis, as clearing house and centre of obser-
vation, as curative centre, as clinic for examination of “ contacts ”
in the case of infectious maladies, as centre for after—care and following
up, and as bureau of information and education. Now these are
invaluable characteristics and they represent an essential factor in
the organisation of a public medical service. The immense popularity
of the school clinic and the maternity and infant welfare centre
furnishes indisputable evidence of their necessity. Neither mothers-
nor children go to these places for amusement; they go because
of the substantial and prompt assistance they receive. It is
'obvious that clinics for tuberculosis, for venereal disease, for mental
disorder, or for orthopaedics cannot be popular in the same degree.
But they too are essential, at least in the present stage of the develop-
ment of a public medical service.

171. The clinic system will undoubtedly extend and develop.
It is desirable that it should expand on the lines which will include
essential principles. First, among these is the necessity of efficiency
and prompt, sympathetic assistance. Nothing can justify the
establishment of unsatisfactory and unpopular institutions which
fail to meet the needs of the patient. Secondly, the private prac-
titioner should take his full share in their work and service. He should
send suitable cases and he should work, as far as his special qualifica-
tions allow, either on the staff or otherwise, in close association
with the clinic. Thirdly, appropriate combination or differentiation
of functions of the various forms of clinic should be considered.
Lastly, these clinics should serve as educational centres, demonstrating
the oneness of preventive and curative medicine, true “ health
centres.” It is not necessary that clinics for all of the six above-
named purposes should be “ housed ” each in a separate institution.
Indeed, there may be obvious advantages of economy and of efficiency
in establishing a combined centre, where at specified times any of
these conditions may be dealt with, even as there are advantages in
weaving together different forms of clinic in association with a
hospital or other institution having bed accommodation. Most
types of clinic may need subsidiary clinics or branches, and certain
types should always be associated with or attached to a well--
equipped hospital. In the consideration of an extension of the
clinic system, regard should be had to need for dealing with the
diseases of women and children in particular. In many areas there-

141

is urgent need for gynaecological clinics, dental clinics, and special
clinics for all forms of remedial work.

(iv) H ospitals and Residential Institutions.

172. The earliest charitable institutions in England were houses
of hospitality, which was rightly regarded as a religious obligation.
Hospices for indigent persons were founded in the tenth century,
but in 1170 the pilgrimages to the shrine of St. Thomas of Canterbury
led to the foundation of a further type, and in the fourteenth century
yet another kind of hospital was established for vagrants, paupers
and the sick poor. Alongside this slow growth, almshouses, lazar—
houses and refuges for the insane began to be created, in due course
the famous hospitals of St. Bartholomew and St.Thomas were founded,
and in the eighteenth century many of the great London hOSpitals
were built.* The poor law infirmaries and the isolation hosPitals
for cases of infectious disease must also be included. Now, if to-day
we take any given sanitary area, we find a larger or smaller collection
of residential institutions for the treatment of disease. A large
county area will contain general and special hospitals of various
sizes and purposes (general, county and cottage hospitals, poor law
infirmaries, isolation hospitals for infectious diseases, hospitals and
sanatoria for tuberculosis, hospitals and asylums for mental disease,
lying-in institutions, hospitals or homes for women and children,
and hospitals for special diseases—venereal, skin, eye, ear and throat,
orthopaedic, &c.). The poor law, the sanitary authority or philan-
thropy are the chief sources of origin; the Church, the State and
Science have all had their share. If we map out our imaginary coun-
ty, we shall discover that the hospital institutions are dotted about
with but little regard to the present needs of the population. Ancient
and mediaeval reasons account for distribution, a score of accidental
factors, other than the essential factor, have played their part. There
is entire absence here, redundance there ; sound representative
government here, but arbitrary and capricious control there ; here
is an open door and a crowded out—patient department, there is a
“ letter ” system at work and no out-patient accommodation. And
there are differences of conditions of admittance and fee, of nursing
and treatment, and so forth. Yet the essential factor is adequacy;
adequacy in relation to population, a proposition in quantity, in
relation to the medical needs of that population, a matter of
quality]L

* See The M edizeval Hospitals of England (Clay), and the records of Charing
Cross Hospital (Hunter) and St. Bartholomew‘s (Moore). The monumental
work of Sir Norman Moore, The History of St. Bartholomew's Hospital (2 vols.,
1918), represents the highest standard of historical record of a great hospital
and illustrates in exceptional degree the varied and complex origins from
which the English hospital arose.

T See Report on Voluntary Hospital Accommodation in England and
Wales, 1925 (Cmd. 2486), Price 65.; and The Voluntary Hospitals in Great
Britain, 1925 (British Red Cross Society), Price Is.

 

142

173. There is, in fact, no general hospital system in England.
There are hospitals ; and in respect of the poor law institutions and
the isolation hospitals there is organisation.* But when we turn
to reflect upon the general hospital system we shall find it unorganised
and insuificient. Consider, for example, the inadequacy of the
number of general hospital beds per population, or the number of
beds for early mental cases, or the number of beds for maternity.
Yet this question of accommodation for the institutional treatment
of normal and abnormal cases of confinement stands in the front
rank of national requirements in respect of maternity. The great
centres of population are in need of two—fold provision, maternity
hospital accommodation for abnormal cases, maternity home accom-
modation for normal cases which cannot be normally or even safely
dealt with in overcrowded, insanitary or unsuitable tenements.
Relatively speaking the need for similar provision in rural districts,
is equally great. Many rural districts are wholly without such
accommodation, and in others it is inadequate. What is required
is, say, not less than one maternity bed per 2,000 of the population,
possibly attached to or associated with the local hospital or headquar-
ters of the district nurses. There should be a small general ward,
a confinement ward, an isolation or observation ward, and where
possible single wards for patients able to pay larger fees. A com-
petent midwife—matron should be in charge, and the medical

 

* It may be convenient to add the estimated figures of hospital provision
in England and Wales :—

No. of Institutions. No. of Beds,

 

England. Wales. Total. England. Wales. Total.

 

*General . . . . . . 749 56 805 48,201 2,259 50,460

Isolation and Port Sanitary 970 75 1,045 36,400 1,800 38,200
Hospitals.

Tuberculosis Hospitals and 4741' 16 490 21,262 1,393 22,655
Sanatoria.

tInstitutions, Registered 417 18 435 132,579 6,543 139,122
Hospitals and Licensed
Houses for Lunatics and

Mental Detectives.
§Poor Law .. .. .. 668 45 713 116,607 3,628 120,235

 

 

 

 

 

 

 

* Includes General, Cottage and Special Hospitals.

1' Includes Isolation Hospitals with accommodation for tuberculous
patients. '

1 Includes 158 Poor Law Institutions (150 in England, with 8,186 beds,
and 8 in Wales, with 266 beds) approved under Section 37 of the Mental
Deficiency Act, 1913 ; excludes Broadmoor Criminal Lunatic Asylum.

§Including Institutions but excluding beds for Mental Defectives in
Institutions certified under § 37 of Mental Deficiency Act, 1913.

143

practitioner should attend his own cases. What is true for maternity
is equally true for surgery. In urban and rural districts there is
need for adequate provision for emergency and minor surgery, a
network of clinics and hospitals.

174. It is obvious that a complete and satisfactory hospital
system cannot be provided for many years. But a beginning may
be made. In the first place, the whole question of proper hospital
accommodation should receive formal and deliberate consideration
in every sanitary area. A careful survey should be made, which
comprehends the whole case : the existing provision of all kinds
(general, maternity, surgical, children, &c.), the total medical needs
of the area, the new accommodation which is necessary, its character,
degree and relative urgency. The old idea that only critical, advanced
or emergency cases should be admitted to hospital must be discarded.
Essential treatment, not otherwise obtainable, should be the criterion.
Then, secondly, even before new hospitals are built, steps should
be taken to co-ordinate and bring together in co—operative action
the existing accommodation of the area, to determine its relation to
available accommodation outside the area, its relation to a system
of clinics, to medical practice of all kinds, to midwifery and nursing,
to the poor law accommodation and so forth, within the area. The-
hospitals of an area should be re—organised on a basis of a central
hospital, having auxiliary, special and convalescent hospitals asso-
ciated with it, a co-ordinated network. Thirdly, the out—patient
departments attached to the hospitals of an area should be examined
as to their adequacy. The waiting lists of patients should be con-
sidered and the possibilities of treatment investigated. Some of
these patients may be able to afford to pay for treatment, and this
will raise the further question whether some hospital accommoda-
tion should not be available for ” paying cases." In any case a
long waiting list is an anachronism, itself a condemnation of our
inadequate hospital provision. Lastly, the hospital service of an
area must be brought into much closer relation with the medical
practice of the area : (a) some practitioners should be on the staff
of the hospital, (b) all should look to it as a centre both of education
and of assistance in the discharge of their professional work, and (c)
all should be enabled to send their cases to its wards, not only, as
now, the critical or surgical cases, but many others that really stand
in need of efficient hospital treatment, observation, dietary, nursing,
massage, &c.

(v) Public Medical Services.

175. The increasing appreciation of the physical needs of the
people and the development and organisation of the medical pro-
fession has led the State, step by step, to provide first one and then
another public medical service, until at the present time we probably
have in this country the most complete and advanced scheme of such

144

official facilities as exist in any part of the world. The land is
completely covered with local Sanitary Authorities whose duty it
is to ensure a sanitary environment for all men ; there is a maternity
and child welfare service responsible for maternity and infant welfare ;
there is a school medical service for the medical care of the child of
school age ; there is medical supervision of factories, workshops
and workplaces, comprising a wide and far—reaching scheme of
industrial welfare ; there are facilities in every district for dealing
with infectious diseases, tuberculosis, venereal, and for some non-
infective maladies; there are institutions for the custody and
treatment of persons suffering from lunacy and mental defect, and
for patients under the Poor Law (and this is in addition to the great
and small voluntary hospitals in all parts of the country). Above
all, there is the insurance service which now includes within its ambit:
(a) national health insurance for fourteen million persons ; (b) in-
surance against unemployment ; (6) insurance against accidents ;
(d) old—age pensions ; and (e) pensions for widows and orphans—
all, save one, on a contributory basis which anchors a man’s values
in self-security and self-interest, and also in the financial stability
of the State. It may well be that this system is capable of further
development, but it is the largest and most comprehensive scheme
of Public Medicine which history records.

176. Here then are five typical elements or factors which are
constituent parts of any national medical service on behalf of the
sick. It will be recognised at once that they are 'all, in greater
or less degree, in existence. They do not call for creation ; they
call rather for readjustment, correlation and development. At
present, in some districts, these factors appear to be sporadic,
incidental, isolated, almost occasional. Above all, an adequate
medical service must seek to fulfil and conjoin all the varied elements
of a national health policy, environmental and personal. There
must be no divorce between the epidemiologist and the practitioner.
Their purpose is ultimately the same. Sanitation, maternal and
child welfare, industrial hygiene, medical practice, health education,
epidemiology, research and investigation, the prevention of disease
—it is “ the track of the one into the many and the many into the
one.” To be made really effective in the national interest and
well-being the “ many ” must be woven into one piece, the warp
and woof of one texture, they must be fitted together as parts of one
machine, and, suitably co-ordinated, they must be brought into
living association as members of one organism, and they must be
directed to the exact issue to which they are designed. Moreover,
to use one instrument and neglect the others may be to spoil the
whole result. To accomplish this there must be partnership, at
the centre and right out to the circumference, between medical
men and laymen, between science and administration.

 

145

SECTION VIII.
SOME PRINCIPLES OF MEDICAL ADMINISTRATIVE MACHINERY.

177. The sanitary government of England is partly central
and partly local. Speaking generally, the function of the central
is supervisory and of the local, executive. " The principle of local
self-government has been generally recognised as the essence of our
national vigour. Local administration under central superinten-
dence is the distinguishing feature of our government. The theory is
that all that can should be done by local authority, and that the
public expenditure should be chiefly controlled by those who con-
tribute to it. Whatever concerns the whole nation must be dealt with
nationally, while whatever concerns the district must be dealt with
by the district.”* The history of the varying expression of these
two principles during the last eighty years is recorded elsewhere,1'
and it is unnecessary to recapitulate.

That long and chequered history has found its consummation
in the Ministry of Health Act, 1919, and these pages must have
reference only to the present position. There are, however, two
general matters which must be named, first, the underlying principle
of sanitary government (though not of sanitary government alone),
and secondly, its limitations. The positive principle which is so
vital to the administration of a medical service is that the method
of government, be it central or local, shall have regard to the content
of medicine and its progress. When Dr. Richard Mead issued
his quarantine recommendations in 1720, their administration was
a different problem from that which now demands our attention.
Then, as now, there was some vision of the preventive aspect of
medicine ; then, as now, environment played the part of a prime
factor ; then, as now, a local executive had to be provided for. But
to-day, two hundred years have accumulated for us a wider know-
‘ ledge of disease—its causes and means of prevention—an immense
volume of administrative experience and a large and comprehensive
organisation. (See Section II.) This has profoundly changed the
situation and made it necessary to have regard, both centrally and
locally, to the principle that (a) governmental action shall closely
follow the commonly accepted knowledge of disease and its preven—
tion, (1)) it shall be inspired and controlled by the consent of the
governed, and guided, as far as may be, by the will of the people
finding its expression through representative institutions, and (c) it
shall be carried into practice by a partnership of central and local
government, and of professional and lay opinion. The fundamental
reason for this kind of government is that the practice of preventive

* Report of Royal Sanitary Commission, 1871, p. 16.
1 English Sanilary Institutions, Sir J. Simon, pp. 173—432. Public Health,
a Survey. (Reconstruction Pamphlet, No. 23, 1919.)

(a 32/931)g g

146

medicine involves not science only, but far—reaching personal and
social considerations, which affect not only the habits, occupation
and susceptibility of the individual, but the capacity, security and
Well the existence of the nation.

178. So much for the positive side. A word must be added as
to the negative, namely, the limitations of government so prescribed,
particularly in relation to medical service. It means——

(a) a considerable degree of uniformity ;

(b) a standard of objective and of work which constitutes
something of the nature of a national minimum of what
is both necessary and practicable in all areas, rather than
what might be desirable it carried out by the most
enlightened and competent authorities ;

(c) the undertaking only of what is immediately practical and
obviously beneficial, rather than the adoption of a
medical system of higher scientific value and statistical
accuracy, but less obviously ameliorative or remedial
in purpose ;

(d) the achievement of its ends within the limits of law and
through the agency and understanding of local authori-
ties ; .

(e) a regard for public economy, for the adaptation of means to
ends in each locality, and for the application of remedies
appropriate to the district and proportionate to the
problems to be solved ; and

(f) an appreciation of the relative spheres of the State and
the individual, of statutory and voluntary service,
and of central and local authority.

The validity of most of these propositions will be obvious, nor
is it necessary in this place to furnish argument in their support.
They are in some degree a safeguard and a security ; but it is equally
obvious that loyalty to them imposes somewhat severe restrictions
upon the sphere and compass of a national health system. It is
important that this should be recognised by all concerned, but
particularly by those who assume that in the sphere of national health
anyone may propose any course which seems good to him. Investi-
gation, research, even experimental work there must be, if there is
to be progress ; but both authorities and medical men will do well to
bear in mind the necessity of paying regard to the relation which
their proposals for an adequate medical service bear to the district
as a locality or to the nation as a whole. Schemes in themselves
admirable are not always, on this account, practicable or expedient.

179. The medical problem to be solved, both centrally and locally,
is one of simplification and unification. At the centre there have
been anomalous extensions for three generations—the Poor Law

147

Board and the Board of Health of 1848—58, the Privy Council
Committee 1858—71, and the Local Government Board 1871—1919,
acting as the central medical department of the Government ; then
as the years passed and Medicine came into closer touch with the
State, other central offices formed medical departments or were
assigned medical duties, the Home Office, the Board of Education,
the Board of Trade, the Board of Agriculture, the National Health
Insurance Commission, and so on, till at last a score of central offices
discharged some kindred medical duties. At the periphery a similar
multiplication occurred of Authorities concerned with health—the.
Board of Guardians, the local Sanitary Authority, the local Educa—
tion Authority, the Insurance Committee, &c., involving in their
compass local bodies connected with the County (or shire), the
hundred (or wapentake), the borough, the urban and rural districts,
and even the parish. It is now proposed to correct the resulting
confusion and overlapping by Poor Law reform.

180. No one can realise the age-long accumulation of tradition
and practice without being convinced of the need for simplification
and unification ; and this leads me finally to a brief reference to the -
question of the medical administration of Preventive Medicine.
Such administration has both a medical and non-medical aspect.
This memorandum is not, however, concerned with the large and
essential sphere of non—medical administration represented at the
centre by secretaries, assistant secretaries, lawyers and clerks, and
in the locality by the clerks of the County, Town, and District
Councils and their respective advisers and assistants. It is con—
cerned only with certain medical aspects of the situation. But, of
necessity, these concern both central (including international) and
local spheres.

Central Medical Administration.

181. The Ministry of Health has been established to unify and
' co-ordinate the health policy and medical activities of civil governe
ment. Speaking generally, its functions may be set out briefly as
follows :—

(i) to advise upon, supervise and regulate the health and
housing work of local authorities, providing grants in
aid of financial expenditure for the fulfilment of certain
functions ;

(ii) to aid in the acquisition of knowledge and the prosecution
of investigations both in the advancement and in the
application of medical science, forming a medical
.intelligence service ;

(iii) to advise upon, guide or initiate health legislation ;

(iv) to co-ordinate the health work of central government ;

(v) to furnish advice and assistance in regard to foreign and
imperial health matters (see below) ;

(vi) to foster and encourage the practice of PreventiVe
Medicine.

148

It is clear that any one or all of these brief statements could be
expanded to cover a wide ground, but, in a .word, the chief business
of the Ministry is supervision, unification and co-ordination ; its
chief purpose sound national progress. Its responsibility is partly
central, partly local. Centrally it is concerned to promote} the
health of the people and to guide all health activities to asingle goal.
The duties of the Minister of Health are defined by the Ministry
of Health Act, 1919, as being :—

“ To take all such steps as may be desirable to secure the prepara-
tion, effective carrying out, and co-ordination of measures
conducive to the health of the people, including—

(i) the prevention and cure of diseases ;
(ii) the avoidance of fraud in connection with alleged
remedies ;
(iii) the treatment of physical and mental defects ;
(iv) the treatment and care of the blind ;
(V) the initiation and direction of research ;
(vi) the collection, preparation, publication, and dissemina-
tion of information and statistics ;
(vii) the training of persons for health services."

In addition to the powers thus specified in the Ministry of
Health Act, Parliament has since 1875 passed various Public Health
and other Acts, which have for their purpose the practice of pre-
ventive medicine, and the administration of these Acts falls within
the province of the Ministry of Health or other Departments
concerned with the public health.*

 

* The most important of these Acts are :—

(1) Public Health Acts, 1875 (sanitation, infectious diseases and hospitals,
prevention of epidemic diseases, etc.) ; 1878 (water) ; 1879
(interments); 1882 (fruit piekers’ lodgings); 1883 (support of
sewers) ; 1885 (ships, &c.) ; 1888 (buildings in streets) ; 1890
(Amendment Act) ; 1891 (London) ; 1896 (ports) ; 1907 (regula-
tions as to food) ; 1907 (Amendment Act) ; 1913 (prevention and
treatment of disease):;'ll921 (tuberculosis) ; 1921 (officers) ; 1925
(sanitationaverminous premises, infectiousldisease, propaganda,
&c.):;

(2) Sale of_Food and Drugs Acts, 1875 ; 1879 (Amendment Act) ; 1899 ;

(3) Rivers Pollution Prevention Acts, 1876 ; 1893 ;

(4) Canal Boats Acts, 1877 ; 1884 ;

(5) Housing of the Working Classes Acts, 1885; 1890; 1894; 1900;
1903.; (consol. with others, 1925) ;

(6) Housing and Town Planning, 850., Acts, 1909 ; 1914 ; 1914 (No. 2) ;
1919; 1923; 1924‘; (consol. with others, 1925);

(7) Local Government Acts, 1888; 1894; 1903 (transfer of powers);
1913 (adjustments) ;

(8) Lunacy Act, 1890 ;

(9) Infectious Diseases (Prevention) Act, 1890 ; 1889, 1899 (notification) ;

(10) Factory and \Vorkshop Acts, 1891 ; 1901 ; 1907 ;

149

182. International Service—The Local Government Board, and
before its day the Privy Council, found one of its most honourable
services in furnishing advice and assistance through the Foreign
Office in regard to imperial and international health. In the first
year of the Ministry of Health (1919) this old tradition was vigorously
renewed and extended, in relation both to the Office International
D’Hygiéne Publique at Paris and to the new Health Commission of
the League of Nations at Geneva. International sanitary con-
ferences had been held since 1851, and in that which assembled in
Paris in 1903 assent was given to the creation of an international
sanitary bureau which came into being at Rome in 1907. This
Office International was the first world-wide organisation for public
health. Twelve nations ratified the agreement and upwards of 40
nations have since participated in the work of the Office. It forms
the meeting place twice a year of official and professional delegates
of the participating Governments ; to collect and exchange informa-
tion on current questions of practical importance, and where necessary
to prepare International Agreements. Its work has included studies
of rat destruction in relation to plague; the prevention of plague,
cholera and yellow fever; the standardisation of vaccines, sera and
biological products ; purification of water supplies ; types of scarlet
fever and smallpox; anti—typhoid vaccination ; and the study of
preventive methods for Malta fever, trachoma and leprosy. After
the European War of 1914-18 the Office set to work on the revision
of the Sanitary Convention of Paris, 1912, by which quarantine
measures are regulated, and dealt with influenza, typhoid, plague,
venereal disease, the regulation of therapeutic substances, deratisa-
tion of ships. an international classification of disease, standardisa—
tion of sera, &c. The Office has issued a Monthly Bulletin since 1909.

(11) Isolation Hospitals Acts, 1893 ; 1901 ;

(12) Education Acts, 1893 (blind and deaf children); 1899 and 1914
(defective and epileptic children) ; 1906 and 1914 (provision of
meals); 1907 (administrative provisions); 1909 (medical treat-
ment) ; 1918 ; 1919 (medical inspection and treatment of children
and young persons, 85c.) ; 1921 (consolidation) ;

' ) Cleansing of Persons Act, 1897 ;

) Vaccination Acts, 1898 ; 1907 ;

) Midwives Acts, 1902 ; 1918;

) Employment of Children Act, 1903 ;

) Notification of Births Act, 1907 ; 1915 (Extension Act) ;

)

)

 

Children Act, 1908 ;
National Insurance Acts, 1911; 1917; 1918; 1919; 1920; 1921;
1924 (Consolidation Act) ;
(20) Mental Deficiency Act, 1913 ;
(21) Milk and Dairies Act, 1914 ; 1915 (Consolidation Act) ; 1922 (Amend-
ment ;
(22) Venereal Disease Act, 1917 ;

(13
(14
(15
(16
(17
(18
(19

) Nurses Registration Act, 1919 ; N
) Blind Persons Act, 1920 ;

) Dangerous Drugs Acts, 1920 ; 1923; 1925 ;

) Dentists Acts, 1921 ; 1923,

150

183. After the war the League of Nations organised an inter-
national Health Commission with the following functions :—

(a) To advise the League of Nations in matters affecting health.
(b) To bring administrative health authorities in different countries into
closer relationship with each other.

(6) To organise means of more rapid interchange of information on
matters where immediate precautions against disease may be
required, and to simplify methods for acting rapidly thereon.

(cl) To promote the conclusion of international agreements necessary
for administrative action in matters of health, and their revision
when required, and to collect information as to their fulfilment.

(e) To co-operate with the International Labour Office in matters
affecting labour and health.

(f) To confer and co—operate with Red Cross Societies and other similar
societies.

(g) To advise, when requested, other voluntary organisations in health
matters of international concern.

(h) To organise missions in connection with matters of health.

It has co-operated with, rather than absorbed, the Office Inter—
national, the Committee of which accepted the additional responsi—
bility of acting as a Consultative Council to the League—a duty
which its representative and official character made specially fitting——
and ‘it has created a permanent Health Committee (16 members)
and a health section in the Secretariat of the League with headquarters
at Geneva (Medical Director, Dr. Ludwik Rajchman). In practice
the Health Organisation has undertaken work under five heads :—

(1) Measures for the control of epidemics.
(2) The standardisation of certain laboratory products and procedures.

(3) Co-operation with other League of Nations organisations in matters
that involve medical or public health questions.

(4) Promotion and improvement of public health work by the inter-
change of health officers between the various countries, and by
technical advice to various Governments.

(5) The collection and dissemination of epidemiological information,
the co—ordination and improvement of vital statistics for inter-
national use, and epidemiological research.

Epidemic commissions have taken part in the combating of typhus
fever in Poland and Russia, smallpox in Greece, malaria in the
Near East, epidemic disease in the Far East, and sleeping-sickness
and tuberculosis in Equatorial Africa. Intensive studies in tuber-
culosis and cancer mortality, anthrax, and the standardisation of
laboratory products have also been undertaken. Two further most
valuable services have been the interchange of sanitary personnel
and the organisation of an epidemiological intelligence service. The
scheme of interchange which commenced in 1922 has had for its object

151

the general advancement of public health administration in different
countries and the promotion of international co-operation. This
interchange is not an actual exchange of public health officials between
the countries, but consists, in general, of courses of “ travel studies "
by the technical personnel for a period of six to twelve weeks. Under
this plan officials of the various health administrations are brought
together in a particular country, given a course of lectures on the
health administration of that country by the technical experts and
responsible public health officials, and are shown the hospitals, water
supplies, sewerage systems, laboratories, and other interesting phases
of public health administration. In addition to the interchanges
of general health officers, interchange studies are also provided for
special workers, such as those interested in school hygiene, tuber—
culosis, port sanitation, serological work, &c. Some 20 such inter-
changes have taken place concerning more than 30 different nations.

184. A service of epidemiological intelligence and public health
statistics has been developed by the health organisation of the
League, aided greatly by funds provided by the Rockefeller
Foundation. Its programme includes a study to evolve simple and
reliable methods for collecting information regarding the incidence
of communicable diseases; a study of the comparability of vital
statistics of the various countries; a comparative study of the
character and significance of observed differences in the prevalence
of particular diseases in different countries; the preparation and
distribution of special periodical publications; a survey of the
public health work of the principal countries of the world, and
the issue of monographs on this work; and the organisation of a
rapid interchange of information on epidemic diseases in cases in
which prompt action may be necessary. The health section issues
monthly the Epidemiological Report, printed in two languages,
French and English, containing a résumé of the most recent data
available regarding the prevalence of the principal communicable
diseases (case incidence and mortality) in the countries furnishing
.data to the League. A comprehensive annual report in similar
form is also compiled.

185. It should be added that the International League of Red
Cross Societies also continues its work in relation to education and
the training and development of nursing services. Thus the Office
International, the Health Committee of the League of Nations, and the
Red Cross Societies work in friendly and collateral association, assist—
ing and supplementing each other, but leaving national work in all
cases to be done by the respective nations, thus safeguarding national
economy, autonomy and responsibility. Similarly the people of
North and South America, though co—operating in the European
organisations, have their own Pan—American Sanitary Bureau which

152

has held seven representative international sanitary conferences
since 1902, dealing with many of the same questions as the inter-
national organisations on this side of the Atlantic. In these modern
developments the Ministry of Health in Great Britain has played its
part as older brother among the nations. We began our public
medical services in the eighteenth century. The seed thus sown
has grown into a wide-spreading tree, and its fruits are now for
the healing of the nations.

Local Medical Administration.

186. It is not, however, the Ministry of Health but the local
authority in whose hands will rest the main business of the execution
of a national health policy in every land. It is in the local area, in
direct touch with the patient, that the integration of medicine
is to be achieved. It is there that early diagnosis is to be made,
that prognosis is to be estimated, and a prompt and adequate
medical service, both preventive and curative, is to find its
fulfilment. It is there that the systematic and continuous attack
is to be made, for there is the fighting line. It is there and not in
Whitehall that the actual battle will be lost or won. Racial
questions, maternity, child welfare, industrial hygiene, the control
of the food supply, the problems of environment, the prevention of
disease, the education of the public—these matters can only be dealt
with where the people are born and live and work and die.

187. We have already seen that the local authority is of four or
five types for the performance of different functions, each of them
having its medical adviser. There is the Medical Officer of Health
and his deputies ; there are the special medical officers for the poor
law, for schools, for factories, for tuberculosis or venereal disease ;
and there are the medical practitioners.* These are the medical
representatives of an adequate public service, the integrators, co—
operators and educators. In their hands lies in large measure the
future of preventive medicine in their local district and thus in the
nation at large. They “ must either take the helm,” as Sir John
Robertson has said, “ or give it to a better trained medical officer.”

The man who is to “ take the helm " in any area in this great
enterprise, be he who he may, must have a large apprehension both
of his opportunity and his function. He must possess not only the
clear and comprehensive vision which can

“ look into the seeds of time
And say which grain will grow and which will not,”

but he must have courage, discernment and patience. For, first,
preventive and curative medicine have to be brought together and

 

* Midwives, nurses, health visitors and sanitary inspectors also have their
duties and sphere in each area.

153

practised in harmony. The extension of the public health service
in respect of tuberculosis, venereal disease, insurance work, maternitv
and infant welfare, the school child, and industrial hygiene, means
that every medical practitioner is a workman for the public health,
a missionary of an imperial cause. He may seize the occasion with
gladness, or he may protest, but he cannot escape. Secondly, there
must be not only a co-ordination of medical men, but also of the insti-
tutions in which they work—the private surgery, the laboratory, the
clinic, the out—patient department, the hospital. Institutions are
things to be adapted and directed by persons, in order to reach
prescribed ends. They are instruments which must be fashioned
to secure, with certainty, the purposes for which they are designed.
Thirdly, there must be true and active understanding, co-operation
and goodwill between the official element of government and that
great and invaluable voluntary element which exists, happily for this
country, in every district of the land. These conditions mean that,
in every area, the principal medical organiser and all other responsible
medical officers charged with these duties should be men of wide and
liberal sympathy, trained in administrative work, accustomed to
handle problems of environment and sanitation in the broadest
sense, but able also to be ” clinical ” in understanding and in spirit,
able to join together and direct all branches of medicine, “ the one
into the many and the many into the one.” Clearly, one man
cannot do everything or be specialist in all departments, but one
man can have a fair and proper View of the wholeness of Medicine,
and so do his work as to allow for the “ give and take,” the strain
and counter—strain, necessary in all sound construction. It is a pro-
blem in construction—the patients, doctors, institutions, and know-
ledge are all there, what is needed is inter-dependence, co-operation,
joint action, integrity. The result will be a true foundation in every
part of the land for the practice of Preventive Medicine.

188. Thus the sound mind in the sound body, the full capacity
and opportunity of labour, the true joic de vivre which springs from
all-round health, may in some larger and more liberal measure
become established in the homes of the English people.

189. It has been said that we stand to—day at the door of oppor-
tunity, and that upon us of this generation has been imposed the
duty of laying the foundations of a new epoch. It is true that other
and better men have gone before us, and we enter into their labours,
as other and better men will follow us and enter into ours. But
our responsibility is none the less sure. Knowledge, clearness of
mind, the broad vision, strength of will and sympathy of heart have
been in the past, and they will be in the future, the inspiration of all
high human endeavour. As a student and a workman, I avow my
belief that in order to reach their fulfilment the science and art

(B 32/931)Q G

154

of Preventive Medicine need the same inspiration. No far-reaching
medical reform is separable from social reform, which in its turn
finds its source in the highest aspirations of the people. Thus, here
on this common physical plane, here or nowhere, the issue must be
determined and the ancient ideal of Hippocrates attained—“ the
love of humanity associated with the love of craft.” The impair—
ment of the physique of the human body is the impairment of
intellectual and moral fibre, for the body is the tabernacle of the
spirit of man.
G. N.

Printed under the authority of H18 MAJESTY'S STATIONERY UFFIOE
My Harrison and Sons, Ltd.. 44747. St, Martin‘s Lane. W.(I 2

[6/261 (n32/931)Q 16787—1140 4000 11/26 H&SLtd. Op 32 (776)

Publications relating to the work of the Medical
Department of the Ministry of Health.

These and other publications of the Department may be obtained
by purchase in the manner stated on the cover of this Report.

ANNUAL REPORTS OF THE CHIEF MEDICAL OFFICER,
MINISTRY OF HEALTH.

1919-20 :———Cmd. 978, 3s. 6d. (by post, 43.).
1920 z—Cmd. 1397, ls. 6d. (by post, ls. 9a.).
1921 :—15. 6d. (by post, ls. 8d,).

1922 :—2s. 6:1. (by post, 25. 8M).

1923 :—3s. Cat. (by post, 35. 3d).

1924 :—3s. 6d. (by post, 33. 10%.).

1925 :—3s. 0d. (by post, 33. 3%d.).

OTHER REPORTS, ETC., BY THE CHIEF MEDICAL OFFICER,
MINISTRY OF HEALTH.

Some Notes on Medical Education in England: Cmd. 9124, 1918,
9d. (by post, 11%.).

The Place of Public Opinion in Preventive Medicine (The Lady
Priestley Memorial Lecture) : 1920, 4d. (by post, 5%d.).

Recent Advances in Medical Education in England: 1923, Is. 3d.
(by post, ls. 6d).

“ A romance of medicine.”—0bserver.
“ A document of much importance.”——-British Medical Journal.

“ So remarkable a performance has certainly never before been achieved.”
—Times.

Public Education in Health : Revised 1925, 603. (by post, 7d).

MEMORANDA ON HEALTH QUESTIONS.

Smallpox: Memorandum on the Steps specially requisite to be taken by Boards
(1 Guardians on the Occurrence of Smallpox: Memo. 71 Mad, November,
1922, 1d. (by post, 1111.).

Smallpox : Memorandum of the Steps requisite to be taken by Sanitary Authorities
on the Occurrence of Smallpox: Memo. 71a Med., November, 1922, 1d. (by
post, 1%.).

Cancer: Memoranda prepared by the Departmental Committee—(i) Aetiology
and Incidence, Circ. 426; (ii) Effects of Radium and X-rays, Ciro. 476;
(iii) Cancer of the Breast, Circ. 496 ; (iv) 0n Experimental Cancer Research,
Circ. 516. Price 1d. each (by post, 1%.).

Encephalitis Lethargica: Memo. 45 Med., Revised, May, 1924. Price 1d. (by post,

lid-)-
Memorandum on the Duties of Medical Officers of Health in England and Wales,

1925. Price 2d. (by post, 211d)
Memorandum on Closure of and Exclusion from School, 1925, 4d. (by post, 4111.).

[Continued on page 4 of cover.

Reports on Public Health and Medical Subjects.

The following Reports in this series have been issued by the Ministry of Health
since 1920 :—

No. 1.—The Complement Fixation Test in Syphilis (Wassermann). (Price 53.)

No. 2.—Incidence of Notifiable Infectious Diseases during the year 1919. (Price
15. 3d.)

No. 3.——The Progress and Diffusion of Plague, Cholera and Yellow Fever throughout
the World, 1914-17. (Price 78. 6d.)

No. 4.—Report on the Pandemic of Influenza, 1918-1919. (Price 108.)

No. 5.—Dr. A. A. Jubb’s Report on the Occurrence of Gastro-Intestinal Illness
in Sandown, Isle of Wight. (Price 6d.)
No. 6.—Incidence of Notifiable Infectious Diseases during the year 1920. (Price 28.)

No. 7.——Report on the Causation of Foetal Deaths. (Price 103.)

No. 8,—Sniallpox and Vaccination. (Price 3d.)

No. 9.—Diet in Relation to Normal Nutrition. By Dr. Hamill. (Price 3d.)
No. 10.—Report on Diphtheria. (Price 18.)

No. 11.—Report on Encephalitis Lethargica. (Price 103.)

No. 12.—Dr. W. V. Shaw’s Report on an Outbreak of Enteric Fever at Bolton-
upon-Dearne. (Price 23.)

No. 13.——Bncteriological Studies on the Pneumococcus. By Dr. Grifiith, Dr.
Eastwood, and Dr. Scott. (Price 28. 6d.)

No. 14.-—Dr. T. W. Wade’s Report on the Occurrence of Bacillary Dysentery in
Glamorgan. (Price 18. 6d.)

No. l5.———Dr. Janet Campbell’s Notes on the Teaching of Obstetrics and Gynaecology
in Medical Schools. (Price 18. 3d.)

No. 16 -—Report on Scarlet Fever and Diphtheria in Ramsbury. By Dr. J. R.
Hutchinson. (Price 9d.)

N0. 17 .——Dr. J. M. Hamill’s Notes on the Pasteurieation of Milk. (Price 2d.)

No. 18.—Bacteriological Studies on the Pneumococcus. By Dr. Griflith and Dr.
Eastwood. (Price 18.)

No. 19.—Report on the Use of Hydrocyanic Acid for Fumigation Purposes. By
Dr. P. G. Stock. (Price 23. 6d.)

No. 20.—Report on an Outbreak of Dysentery in Lynton, Devon. By Dr. G.
C. Hancock and 1’. Bruce Wright, Esq., B.Sc. (Price 4d.)

No. 2l.——'Ihe Training of Midwives. By Dr. Janet Campbell. (Price 18. 3d.)

No. 22.——Bacteriological Studies on Diphtheria and Bacterial Virulence. (Price 29.)
No. 23.——The Incidence of Rheumatic Diseases. (Price 23. 6d.)

No. 24.——Report on Composition of some Commoner British Wines. (Price 1.9. 6d.)
No. 25.-—Maternal Mortality. By Dr. Janet Campbell. (Price Is.)

No. 27.——R-eport on an Outbreak of Dermatitis caused by the Wearing of Certain
Kinds of Dyed Fur. By Dr. Allan C. Parsons. (Price 9d.)

No. 28.—A Statistical Investigation of the Literature on Operated Cases of Cancer
of the Breast. By Dr. Janet E. Lane—Claypon. (Price 2.9. 6d.)

No. 29.~—The Solubility of Glazes and Enamels used in Cooking Utensils. By Dr.
Monier-Williams. (Price 6d.)

N0. 30.—Dr. W. V. Shaw’s Report on an Outbreak of Paratyphoid Fever in the
Borough of Chorley. (Price 2d.)

No. 31 .-—Report on Infestation of the Human Subject by the Nematode Worm, Ascaris
Lumbricoides. By Dr. Monckton Copeman, M.D., F.R.S. (Price 6d.)

No. 32.——A further Report on Cancer of the Breast. By Dr. Janet E. Lane-Claypon.
(Price 38.)

No. 33.-—A Report on Natural Duration of Cancer. By Dr. Major Greenwood.
(Price 901.)

No. 34.-—A Report on Late Results of Operation for Cancer of the Breast (Leeds).
(Price 6d.)

a...

CIERKELEV LIBRARIES

IIIIIIIIIIIII

(020552002