Abstracts from Reports KASHMIR MEDICAL MISSION OF THE CHURCH MISSIONARY SOCIETY: REPORT FOR 1938 Although much progress has been made by the State in recent years in Kashmir, there is still much unalleviated sickness and suffering. The Mission Hospital is not the only medical institution in Kashmir. In Srinagar there is a State General Hospital and also two women's hospitals. There is also a tuberculosis sanatorium and a leper hospital. In most of the larger towns and villages there are dispensaries where patients can receive treatment and medicine. The large number, both of out-patients and of in-patients, that come to us year by year, is an indication of the high esteem in which this hospital is held by the people of Kashmir.^ On the medical side, consumption is very rife. This year a special tuberculosis clinic has been held twice a week to deal with the large number of patients that come to us. A new form of injection treatment has been tried, but it is early yet to state how successful it is. Several cases that have been operated upon this year for abdominal conditions have been proved at the operation to be malignant. We have had cases of cancer of the stomach, bowel, breast, mouth, eye and limbs. Venereal disease is rampant in Kashmir. Patients usually come to hospital in the secondary or tertiary stages, and late manifestations are all too common. A venereal disease clinic is held twice weekly, and the routine treatment with blood tests is carried out. An interesting fact about syphilis in Kashmir is that it seldom affects the nervous system. Tabes dorsalis and general paresis are almost unknown. Indeed, nervous diseases of any kind are rare, although there has recently been a case of chorea, and a case of paralysis agitans in the hospital. Another interesting medical anomaly is that while rheumatic heart disease is exceedingly common, acute rheumatism is very rare. Neither is rheumatoid arthritis met with in Kashmir. Typhoid is endemic and we usually have cases in hospital. It is seldom virulent and most cases recover. Dysentery is common and is usually amoebic, responding well to emetine treatment. This year there was a mild outbreak of cholera. It did not prove serious and there were only a few cases. On the surgical side, osteomyelitis is by far the commonest disease. It affects the underfed and those exposed to manual work. It is more common in men and boys than in women and girls. The leg and thigh bones are more frequently affected than the bones of the arm or forearm. Most cases come to hospital in the chronic stage, and we usually perform an osteotomy or sequestrectomy. Tuberculosis affecting bones and joints is becoming increasingly common, and we are seldom without several cases of tuberculosis of the hip, knee or ankle in the wards. A large number of abdominal operations have been performed. Appendicitis is fairly common, and so are gastric and duodenal ulcers. For the latter conditions we frequently perform gastroenterostomy. Gall stones are not infrequent, and occur more commonly in women than in men. Stones of the bladder and kidney _
_
less common than in the hotter parts of India, bu have had several cases during the year. Hydati cysts of the liver, intestinal obstruction, abdornina tuberculosis and ovarian cysts have contributed our list of abdominal operations. Goitres, hernia > hydroceles and haemorrhoids are all very comm? Cataract and commonest trichiasis are the are
we
.
?
operations.
,
.
?
A word concerning the background of these patien The majority of them live in squalor and di scarcely believable to those living at home. Their consists of rice, vegetables, milk and a little_ me J In terms of calories the food value of this diet is ,v r ^ small?very much less than is theoretically required a healthy person. Small wonder that they a undernourished and succumb so readily to disease, small wonder that few live to reach an old age. f In this hospital we are trying to alleviate some in the sickness and suffering in Kashmir. There are j people who have been patients here, who are ?ra^ to those who support this hospital, and make this possible. We hope that all those who have ^ generously helped us in the past will still continue do so in the future.
P?Vjr-et
.
REPORT
OF
THE
RESEARC?
MEDICAL
COUNCIL, LONDON, FOR THE YEAR
l937"ily
PUBLISHED BY HIS MAJESTY'S STATIONEK OFFICE, LONDON. PRICE, 3s. 6d. POSTAL EXTRA
It is now twenty-five years since the Govern? decided to promote medical research by setting up Medical Research Committee, which became Medical Research Council in 1920. In this period ^ has been a great increase in medical investigation ^ Great Britain, some of which are undoubtedly 1 xrje3 the support provided by the State. In other 0f there has been a similar acceleration in intensity medical discovery, particularly in the United o of America, where it has been made possible a. hout private endowment. All this activity has brought n ^ a great increase in knowledge of the body in uS and disease?greater even than that of the Pre ns Histo twenty-five years, which in itself was large. to as are likely pronounce this period the improved level of health of civilized comrrtu made possible by the access of knowledge w?n medical research. _
.
?
outstanding-
The
application
of
knowledge
in
treatment
Apart from its effect in raising the standard of ae'^vo and physique, this new knowledge has had ^ce, influences which, in their effect on medical Pr' jo It has resin are often opposed to each other. 0f the first place, in a great improvement in n}. veyieS, diagnosis and treatment of disease. These "isc0 -ence together with the development of the social .c??vjdu^> of the community in regard to the unhealthy in011 ,
have involved a vast increase in medical servl?Gprjva'e number of medical men, both in public and P. ^.joO accom? has increased greatly, hospital practice,
ABSTRACTS FROM REPORTS
Aug., 1939]
and facilities have multiplied, and the total cost of Medical care has risen enormously. The development of new methods of diagnosis and treatment has called for so much additional personnel and costly apparatus that it has become more and more necessary f?r the sick to enter public institutions in order to receive the full benefits now available. The radioSraphic department, the biochemical, the hematological and the bacteriological laboratories, which hardly large and existed twenty-five years ago, are now important factors in all efficiently run medical Institutions. Hardly a patient enters such an institution whose condition does not call for the help of these ne5ly. grown hospital services. While everyone will agree that all these changes have often pass Pken justified and beneficial, there must through the mind the question?what is to be the end ?f this its development? Will medical science withtheir ever greater knowledge require hospitals and scientific services to grow continuously; are there to be 110 limits to their size? The economist might even bonder whether a time will not come when the expense and trouble involved will hardly justify this extension Oi medical practice, especially that large part concerned chronic and degenerative forms of disease and 101 vjth vhich the practical return in terms of human health is ?ften small. of course, is only one aspect of the matter. rp/his, he whole trend of medicine in the present century ?a?. been to study the basic {etiological factors ol ^dividual diseases in order to find methods for curing of this side ol and it is to the
application Medicine that the extended hospital services are mainly Uected. A large number of diseases of which treatlont at the beginning of the century was essentially ^ncerned with the relief of symptoms and the comfort of ?
s
Patients?leaving
the
cure
to
the
care
medicatrix natures?can now be cured or controlled ?Pe?ific remedies and the sufferers returned to normal ho althy existence. Many thousands of patients suffering were ago, years in001 .leases which, twenty-five now be restored to hno'ui as and uncontrollable, can -1 the result of recently acquired knowledge a Plicable to diagnosis and treatment. PPhcutions of chemotherapy.?It sometimes happens ,
knowledge of curative treatment may in itseli .ring about reduction in incidence of disease, as, those of a cu ^stance, in infectious diseases and nature. This will probably prove to be the 111 some infectious diseases following the recent afj allied SULa.nces in treatment by sulphanilamideandandeffective For example, the more rapid euro ailcesto result in jl i ??\ gonorrhoea by these drugs ought because of J6;*11?1*-6 reduction in its incidence, not only reduce tlip ,eir c,lll-ative action but because they may spread of the infection. lead ?nt fesults give hope also that these drugs may chirm ,^e reduction of one of the most common which ?ften 1Cf ?lsat)ilities, namely, middle ear disease, be a ?dows measles and scarlet fever or may seqi.pi to a sore throat due to If ii streptococcal infection. aims that 2-sulphanilyl-aminopyridine has a , ; destructive action on the pneumococcus prove to k *t ought to be possible to extend the cUratf, 6 are di, f c'. to those cases of middle ear disease which tive pff \? th!s organism. How enormous such preventhat tK s misht prove can be estimated from the fact With rr L,are said to be 2,500,000 people in this country the mviji g degrees of deafness, and that disease of Pror>ort ?ar *s admittedly responsible for a large these cases. Thus it has been estimated hat tv,1-011 cent of casocf P*c.ondition is responsible for 90 per It js acquired incomplete deafness in children. Hill ho V1i?.u'^ that optimum results along these lines to the deveW ?"tained only by medical skill alert in young the especially condition, ,cbildrPn 6ntj an y the A ,*? the need for immediate treatment asenfs now available. A good ?PPort,,n?femotheraPeutic 1 Middle j^ay we^ be at hand for seriously attacking aHd serirf1", j?eas?.and reducing greatly this widespread US a^dity and its sequela), running ears and a] 0
f0
ca^n-C
^eafness
Application
op knowledge in preventive
505 medicine
On the other hand, medical research has brought another kind of knowledge which, if properly used, leads directly to the prevention and elimination of disease. The effect on medical practice and its ancillary services of this kind of knowledge is clearly opposed to the first-mentioned effect since, by eliminating disease, it tends to reduce the needs for curative aids. In view of the large increase in hospital services and medical personnel in recent times, it might be thought that the results and effects of research in preventive medicine must be negligible. This is not, or ought not to be, the case; but undoubtedly there is often great delay in bringing about the application of new discoveries to preventive ends. Fresh means of curative treatment, on the other hand, are generally applied at once by medical practitioners, and the latent period between such discoveries and their application is often short. Everybody will agree that, of the two types of knowledge, that which leads to the eradication of disease is much the more important to the community. Why then should there be great delay in its application? No simple answer can be given to this question. Prophylaxis against disease does not depend solely on the alertness of medical men or of Government departments to procure rapid application of new knowledge. Just as important is enlightenment of the public as to the merits of a particular discovery, since these applications of medical science often require direct action on the part of individuals. The public, however, cannot understand the merits of such very technical subjects unless they are clearly expounded and the meaning of the results driven home. Again, successful cure of disease is always dramatic, and brings with it intense relief both to patients and their friends. There is, however, nothing dramatic about the disappearance of disease. It is here to-day and gone to-morrow, and the very success of prevention of disease is measured thinks by forgetfulness. Whoever nowadays of the decimation once caused in this country by plague, cholera, typhus and other diseases now eliminated from our midst? The relative lack of dramatic interest in the prevention of disease, as compared with that in its cure, is partly responsible for the difference in rates with which their advantages are obtained by the public. A third cause of delay is the fact that preventive medicine mostly concerns children, and it is curious that illness and death in the young do not. apparently, impress themselves on the public mind with the emphasis associated with disease in the adult. It is becoming every day more clear that these difficulties in matters of health and disease, especially when the co-operation of the public is necessary, will remain so long as there is no means of educating and giving them the requisite guidance. It does not seem to be anybody's business in this country to undertake this task. Only too often are the public dependent for information and guidance on advertising propaganda, exaggerated and false as it so often is, financed by those with something to sell. Others who are most assiduous in publicity are those who believe that advances in medical knowledge, especially when of great practical value in public health, are snares and delusions, and who by extensive propaganda mislead in every conceivable way and hinder the process of application. It is not the duty of the Medical Research Council to guide the public on the importance of medical discovery in its practical applications to human needs. Their task is wholly to promote discovery and to They cannot announce it to the world when it is made. but view with regret, however, the delay which so often occurs between medical discovery and its application, provides an especially when the discovery is one that immediate opportunity of preventing or even eliminating disease. What the ultimate solution of this difficulty will be is not obvious, but with the present increase in knowledge of methods of preventing disease, a better method of informing and educating the public becomes
imperative.
506
THE INDIAN MEDICAL GAZETTE
The prevention oj diphtheria.?One of the most striking instances of the delay in the application of new knowledge is the relative lack of public recognition, in Great Britain at the present time, of the existence of a method of proven value for the prevention of diphtheria. Diphtheria is the commonest single cause of death among school children. In 1937, there were 61,339 cases of this disease in England and Wales, causing 2,963 deaths, nearly all in children between the ages of 1 and 15 years. This is pure tragedy, in view of the needlessness of such deaths, for since 1929 prophylactic inoculation against diphtheria has proved increasingly successful wherever it has been properly used. The value oj
.
.
nutrition.?A second type of against disease, of which the proper application has now been delayed for many years, is to be found in improved nutrition. The need for this has been often discussed in previous Annual Reports of the Council; but the adoption of modern teachings on the subject by the public is depressingly slow, in spite of the evidence often advanced that the increased consumption of protective foods would not only be beneficial to the physique and general health of the people but also of great economic value to the country. Better feeding in infancy has caused a gratifying reduction in rickets throughout the country, although the time has not yet arrived when an incident would be possible here such as recently occurred at the Children's Hospital at Toronto, where a case of rickets created such surprise that a meeting of staff and students was summoned to examine the baby. There is still room for great improvement in this respect, for, with the knowledge and public assistance available, the persistence of rickets in this country is an indication of ignorance or neglect. It is of interest to recall that an attack on the problem of rickets was included in the first research programme of the original Medical Research Committee in 1914, and that it is owing to
preventive
improved
measure
the results of this work that the disease
can
now
be
prevented.
A much greater consumption of milk, and other dairy products, of eggs, of vegetables, including potatoes, of fruit, and of fat fish, at the expense of bread, biscuits, sugar and sweets, especially in early life, is an urgent national requirement; it will not only improve the physique of the people but will reduce the amount of dental decay and greatly raise the standard of health. An increase in breast-feeding will still further reduce the high mortality rate of infants from gastro-intestinal
troubles and broncho-pneumonia. Whatever advances in medical knowledge may come, until these simple precepts are adopted there will still remain a great deal of preventable disease in this country. The co-operation oj the public.?These few instances will probably suffice to emphasize the possibilities of applying the results_ of medical research to immediate problems of preventive medicine. It is clear that some of the methods for preventing disease require close co-operation on the part of an enlightened public. There is great need for some authoritative body to transmit the necessary information which will stimulate public co-operation. With a more rapid understanding of the facts on the part of the public, delay in application of new knowledge to human needs ought not to be so long as it has been in the past. Only by improving the general health and eliminating disease can it be hoped to reduce this present tendency of ever-increasing medical services, and the annual expenditure of between two and three hundred million pounds which such services necessitate. _
Research
policy
While the Medical Research Council must necessarily be interested in the general problem of the practical application of new knowledge, they are more directly concerned with the question of the best methods of promoting the research work itself. The over-riding consideration must obviously be the acquisition of knowledge which will make possible improvement in the standard of mental and physical health, and the preven-j tion, alleviation and cure of disease. It is by no means1
[Aug., 1939
certain, however, by what policy such knowledge niay be most quickly and effectively obtained. Some thin it is to be done by directing attention to disease and others by promoting fundamental studies of w* physiology and chemistry of the body. These need not be discussed further, because it cannot doubted that knowledge of practical significance matters of health and disease can come from direction. The work of Pasteur on fermentation led ^ the work of Lister on prevention of wound infec" On the other hand, the discovery of Eijkman ot aeaciei cause of beri-beri led ultimately to more researches on the part played by vitamin Bi 111 oxidation of carbohydrate. Experience has shown experimental work from any quarter may lead to solution of problems from any other quarter. The question may then be asked, what is the of the Council in promoting research? Do they inu tQ research, and, if so, in what way; or do they leave individuals the choice of subject and support J. satisfactory? Do they favour research on disease irather than on more academic problems of and biochemistry? A complete answer to these tions cannot be given here, but the general 6 ' stands as follows. Actual promotion of specific res ^ by the Council is usually done by appointmen .e individuals to their permanent staff. This c depends on the subject which seems to require attention and the merits of the person chosen, ^joii once appointed the individual has wide liberty oi a. 0?e in planning investigation. The Council seldom c ^ie particular diseases for investigation; choice is of a broader nature, so as to of an ajtiological factor common to a group of "1 vgtem or a type of treatment of wide application, or a syof physiological or biochemical control. at Examples of such broad subjects of investigatoo ^ the present time are virus diseases, chemotherapy. In each of these cases workers have been appointed to follow lines oi 1 c^ed gation in their own province and they' are to be familiar with, and prepared to help, res 1 cognate to their own throughout the country. otj1er able opportunity offers itself, investigations by foe workers in the same fields are also assisted 01 Council. By this co-ordination means throughout the country is brought about. For another large part of the work, helped Council by means of personnel and expenses gra eStigainitiative in choice of subject and method of in j jn tion lies with the head of a laboratory or the respect of some individual worker, or with upoD himself. The success of the application depen_ arCb. ox the merits of the individual and the subject Lxutio?! The Council do not provide money for but for individuals, because they regard it as cjj0ice that they should retain direct control over t" oged. of the worker and the type of investigation Pr As to whether the Council encourage the direc the of disease or of the more fundamental s,?iel?,:n(j3 general answer is that they welcome both * th^ investigation. At the same time they rec0Jf nf work at present there is a dearth ^is relatively great in clinical science and in experimental pathology. ot eg brai country, as compared with many other ^lS medical science. So impressed indeed are they efforts state ^of affairs that they are makingoffering jspec1^ scn^ fiC^0lar^ to enlame 'lKn?-rPersonnel by *** me" ships and ^ enter these ?red. ^ds of inquiry. In ?r, J?!! they have v0t posts> anfI they arefor d^c' as opportunitv to establish more units _
yie|
_
,
P.?-^e
P^ysl?ueS^arCh
sPyjiell
general-tu(jy incluj-seases> .
_
endocrinology^ ?r?l^vesti-
ye$0rt
^?^^v0rker inSpSSenti&'
f^^dy
?f
JmSS*
felW^v
f? e.n'1bIe nffPSPe+
investigation
Pre{jn;cal '
of
medical
researchi of
mainlv ^ thr^'p&S ^jtiation T ^ objectives send They ^eiVe. hoping ^ vera? dSi ancI in different seas, } jj
concerned distant and in se
are
rnmn
individuals will shows itself in
reseat
f?rm of OI
mv an ?n
any
sPeciaI prize of discovc
qU^ Sod*?PP?rt?nity
In the
^ ,D c0lT A v 0y
that offers itsel/ work ad hoc problem is taken, and
J/T
ABSTRACTS FROM REPORTS
Aug., 1939] thus be expressly directed
to
the solution of
specific
questions.
Tropical
research in the colonial empire
medical
This activity of the Council was discussed at length fiom hi the Annual Report for 1935-36. It resulted the desire of the Colonial Office that the Council should extend their research interests to problems ot .
invitation has been accepted It clearly offered opportunities discovery, almost unequalled in any other field. (Jn Jor the one hand, any discoveries made would almost ceitainly be of great practical consequence and might assist in raising the standard of health in countries 101 which Great Britain has a special duty and responsibility; on the other hand, some diseases in the tropics, ?uch as pneumonia and tuberculosis, are also common that the w this country, and there was the probability sampler conditions of life might allow easier investiga-
tropical medicine,
and
with greater pleasure.
no
tion than here. One of the difficulties this request
was
to be overcome in accepting to the dearth of investigators trained
study tropical diseases, and, f
Council devised
m
fellowships
to
a
as
scheme
previously
of
junior
explained,
and
semen
young workeis to education and
promising undergo special
encourage
??ter this field and training. In the three years since the scheme was eight junior and three senior fellowships have Initiated, have been been awarded. Fully trained investigators sent to the Territory, and Tanganyika Gambia, Uganda drugs on p study the action of chemotherapeutic and other the natural history of yaws,
peeping sickness, Problems.
Nutritional In the past year
problems in the colonies
a different kind of opportunity ot the Colonial Office, as the result nutritional problems. In ino/? w,orld-wide interest in out *936 the Secretary of State for the Colonies sent circular despatch drawing the attention of Governor colonial territories within the Empire to modern Pects of nutrition and their relation to health, and a" 'nS for their comments and advice on such matters .ey affected each territory. The response was s pnsmgly great and resulted in the setting up of an dvisory Committee on Nutrition in the Colonial Council ^lre uPon which the Medical Research ,, vere represented. Many of the replies received from of colonial territories, while showing the c, vfmors of its i"** interest in the subject and realization more mformaalso much it that made clear rnce? tinn?r the i actual dietetic and nutritional problems e faced : in each territory was needed, and that this further invJ1?51 1(?u could be obtained only theby Advisory Tq meet this situation, e on Nutrition set with up a sub-committee, Sir tvi a coordm + 6 jr^ Mellanby as Chairman, to prepare ^an field surveys and research which Hiio'Vif with advantage be carried out with regard to
arose for
assisting
.
Cortftigation. ?
Aft
n
ln.th(r
Colonial Empire.
the situation, the sub-committee for the n i .recomniendation to the Secretary of State be jsi. I"'? that the Medical Research Council should the first ;7 to aPPoint, for a period of five years in to sraah Staff whose duty would be UndP,^!anc,e'e ascientific co-ordination of a series ot field c,a Urveys of diet in relation to health and physique in co*onial territories. It was also recommended that officers second ^ a^tual field surveys should be made by
Qiarlc>eJi. reviewing
*1
the colonial service in each territory ^at the main duty of the staff e Council should be to co-ordinate the ^Quirin s' * ensure the adoption of comparable methods and j *n the different territories and the Unifo of the complete results. These sUggp
_
less common than in the hotter parts of India, bu have had several cases during the year. Hydati cysts of the liver, intestinal obstruction, abdornina tuberculosis and ovarian cysts have contributed our list of abdominal operations. Goitres, hernia > hydroceles and haemorrhoids are all very comm? Cataract and commonest trichiasis are the are
we
.
?
operations.
,
.
?
A word concerning the background of these patien The majority of them live in squalor and di scarcely believable to those living at home. Their consists of rice, vegetables, milk and a little_ me J In terms of calories the food value of this diet is ,v r ^ small?very much less than is theoretically required a healthy person. Small wonder that they a undernourished and succumb so readily to disease, small wonder that few live to reach an old age. f In this hospital we are trying to alleviate some in the sickness and suffering in Kashmir. There are j people who have been patients here, who are ?ra^ to those who support this hospital, and make this possible. We hope that all those who have ^ generously helped us in the past will still continue do so in the future.
P?Vjr-et
.
REPORT
OF
THE
RESEARC?
MEDICAL
COUNCIL, LONDON, FOR THE YEAR
l937"ily
PUBLISHED BY HIS MAJESTY'S STATIONEK OFFICE, LONDON. PRICE, 3s. 6d. POSTAL EXTRA
It is now twenty-five years since the Govern? decided to promote medical research by setting up Medical Research Committee, which became Medical Research Council in 1920. In this period ^ has been a great increase in medical investigation ^ Great Britain, some of which are undoubtedly 1 xrje3 the support provided by the State. In other 0f there has been a similar acceleration in intensity medical discovery, particularly in the United o of America, where it has been made possible a. hout private endowment. All this activity has brought n ^ a great increase in knowledge of the body in uS and disease?greater even than that of the Pre ns Histo twenty-five years, which in itself was large. to as are likely pronounce this period the improved level of health of civilized comrrtu made possible by the access of knowledge w?n medical research. _
.
?
outstanding-
The
application
of
knowledge
in
treatment
Apart from its effect in raising the standard of ae'^vo and physique, this new knowledge has had ^ce, influences which, in their effect on medical Pr' jo It has resin are often opposed to each other. 0f the first place, in a great improvement in n}. veyieS, diagnosis and treatment of disease. These "isc0 -ence together with the development of the social .c??vjdu^> of the community in regard to the unhealthy in011 ,
have involved a vast increase in medical servl?Gprjva'e number of medical men, both in public and P. ^.joO accom? has increased greatly, hospital practice,
ABSTRACTS FROM REPORTS
Aug., 1939]
and facilities have multiplied, and the total cost of Medical care has risen enormously. The development of new methods of diagnosis and treatment has called for so much additional personnel and costly apparatus that it has become more and more necessary f?r the sick to enter public institutions in order to receive the full benefits now available. The radioSraphic department, the biochemical, the hematological and the bacteriological laboratories, which hardly large and existed twenty-five years ago, are now important factors in all efficiently run medical Institutions. Hardly a patient enters such an institution whose condition does not call for the help of these ne5ly. grown hospital services. While everyone will agree that all these changes have often pass Pken justified and beneficial, there must through the mind the question?what is to be the end ?f this its development? Will medical science withtheir ever greater knowledge require hospitals and scientific services to grow continuously; are there to be 110 limits to their size? The economist might even bonder whether a time will not come when the expense and trouble involved will hardly justify this extension Oi medical practice, especially that large part concerned chronic and degenerative forms of disease and 101 vjth vhich the practical return in terms of human health is ?ften small. of course, is only one aspect of the matter. rp/his, he whole trend of medicine in the present century ?a?. been to study the basic {etiological factors ol ^dividual diseases in order to find methods for curing of this side ol and it is to the
application Medicine that the extended hospital services are mainly Uected. A large number of diseases of which treatlont at the beginning of the century was essentially ^ncerned with the relief of symptoms and the comfort of ?
s
Patients?leaving
the
cure
to
the
care
medicatrix natures?can now be cured or controlled ?Pe?ific remedies and the sufferers returned to normal ho althy existence. Many thousands of patients suffering were ago, years in001 .leases which, twenty-five now be restored to hno'ui as and uncontrollable, can -1 the result of recently acquired knowledge a Plicable to diagnosis and treatment. PPhcutions of chemotherapy.?It sometimes happens ,
knowledge of curative treatment may in itseli .ring about reduction in incidence of disease, as, those of a cu ^stance, in infectious diseases and nature. This will probably prove to be the 111 some infectious diseases following the recent afj allied SULa.nces in treatment by sulphanilamideandandeffective For example, the more rapid euro ailcesto result in jl i ??\ gonorrhoea by these drugs ought because of J6;*11?1*-6 reduction in its incidence, not only reduce tlip ,eir c,lll-ative action but because they may spread of the infection. lead ?nt fesults give hope also that these drugs may chirm ,^e reduction of one of the most common which ?ften 1Cf ?lsat)ilities, namely, middle ear disease, be a ?dows measles and scarlet fever or may seqi.pi to a sore throat due to If ii streptococcal infection. aims that 2-sulphanilyl-aminopyridine has a , ; destructive action on the pneumococcus prove to k *t ought to be possible to extend the cUratf, 6 are di, f c'. to those cases of middle ear disease which tive pff \? th!s organism. How enormous such preventhat tK s misht prove can be estimated from the fact With rr L,are said to be 2,500,000 people in this country the mviji g degrees of deafness, and that disease of Pror>ort ?ar *s admittedly responsible for a large these cases. Thus it has been estimated hat tv,1-011 cent of casocf P*c.ondition is responsible for 90 per It js acquired incomplete deafness in children. Hill ho V1i?.u'^ that optimum results along these lines to the deveW ?"tained only by medical skill alert in young the especially condition, ,cbildrPn 6ntj an y the A ,*? the need for immediate treatment asenfs now available. A good ?PPort,,n?femotheraPeutic 1 Middle j^ay we^ be at hand for seriously attacking aHd serirf1", j?eas?.and reducing greatly this widespread US a^dity and its sequela), running ears and a] 0
f0
ca^n-C
^eafness
Application
op knowledge in preventive
505 medicine
On the other hand, medical research has brought another kind of knowledge which, if properly used, leads directly to the prevention and elimination of disease. The effect on medical practice and its ancillary services of this kind of knowledge is clearly opposed to the first-mentioned effect since, by eliminating disease, it tends to reduce the needs for curative aids. In view of the large increase in hospital services and medical personnel in recent times, it might be thought that the results and effects of research in preventive medicine must be negligible. This is not, or ought not to be, the case; but undoubtedly there is often great delay in bringing about the application of new discoveries to preventive ends. Fresh means of curative treatment, on the other hand, are generally applied at once by medical practitioners, and the latent period between such discoveries and their application is often short. Everybody will agree that, of the two types of knowledge, that which leads to the eradication of disease is much the more important to the community. Why then should there be great delay in its application? No simple answer can be given to this question. Prophylaxis against disease does not depend solely on the alertness of medical men or of Government departments to procure rapid application of new knowledge. Just as important is enlightenment of the public as to the merits of a particular discovery, since these applications of medical science often require direct action on the part of individuals. The public, however, cannot understand the merits of such very technical subjects unless they are clearly expounded and the meaning of the results driven home. Again, successful cure of disease is always dramatic, and brings with it intense relief both to patients and their friends. There is, however, nothing dramatic about the disappearance of disease. It is here to-day and gone to-morrow, and the very success of prevention of disease is measured thinks by forgetfulness. Whoever nowadays of the decimation once caused in this country by plague, cholera, typhus and other diseases now eliminated from our midst? The relative lack of dramatic interest in the prevention of disease, as compared with that in its cure, is partly responsible for the difference in rates with which their advantages are obtained by the public. A third cause of delay is the fact that preventive medicine mostly concerns children, and it is curious that illness and death in the young do not. apparently, impress themselves on the public mind with the emphasis associated with disease in the adult. It is becoming every day more clear that these difficulties in matters of health and disease, especially when the co-operation of the public is necessary, will remain so long as there is no means of educating and giving them the requisite guidance. It does not seem to be anybody's business in this country to undertake this task. Only too often are the public dependent for information and guidance on advertising propaganda, exaggerated and false as it so often is, financed by those with something to sell. Others who are most assiduous in publicity are those who believe that advances in medical knowledge, especially when of great practical value in public health, are snares and delusions, and who by extensive propaganda mislead in every conceivable way and hinder the process of application. It is not the duty of the Medical Research Council to guide the public on the importance of medical discovery in its practical applications to human needs. Their task is wholly to promote discovery and to They cannot announce it to the world when it is made. but view with regret, however, the delay which so often occurs between medical discovery and its application, provides an especially when the discovery is one that immediate opportunity of preventing or even eliminating disease. What the ultimate solution of this difficulty will be is not obvious, but with the present increase in knowledge of methods of preventing disease, a better method of informing and educating the public becomes
imperative.
506
THE INDIAN MEDICAL GAZETTE
The prevention oj diphtheria.?One of the most striking instances of the delay in the application of new knowledge is the relative lack of public recognition, in Great Britain at the present time, of the existence of a method of proven value for the prevention of diphtheria. Diphtheria is the commonest single cause of death among school children. In 1937, there were 61,339 cases of this disease in England and Wales, causing 2,963 deaths, nearly all in children between the ages of 1 and 15 years. This is pure tragedy, in view of the needlessness of such deaths, for since 1929 prophylactic inoculation against diphtheria has proved increasingly successful wherever it has been properly used. The value oj
.
.
nutrition.?A second type of against disease, of which the proper application has now been delayed for many years, is to be found in improved nutrition. The need for this has been often discussed in previous Annual Reports of the Council; but the adoption of modern teachings on the subject by the public is depressingly slow, in spite of the evidence often advanced that the increased consumption of protective foods would not only be beneficial to the physique and general health of the people but also of great economic value to the country. Better feeding in infancy has caused a gratifying reduction in rickets throughout the country, although the time has not yet arrived when an incident would be possible here such as recently occurred at the Children's Hospital at Toronto, where a case of rickets created such surprise that a meeting of staff and students was summoned to examine the baby. There is still room for great improvement in this respect, for, with the knowledge and public assistance available, the persistence of rickets in this country is an indication of ignorance or neglect. It is of interest to recall that an attack on the problem of rickets was included in the first research programme of the original Medical Research Committee in 1914, and that it is owing to
preventive
improved
measure
the results of this work that the disease
can
now
be
prevented.
A much greater consumption of milk, and other dairy products, of eggs, of vegetables, including potatoes, of fruit, and of fat fish, at the expense of bread, biscuits, sugar and sweets, especially in early life, is an urgent national requirement; it will not only improve the physique of the people but will reduce the amount of dental decay and greatly raise the standard of health. An increase in breast-feeding will still further reduce the high mortality rate of infants from gastro-intestinal
troubles and broncho-pneumonia. Whatever advances in medical knowledge may come, until these simple precepts are adopted there will still remain a great deal of preventable disease in this country. The co-operation oj the public.?These few instances will probably suffice to emphasize the possibilities of applying the results_ of medical research to immediate problems of preventive medicine. It is clear that some of the methods for preventing disease require close co-operation on the part of an enlightened public. There is great need for some authoritative body to transmit the necessary information which will stimulate public co-operation. With a more rapid understanding of the facts on the part of the public, delay in application of new knowledge to human needs ought not to be so long as it has been in the past. Only by improving the general health and eliminating disease can it be hoped to reduce this present tendency of ever-increasing medical services, and the annual expenditure of between two and three hundred million pounds which such services necessitate. _
Research
policy
While the Medical Research Council must necessarily be interested in the general problem of the practical application of new knowledge, they are more directly concerned with the question of the best methods of promoting the research work itself. The over-riding consideration must obviously be the acquisition of knowledge which will make possible improvement in the standard of mental and physical health, and the preven-j tion, alleviation and cure of disease. It is by no means1
[Aug., 1939
certain, however, by what policy such knowledge niay be most quickly and effectively obtained. Some thin it is to be done by directing attention to disease and others by promoting fundamental studies of w* physiology and chemistry of the body. These need not be discussed further, because it cannot doubted that knowledge of practical significance matters of health and disease can come from direction. The work of Pasteur on fermentation led ^ the work of Lister on prevention of wound infec" On the other hand, the discovery of Eijkman ot aeaciei cause of beri-beri led ultimately to more researches on the part played by vitamin Bi 111 oxidation of carbohydrate. Experience has shown experimental work from any quarter may lead to solution of problems from any other quarter. The question may then be asked, what is the of the Council in promoting research? Do they inu tQ research, and, if so, in what way; or do they leave individuals the choice of subject and support J. satisfactory? Do they favour research on disease irather than on more academic problems of and biochemistry? A complete answer to these tions cannot be given here, but the general 6 ' stands as follows. Actual promotion of specific res ^ by the Council is usually done by appointmen .e individuals to their permanent staff. This c depends on the subject which seems to require attention and the merits of the person chosen, ^joii once appointed the individual has wide liberty oi a. 0?e in planning investigation. The Council seldom c ^ie particular diseases for investigation; choice is of a broader nature, so as to of an ajtiological factor common to a group of "1 vgtem or a type of treatment of wide application, or a syof physiological or biochemical control. at Examples of such broad subjects of investigatoo ^ the present time are virus diseases, chemotherapy. In each of these cases workers have been appointed to follow lines oi 1 c^ed gation in their own province and they' are to be familiar with, and prepared to help, res 1 cognate to their own throughout the country. otj1er able opportunity offers itself, investigations by foe workers in the same fields are also assisted 01 Council. By this co-ordination means throughout the country is brought about. For another large part of the work, helped Council by means of personnel and expenses gra eStigainitiative in choice of subject and method of in j jn tion lies with the head of a laboratory or the respect of some individual worker, or with upoD himself. The success of the application depen_ arCb. ox the merits of the individual and the subject Lxutio?! The Council do not provide money for but for individuals, because they regard it as cjj0ice that they should retain direct control over t" oged. of the worker and the type of investigation Pr As to whether the Council encourage the direc the of disease or of the more fundamental s,?iel?,:n(j3 general answer is that they welcome both * th^ investigation. At the same time they rec0Jf nf work at present there is a dearth ^is relatively great in clinical science and in experimental pathology. ot eg brai country, as compared with many other ^lS medical science. So impressed indeed are they efforts state ^of affairs that they are makingoffering jspec1^ scn^ fiC^0lar^ to enlame 'lKn?-rPersonnel by *** me" ships and ^ enter these ?red. ^ds of inquiry. In ?r, J?!! they have v0t posts> anfI they arefor d^c' as opportunitv to establish more units _
yie|
_
,
P.?-^e
P^ysl?ueS^arCh
sPyjiell
general-tu(jy incluj-seases> .
_
endocrinology^ ?r?l^vesti-
ye$0rt
^?^^v0rker inSpSSenti&'
f^^dy
?f
JmSS*
felW^v
f? e.n'1bIe nffPSPe+
investigation
Pre{jn;cal '
of
medical
researchi of
mainlv ^ thr^'p&S ^jtiation T ^ objectives send They ^eiVe. hoping ^ vera? dSi ancI in different seas, } jj
concerned distant and in se
are
rnmn
individuals will shows itself in
reseat
f?rm of OI
mv an ?n
any
sPeciaI prize of discovc
qU^ Sod*?PP?rt?nity
In the
^ ,D c0lT A v 0y
that offers itsel/ work ad hoc problem is taken, and
J/T
ABSTRACTS FROM REPORTS
Aug., 1939] thus be expressly directed
to
the solution of
specific
questions.
Tropical
research in the colonial empire
medical
This activity of the Council was discussed at length fiom hi the Annual Report for 1935-36. It resulted the desire of the Colonial Office that the Council should extend their research interests to problems ot .
invitation has been accepted It clearly offered opportunities discovery, almost unequalled in any other field. (Jn Jor the one hand, any discoveries made would almost ceitainly be of great practical consequence and might assist in raising the standard of health in countries 101 which Great Britain has a special duty and responsibility; on the other hand, some diseases in the tropics, ?uch as pneumonia and tuberculosis, are also common that the w this country, and there was the probability sampler conditions of life might allow easier investiga-
tropical medicine,
and
with greater pleasure.
no
tion than here. One of the difficulties this request
was
to be overcome in accepting to the dearth of investigators trained
study tropical diseases, and, f
Council devised
m
fellowships
to
a
as
scheme
previously
of
junior
explained,
and
semen
young workeis to education and
promising undergo special
encourage
??ter this field and training. In the three years since the scheme was eight junior and three senior fellowships have Initiated, have been been awarded. Fully trained investigators sent to the Territory, and Tanganyika Gambia, Uganda drugs on p study the action of chemotherapeutic and other the natural history of yaws,
peeping sickness, Problems.
Nutritional In the past year
problems in the colonies
a different kind of opportunity ot the Colonial Office, as the result nutritional problems. In ino/? w,orld-wide interest in out *936 the Secretary of State for the Colonies sent circular despatch drawing the attention of Governor colonial territories within the Empire to modern Pects of nutrition and their relation to health, and a" 'nS for their comments and advice on such matters .ey affected each territory. The response was s pnsmgly great and resulted in the setting up of an dvisory Committee on Nutrition in the Colonial Council ^lre uPon which the Medical Research ,, vere represented. Many of the replies received from of colonial territories, while showing the c, vfmors of its i"** interest in the subject and realization more mformaalso much it that made clear rnce? tinn?r the i actual dietetic and nutritional problems e faced : in each territory was needed, and that this further invJ1?51 1(?u could be obtained only theby Advisory Tq meet this situation, e on Nutrition set with up a sub-committee, Sir tvi a coordm + 6 jr^ Mellanby as Chairman, to prepare ^an field surveys and research which Hiio'Vif with advantage be carried out with regard to
arose for
assisting
.
Cortftigation. ?
Aft
n
ln.th(r
Colonial Empire.
the situation, the sub-committee for the n i .recomniendation to the Secretary of State be jsi. I"'? that the Medical Research Council should the first ;7 to aPPoint, for a period of five years in to sraah Staff whose duty would be UndP,^!anc,e'e ascientific co-ordination of a series ot field c,a Urveys of diet in relation to health and physique in co*onial territories. It was also recommended that officers second ^ a^tual field surveys should be made by
Qiarlc>eJi. reviewing
*1
the colonial service in each territory ^at the main duty of the staff e Council should be to co-ordinate the ^Quirin s' * ensure the adoption of comparable methods and j *n the different territories and the Unifo of the complete results. These sUggp
