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HISTORICAL EVOLUTION OF PRIMARY PREVENTION* GEORGE ROSEN, M.D., Ph.D. Professor of the History of Medicine and of Epidemiology and Public Health Yale University School of Medicine New Haven, Conn.

T N 1953 J. M. Mackintosh, professor of public health at the University of London, noted a trend which characterized British public opinion on individual and community health during the first 50 years of this century. "Everyone says that prevention is better than cure," he observed, "and hardly anyone acts as if he believes it.... Palliatives nearly always take precedence over prevention, and our health services today are too heavily loaded with salvage. Treatment-the attempt to heal the sick-is more tangible, more exciting, and more immediately rewarding, than prevention."' Twenty years later this estimate of the position of prevention in health care still embodies a large measure of truth. Why? This question can be answered, at least in part, by a backward look at the evolution of preventive medicine. Actions to prevent disease and its consequences occur in one form or another in the various regions and countries of the world from the earliest cultures up to the present. However, the operational expressions of such action have varied greatly, depending on the nature and the organization of the social group and on the knowledge and the technical means available to it. Understanding the nature and cause of disease can provide a basis for preventing its occurrence and for dealing with the needs of those at risk. Yet the application of such knowledge more often than not depends less on the urgency of the health problem than on economic, political, ideological, and cultural factors. Current examples are obvious: in recent outbreaks of poliomyelitis and diphtheria; in attempts to deal with malnutrition; and in efforts to provide sex education in schools, to reduce motor vehicle accidents, or to control the pollution of air and water. The existence of health problems does *Presented in a panel, Prevention: The State of Knowledge, as part of the 1974 Annual Health Conference of the New York Academy of Medicine, Prevention and Health Maintenance Revisited, April 25 and 26, 1974.

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not guarantee that attention will be directed to them, nor does the accretion and availability of knowledge assure application. As William H. Welch noted in 1925, "The health field has a woefully ineffective distribution service as compared with the marvelously effective production service in the laboratories of the world. We know how to do a lot of things which we won't do or do on a wretchedly small scale."2 Despite various limitations, however, the desire to prevent disease has led societies to make such efforts as seemed necessary and appropriate for the purpose. This is the historical core of preventive medicine. By investigating this history it is possible to understand forces and trends that have led to the problems of our own time-and perhaps to grasp the possibilities for further change. A detailed review of the history of preventive medicine would far exceed the available time. Instead, I shall examine, theoretically and practically, the distinct types of preventive medicine which have evolved and how each type changed or was superseded by other forms of preventive medicine. At the opening of the Women's Medical College of the New York Infirmary on November 2, I868, Elizabeth Blackwell delivered an address in which she called attention to a feature of the College for which, she said,3 "I feel . . . a profound and special interest: it is the introduction of hygiene in our course as a prominent and obligatory study." She went on to remark how strange it seemed that the prevention of disease should not always have engaged the thought and instruction of the guardians of the public health at least as fully as the cure of disease, and yet I believe that this is the first college in America to found a chair of hygiene. Consider the subjects involved in the development of a healthy human organization-a healthy race. Physical and moral training; the inheritance and transmission of qualities; the peculiarities of individual constitution; the nature and influences of climate, soil, food and customs; the prevention of epidemics; the municipal regulations of our cities; etc.-all these subjects come directly and unavoidably into the department of hygiene. Surely every student who receives the degree of Doctor should be thoroughly acquainted with all that Science at present knows on these subjects. The establishment of a chair of hygiene was undoubtedly innovative, even though such posts had been created earlier in Bavaria and Bull. N. Y. Acad. Med.

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England. Max Pettenkofer became professor of hygiene at Munich in i853. A year later a lectureship in public health was established at St. Thomas' Hospital in London, and Edward H. Greenhow was appointed to the post in I 856. Then, in i86o, E. A. Parkes accepted the chair of hygiene at the newly founded Army Medical School at Chatham. Judging from the topics listed by Dr. Blackwell, however, the material to be taught by the occupant of the New York chair was certainly not novel. Indeed, for the most part it represented a tradition rooted in classical Greek medicine, and which with modifications was an integral part of medical thought and practice from antiquity into the I9th century. From the very beginnings of Greek medicine, efforts to preserve health seemed more important than reliance on the possibilities of cure. Health was a condition in which the various elements and forces (humors, qualities) constituting the body were in a state of balance. Disease was a consequence of disturbed equilibrium. Since the balance could easily be upset by external factors, a great deal of attention was devoted to the influence of physical and nutritional factors on the body. The ideal mode of life, according to Greek physicians, was one in which nutrition and excretion, exercise and rest were properly balanced. In addition, for each individual account had to be taken of age, sex, constitution, and the seasons. In terms of their causative roles in the etiology of disease, the innate, constitutional factors were termed the "naturals" and the external environmental factors the "non-naturals." In this classification, derived in part from Galen, the non-naturals eventually came to include air, food and drink, rest and exercise, sleep and waking, excretions and retentions (coitus), and mental affections.4 Because Greco-Roman medical theory was essentially ecological in nature-that is, health and disease were considered as consequences of the interaction between organism and environment-the factors grouped together as the non-naturals were regarded as highly significant in the maintenance of health. Theoretically, by regulating diet, exercise, and other external factors the body could be kept in a state of health; but this meant that an individual's mode of life had to be organized around this goal-and very few could afford to do so. This was a regimen for an upper class with enough leisure to follow instructions on the correct kind and quantity of food, drink, exercise, sexual intercourse, etc., so as to maintain the balanced blend of humors and qualities necessary for health. Even though few could fully practice this type of nonspecific Vol. 51, No. 1, January 1975

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primary prevention, it remained pervasive for centuries wherever the basic concepts and principles of Greco-Roman medicine were accepted. The same basic approach and point of view are obvious in a wide range of medical writings on health maintenance-extending, for example, from Galen's De samitate tuenda (2nd century A.D.) through the Regimen sanitatis of Salerno (ca. I2th century) to George Cheyne's Es-say of Health and Long Life ( 724).5 Over the centuries, however, as the theme was repeated it also exhibited some variations. For example, the Salernitan Regimen succinctly advises that "Wine, women, baths by Art or Nature warme, Us'd or abus'd do men much good or harme..... This sage admonition is presented at considerably greater length in the early i 8th century by Jeremiah Wainewright in his Mechanical Account of the Non-Naturals.6 Where the medieval author still operates with concepts of humors and qualities, for Wainewright "The Human Body is a curious Machine . . . composed of Solids and Fluids, both govern'd by the Laws of Gravitation, Impulse and Reaction, and what changes are brought about in the Animal Oeconomy by the Motion of matter, under the conduct of these Laws, can no way be estimated without some assistance from the Mathematicks."6 But whatever the theoretical underpinning-whether humoral, mechanical, or cellular-nonspecific primary preventive medicine concerned with the individual continued to be practiced; indeed, it is still with us in somewhat more sophisticated forms. Alongside this type of primary prevention there developed a second nonspecific form to deal with transmissible diseases. This. approach to prevention began to develop during the early Middle Ages with the appearance in Europe of leprosy as an important health problem. The need to control leprosy gave rise to a form of community action which is still employed: the isolation of persons with communicable diseases and the cleansing of their environment. Leadership was taken by the Church, using as a guiding principle the concept of contagion embodied in the Old Testament, where spiritual and physical uncleanness are linked. The idea and its practical consequences are clearly presented in Leviticus, which deals not only with spiritual uncleanness but also with physiological processes such as menstruation, and with pathological conditions such as urethral discharges, through which an individual became unclean. Such persons were to be isolated from the rest of the community until they had undergone specific purification rites. Much more Bull. N. Y. Acad. Med.

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severe was the isolation prescribed for unfortunates afflicted by a skin disease called zara'ath. Once the condition had been established, the patient was to be segregated and excluded from the community. To combat leprosy, the Church and the communities guided by it followed these precepts. The leper was expelled from the community as a public menace to protect its healthy members. Since the disease was incurable, the individual became an outcast for life and therefore was to be considered socially dead. This endeavor to combat leprosy introduced a basic principle of preventive medicine, which eventually was made effective through more accurate knowledge and governmental power. This principle-the interruption of the chain of transmission by separating the affected individuals from others and thus rendering them ineffective as carriers of the causative element-was carried further in dealing with that other great scourge of the Middle Ages, the bubonic plague, which was also generally considered communicable. The chief defence was the avoidance of infection. By law, patients had to be reported to the authorities. They were then examined and isolated in their houses or in special hospitals for the duration of their illness. Every house containing a plague victim was placed under a ban, and all who had come into contact with the patient were compelled to remain in isolation. Food and other necessities were provided by municipal authorities through special messengers. The dead were passed through windows and removed from the community in carts. Burial outside the city was likewise intended to prevent the spread of the disease. When a plague patient died the rooms were aired and fumigated and the effects of the deceased were burned. In addition to these measures taken within the community, it was necessary as well to prevent the entry of the plague. The method employed to achieve this objective, and thus to safeguard the community, was to isolate and to observe all suspected persons and objects for a specified period under stringent conditions until it was definitely established that they were not bearers of the plague. From this endeavor grew a basic contribution to primary prevention: the practice of quarantine. Stirred by the pandemic of plague in the middle of the i4th century, public officials in Italy and southern France created a system to combat the propagation of communicable diseases from one place to another, using cordons sanitaires, observation stations, isolation facilities, and disinfection procedures. These practices were widely adopted Vol. 51, No. 1, January 1975

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and by the i7th century they were common in Europe. Owing to ignorance or inadequate knowledge of the etiology and epidemiology of many communicable diseases, quarantine systems were of only questionable effectiveness until the end of the i9th century. Regulations could be elaborate, as they were in Marseilles, yet that city suffered a devastating plague epidemic in I720.7 Moreover, as Jacques Casanova relates in his memoirssuch arrangements could be circumvented with relative ease." Nevertheless, certain measures taken without regard to any concept of etiological specifity were found empirically to be effective, even though the cause of the particular disease was not known. In I758, shortly after his appointment as physician to Haslar Hospital, James Lind described the measures which he took to prevent outbreaks of fever.9 "No patient is admitted into the hospital," he wrote, until he is stripped of all his cloths & well washed with warm water & soap in tubs always kept for the purpose, he is allowed the hospital dress during the time he continues in the hospital or until his clothes are returned to him quite clean, & he is regularly shifted and kept quite neat clean & sweet at the Government's expence. None of his cloths bedding &c is ever permitted to be brought into the hospital we have large outhouses for their reception. In cases of fevers the Patients cloths are directly fumigated with Brimstone in the smoak house and baked in an oven sprinkled with vinegar. The fever Wards are cut off from all communication with the rest & nothing but hospital dresses are used in them. Lind put into practice measures he had urged in his Essay on the Most Effectual Means of Preserving the Health of Seamen, published in 1757. As a naval surgeon, he had observed that members of crews impressed from prisons not infrequently brought jail fever (typhus) with them, and apparently transmitted the "emanations" to which the disease was due by means of filthy clothing and bedding. Consequently he urged the destruction of fomites, the isolation of patients, and the strict practice of cleanliness and personal hygiene to prevent the "emanations" from exerting a pathogenic effect. Not until 178i, however, did the Royal Navy arrange for newly impressed men to be received first on "slop ships" where they were bathed and supplied with Bull. N. Y. Acad. Med.

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new clothing before joining their ships. Shortly thereafter, in 1784, Lind's measures were first applied in civilian hospital practice by John Haygarth when he opened fever wards in the Chester Infirmary. Based on this approach, a system of fever hospitals grew up in Great Britain, primarily for patients with "fevers," a portmanteau term which in the I9th century included not only typhus, typhoid, paratyphoid, and relapsing fevers, but occasionally other febrile conditions as well. These institutions served to lower the incidence of typhus, but they could not eradicate the disease as had been done in British prisons as a result of the work of John Howard. The role of the louse in the transmission of typhus, the nature of the causative organism, and the character of the essential lesion of the disease were all largely unknown during the Victorian period; they were not fully established until the 20th century. Nevertheless, after i869-when typhus fever began to be tabulated separately in the registrar-general's reports-it ceased to be epidemic and thereafter the number of fatal attacks declined almost continuously. In i869 there were 4,28i typhus deaths in England; by i885 the number had dropped to 318. By i906, three years before Charles Nicolle's discovery that the body louse transmitted typhus, the annual report of the London County Council stated that there were no deaths from the disease that year. The trend in the United States was similar. Indeed, the decline had been noted by the end of the i 9th century. In i899 A. C. Abbott, professor of hygiene and bacteriology at the University of Pennsylvania, observed that "In i883 a small epidemic of typhus fever occurred in the Philadelphia Hospital, and in i88i to i 882 over 700 cases were admitted to the Riverside Hospital in New York. Other than these, there have been no outbreaks of any moment in this country since those that occurred between i867 and I87o."1O The decline of typhus fever was even more emphatically noted in i908 by Frederick Forchheimer, professor of medicine at the Medical College of Ohio, in discussing the care of patients with typhus fever. During the i9th century an important qualification for those attending patients with infectious diseases was that they themselves had had the disease, that they had been "salted," to use the term then applied to those who had survived an attack of typhus. For this reason G. H. F. Nuttall in I893 advised that "Nurses presumably immunified by having had the particular [infectious] disease themselves are to be preferred."" Fifteen Vol. 51, No. 1, January 1975

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years later Forchheimer found it strange that some medical authors were still insisting on this qualification in view of the situation in the United States. "In this country," he wrote, "so rare is typhus fever at present that very few physicians or nurses could be found if this rule were followed."12 How had this change come about, even though the cause of typhus remained unknown? It had long been noted that the occurrence and prevalence of typhus was intimately related to the socioeconomic circumstances of its victims. Typhus was closely associated with poverty, destitution, poor housing, overcrowded dwellings, and poor personal hygiene and was called, not inaccurately, the poor man's disease.1 It was not a characteristic problem of the middle and upper classes, with the exception of those whose occupations brought them into close proximity with the sick, the dead, or their environs, such as physicians, nurses, and the clergy. Despite an inadequate understanding of the ecological complex which produced epidemics of typhus fever, rules for preventing the spread of the disease were worked out empirically and proved to be quite effective. Patients were to be isolated and bathed and their clothes and bedding disinfected or destroyed, thus dealing with the problems of overcrowding and transmission by vectors.14 Moreover, it was known that a basic solution of the typhus problem required a higher standard of living and improved housing which would provide the poor with the facilities for keeping clean. And this is precisely what sanitary and social reformers did during the last third of the i 9th and the early years of the 20th centuries. Acting on the premise that a clean city is a healthy city, they undertook to clean upi the physical environment, to improve housing, and in general to provide decent living conditions for the majority of city dwellers. Thus, in i871 the annual report of the Association for Improving the Condition of the Poor, commenting on sanitary conditions in New York tenements, noted that: "Though greatly improved in late years, it is still the disgrace and curse of the city, that half of the inhabitants live in this class of houses, from which proceeds threefifths of the crime and three-fourths of the mortality. If we could abate these evils, the wretched domiciliary conditions of the occupants of these tenements must be improved."'5 Slum clearance, regulation of lodging houses, provision of public baths and washhouses, increased use of cotton clothing, particularly underwear, and the consequent Bull. N. Y. Acad. Med.

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improvement in personal cleanliness, each played a part in achieving these goals and thus reducing the occurrence of typhus fever. Slum clearance tended to disperse workers to newer districts where they could live without crowding because at that time new means of transportation also became available. In addition, as Charles Creighton observed in i894, "food has been for a long time cheap and wages good. . . . So, long as our cheap supplies of food, fuel and clothing are uninterrupted, there is small chance of typhus or relapsing fever."'6 Seen in retrospect, the decline of typhus seems clearly due to the application of preventive measures designed to be used on a relatively small scale in selected populations such as sailors or prisoners to much larger groups-in fact, to whole social classes. What Lind and Howard had done for naval hospitals and prisons was extended to major segments of the community. These measures were taken without any knowledge of a specific etiological agent or of the mode of transmission by a vector, but they were effective on the whole because they affected the vector. For this reason the pattern illustrated by the history of typhus fits the experience with typhoid fever only in part. In the middle of the i9th century evidence began to accumulate that contamination of drinking water by human fecal sewage caused typhoid and cholera and that some agency resembling a living organism was the immediate cause in each disease. Initially this view, developed by John Snow and William Budd in connection with epidemics of cholera and typhoid fever, was accepted only with reservations or was rejected in favor of other nonspecific environmental theories. But no matter what the precise means of spreading these diseases might be, the available evidence appeared to point to the need for proper sewerage and unpolluted water. Emphasis on the need for the correction of sanitary inadequacies did not remain without results. By I866 John Simon was able to show statistically, from a study by one of his epidemiologic investigators, George Buchanan, that the installation of satisfactory sewerage and water-supply systems was reducing the number of deaths from typhoid fever and diarrhea. Consequently, his prescription for the continued improvement of urban health was more of the same.17 The typhoid problem, however, was more complex than was first realized. Even in places where good sewerage systems and water works were installed, outbreaks still occurred. It was not until the last decades of the I9th century that epidemiologic Vol. 51, No. 1, January 1975

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studies established the more obscure channels by which infection was conveyed to its victims and such knowledge was made even more precise with the discovery of the typhoid bacillus by Carl J. Eberth in i88o and the development of the diagnostic agglutination test for the disease by Mlax Gruber, Fernand Widal, and Albert GrUnbaum in 1896. As knoxvledge accumulated and was applied, as cities and towns wvere cleaned up with greater or lesser rapidity, the incidence and prevalence and the morbidity and mortality from typhoid fever diminished. At any given time during the later i9th and the early 20th centuries the typhoid situation was variable and spotty, but the long-term trend was downward. By the last two decades of the i9th century light was being cast on the communicable diseases by the demonstration of specific causative organisms in numerous instances and by a number of brilliant investigations that revealed the part played by vectors in the transmission of such diseases. As early as I855 Pettenkofer had suggested that healthy human carriers could transmit cholera, but it was not until the end of the century that this hypothesis was substantiated and the significance of the human carrier recognized. Between I893 and 1o900 this mode of transmission was demonstrated for cholera, diphtheria, and typhoid and by i9io-when C. V. Chapin published his classic book on The Sources mid Modes of Infection-the role of the human carrier was well established. Paralleling these contributions was the equally important demonstration of the role of the animal vector. Following the work of Theobald Smith and F. L. Kilborne on Texas cattle fever in I893, the animal carrier could not be overlooked, and in the following years this method of transmission was demonstrated in other important transmissible diseases-including malaria, plague, yellow fever, and epidemic typhus. Concurrently, microbiology profoundly affected the concepts and practices of preventive medicine and public health in still another important respect: through the development and application of immunology. The artificial production of immunity had been known for more than i00 years, having been employed for the prevention of smallpox, first through the introduction of variolation and later by the discovery and application of Jennerian vaccination. The essential principle that a mild case of the disease protected the individual from further attacks even when the infection is potent was employed empirically without Bull. N. Y. Acad. Med.

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any understanding of the underlying mechanism. The development of protective vaccines by Pasteur (chicken cholera, i88i; swine erysipelas, 1883; rabies, 1884-I885) stimulated interest in the phenomenon of immunity and led investigators to look for the mechanisms that inoculation set in motion. By the end of the i 9th century it had become evident that a high degree of resistance to the causative organisms of certain communicable diseases could be produced by the injection of these germs in an attenuated live state or when dead, or by inoculation with extracts from such organisms. At the same time it was found that the blood of immunized animals and humans contained substances, antibodies, that had significant prophylactic and therapeutic powers when injected into healthy or sick persons. Pasteur's discovery of prophylactic vaccines was followed by the development of others for such diseases as plague, cholera, typhoid and paratyphoid, tuberculosis, yellow fever, pertussis, and poliomyelitis. Immune sera were also developed for diphtheria, tetanus, snake-bite poisoning, and botulism.18 These developments were paralleled by an increasing knowledge of wound infection and the means to avoid it by antisepsis and asepsis, as in surgical operations. Today, action to prevent the occurrence or spread of communicable diseases comprises an intricate combination of procedures and practices, largely involving the application of bacteriological and immunological knowledge. As established in the I 9th century, health departments were concerned essentially with the control of contagious diseases through environmental sanitation. The real objective of public health administration in abating sanitary nuisances was to prevent outbreaks of contagious disease, yet the efficacy of empirical, shotgun measures was open to question. For example, in i866, when an invasion of Asiatic cholera was expected, Edwin M. Snow, the health officer of Providence, R.I., undertook to clean up the city by removing refuse and filth from cellars, yards, privies, and cesspools; by whitewashing cellars, rooms, and passages in houses; and by maintaining surveillance of places where "diseases of an epidemic, contagious, or infectious character appeared." Yet in his report for I866-i867 Show wrote, "As to the actual results of these measures, in the prevention of disease, it is difficult to make any positive statement in figures, and it is dangerous ground to claim positively, that any definite number of cases of disease, or of deaths, was [sic] prevented by them." He went on to say that "While, then, 1 Vol. 51, No. 1, January 1975

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would claim that sanitary measures, in Providence, in i866, prevented some cases of cholera, and many more cases of other diseases, and that they saved some lives, I would not claim what another year, with the same measures in operation, may prove to be false, that sanitary measures were the chief and only cause of the extremely limited amount of Asiatic Cholera that we had that year."19 However, as bacteriologists identified microorganisms responsible for specific diseases and uncovered their mode of action the way was opened for the control of infectious diseases on a more specific, accurate, and rational basis. Thus, the early decades of the 2oth century had a solid basis for specific primary prevention and control of a number of communicable diseases, and in all the succeeding decades up to the present advances have continued along this line. With the emergence of a concept of specific etiology for various communicable diseases and the development of specific means of primary prevention, the nonspecific ecological approach involving environmental factors tended to recede in significance, yet the environmental context of health and disease for individuals and communities could not be overlooked. Attention had to be directed, not only to microorganisms and their consequences, but also to the individuals whom they invaded and the circumstances under which this happened. As H. W. Hill wrote in i9i6 about the new public health:20 Modem public-health practice for the control of infectious diseases consists, not in the physical surveillance of whole communities, but in the sociological study of the infected persons in them. This practice is best illustrated in the modem handling of typhoid fever epidemics, because this disease is all-inclusive, i.e., it travels by all four of the great public routes (water, food, flies, and milk), as well as by the private fifth route, contact; also because typhoid is an intestinal infection and, of all the infectious diseases of the temperate zone, the intestinal infections alone travel by all of these five great routes. Similarly Robert Koch's discovery in i882 of the tubercle bacillus as the etiologic agent in tuberculosis did not immediately provide a solution to its prevention and control. What it did was to provide a means of opening up the complex of interdependent causative factors, and to make possible an understanding of the way in which social conditions Bull. N. Y. Acad. Med.

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and biological factors interacted so that control measures could be developed to deal with them.21 At this very time evidence was being collected, observations made, and inferences drawn that were to reinforce the need in primary prevention to deal with individuals as well as their societal environments. This was due to the slow realization that disease also could be due to a lack of substances essential to the normal functioning of the body. To appreciate what this meant, one must remember that at the turn of the century the world of medicine and public health was still adjusting itself tot the revolutionary discoveries of Pasteur, Koch, and other microbiologists. Overwhelmingly, disease came to be considered as caused by exogenous agents-germs and toxins-and medical scientists turned naturally to microbial hypotheses. As Frederick Forchheimer sunmmed up the situation in 1908:22

It was natural that the discovery of the bacterial origin of some diseases should be followed by a period in which this was considered the origin of all diseases. Even now twenty years after the first publication of R. Koch's [sic] appeared, bacteria are alleged to be the causes of disease, where the nature of scientific evidence proves the contrary. But the bacterial theory for a long time led to the utter neglect of the human being as a part of that combination which makes disease, and the structural changes due to disease were brushed aside as being of no material importance. . . . Repeated and continued observation has shown that the bacterium is only one of the causes of organic change-this and nothing more. To the bacterial cause we must add chemical, physical and biological causes, the study of which has been somewhat in abeyance while the bacterial theory has occupied the stage.... We now come to the characteristics of the individual human being as a cause of disease. During the last two decades of the i9th century, however, there were already a few Dtraws in the scientific wind which, in another climate of opinion, might have led somewhat sooner to a recognition of those diseases which are caused by nutritional deficiencies. Although the role of fresh fruit and vegetables-in particular, the juice of citrus fruits-in preventing scurvy had been recognized by the end of the I 8th century, there was little further progress along this line. Similarly, the use of cod liver oil, introduced during the i9th century in the treatment Vol. 51, No. 1, January 1975

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of rickets, did not lead to any greater understanding of the disease. These were purely empirical procedures and lacked any precise scientific foundations. This was the situation in 1913 when Grover F. Powers, later to become professor of pediatrics at Yale, first joined the staff of the Harriet Lane Home at Johns Hopkins University. "It seems unbelievable," he observed in I939, "that when, on my first day in the Harriet Lane Dispensary I inquired concerning a row of bottles of 'cod-liver oil and phosphorus' in the drug room, I was told that some physicians used that medicine in the treatment of rickets and I was free to prescribe it since it was harmless, but really the stuff had little value."23 This was approximately the point at which the first chapter in the evolution of the modern concept of deficiency disease came to a close. Following the work of the naval surgeon T. K. Takaki, who practically eradicated beriberi from the Japanese navy (i882-1887), and by the investigations of C. A. Pekelharing, Christian Eijkman, and C. Grijns on beriberi (i886-i905), and F. Gowland Hopkins on rickets and scurvy (i906-I912), it became clear that the diet must contain minute amounts of certain essential substances ("accessory nutritional factors") other than the basic nutrients which were thitherto accepted if the organism was to remain in good health. These substances were then named vitamins by Casimir Funk. The next chapter, which began after I912, has been concerned with the elaboration and confirmation of the vitamin concept and the application of the knowledge that has been acquired to prevention and therapy. A number of accessory dietary factors have been isolated and associated with specific diseases. As vitamins became known, efforts were made to determine their chemical nature and metabolic functions. Methods were developed to determine the vitamin content of foods as well as norms for optimal nutrition. Finally, administrative and educational tools were developed to utilize this knowledge to improve individual and community health. I have time only to mention the discovery of the hormones which also occurred during this period. An understanding of the role of these substances in the physiology and pathology of the organism opened up new avenues of specific primary prevention as well as therapy. The prevention of endemic goiter is a prime example.24 Nor can I do more than mention the very important area of primary prevention concerned with the health of workers, which involves both specific and nonspecific approaches. Bull. N. Y. Acad. Med.

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All these areas of primary prevention must be seen in their ecological contexts, where various factors may hinder or facilitate prevention. For example, Werner Forssmann, the German surgeon and Nobel laureate, describes his experience during a I936 diphtheria epidemic in Dresden about I936, in the course of which he performed more than 50 tracheotomies in six weeks.25 This and other large-scale outbreaks in Germany between 1935 and 1937 occurred at a time when the disease had been virtually eliminated as a cause of death in New York and other American cities, and resulted essentially from the reluctance of German health authorities to use immunization against diphtheria.26 The English experience with immunization against diphtheria was not dissimilar. Sometimes professional tunnel vision leads physicians to overlook the wider context of a primary preventive measure and to neglect or drop it because the incidence of disease has declined and the benefits are alleged to be outweighed by harmful effects. Gonorrheal ophthalmia neonatorum is a case in point. In 1957, for example, after silver nitrate prophylaxis was discontinued at the Sloan Hospital for Women, a i5fold increase in cases of gonorrheal ophthalmia neonatorum occurred over the subsequent seven-month period.27 The recent increased incidence of gonorrhea in adolescents and young adults has brought in its wake a resurgence of gonorrheal ophthalmia in newborns, as well as an increased emphasis on primary prevention by means of silver nitrate prophylaxis and on secondary prevention by careful identification of infection and prompt, adequate treatment of pregnant women.28 In retrospect, it is clear that the major targets of primary prevention usually have been the epidemic or transmissible diseases and the deficiency diseases. To deal with these problems, three approaches have been employed: i) the inculcation of nonspecific individual hygiene based on an ancient ecological model, 2) a form of group action intended to interrupt a process of communicability between organisms and their environment by isolating individuals and by cleansing or destroying aspects of the environment, and 3) the discovery of specific etiologies for infectious and deficiency diseases, as well as the factors which determine their occurrence or control. The continuing need for these forms of prevention cannot seriously be questioned. For example, as long as communicable diseases are controlled through immunization of the population at risk, then specific prevention of this type must be continued. Failure to immunize children Vol. 51, No. 1, January 1975

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against diphtheria, polio, or any of the other communicable diseases for which specific protection is available simply means that outbreaks can be expected as soon as the necessary factors are present. In some conditions-such as those associated with atherosclerosis-the approach is nonspecific, with emphasis on the individual's mode of life and is likely to remain so in the foreseeable future. Since the early years of this century, attention increasingly has been directed to the practice of early detection of these conditions. In 1927 Fisk and Crawford urged "the detection of physical impairment or predisposition to disease, and faults in living habits, the correction of which would have even a remote beneficial influence on the life of an individual."29 This was to be accomplished by periodic health examination to search for and record accurately "the slight impairments which are present in the subject examined, and which would ultimately lead to disease conditions if not corrected." A similar approach was proposed by Newsholme in 1932: he recommended the early detection of disease so that it could be treated expeditiously to prevent recurrences and later consequences.80 As long as means of primary prevention do not exist, early detection will be pursued by such means as are feasible and effective, as for example cytologic screening. There is also the possibility of nonspecific primary prevention, even where precise pathogenetic mechanisms are still unclear, by altering the environment, by reducing exposure to noxious agents such as coal dust, asbestos fibers, tars produced by combustion, and chemicals such as vinyl chloride, and numerous other products known to be hazardous. Primary prevention can also be practiced by attending to the safety of machines, tools, toys, buildings, and a variety of hazardous or potentially dangerous elements of our environment. Monitoring the experience of population groups, particularly those considered vulnerable in some respect, can lead to investigation and perhaps focus preventive action more precisely. In any event, the major goal must still be primary prevention by whatever means possible. Any successes achieved by secondary prevention can only be second best since its practice is largely the result of ignorance of the means for primary prevention. Whatever means of prevention are used, they do not exist in a vacuum. Application requires action by individuals and groups deriving from research, legislation, education, and admrinistration. These elements must come together in the right way at the right time for prevention to be effective. Bull. N. Y. Acad. Med.

EVOLUTION OF PRIMARY PREVENTION

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NOTES AND REFERENCES 1. Mackintosh, J. M.: Trends of Opinion about the Public Health 1901-1951. London, Oxford University Press, 1953, p. 5. 2. Welch, W. H.: State Charities Aid Association News, December 1925, p. 2. 3. Blackwell, E.: Essays in Medical Sociology, 2 vols. London, Bell, 1902, vol. 2, pp. 205-06. 4. This list is taken from Garrison, F. H.: An Introduction to the History of Medicine, 4th ed. Philadelphia and London, Saunders, 1929, p. 113, where there is an elaborate discussion of Galenic physiology and pathology. Recent discussions of the concept and terminology of the "non-naturals" are presented in Jarcho, S.: Galen's six non-naturals: A bibliographic note and translation. Bull. Hist. Med. 44:372-77, 1970; Rather, L. J.: The "six things non-natural": A note on the origins and fate of a doctrine and a phrase. Clio Med. 3:33747, 1968; Bylebyl, J. J.: Galen on "the non-natural causes" of variation in the pulse. Bull. Hist. Med. 45:482-85, 1971; Niebyl, P. H.: The non-naturals. Bull. Hist. Med. 45:486-92, 1971. 5. Galen: Hygiene (de sanitate tuenda),

6.

7.

8. 9.

Green, R. M., translator. Springfield, Ill., Thomas, 1951; The School of Salernum (Regimen sanitatis Salernitanum), Harrington, J., translator, and Packard, F. R., editor. New York, Hoeber, 1920; Cheyne, G.: An Essay of Health and Long Life. London, Strahan, 1724. Wainewright, J.: A Mechanical Account of the Non-Naturals: Being a Brief Explication of the Changes made in Human Bodies, by Air, Diet &c., 4th ed. London, Clarke, 1722, pp. A2-verso. R6glemens du Bureau de Santi, de Marseille. D'apres ceux de 1730, des Suppl4mens de 1786 et 1787. . . . Marseille, Mossy, An V de la RWpublique. Casanova, J.: Histoire de ma vie, 12 vols. Wiesbaden, Brockhaus; Paris, Librairie Plon, 1960, vol. 2, pp. 48-49, 53. Stockman, R.: James Lind and scurvy. Edinburgh Med. J. (new ser.) 33:32950, 1926 (see esp. pp. 335-36).

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10. Abbott, A. C.: The Hygiene of Transmissible Diseases: Their Causation, Modes of Dissemination, and Methods of Prevention. Philadelphia, Saunders, 1899, p. 212. 11. Nuttall, G. H. F.: Hygienic Measures in Relation to Infectious Diseases.... New York, Putnam, 1893, p. 33. 12. Forchheimer, F.: The Prophylaxis and Treatment of Internal Diseases. New York, Appleton, 1908, p. 24. 13. Bartlett, E.: The History, Diagnosis, and Treatment of Typhoid and Typhus Fever. Philadelphia, Lea and Blanchard, 1842, p. 236; Second Annual Report of the Metropolitan Board of Health ... 1867. New York, Union Printing House, 1868, p. 43; Nuttall, op. cit., p. 92; Abbott, op. cit., p. 211; Notter, J. L. and Firth, R. H.: Hygiene, 4th ed. London, Her Majesty's Stat. Off., 1900, p. 291; Forchheimer, op. cit., p. 23. 14. Second Ann'ual Report. . ., op. cit., pp. 55-56; Abbott, op. cit., pp. 212-213; Forchheimer, op. cit., p. 23. 15. De Forest, R. W. and Veiller, L.: The Tenement House Problem, 2 vols. New York, Macmillan, 1963, vol. 1, p. 97. 16. Creighton, C.: A History of Epidemics in Britain, 2 vols. Cambridge, England, Cambridge University Press, 1894, vol. 2, p. 215. 17. Second Report of the Medical Officer of the Privy Council, 1859. 1860, p. 34. 18. For information on vaccines and sera see Parish, H. J.: A History of Immunization. Edinburgh and London, Livingstone, 1965. A detailed account of the development of microbiology and immunology and their application is presented in Rosen, G.: A History of Public Health. New York, M.D. Publ., 1958, pp. 304-43. 19. Snow, E. M.: Report upon the Prevention of Disease in the City of Providence in 1866 and 1867. Providence, 1867, pp. 8, 11. 20. Hill, H. W.: The New Public Health. New York, Macmillan, 1916, p. 77. 21. Russell, J. B.: On the Prevention of Tuberculosis. Boston, Wright and Pot-

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22. 23. 24.

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ter, 1896; A Handbook ol the Prevention of Tuberculosis . . . New York, Charity Org. Soc., 1903. Forchheimer, op. cit., pp. 1-2. Powers, G. F.: Developments in pediatrics in the past quarter century. Yale J. Biol. Med. 12:1-22, 1939 (see p. 10). Marine, D.: The Prevention of Simple Goiter as a Public Health Problem. In: De Lamar Lectures 1925-1926 (Johns Hopkins University School of Hygiene and Public Health). Baltimore, Williams and Wilkins, 1927, pp. 1-18. Forssmann, W.: Selbstversuch. Erinnerungen eines Chirurgen. Dusseldorf, Droste, 1972, p. 192. O'Hara, D.: Air-Borne Infection. bSome Observations on its Decline. New York, Commonwealth Fund, 1943, pp. 23-24; Russell, WV. T.: Medical Research Council, London, 1943; Special Report Series, No. 247; Burnet, M.: Natural History of Infectious Diseases. Cambridge, England, Cambridge University Press, 1953, pp. 269-70, Immunization programs in Germany did not start until after 1934 when the Reich and Prussian Minister of the Interior approved

27.

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29.

30.

the procedure, but it was not made compulsory. The full effects were not felt until after World War II. Mellin, G. W. and Kent, M. P.: Ophthalmia neonatorum. Is prophylaxis necessary? Pediatrics 22:1006, 1958. Lehrfield, L.: Prophylaxis against ophthalmia neonatorum. J.A.M.A. 135:306, 1947; Ormsby, H. L.: Ophthalmia neonatorum. Canad. Med. Ass. J. 72:576, 1955; Hansen, T.; Burns, R. P., and Allen, A.: Gonorrheal conjunctivitis. An old disease returned. J.A.M.A. 195: 1156, 1966; Smith, J. A.; Ophthalmia neonatorum in Glasgow. Scot. Med. J. 14:272, 1969; Snowe, R. J. and Wilfert, C. M.: Epidemic reappearance of gonococcal opthalmia neonatorum. Pediatrics 51:110-14, 1973; Shaw, E. B.: Gonorrheal ophthalmia neonatorum. Pediatrics 52:281-82, 1973. Fisk, E. L. and Crawford, J. R.: How to Make the Periodic Health Examination, New York, Macmillan, 1927, pp. 17-18. Newsholme, A.: Medicine and the State. London, Allen and Unwin, 1932, pp. 35-36.

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