Prophylaxis in practice

T H E IRISH J O U R N A L MEDICAL SCIENCE THE OFFICIAL JOURNAL OF THE ROYAL ACADEMY OF MEDICINE IN IRELAND

OF

SIXTH SERIES. No. 159. MARCH, 1939.

P R O P H Y L A X I S IN PRACTICE '~.

By JOHN MOWBRAY.

T HE most difficult task for a writer on this subject is to catch it firmly so as to hold it up for inspection. It insinuates itself into so many ramifications of the

ordinary life of the State, the citizen and the doctor, it is found at times so far away from and apparently quite unrelated to the condition one is trying to eliminate, it shows itself in so many different guises, it acts through such an extraordinary number of diverse agents that one becomes almost worn out trying to make it stand out as an enti ty; rather does one feel like letting it get on with its activities willy-nilly in a hopeless world. But it would be tragic if such a tremendous force were not harnessed to do the greatest good for the greatest number; both the laity and profession interested in the various ways it can be made to safeguard the gift which is one of God's greatest and perhaps least appreciated (until, of course, it is lost)--good health with all the happiness it brings. Any person, lay or medical, may say that he or she has been practising prevention for years, nor can this be denied. We must freely admit that the most brilliant minds of the past and present have devoted themselves to this entrancing work with the most fruitful and brilliant results: witness the disappearance from our islands of such horrors as smallpox and leprosy. But there is still far too much prevent- able disease and suffering and the time is ripe for a great co-ordinated and concerted study of prophylaxis as distinct from sporadic attempts by individuals at unconnected points. There is far too much complacency about the standard of health. The percentage of people who enjoy vigorous health is so low that, when it is flaunted openly, the envious majority indict the offender as being aggressively healthy.

Health has been well defined as a state of relative equilibrium of body form and function which results from its successful dynamic adjustment to forces tending to disturb it. The body is a hive of ceaseless activity of a highly organised kind, the nature of which is a response to forces or energies which may either originate outside the body or in some of the cell groups

*Presidential 'Address delivered to the Medical Society, University College, Dublin, March 1st, 1939.

98 IRISH JOURNAL OF MEDICAL SCIENCE

of the body itself. Complete static equilibrium is never found, and one must allow for a certain amount of give and take in this tug-of-war as long as the system does not pass beyond a point from which it cannot readily sway back to its normal position. It is very important to admit this normal instability and indeed it is the lot of every one of us to experience temporary sensations commonly described as being " out of sorts " as quite distinct from being ill.

I t is not possible to define the exact point at which disease is said to have occurred. Health and disease are only working definitions. In health the body is in a constant state of flux, breaking up material taken from its environment, building it up again into different combinations, with hundreds of mechanisms working simultaneously and in a wonderful harmony, the well-called wisdom of the body. Into this mass of processes may come the forces of sabotage and, if order is upset to such a point that equilibrium cannot be easily restored, disease is said to have resulted. But still more is disease a process and not a static entity. When the writer of a textbook takes it on himself to describe a disease he should be careful to make it clear that the resultant of certain forces has produced certain changes which occur often enough to allow themselves to be given a common name. If this were done, the doctor in his early years of practice would not be so surprised that the condition he is treating refuses to tally sign for sign :and symptom for symptom with what he has regarded as the gospel of the textbook. He is not practising in a settlement of ameeb,e. Just as carbon, hydrogen, nitrogen and oxygen can be combined in almost an illimitable number of ways to produce millions of complete organic compounds due to the endless possibilities of permutations and combinations, so, but to an immensely greater degree, can the genes within the chromosomes form as many patterns as there have been human beings on the earth for, unless one concedes the rare exception of identical twins, no two patterns are the same. That means, in this argument, that no two living human beings, or rather processes, can be expected to react to any disturbing force in exact!y the same way. When one considers that the force itself varies in quality and strength and that all sorts of environmental and other factors are equally variable and numerous, one sees that the wonder is that a collection of signs and symptoms sufficiently typical to take .a place in a textbook is ever found.

When one realises that a disease process in any human organism must of necessity be a resultant of many variable interacting forces, it almost seems an impossible task to unravel the mystery, but any reader of detective fiction (and what doctor is not?) will agree that our only hope lies in beginning at the beginning. There is no effect without a cause. The human mechanism, complicated as it undeniably is, is nevertheless built up from simple actions and reactions between

PROPHYLAXIS IN PRACTICE 99

elemental principles. The disease process adds further com- plications, but elucidation must ultimately depend on a sound knowledge of the causes which act on the human process to produce the .disease process. Medical science through the centuries has brought to light many aspects of the causes of most human diseases, but in very few cases do we know what Perkins, of New Orleans, styles their " natural history." That means tracing the development from the prime factors through the changes in anatomy and physiology which we style pathology, noting at what points and with what results secondary causes act, right through to the end whether that be the restoration of the normal process or its disintegration into processes which are no longer our concern but which, nevertheless, it might be noted, continue the inexorable law of cause and effect. The writers of textbooks have, in spite of their attempts at etiology with its subdivisions into primary and secondary causes, with the further subdivision of the latter into contributory, accessory and predisposing causes, failed to tackle this idea of the natural history of a disease. The primary cause is often not as much concerned with the final result as the secondary causes. Nor must we be content to start the natural history of a disease from the moment the human organism is attacked--we must go back into the hereditary factors or out into the environment until we find the answer to our last why.

Malaria has been advanced as a good example of a far-flung natural history. We know the malaria parasite to be the specific cause and when it conforms to its types the disease is eminently recognisable and describable. But actually neither the host nor the parasite, important though they naturally are, takes pride of place. That is reserved for those factors which are not to be seen at all at the bedside but outside where one explores climatic conditions, drainage, vegetation, the breeding places of the mosquito, its struggle for existence and the protective devices employed by the host to escape its bite.

One can begin to see the fascination of the study of the natural history of a disease, the building up, not of stone on stone, but force on force, with the consoling thought that they are all familiar causes in the physical world and, again quoting Perkins, that the first effects are simple biophysical and biochemical responses to them.

In due course the natural history from alpha to omega will be built up but, as due course in medical matters has a tendency to run into centuries, we of the twentieth must at least renounce the besetting sin of narrowness of conception which leads us to ascribe all disasters to happenings within the body. Let us rather develop the breadth of view of a Finance Minister on the eve of the Budget with the added incentive that our cause, while just as desperate as his, is a righteous one.

The word " classification " has not so far figured in this paper and one might be forgiven for side-tracking this most important


question. The enormous widening of the etiological field which follows from these new conceptions would seem to make the task of classification almost impossible. Fisk (1929) presented ten categories :--heredity, infections, poisons, food deficiency or excess, air deficiencies or defects, hormone deficiencies or excess, physical trauma or strain, psychic apathy or disuse. Perkins attacks this attempt on very logical grounds, showing what are very obvious overlappings and alternatives and slashing with no uncertain stroke at such a phantasy as apathy. In their place he offers a list of categories, each of which includes only what is entitled to find a place under its banner, excluding all factors in other categories although such factors might act secondarily. They are

Category 1. II. III. IV. V.

V.I.

5nherited factors. Defects of nutritive elements. Endogenous chemical agents. Physical forces and energies. Vital activity of invading organisms. Psychobiologic and biosocial influences.

A careful analysis of these etiological factors will convince one that they are primary and that from them as centres radiate the lines of forces which terminate in disease. Impinging on the lines are side arrows which are undoubtedly influencing factors which play their parts, and most important parts, but which must be relegated to their proper positions as secondary if we are to have our natural histories of disease in proper perspective. Thus occupation and climate, for example, are side arrows. Our final picture, but remember it is a motion picture, is of innumerable spokes with many side arms but all radiating from a core of only six distinct divisions, a gigantic scheme of natural histories of disease. Far too many of the spokes are broken by gaps of ignorance, the prime factors themselves are far from their ~nal analysis, and in these days and in this state where medical research is looking for fields to conquer, the completion of this picture offers the prospect of eminently useful work for years to come. In the meantime let us work on the framework we have with the realisation that for preventive work it is only necessary to have one or two really vulnerable points in the spoke where a well-timed blow will dissipate the whole force of the energy line and render it innocuous. This method of attack has proved successful when the gaps in our knowledge were much wider than they are to-day. This intro- ductory concept of the idea of disease and the ideal of prophylaxis must now be subjected to close-ups at a few points because it would be manifestly impossible to do more within the confines of a paper such as this.

The category of " defects of nutritive elements " has of recent years come in for special consideration by both the profession and laity. It is at last generally recognised that it is too late to commence prophylaxis after the child is born, and ante-natal


is ~early as well known to this generation as Uncle Tom was to those preceding it. Before plunging into this question, let us steady ourselves with the findings of Drs. Dockeray and Fearon recently here in Dublin. In an investigation into the diet of fifty women--the wives of unemployed men--at tendin~ the ante-natal department of the Rotunda Hospital they found great deficiencies. There was no great mystery about the cause in these cases because deducting rent, insurance and fuel from the income of the fifty families concerned, the munificent sum of 3/- per head remained for everything else. When one considers that the B.M.A. Committee on Nutrition found the minimum costs to be 5/10�89 a week for adults and 2/6 a week for children under three years, figures which are regarded as sub-minimal by sub- sequent investigators, and contrasts the cost of living here with that in an English town, one wonders whether it would not be better to te~vr up this paper at this point and talk about something practicable. Just in case the charge might be levelled against the medical profession that it is living in the clouds of theory where it occasionally looks at civic realities through the bottom of a medicine bottle, it might also be added that, although the doctors of Dublin may not write to the papers or be as vocal as their intimate knowledge and experience would entitle them to be, they are fully alive to the slum problem which threatens to set at naught our best efforts. At the last survey the number of families living in places unfit for human habitation was over 13,000. In 1926 some 90,000 people were living in single rooms, 60,000 of them in families having an average of five persons. The rent of these rooms averages about 9/- per week. One cannot safely assume that the excess of the influx of the population over the number of new homes provided has prevented any amelioration of these conditions and while it would be ridiculous to assume that any one man or factor is responsible for this horror, it is equally obvious that if the parts of the machinery necessary for the slum-abolition drive could be fitted together the main obstacle would be overcome. Our medical officers of health cry out against this overcrowding in no uncertain voice, but we also, during the course of our daily work, should never lose an opportunity of keeping the public con- science uneasy about this scandal. Our eyes should always be opened to the fact that, whatever spoke we examine in our gigantic framework, :a strong secondary will always be named overcrowding with its concomitant dirt and squalor.

Defects of Nutritive Elements. While it may have been a day of rejoicing for some pre-

historic mother, it certainly was a sorry discovery for the human race that a baby could survive on the milk of other mammals, because millions of lives have been lost as a result of it. Perhaps a statement like that should be supported by some statistical proof, if there be such a thing as statistical proof. Grulee and


Sanford in Chicago investigated the morbidity and mortality rates in 20,000 infants. The morbidity rate in the breast-fed group was 37 per cent., in the partially breast-fed group 53 per cent., and in the artificially fed group 63 per cent. Pret ty con- clnsive; but grimmer still were the mortality rates. Of their 9,749 breast-fed infants, only 15 died; of 8,605 partially breast- fed 59 died; and of 1,707 artificially fed infants 144 died. No one could ignore these figures nor that contained in the report of the M.O.H. for Dublin, Dr. M. Russell. He gives the number of deaths of infants under one year of age in 1937 as 1,231 in the City of Dublin--that is, a rate of 106 per 1,000 births. He also agrees with the universally-held dictum that the prevention of disease in infancy is mainly a matter of feeding and, of course, that the best feeding is breast-feeding. No figures are available as to the percentage of breast and artificially fed infants in Dublin. The enquirer in this, as in other researches, finds that the only person who takes any interest in the health ef the citizen from a statistical point of view is the Registrar of Births and Deaths. For that apparently uninteresting period when he is just alive there are few, if any, figures, except of course those which concern his right to mark a voting paper. At the same time, by comparing Dublin generally with other cities, for example Edinburgh, where this question has been studied, it can safely be stated that 25 per cent. of babies are artificially fed from birth in Dublin and not more than a third of the mothers are fully feeding their babies right up to the sixth month. As these figures are mainly due to the well-known spreading power of a bad habit, it may be assumed that unless something is done to stop the rot, the situation will be much graver in another quarter century. What factors are responsible for this scandalous decline in breast feeding? Grulee writes: " My personal opinion is that all this talk of modern woman being unable to nurse her baby is due very largely to the modern nurse's tendency to poke a bottle of milk in the baby's mouth, which of course is due to the indifference of the physician." I t would be a good thing to examine our consciences on this score as it is disquieting to read that the principal work of the Infant Aid Society is the distribution during the year of almost three million pint bottles of cow's milk, while the Babies' Club ,Com- mittees distributed 4,500 tins of dried milk. Nothing is as evident to even the casual observer than that child welfare has grown by leaps and bounds during the last five years and these two admirable associations have given yeoman service, but the point must be made that there are still far too many women failing in their duty.

The surrender to artificial feeding usually takes place when the mother leaves the planned and carefree routine of the maternity hospital for the home, where either the family doctor, as long as he is still with us, or a properly instructed health visitor could step in at this point and cut the vicious cycle of


insufficient milk---crying hungry child--sleepless mother, father and neighbours--anxious, tired, harassed mother--further decrease of breast milk. This would be so much better than bleating " breast milk is best " while the infant, whom we really want to pay lip service to the breast, is surreptitiously handed the bottle. One last observation, made by Spence, of Newcastle- on-Tyne, is that out of a common pedigree stock of shorthorn cows the breeders by selection have produced in thirty years two distinct strains, the dairy shorthorn and the beef shorthorn. Intensive breeding of these strains has resulted in a remarkable difference in their milking capacity so that now there is a danger that the beef-strain shorthorn will become incapable of yielding enough milk for her own calves. Verb. sap!

Whether breast or bottle fed, the infant for the first six months of its life is fed at regular stated intervals, which have been found from experience will anticipate hunger and institute a rhythm which will give the rest of the inmates of the house a modicum of mental and physical rest. This is the beginning of training and the difference between the i l l - a n d well-trained baby is too awful to elaborate. One does not now, thanks to the official and voluntary organisations for instructing the mother in dietetics, hear so many of the wild heresies of other years or see their pathetic results in such numbers. I t is at the change over to artificial feeding from the safe monotony of milk that disasters are still rife, and a great number of them is due to the extraordinary likes and dislikes which are developed and which bid fair to make it impossible to feed the child on a rational diet. We are faced with tots between one and two who will not take porridge, milk puddings, and reach the pinnacle of absurdity in their refusal to take milk. Clara Davis has made an exhaustive study of the question of self-selection of foods by infants and young children in the United States, and she supplies convincing proof that children relish simple foods well prepared and served, even though offered with monotonous repetition. Examples of this established fact are familiar to all of us. It is quite definite, therefore, that these likes and dislikes, leaving aside the rare exceptions due to idiosyncrasy or actual indigestibility, are due to psychic factors among which are included imitation of adult eccentricities, association of the food with unpleasant experiences, misguided compulsion or coaxing, un~esthetic preparation and the twin errors of thinking that either the child can judge what is best for itself or that an untutored grown-up can be inspired to judge for it.

Thus, at the very age when good eating habits are most important, we find the very reverse being inculcated by those whose function it should be to l a y the foundation of rational dietetics with consequences that often last throughout life. Let us without fear or favour guide those in charge of children so that the charge of acquiescence or ambiguity may never be laid against us. In this, as in other matters related to nutrition, it may be


safely asserted that the doctors are not doing their full duty. We know the normal calorific requirements per pound body weight, every foodstuff has been analysed into, its component parts from which it is child's play to work out its calorific value. We know, broadly speaking, that the intake varies between 2,500 and 3,500 calories per day and is provided by 300-500 grammes of carbohydrate and some 100 grammes each of protein and fat; yet how many doctors have assured themselves scientifically that they and their families are living on a correct balanced diet? Lawrence, without adducing any proof what- soever, thinks that the healthy dictates of appetite are followed in perhaps 80 per cent. of people and that in most cases the amount of food eaten is automatically adjusted to meet varying calorific requirements. He finds that the calorific output equals the intake, thus explaining the average remarkable constancy in weight, but surely this only means that a human being is restricted by some mechanisms from spending more energy than he possesses. The under-nourished man is and must be a poor worker. There is na evidence in Davis' studies that there is any conscious or subconscious choice of foodstuffs which could be interpreted as an attempt to satisfy physiological requirements and we must come to the conclusion that the factors common to most habits and customs are the only explanation for the choice of food in health. This is shown clearly by the dis- tinctive diets of various countries, varying from the heavy meat and potato meals of the English to the elaborate cuisine of the French who are criticised by the former for their belief that vegetables are food. So well known as h~rdly to require mention- ing are sugar-saturated, vitamin-starved America, rice-ridden China and the tea drunkards of Ireland. How little physiology and how much a factor like advertising can affect a nation's diet is shown by the fact that the average yearly consumption of sugar per head in the United States is 115 lbs., an increase of over 500 per cent. in the last fifty years. Are we to believe that a feeling of comfortable satiation is a proof that the contents of the stomach are accurately adjusted to physiological needs and contain optimum amounts of vitamins and minerals? So little work has been done on this subject (and what a sad commentary on our interest in it is this admission) that it is impossible to speak of it with scientific accuracy. Even Lawrence has to admit that he cannot correlate the level of the blood sugar with appetite or hunger. It is certain that no such instinctive fo~rces govern our appetites as, through the sensation of thirst, drive us to maintain a physiological water balance, or, through more subtle agencies, automatically ensures that we will seek a sufficiency of salt. Everything points to the fact that, if we do happen to live on a correctly balanced diet, it is move by good luck than good guidance and the vast number of patients seek- ing relief from the protean symptoms referable to disturbances of the gastro-intestinaJ system show that it is the minority who


enjoy continued luck. If we refuse to take any interest in the laity unless they can produce an ulcer, gall-stones or an appendix and fail to help them by example and instruction to reach and maintain perfect nutritiona~ health, is it any wonder that they begin to treat themselves or take advice from food-faddists or, worst of all, join some cult which has for its principal gospel the negation of physiology? Are you not alarmed by the new belief in the incompatibility of protein and carbohydrate which was blown sky-high by Rehfuss in 1934, if indeed it required such a celebrated authority to show how ridiculous it was? It is a physical impossibility to prepare a meal of common foods without a mixture of these common substances since all animal foods have some carbohydrate in them. The numerous other arguments which even a rudimentary knowledge of physiology would bring forward are superfluous before this simple fact. In the same rogues' gallery are fluid extracts of meat, which can neither put beef into you nor specifically prevent disease, and preparations of toasted wheat which are exploited as being the last word in nutrition, but with which a humble piece of toasted bread could favourably compare. Let us, therefore, realise that the standard of nutritional health is far from optimal and that the only way of weaning the people away from bad racial customs and personal habits is by teaching dietetics to the young in such a sane and simple way that they in turn will be able to teach their parents. The sympathetic co-operation of the children would doubtless be more readily ensured if the generation they are expected to instruct would show they were really educable by arranging for such elementary necessities as time for a sit-down breakfast and a hot midday meal.

Vitamins must be included under this category as they, or their precursors, come with the food supply and the amount and nature of them are determined by the type of food, its preparation and the ease or difficulty of obtaining it. Ever since it was proved that the higher forms of life could not enjoy a maximum vitality without them (from which characteristic they derived their name) research workers in every land have given themselves up to incessant experimentation but, unfortunately, in many instances have yielded to their predominant passion of publishing their results prematurely. Gone are the easy-going days when the first four letters of the alphabet covered the range of their discoveries. Vitamin B is now Vitamin B complex and contains, according to some, B t, B ~, B 3, B 4 and B s. The really rabid exponents of Divide et impera insist on referring to B 2 as G, P.P. or F. [When one reads that Vitamin B 4 deficiency seems to resemble a state of chronic or persistent deficiency of Vitamin B i since it can always be cured by the administration of a sufflcently large dose of Vitamin B t, one may be forgiven for retiring gracefully and delicately from the scene of researclr's travail and refusing all invitations to christenings until the sponsors can make up their minds. One or two observations


buil t on the firm foundations of proof and experience must, how- ever, be made. They will not include the statement so beloved of manufacturing chemists that Vitamin A is the anti-infective vitamin. Apart from the fact that a gross deficiency of it is known to lead to keratinisation of mucous membranes, from which one deduces that it is a factor in maintaining them in .a healthy state so as to resist the invasion of micro-organisms and that, when administered to a person in whose diet it has been almost absent, it takes some part in restoring him to health and vigour, it has not been shown to have any direct effect on the immunising capacities of the body. It is wrong to credit this vitamin with omnipotent powers or to assume that deficiency of it is common. The body's storage capacity for it is not great and yet genuine clinical avitaminosis---A is rarely met with and then only on absolutely freak diets. We must come to the same conclusion about Vitamin B and agree with McCance that there is little, if any, definite proof that a shortage of B vitamins ever occurs in these islands. During pregnancy and lactation in women living in poor circumstances there is a definite likelihood of deficiency and chronic, and need one add, grateful alcoholics have by its parenteral administration been once more enabled to continue their bottle a day without suffering the pangs of neuritis, but beyond these indications the profession must refuse to be stampeded into empirical prescription of this vitamin as a prophylactic. Vitamins C and D have, on the other hand, very definite value in preventive medicine. I t is the exception to find a mother in these days who does not know that her infant requires orange juice, but there undoubtedly exists a sub- scorbutic state in many children and adults which can be demonstrated by a simple titration of the urine with a standard solution of a coloured dyestuff. Very probably the school dentist would not have to earn his bread with the sweat of his brow if proper formation of cementing substances in the children's teeth was assured by a sufficiency of orange juice which is estimated as 70 milligrammes per kilogramme of body weight.

But to return to the vitamins. 'The bow-legged, pot-bellied pseudo-philosopher of the slums is now, thanks to the education of the masses in the necessity for Vitamin D, al relatively rare visitor to the out-patient departments of children's hospitals, but nevertheless it is certain that mild or subacute rickets is very common and our duty has not been done until this sub- rachitic state has been eliminated. There are very few ordinary foods of any appreciable value as sources of Vitamin D, and cod liver oils have values ranging from 50 to 300 units per gramme. Carefully controlled experiments point to 1,500 units daily as the average amount ~necessary for prophylaxis and 3,000 units for cure. No cod liver oil should be prescribed which has not been assayed for Vitamin D and bears the vouched for number of units per ounce on the label of the bottle. The suppliers of synthetic vitamin and halibut liver oil .are meticulous in this


respect and greatly simplify the task of ensuring accurate dosage but they, by putting on the market concentrates with as many as 50,000 units per gramme which are like so many other dangerous products easily available to the public over the chemist's counter, have produced the new menace of over-dosage. 10,000 units per day constitutes a serious excess and intoxication with over-deposition of bone at the epiphysis and an accumula- tion of calcium salts in other systems, especially the arterial, can result from greater amounts. In a word, the prophylaxis of avitaminosis-D should no longer be haphazard but should have all the accuracy of a prescription. The question of how far this vitamin is concerned with dental caries is by no means settled. Klein and McCollom have brought forward evidence that deficient phosphate is of more importance in its production than a lack of vitamin but, as the idea behind this paper is to deal with prophylactic measures on which there is a universal agree- ment, we shall leave this most interesting category of defects of nutritive elements without any apology for the amount of space given to it, since the whole problem of nutrition has been adjudged sufficiently important to warrant a full investigation by the British Medical Association in the near future.

Vital Activity of Invading Organisms. The next section of our etiological axle that will repay study

is that entitled " Vital Activity of Invading Organisms," and, as we scrutinise the spokes and side-branches, we shall endeavour to focus attention on those points which seem most vulnerable and which will best repay attack. Once again we seem fated to return to food, not, this time, in its nutritive capacity, but in its unfortunate r61e as a carrier of micro-organisms. Fresh milk, new milk, sweet milk--milk, no matter how innocent or enticing the adjective which popular opinion has applied to it, has been arraigned and proved guilty of disseminating such terrible diseases as bovine tuberculosis, undulant fever, scarlatina, septic sore throat, diphtheria, enteric and dysentery. By far the most important is bovine tuberculosis an account of its frequency in cattle, its infectivity and the havoc it works among the young. It is impossible to estimate the percentage of infected cows in ]~ire since the tuberculin test, which is .the only criterion of infection, has not been carried out wholesale. Where a representative herd has been subjected to the test, half of them usually react. Dr. Hamill, the Senior Medical Officer in the British Ministry of Health, makes it clear by a controlled investigation that, while it is wrong to state that any but a small percentage of these infected cows are at any time yielding tuberculous milk, they are potential disseminators, since it is known to be a progressive disease. The actual proportion is estimated as somewhere between 1 and 2 per cent. This small figure is not as insignificant as it sounds because it must be remembered that the milk from the cows in any herd is mixed and, in the case of further mixings at a collecting depSt,


the percentage of samples of milk infected rises in proportion. In England it was found to average 7 per cent. There is no compara- tive work in the Public Health report for Dublin, which only deals with samples of milk taken from cows with clinically diseased udders, but it may be accepted that we cannot stand on a pedestal and sneer. Now, anyone who takes the trouble to wade through the Milk and Dairies Act, 1935, with the regulations of 1936 and 1938 will at once concede that our Oireachtas has given this matter its serious attention and, when one considers the courage required for the introduction of the Act, we must not be too critical if it fails completely to satisfy our exacting demands. The qualifications of Grade A milk under the Act represent a " new high " in preventive medicine. For this designation, tuberculin testing of the entire herd is vigorously enforced in acknowledgment of the fact that a definite percentage of positive reactors which do not show clinical signs of tuberculosis still yield tuberculous milk--in one investigation, 1.4 per cent. The standard is quite definitely lower for the next designation, which is nevertheless " standard " milk. In the production of this only a clinical examination of the milch cows of the herd is compulsory and obviously will not eliminate tuberculous milk. Still less does milk sold under the general designation " milk ...., new milk " or " fresh milk " satisfy this fundamental requirement. The last and apparently least designation is " pasteurised milk " which, in spite of being called after the greatest exponent of preventive medicine, seems to be under a legislative cloud: there are serious penalties for applying heat to any milk other than under this special designation unless when sold as hot milk in restaurants, cafes, etc. Yet, in this imperfect world where the most unpredictable factor is the human factor and where prophecy's only hope of saving its face is by plumping for disaster every time, pasteurisation of the milk supply seems to be the most certain method of ensuring a tubercle- free milk supply to all classes of the community, poor as well as rich, in addition to affording protection against the other organisms mentioned.

What are the objections to pasteurisation? There is a loss of about half the Vitamin C, but ~hen the amount of this vitamin in raw milk is very small and we do not depend on it for our supply. There is a loss in calcium but not more than 2 per cent. and, cow's milk being four times as rich in this mineral as human, can well afford the loss. The depth of cream in the bottle, so prized by dealers, is slightly less but this can be explained to the public. In experiments on that most sensitive animal, the calf, under the auspices of the Milk Nutrition Committee, it has been proved that pasteurisation does not impair the nutritive value of milk to any appreciable extent and it certainly does not render the milk indi- gestible. A very small minority may not like the taste, but surely that out-worn idea of respecting !he wishes of small minorities has been definitely abandoned and, anyway, tastes can be altered. The final objection is that it puts all milk on the same footing, but the


milk dealer who can dodge the 1935 Act, and the thousands of detective inspectors who will no doubt enforce it, would have to be a ~uper-swindler and in a very short time his customers would find out that the keeping qualities of a pasteurised dirty milk, so graphi- cally but rather extravagantly described by one of our veterinary professors as " cooked sewage ", are not to be compared with those of a clean milk similarly treated. In this competitive age honesty is almost becoming compulsory. The people must be told by intensive propaganda that, apart from bone and joint tuberculosis with all their deformities and invalidism, in 80 per cent. of cases of primary abdominal tuberculosis the infection is due to the bovine type of bacillus, that the figure for the mortality rate of 11 per 100,000 for bovine tuberculosis tells only part of the tragic story, because Blacklock has shown that generalised dissemination takes place from a primary abdominal focus in over 30 per cent. of cases. Again, in a survey at Great Ormond Street, the dissemination was shown to have a decided predilection for the meninges and, since diagnosis of the primary abdominal focus is almost impossible except where there are gross findings, prophylaxis is our only hope and the obvious point for attack is the milk supply. And so we finally dispose of the last-ditch argument that milk infected with the bovine tubercle bacillus is a safe immunising agent for human beings. One might as soon make an infant toddle through a diphtheria ward in order to give it protection against that scourge.

The medical profession does not expect a government in this budding State to give subsidies comparable to the s million a year given by the British Milk Industry Bill, but we must affirm that the only designation we can support is " ideal " and that is highest.' .~0"rade milk pasteurised and, perhaps, in a spirit of compromise, standard milk pasteurised. What a pity it is that there seems to be no market value for a child as distinct from, say, a pig. The run- ning over of a young child with fatal results involves no monetary compensation but it is quite otherwise with a pig. It is this anomaly that makes it so difficult to use really powerful arguments such as that the non-pasteurisation of separated milk results in an aggregate annual loss of s resulting from tuberculosis in swine. The arguments of the exponents of preventive medicine would, instead of being just rather disturbing, become unanswerable if they could be presented in terms of s s. d. and the staccato mention of a few million pounds result in a legislative stampede, whereas a paper like this is hardly sufficient to make lawmakers turn in their sleep.

Now that the problem of milk has been settled---or has it ?--let us beguile a few minutes with that of meat as a menace. The 1937 Report of the Chief Veterinary Inspector for Dublin shows what an immense amount of work is being done to protect us from diseases brought in this form of food, such as tuberculosis, undulant fever, aetinomycosis, distomiasis, etc. One very significant fact emerges from the rather queasy reading of the large numbers of lungs, livers and heads condemned on account of disease, viz., that there is only one corporation abattoir which is under wholetime inspection, while

110 I R I S H J O U R N A L O F M E D I C A L S C I E N C E

the re a re 62 p r i v a t e s l augh te r -houses w h e r e inspect ion , t hough pre - s u m a b l y as efficient as possible, ca r r i es w i th i t i ts i nhe ren t fau l t s . The n u m b e r of v i c tua l l e r s u s ing the pub l i c a b a t t o i r is 138 b u t t h e r e r e m a i n 134 who use p r i v a t e s laughter -houses . L e t i t be s t a t ed q u i t e exp l i c i t l y tha t an aba t to i r , which is t r u l y desc r ibed as essen t ia l ly a hea l th s t a t ion a t which al l an imals or t h e i r p a r t s which are f o u n d to h a r b o u r o rgan i sms pa thogen ic fo r m a n a re r e j e c t e d a n d r e f u s e d en t r ance into the c o m m u n i t y , should be u n d e r the whole t ime con t ro l of the hea l th au tho r i t i e s and t ha t the s l a u g h t e r of an imals p r i v a t e l y is an a n a c h r o n i s m and is u n t h i n k a b l e in a c iv i l i sed communi ty .

A s f a r as the r e s t of o u r food is concerned, one can well ima g ine a w r i t e r on this s u b j e c t t owards the close o f th is c e n t u r y r e m i n d i n g his r e ade r s of t h e i r b less ings in words l ike t h e s e :

" I t is difficult to realise what progress has been made in the last fifty years and one can be pardoned for refusing to believe that in this very city meat and fish were exposed uncovered outside shops, and i t was far from uncommon to see careases and portions of meat wrapped in none too clean sacking, delighting the eye of the beholder, in uncovered vans or being carried into the shops on the shoulders and backs of porters. The now universal custom of distr ibuting bread in cellophane wrappers was just creeping in, and handling was a necessary preliminary to any sale of perishable food. But i t was where food and dr ink were offered for public consumption tha t the greatest sins against public health were openly committed and universally condoned. Those engaged in the pre- parat ion of food and the serving of it, although it was even then recognised that the human hand cannot be rendered sterile, were not required to furnish a certificate of clean health renewable annually, and you could never be certain tha t the chef was not a typhoid carrier or the waiter a Casanova with a less respectable complaint. We must remember tha t a Wassermann and fsecal test were only made compulsory twenty years ago. In the public houses or butteries, where men and women of those dark ages found it necessary to consume large quantities of alcohol in various forms in order to experience tha t feeling of ]oie de v ivre which we produce to-day by sound eating and proper exercise, they were apparently so bemused that they completely failed to realise the danger of drinking out of a glass which had not been cleaned to the point of sterilisation by being lowered into boiling water in wire racks, as such utensils are t reated to-day. I t was, s trange to say, not ignorance of the dangers tha t was responsible for all this criminal neglect but an atonic public apathy tha t went so well with the flabby and pendulous abdomens of municipal legis- lators who were already showing signs of physical and mental degeneration at 50."

A n d much more in the same s t ra in . I s the re no hope of a d o p t i n g p r o p h y l a x i s fo r t ha t d a m n i n g sample of desc r ip t ive l i t e r a t u r e ?

U n d e r this c a t e g o r y of " v i t a l a c t i v i t y " we m u s t cons ider p a r t i - cu l a r l y the wel l -known infec t ious fevers. I t is a s t r i k i n g com- m e n t a r y on ou r own slackness, the i n g r a t i t u d e of the public , a n d the c r imina l i n t e r f e r ence of those who shou ld know bet te r , t h a t a med ica l w r i t e r in th i s y e a r of grace shou ld have to devote even one Iine to p o i n t i n g ou t the absolu te and unqua l i f i ed necess i ty f o r vacc ina t ion . P o o r o ld J e n n e r and his t i t l e d l a d y f r i e n d ! I n E n g l a n d , where exempt ion is r e a d i l y ob t a inab l e b y p a r e n t s who a r e conscient ious objectors , the pos i t ion has become lud ic rous and i t i s r a p i d l y r each ing the same p o i n t here. I t bodes i l l fo r the r ecep t ion o f our immun i sa t i on ac t iv i t ies in o the r diseases when this , the mos t b r i l l i a n t l y successful of t hem all, is t r e a t e d wi th such ignoran~ contempt . W i l l no one shout f rom the house tops t h a t the d e a t h


rate in England before Jenner's discovery was 40,000 per annum, or must we wait for an outbreak for the conscientious objectors to keep the poor doctors vaccinating day and night, as occurred not so long ago in Gloucestershire ? It was not for nothing that vaccination was made compulsory and it is not for nothing that we should plead for compulsion also in the matter of diphtheria immunisation. I t must be emphasised that diphtheria is most fatal during the years from 2 to 5, that more than 50 per cent. of the deaths recorded ia this city from this cause for the past ten years have been in this ~oToup, and yet we have our Medical Officer of Health complaining that this very group does not show either the same proportion of those living at that age protected or the progressive increase of " protectors " as do the older age groups. As far as scarlatina is concerned we cannot promise the same lasting degree of immunity as we do in diphtheria, and yet there is a lot to be said for combining the scarlatinal toxin with the diphtheria toxoid. For those using the floccules it only involves one more injection and Dick's report that, of 12,584 nurses and resident medical officers, all Dick nega- tive, working in fever hospitals, not one was attacked, would seem to justify us in our asking parents to give up a couple of months of a child's time at the beginning of its second year to protection against these dangerous diseases. The possibility of unspotted mild cases acting as carriers must be weighed in the balance as a minor disadvantage and the admission made that, according to Bela Schick, 15 per cent. of children cannot be immunised against diphtheria, but, above all, we must acknowledge that in our hands has been placed a great prophylactic agent attacking the condition at the most easily accessible chink in its armour.

Measles and whooping cough have so far defied satisfactory prophylaxis, but at least attention has been drawn to their importance as death-dealers either through that bugbear of children's hospitals, broncho-pneumonia, or their more remote effect in either preparing the soil for or forcing the growth of that most rampant poisonous weed, tuberculosis. The tea parties, which carried on the invita- tion practically a written guarantee of the development of one or both of these fevers at the end of the statutory incubation period, are no longer a slum institution, but overcrowding in these areas still helps to keep up the high figure of infantile mortality. During 1937 in this city 93 per cent. of deaths from measles were in children under 5 years; this is an average figure. When compared with the high mortality figures for whooping cough and broncho-pneumonia under five, we are forced to the conclusion that the three should be grouped together as pulmonary perils. One cause of this failure to deal with them is that they are not compulsorily notifiable and there is no institution to which they can be sent. Our fever hospitals are so full up with diphtheria and scarlatina that there is no room for these Cinderellas and the children's hospitals are naturally afraid to introduce these fevers to children already debilitated from other disease. I t practically amounts to this, that a child who has developed broncho-pneumonia during an attack of measles or


whooping cough must take his chance of survival in his third floor back. Since even an enlarged fever hospital will not have a sufficiency of beds to deal with these cases, we must consider the advisa- bility of choosing the lesser of two evils and giving them the beds usually allotted to scarlatina which has become a mild visitation. Of course, this would he a dangerous choice because it is well known that scarlatina can suddenly, after years of mild guerilla warfare, develop virulence over a wide front. We can only hope that some manageable animal will be discovered which could be readily infected with measles or whooping cough so that a serum can be made as has been done for several animal diseases, such as dog distemper. By the way, what does an anti-vivisectionist say about one using one animal to prepare a serum for the alleviation of pain and suffering in another animal, or does it matter what they say?

One of the most popular regions for our profession to engage in mortal combat with the " vital activity of invading organisms " is ~he tonsillar fossa. In England about 200,000 .tonsillectomies are performed annually costing about half-a-million pounds and resulting in a loss of more than 85 lives. Since 1933 the incidence of this operation in Derbyshire has been reduced by 90 per cent. with a very definite all round improvement in the health of the children. In two neighbouring districts of Greater London the rate of tonsillectomy among the children is in one 4 per cent. and in the other 0.2 per cent. In this city the specialists in this branch are making a determined effort to reserve the operation for cases where the indications are definite and good results are to be expected, but the public must be weaned from the idea (which they did not con- ceive themselves) that all the lymphoid tissue in the throat which calls attention to its presence by a gallant and successful attempt to resist invading organisms or shares in the general lymphoid hyperplasia of the lymphatic child must be summarily extirpated and that a tonsillectomy is a prophylactic for all earthly ills. The school medical officers are most favourably placed to deal with this problem and, if one is to judge their efficiency by the thought- provoking report of Dr. Catherine O'Brien for 1937, we are leaving it in very safe hands. In fact, if periodic contributions to our lay newspapers and periodicals by our splendid team of Medical Officers of Health were not only allowed but encouraged, that greatest asset to preventive medicine, an educated public, would be assured. Such a medical information bureau would not interfere with our tradi- tional aloofness as a profession.

Bio-social Inf luences .

And, finally, a brief word about the sixth category on the llst, " psycho-biologic and bio-social influences ". In these adjectives is to be found the American desire for a language of their very own, and it is just because they have got in on the ground floor of psychology that textbooks on the subject are generally a hotch-potch of incomprehensible verbiage with fallacies chasing one another from page to page but unfortunately never beyond the covers. The


medical profession, either through its failure to realise that the post-war mind was as much in need of treatment as the body or through its failure to supply such treatment, has found itself taking instruction from lay psychologists who are attempting, with a courage born of optimistic ignorance, the task of treating the mind without any reference to the body. And not even the best of them would credit the human being with the possession of a soul. So far has this dangerous outside influence obtruded itself that, in the child guidance clinics established by Carnegie in English centres, it is an essential condition of the grant that the psychologist shall be a layman while the doctors in attendance have to work in con- junction with if not in subservience to him. We in this country would do well to remember that the so-called " Dark Ages " produced St. Thomas Aquinas, in whose writings may be found the solution of all our psychological problems, and that it is unsafe and unwise to lose ourselves in the specious outpourings of neo-pagans on this subject. The salient points of his work are available in an excellent translation which forms a perfect blue glass for spotting psychological ringworm and a safe basis for the doctor who has to go a step further than the illustrious saint in that he has to deal with physiology in addition.

But it is with prevention that we are concerned, and this work must be carried out in infancy and childhood if the mental havoc of the post-war period is not to become an overwhelming national calamity for the generations to come. The infant is an utterly selfish creature and spends its waking hours endeavouring by fair means or foul to ensure that for it life shall hold nothing but pleasure. It develops even in infancy habit patterns fed on previous triumphs and, with the acquisition of new ideas in childhood, these patterns become more complicated and the child is accepted as phlegmatic, fearful, excitable, bad-tempered or, generally, as one from Gloucester Street, aged seven, recently described herself, " high-strung~d ". These temperaments are not inherent but have developed both because they have paid good dividends in personal pleasure and because the emotion itself is pleasurable either men- tally or physically or both. The physical experience of a tantrum has been likened to a form of self-abuse. Owing to the necessity for a herd life these children, grown into adults, are in continuous conflict with their environment and, if the moulding of the class- room or the playing field has been u.navailing against a ferro- concrete habit-block or complex, then the stage is set for the terrible twin terrors of the twentieth century, neurosis and psychosis.

Those who are undertaking the task of training the child mind should combine intelligence with sympathy and firmness and realise that the happy child is he who has the simple rule of obedience to rational and logical commands. Above all, these mentors should not be led astray by that popular fallacy that unless full rein be given to every anti-social impulse there is grave danger of breaking the child's will. In all these cases the will is unfortunately a " won't ". Our task is to convert it into a " will ", and the time


to commence is in infancy for, as sure as the child is the father of the man, the infant is the father of the child. Most of our preventive methods are foiled by the old hope of growing out of things, but the only thing that children can be counted on to grow out of is control and if, during the bud stage, the flower has not learned the great art of adaptation, the ruthless elements of a merciless world' will soon beat it flat. One would have liked to advocate the setting up of something in the nature of the child guidance clinics previously" mentioned to deal with the common behaviour abnormalities of childhood and prevent their development into complicated and intractable complexes but, as long as mental defectives, epileptics and, in fact, most children temporarily or occasionally unmanage- able at home by reason of mental aberration have to be housed in Grangegorman or similar mental hospitals with adult lunatics (to the despairing distress of men of the calibre of Dr. Dunne), one would feel like asking for a clean annexe to the Augean stable which cries out in vain for a local government Hercules.

A paper read by the writer before this Society in 1931 concluded with ~an exhortation to look over some storeys of the unfinished sky- scraper which is being erected by the physicians of to-day and' which they have named prophylaxis and, with the statement that i~ this generation could even complete the first two given over to ~ rheumatism and tuberculosis, it could pass over with a " N u n d dimit t is ". This Address at least shows consistency with those ideals ~ of more callow years. From the student members of this Society' particularly I would win a perhaps belated enthusiasm with a quota- tion from the Regius Professor of Medicine at Oxford which is cal- culated to lift a despondency which sometimes, in these years of overcrowded benches and laboratories, settles on them and per- manently on their parents. I t is as follows: " I am in the habit of preaching that we could do with twice as many doctors as we have but that is only if their work is going to be somewhat different from what it has been in the past. The work of doctors in the future will be that of preserving health and preventing disease. The trend of events is in that direction."

Let us end on this cheerful note.

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Prophylaxis in practice