The organisation of prevention

16

PUBLIC HEALTH,

THE ORGANISATION OF PREVENTION* By VICTOR FREEMAN, M.R.C.S., L.R.C.P., D.P.H., Medical Officer of Health, Metropolitan Borough of Islington T h e costs of t h e nationaIised h e a l t h s e r v i c e s - - o r sickness services, as some prefer to call t h e m - - h a v e b e e n the subject of almost c o n t i n u a l discussion in political a n d medical circles since 1948. N o party, however, seems prepared, to take the responsibility of c u t t i n g or altering the Service to e n s u r e a m a j o r cut in expenditure. T h e increasing c o m plexity of medical t e c h n i q u e a n d t h e i n h e r i t a n c e of old a n d o u t - o f - d a t e hospital buildings, apart f r o m m a n y o t h e r reasons, p r e c l u d e the p r e s e n t possibility of any w o r t h w h i l e reductions, w h i c h can only be sensibly effected b y d i m i n i s h i n g the d e m a n d a n d necessity for hospitalisation a n d t r e a t m e n t . I t is unlikely t h a t s h o r t cuts will soon be f o u n d to this desirable end, b u t medical officers of h e a l t h h a v e a n a t u r a l interest in p r e v e n t i o n , even if its application a n d effects can only b e long term. Before going o n to consider the possibilities of the prev e n t i v e m e t h o d , I h o p e I m a y be allowed a few m i n u t e s to sttmmarise a n d place in perspective the c u r r e n t costs of t h e h e a l t h a n d sickness services.

Health Service Finances T h e Civil E s t i m a t e s for 1953-54 p r o v i d e d a p p r o x i m a t e l y s for E n g l a n d a n d Wales in respect of t h e H o s p i t a l Services, g r a n t s to Local H e a l t h Authorities, t h e G e n e r a l Medical, Dental, P h a r m a c e u t i c a l a n d S u p p l e m e n t a r y O p h t h a l m i c services, a n d o t h e r items. T h e ceiling figure for H e a l t h Service e x p e n d i t u r e f r o m t a x a t i o n was fixed at s in 1950 a n d this figure has b e e n r e t a i n e d b y Chancellors of the E x c h e q u e r for each succeeding year. T h e value of services obtainable w i t h this s u m m u s t , of course, b e d i m i n i s h e d b y increased costs, i n c l u d i n g salaries, w h i c h have taken place since 1950. Local H e a l t h A u t h o r i t y services are paid for partly b y central G o v e r n m e n t grants a n d partly f r o m t h e local rates, a n d the total Local H e a l t h A u t h o r i t y estimates for 1952-53 were a p p r o x i m a t e l y s T h e cost of h e a l t h services n o t u n d e r t h e control of the Local H e a l t h A u t h o r i ties, a l t h o u g h n o t easily separable, c a n n o t b e a m a j o r i t e m of e x p e n d i t u r e . W i n s l o w gives the figure of s as t h e cost of p r e v e n t i v e services in E n g l a n d , Wales a n d S c o t l a n d for t h e year 1949-50, against an all-inclusive N a t i o n a l H e a l t h Service cost for t h e same period of s t h a n six t i m e s as m u c h . T h e public itself also c o n t r i b u t e s a n increasing a m o u n t t h r o u g h p a y m e n t s for specific services w h i c h m a y a m o u n t to some s per annum. T h e view has b e e n expressed b y some t h a t e x p e n d i t u r e of this o r d e r on sickness a n d h e a l t h services m a y have a m a j o r d e t r i m e n t a l effect o n t h e n a t i o n a l economy, b u t The Times, a n d also a r e c e n t P.E.P. Report, have p o i n t e d o u t t h a t t h e H e a l t h Service is n o t h a v i n g so large a share of the n a t i o n a l i n c o m e as i s c o m m o n l y supposed. I f related to t h e gross national income, t h e H e a l t h Service accounts for a b o u t 3 ~ % of the n a t i o n ' s c u r r e n t s p e n d i n g , private a n d public, o n goods a n d services. T h i s is not, of course, to say t h a t s or so is n o t a m a j o r item, a n d t h e r e is certainly n o excuse for u n n e c e s s a r y or wasteful e x p e n d i ture at any p o i n t in the h e a l t h services. O f the total of p u b l i c s p e n d i n g on t h e h e a l t h services, it has b e e n estimated t h a t s or 6 3 % , is n o w t a k e n b y t h e hospital a n d specialist services. T h i s disp r o p o r t i o n a t e e x p e n d i t u r e b e t w e e n t h e curative a n d p r e ventive services appears to b e fairly general. W i n s l o w , in " T h e Cost of Sickness a n d the Price o f H e a l t h , " m e n t i o n s t h a t in D e n m a r k the State s p e n d s n e a r l y three times as m u c h o n hospitals as on basic public h e a l t h work. T h e same applies in Sweden, b u t in G r e a t Britain the p r o p o r t i o n is a p p r o x i m a t e l y six tb one. * Paper read to the Metropolitan Branch, Society of M.O.H., September, 1953.

November, 1953

V a l u e for M o n e y ? I n a recent Times s u r v e y the q u e s t i o n was asked, " W h a t r e t u r n does t h e c o m m u n i t y get for the s or so p o u r e d into t h e hospital and specialist service ? " " Something under a fifth goes on the care of mental patients and mental defectives, a branch of the service which is getting into a parlous state for want of funds. What happens to the rest is only vaguely known, except in particular places. W h a t is the cost of caring for tile tuberculous, of provision for maternity, children, or the chronic sick, of the increasing demands on out-patient facilities made by general practitioners ? How much of what the hospitals ask for each year is really essential for their efficiency as medical institutions ? T o these and many more questions it is very difficult to give coherent answers relating to the country as a whole. " It is known that the efficiency, both medical and economic, of hospitals varies widely and haphazardly. Restriction of budgets has stimulated the cutting down, without detriment to patients, of a good deal of expenditure on food, fuel, and other resources, which should never have been tolerated."

The Times c o r r e s p o n d e n t m i g h t have gone on f u r t h e r to p o i n t out that, o n the o t h e r h a n d , the Local H e a l t h A u t h o r i t y Services, w i t h a m u c h smaller total expenditure, were carefully scrutinised, a n d it was possible w i t h o u t a n y difficulty to give separate h e a d i n g s of e x p e n d i t u r e for s u c h services as m a t e r n a l a n d child health, midwifery, h o m e care, vaccination a n d i m m u n i s a t i o n , etc. Perhaps the m o s t striking contrast, however, is t h a t whilst H o s p i t a l M a n a g e m e n t C o m m i t t e e a n d Regional H o s p i t a l B o a r d financial e s t i m a t e s a n d s t a t e m e n t s are regularly p u b l i s h e d , t h e r e is n o c o r r e s p o n d i n g i n f o r m a t i o n on t h e work w h i c h is the p u r p o s e of this e x p e n d i t u r e . So little systematic i n f o r m a t i o n , in fact, is available t h a t a special s u r v e y has h a d to b e u n d e r t a k e n to collect m o r b i d i t y statistics r e l a t i n g to hospital in-patients. A p r e l i m i n a r y s u r v e y has n o w b e e n p u b l i s h e d u n d e r t h e title of " Hospital M o r b i d i t y Statistics," b u t while some valuable i n f o r m a t i o n has b e c o m e avaiIable, the balance sheets of work for p a t i e n t s c a n n o t be related to the financial.balance sheets.

T h e Hospitals a n d P r e v e n t i o n Some c o n s u l t a n t s themselves are n o t altogether satisfied t h a t the hospital services are o p e r a t i n g in t h e m o s t a d v a n tageous way, or are d o i n g a n y t h i n g very. effective t o w a r d s r e d u c i n g t h e b u r d e n of hospital d e m a n d s . P r o f e s s o r Vines, in a n address to the I n s t i t u t e of Hospital A d m i n i s t r a t o r s , confessed h i m s e l f t i r e d of these massive hospital a c c o u n t s a n d statistics w h i c h , h o w e v e r excellent they m i g h t b e in d e m o n s t r a t i n g saving to the E x c h e q u e r , were quite u n i n formative a b o u t the real work of the hospital, w h i c h was the .care of the p a t i e n t a n d t h e control a n d p r e v e n t i o n of sickness. H e w e n t on to say t h a t a hospital was also a place for investigation into the causes of disease a n d t h e m e t h o d s of t r e a t m e n t . T h e nationalised hospital, h e said, m u s t b e c o m e t h e statistical a n d f u n c t i o n a l e m b o d i m e n t of the national policy for t h e m a n a g e m e n t of the sick, b u t at p r e s e n t it was n o t very obvious t h a t t h e r e was any p a r ticular policy of medical care. T h e l o n g - t e r m policy s h o u l d b e to e m p t y t h e hospitals r a t h e r t h a n fill t h e m . M e d i c i n e t o - d a y was c o n c e r n e d p r i m a r i l y w i t h the cure of disease, or the p a t c h i n g - u p of tissues, b u t it s h o u l d b e c o m e increasingly preventive in its aim. Dr. Bomford, in his B r a d s h a w L e c t u r e at the Royal College of Physicians in 1952, said, " I t seems inescapable t h a t sooner or later we shall come, or i n d e e d we shall b e d r i v e n b y the e c o n o m i c p r e s s u r e of t h e cost of sickness, to regard t h e p r e v e n t i o n o f disease a n d p r o m o t i o n of h e a l t h as m o r e i m p o r t a n t t h a n t h e curative or more often palliative m e d i c i n e to w h i c h at p r e s e n t we devote so m u c h m o r e a t t e n t i o n . " H e t h e n w e n t on to discuss in a b s t r a c t t h e concept of Health, a n d c o n c l u d e d b y saying, " It is n o accident t h a t academic m e d i c i n e has n o concept of h e a l t h ; for the m e c h a n i s t i c idea of disease leaves n o r o o m for one, o t h e r t h a n in t e r m s of no disease, w h i c h is clearly i n adequate."

PUBLIC HEALTH, November, 19-53 W h a t e v e r the theoretical inadequacies m i g h t be, I s h o u l d have s u p p o s e d t h a t a c o n d i t i o n of n o disease w o u l d be an advance in t h e right direction over disease b e i n g present, b u t in any case Dr. B o m f o r d m a d e n o practical suggestions o n the i n t r o d u c t i o n of t h e preventive principle into hospital practice. Sir H e n e a g e Ogilvi~, in the A n n u a l O r a t i o n to the Medical Society of L o n d o n in 1952, said, " W e r e we to ask m o d e r n s t u d e n t s ' W h a t is the p u r p o s e of m e d i c i n e ? ' n o n e w o u l d answer, ' T o heal the sick.' T h e y w o u l d say, ' T o p r e v e n t i l l n e s s ' or ' T o discover the cause of disease.' A scientific r a t h e r t h a n a h u m a n i t a r i a n ideal." I find it difficult to see w h y the p r e v e n t i o n of illness is n o t j u s t as h u m a n i t a r i a n a n objective as the i m m e d i a t e treatm e n t ' o f a sick patient. F r o m the r e p r e s e n t a t i v e samples of c o n s u l t a n t s ' views on p r e v e n t i o n j u s t quoted, t h e r e w o u l d seem to b e some awareness of the p r e v e n t i v e p r o b l e m , b u t little a t t e m p t to deal w i t h it. T h i s is natural, since those w h o have s p e n t t h e i r lives in curative m e d i c i n e can h a r d l y be expected to t h i n k readily along o t h e r lines, a n d the t e c h n i q u e of p r e v e n t i v e m e d i c i n e is not, in general, attractive to clinicians. T h e r e is also the h u m a n factor of the vested interests of particular groups. D r . T o p p i n g , in his Presidential A d d r e s s to the conference of medical officers of h e a l t h at t h e last H e a l t h Congress of the Royal Sanitary Institute, referred to t h e s u d d e n e n t h u s i a s m a m o n g s t general practitioners for a n t e - n a t a l a n d m a t e r n i t y work; so m a r k e d l y at variance w i t h the a t t i t u d e of 90~ of doctors b e t w e e n the wars ; a n d also to t h e n u m b e r of consultants w h o were t r a n s f e r r i n g f r o m f u l l - t i m e to p a r t - t i m e hospital work. Dr. D i x o n , of Leeds UniVersity, has also referred to t h e hospital b o a r d s ' i n h e r e n t "reluctance t o b e i n t e r e s t e d in p r e v e n t i o n , w h i c h c a n only result in the r e d u c t i o n of professional a n d a d m i n i s t r a t i v e empires. However, before we t h r o w stones, we m u s t recognise t h a t t h e p r e v e n t i v e services necessarily a n d u n a v o i d a b l y also have t h e i r o w n vested interests. I t h i n k t h e difference is t h a t the vested interests of the p r e v e n t i v e service are m u c h m o r e in accord w i t h the general p u b l i c interests as c o m p a r e d w i t h t h e curative service. It s h o u l d t h e r e f o r e b e r e g a r d e d as the d u t y of t h e service t h a t practical p r o posals for the i n t r o d u c t i o n of p r e v e n t i v e m e d i c i n e into t h e curative s p h e r e shall b e m a d e b y the p r e v e n t i v e service itself. All of us pay lip-service to p r e v e n t i o n , w h i c h cann o t b e c o m e a practical p r o p o s i t i o n u n t i l m a c h i n e r y is devised w h i c h will p e r m i t application of p r e v e n t i v e p r i n ciples to curative m e d i c i n e . F u r t h e r , it is only t h e practitioners of preventive m e d i c i n e w h o have b e e n specifically t r a i n e d for p r e v e n t i v e work, a n d surely it is in t h e p u b l i c interest t h a t full use s h o u l d be m a d e of this training. I a m p r o p o s i n g to m a k e certain suggestions, a n d the principle u n d e r l y i n g these suggestions is t h a t certain g r o u p s o f sickness, w i d e s p r e a d in t h e c o m m u n i t y , a n d m a k i n g large d e m a n d s u p o n t h e hospitals in particular, are i n fluenced to some e x t e n t b y social a n d e n v i r o n m e n t a l factors. If this is so, t h e n systematic recording of these factors m a y provide i n f o r m a t i o n w h i c h will eventually be helpful towards the d i m i n u t i o n of these particular m a j o r causes of sickness, so r e d u c i n g the b u r d e n of expensive portions of the medical services. Following this, I shall consider how t h e p r e v e n t i v e service m i g h t b e allowed to play a p r o p e r part while closely linked to clinical work. Before considering n o n - i n f e c t i o u s sickness treated at general hospitals, I s h o u l d like, as an aside to the principal subject m a t t e r of this talk, to m e n t i o n one infection w h i c h m i g h t be considered for inclusion in the list of notifiable diseases b y the c u s t o m a r y procedure.

Infective Hepatitis Infective hepatitis belongs to t h a t small b u t i m p o r t a n t g r o u p of infectious diseases w h i c h f r o m time to time b u r s t s w i t h almost explosive violence into epidemics of p a n d e m i c proportions. N o r m a l l y it has a low mortality, a b o u t 0 . 2 % of cases, b u t it usually incapacitates p a t i e n t s for

17 weeks or m o n t h s , a n d it reached fairly w i d e s p r e a d p r o p o r tions d u r i n g the second world war. Infective hepatitis appears to be at p r e s e n t a m o r e serious disease t h a n d i p h t h e r i a or scarlet fever, a n d I f r e q u e n t l y receive i n f o r m a t i o n of sporadic cases r e p o r t e d to m e b y some general practitioners. It is notifiable only in the counties of Bedfordshire, E~sex, H e r t f o r d s h i r e , East a n d \Vest Suffolk, C a m b r i d g e s h i r e , H u n t i n g d o n s h i r e , Isle of Ely a n d Norfolk. F r o m 1944 to 1950 the notifications varied f r o m a m a x i m u m of 3,500 to a m i n i m u m of 1,000 approximately. I n 1950 they n u m b e r e d 1,823, a n d the n u m b e r increased gradually in the three years p r i o r to this. T h e h i g h e s t incidence of notifications is in the five to n i n e age group. All these counties are m a i n l y r u r a l a n d have n o very large centres of p o p u l a t i o n , t h e r e f o r e notification does not necessarily give a n y i n d i c a t i o n of w h a t the incidence of infective hepatitis m i g h t be in large u r b a n areas. W h e n it is realised t h a t in 1951 notifications over the w h o l e c o u n t r y of d i p h t h e r i a were a p p r o x i m a t e l y 2,000, those of acute poliomyelitis 3,100, a n d those of m e n i n g o coccal infections a p p r o x i m a t e l y 2,000, it is obvious t h a t infective hepatitis m u s t b e a fairly w i d e s p r e a d disease. I t is also n o t medically negligible, a n d the Registrar G e n e r a l records the following deaths f r o m infective hepatitis in t h e t h r e e years given : - 1949

1950

1951

230

284

255

T h e s e deaths are exceeded for deaths d u e to infectious disease only b y measles, poliomyelitis (some years), m e n i n g o coccal infections a n d w h o o p i n g cough. I n f o r m a t i o n for the c o u n t r y as a whole, local variations, local seasonal incidence, if any, etc., are u n k n o w n factors, a n d there w o u l d seem to be a case for a d d i n g infective hepatitis to t h e list of notifiable infectious diseases, all t h e m o r e so since we k n o w so m u c h less a b o u t virus infections t h a n bacterial infections.

Cancer of the Lung Passing n o w to consideration of the epidemiology of n o n - i n f e c t i o u s disease, t h e r e appears to b e general agreem e n t t h a t t h e r e has b e e n a g e n u i n e basic increase in c a n c e r of the lung in recent years, a n d t h a t the increase c a n n o t be wholl}r ascribed to greater medical awareness a n d i m p r o v e d diagnosis. I n 1951 t h e r e were 11,166 male deaths f r o m cancer of the lung, a n d t h e c r u d e d e a t h rate p e r m i l l i o m was 530, against c o r r e s p o n d i n g figures in 1931 of 1,635 a n d 85 respectively. I n 1951 t h e r e were 7,903 male deaths f r o m respiratory tuberculosis w i t h a c r u d e d e a t h rate p e r million of 375. F e m a l e deaths f r o m cancer of the l u n g were 2,081 in 1951 against 651 in 1931. W h e n deaths f r o m cancer of the l u n g are s u b - d i v i d e d into separate sites, deaths f r o m cancer specified as actual cancer of the l u n g increased a m o n g males b y 660/o b e t w e e n the ages 40 to 49, b u t cancer specified as of the b r o n c h u s increased b y 2 8 3 % . As a cause of hospitalisation, cancer of the l u n g was t h i r d in the n u m b e r of discharges for males aged 45 to 64 years, and c o n s t i t u t e d the highest single g r o u p for m a l i g n a n t neoplasms in males. C a n c e r of the l u n g a n d s t o m a c h t o g e t h e r r e p r e s e n t e d 37-9% of m a l i g n a n t g r o w t h s a m o n g m e n in the H o s p i t a l M o r b i d i t y Survey. Prior to 1948 the s t o m a c h was the m o s t f r e q u e n t site for male cancers at all ages, b u t in t h a t year cancer of the lung, w h i c h h a d b e e n r e p o r t e d w i t h rapidly increasing f r e q u e n c y in p r e v i o u s years, s u p p l a n t e d cancer of the s t o m a c h as a single leading cause of male cancer mortality. A p a r t from the considerable sex differentiation in cancers of the lung, t h e r e are also considerable geographical variations. T h e d e a t h rates for males a n d females are given in T a b l e I.

18

PUBLIC HEALTH, November, 1953 TABLE I : LUNG CANCER MORTALITY

Greater London

County Boroughs outside Greater London

Urban Districts outside Greater London

Rural Districts outside Greater London

Males Death rate per million . . . . . . Cancer of respiratory system as p e r c e n t a g e of cancer of all sites Death rate per million . . . . . . Cancer of respiratory system as p e r c e n t a g e of cancer of all sites

594

517

396

296

29

25 Females

20

16

113

95

82

79

6

5

5

5

T h e principal factors w h i c h have b e e n b l a m e d for the increase in l u n g cancer are : - (1) T h e increase in tobacco smoking. (2) T h e smokiness of the a t m o s p h e r e , either b y itself p r o d u c i n g or s t i m u l a t i n g l u n g cancer, or r e d u c i n g s u n shine, w h i c h m a y be an i m p o r t a n t factor in p r e v e n t i n g its incidence. R o a d dust a n d petrol e n g i n e e x h a u s t gases have also b e e n m e n t i o n e d as possible c o n t r i b u t o r y causes. W h a t e v e r t h e final verdicts in r e g a r d to causation m a y be, it w o u l d s e e m to be o b v i o u s t h a t social a n d e n v i r o n m e n t a l factors have played a m a j o r p a r t in l u n g c a n c e r increase, a n d if these factors can b e defined, they m a y p o i n t t h e way to steps w h i c h can be t a k e n for r e d u c t i o n of l u n g cancer, if n o t to its elimination. L u n g cancer w o u l d therefore seem to b e an e m i n e n t l y suitable subject for e n q u i r y along epidemiological lines.

Peptic U l c e r Peptic ulcer is a disease of great social a n d e c o n o m i c i m p o r t a n c e . T h e sex i n c i d e n c e has c h a n g e d d u r i n g the last 50 years, a n d f r o m b e i n g h i g h in y o u n g females a n d low in y o u n g males, it is n o w h i g h in y o u n g males a n d low in females. I t has b e e n e s t i m a t e d t h a t t h e r e are 1,000,000 p e p t i c ulcer p a t i e n t s in this c o u n t r y t o - d a y a n d t h a t 10% of m e n in t h e late forties have an active d u o d e n a l ulcer. T h e r e is also a geographical variation of incidence. T h e m o r t a l i t y rates for peptic ulcer for m e n over 45 are approxim a t e l y 7 5 % h i g h e r in t h e C o u n t y of L o n d o n t h a n in the rural areas. Again, t h e r e is a considerable sex differentiation. I n the H o s p i t a l M o r b i d i t y E n q u i r y t h e r e were 1,066 disch.arges of males w i t h s t o m a c h ulcer as against 425 females (nearly two a n d a half times greater) a n d 2,200 males w i t h d u o d e n a l ulcer as against 415 females (five times). Peptic ulcer is also a m a j o r cause for hospitalisation. It was responsible for t h e h i g h e s t n u m b e r of hospital discharges of any single c o n d i t i o n in t h e male age-group 15 to 44, a n d a c c o u n t e d for 8 % of all male admissions. T h e p r o p o r t i o n a t e age d i s t r i b u t i o n for t h e d u o d e n a l type of ulcer r e a c h e d its peak at an earlier age t h a n t h a t for gastric ulcer. F o r m e n in the age-group 45 to 64 it a c c o u n t e d for a b o u t 1 in every 10 admissions. I n view, therefore, of t h e social as well as personal factors involved, peptic ulcer s h o u l d yield profitable d i v i d e n d s to systematic epidemiologic enquiry.

Domestic Accidents D o m e s t i c accidents, to w h i c h are ascribed 5,000 to 6,000 deaths annually, a n d w h e r e t h e t e n d e n c y is for an increase to take place each year, c o n s t i t u t e a m a j o r g r o u p of fatalities. A b o u t 2 0 % of the fatalities o c c u r r e d in c h i l d r e n u n d e r five years of age, a n d a b o u t 6 0 % in those over 65 y e a r s ; b u t m o r e c h i l d r e n u n d e r 15 die f r o m accidental causes in t h e h o m e t h a n are killed o n t h e roads.

N o n - f a t a l d o m e s t i c accidents w h i c h require m i n o r t r e a t m e n t m u s t c o n s t i t u t e a considerable b u r d e n of work to practitioners a n d hospitals, b u t t h e r e are no statistics available w h i c h will give a c o m p r e h e n s i v e picture of the v o l u m e of medical t r e a t m e n t d o n e for n o n - f a t a l accidents. T h e reasons for accidents are partly personal a n d p a r t l y social a n d e n v i r o n m e n t a l , a n d m u s t therefore be r e g a r d e d as p r e v e n t a b l e to some extent. T h e r e m u s t be local variations in incidence as well as causes, a n d these can only b e ascertained, w i t h t h e a p p r o p r i a t e advice to b e given, a n d p r o p a g a n d a to be u n d e r t a k e n or o t h e r m e a s u r e s to be a d o p t e d on i n f o r m a t i o n g a t h e r e d locally. T h e Medical Officer of H e a l t h s h o u l d have s u c h i n f o r m a t i o n systematically f r o m practitioners a n d hospitals.

Hospitalised Morbidity Among Women A m o n g w o m e n aged 15 to 44, obstetrical conditions a n d diseases of the congenital t r a c t p r e d o m i n a t e . T h e discharges relating to p r e g n a n c y a n d c h i l d b i r t h a m o u n t e d to 25-7% of the total, a n d at least one in every t w o admissions at aged 15 to 34 related to obstetrical conditions, a m o n g w h i c h over half were admissions at t e r m for n o r m a l or other deliveries. A p a r t f r o m hospitalisation in c o n n e c t i o n w i t h c h i l d b i r t h a n d pregnancy, t h e principal causes for hospital a d m i s s i o n in w o m e n age-group 15 to 44 were appendicitis, m e n s t r u a l disorders, tuberculosis, f i b r o - m y o m a t a of the u t e r u s a n d utero-vaginal prolapse, in t h a t order. F o r w o m e n aged 45 to 64 b y far the h i g h e s t n u m b e r of admissions were d u e to utero-vaginal prolapse a n d f i b r o - m y o m a t a a n d o t h e r b e n i g n u t e r i n e neoplasms, again in this order. Uterovaginal prolapse is, therefore, a very c o m m o n a n d i m p o r t a n t cause of female invalidism, f r e q u e n t l y over a very p r o longed period. I t is m a i n l y associated w i t h child bearing, b u t not invariably so, a n d social a n d e n v i r o n m e n t a l factors m a y well play a part in the exacerbation, if n o t causation, of this condition. T h e r e is little precise i n f o r m a t i o n as to the extent of i n v a l i d i s m a n d s e m i - i n v a l i d i s m caused b y this condition, especially in m i d d l e - a g e d w o m e n , a n d e p i d e m i o logical enquiries s h o u l d yield useful i n f o r m a t i o n .

Tonsillectomies It has r e c e n t l y b e e n estimated t h a t o f t h e total on t h e national hospital waiting list of 500,000 or so, some 150,000 are awaiting a d m i s s i o n for tonsillectomy.* A c c o r d i n g to the Hospital M o r b i d i t y Statistics, 3 1 % of all a d m i s sions for c h i l d r e n of school age were attribu}ed to tonsils a n d adenoids. I t was also m e n t i o n e d t h a t t h e b u r d e n on hospital resources, t h o u g h heavy, was n o t quite so heavy as the figure of 31 in every 100 discharges m i g h t suggest, for while tonsils a n d adenoids a c c o u n t e d for a b o u t 5 % of discharges at all ages, t h e c o r r e s p o n d i n g p r o p o r t i o n of b e d - d a y s was j u s t u n d e r 1%, owing t o t h e s h o r t average stay. H o w e v e r , a l t h o u g h the t u r n o v e r of cases of " T s a n d As " is rapid, a very great total of time for operative work m u s t be i n v o l v e d a n d a good deal of n u r s i n g a t t e n t i o n m u s t be given d u r i n g the short stay in hospital. A p a r t f r o m the a m o u n t of hospital work done in c o n nection w i t h tonsillectomies, t h e r e is a n o t h e r aspect w h i c h should also be considered. T o n s i l l e c t o m y is n o t in itself w i t h o u t risk. A p a r t fro~m the associated risks s u c h as poliomyelitis a n d cross-infection in hospital wards, t h e Registrar G e n e r a l has given t h e following figures for deaths associated with tonsillectomies : - -

0 to 5 years 5 to 15 years

... ...

1939

1942

1945

1948

21 37

24 39

15 26

32

58

63

41

47

15

*The Ministry of Health Report for 1952 (Part 1) gives in page 133 an E.N.T. waiting list of 171,455 cases at 31st December, 1952. It is assumed that the great majority of these were for tonsillectomy.

I'UBI,IC HEALTH,

Nm'ember, 1953

19

It is u n f o r t u n a t e t h a t after 1948 the I n t e r n a t i o n a l Classification of D e a t h s no longer gives i n f o r m a t i o n of conditions associated w i t h tonsillectomy, b u t deaths are ascribed to h y p e r t r o p h y of tonsiIs a n d adenoids. It w o u l d b e reasonable to assume t h a t b y far t h e greater part of these deaths are due not to h y p e r t r o p h y b u t to associated tonsillectomies. T h e total deaths due to h y p e r t r o p h y of tonsils a n d adenoids were : - 1949 1950 1951 40

49

43

T h e operative risk w i t h possible fatal c o n s e q u e n c e s is not, therefore, altogether negligible. It has b e e n p o i n t e d out t h a t tonsillectomy is h a r d l y ever p e r f o r m e d as an u r g e n t operation in children, a n d even if not p e r f o r m e d , the sequelae of the conditions for w h i c h tonsillectomy is r e c o m m e n d e d are very rarely fatal in themselves. T o n s i l l e c t o m y deaths are all t h e m o r e tragic since approximately t w o - t h i r d s of all tonsillectomy deaths occur in those u n d e r the age of 15 years. T o n s i l l e c t o m y is the m o s t f r e q u e n t surgical p r o c e d u r e necessitating a general anaesthetic b u t there are t r e m e n d o u s variations in local tonsillectomy rates, e.g., in 1948 a B i r m i n g h a m child was four times m o r e likely to b e tonsillectomised t h a n one living in M a n c h e s t e r . Bristol t r e b l e d t h e p r e - w a r rate, b u t t h e L e e d s rate was r e d u c e d to o n e fifth. T h e H e r e f o r d s h i r e rate was six times the G l o u c e s t e r shire, a n d B u c k i n g h a m s h i r e h a d a rate five t i m e s greater t h a n its n e i g h b o u r , B e d f o r d s h f f e . G l o v e r said, " T h e eccentricities of this incidence dist i n g u i s h it f r o m any o t h e r surgical p r o c e d u r e , " a n d T . B. L e y t o n in 1948 expressed the view t h a t the profession as a whole s h o u l d r e c o n s i d e r its a p p r o a c h to tonsillectomy. T h e M i n i s t r y of E d u c a t i o n had, s h o r t of dictation, d o n e all it could to limit the n u m b e r arising f r o m school inspections, a n d still it w e n t on to s u c h an e x t e n t t h a t it could only be explained as b e i n g due to d i s h a r m o n y of the h u m a n m i n d . H e believed t h a t f u t u r e generations w o u l d w o n d e r at it j u s t as we do at the b l e e d i n g a n d p u r g i n g at the e n d of t h e 18th century. T h e British M e d i c a l J o u r n a l was exceptionally categorical o n this m a t t e r in 1948. I t said t h a t t h e r e are certain aspects of tonsillectomy w h i c h justify definite statements. It is a m a j o r operation, n e v e r u r g e n t , a n d it s h o u l d b e p r e c e d e d b y a period of o b s e r v a t i o n of six m o n t h s after the c o m pletion of any necessary t r e a t m e n t of t e e t h a n d sinuses ; it s h o u l d n o t b e p e r f o r m e d in w i n t e r or early spring, n o r w h e n infectious diseases are p r e v a l e n t ; a n d it seldom i m p r o v e s the c o n d i t i o n of patients w i t h established systemic diseases such as n e p h r i t i s or r h e u m a t i s m . T h e r e m u s t be extreme d o u b t as to w h e t h e r all the 300,000 waiting tonsillectomies are likely to have these criteria satisfied. H a v e areas w i t h h i g h tonsillectomy rates b e t t e r child h e a l t h t h a n areas w i t h low tonsillectomy rates ? It w o u l d seem e x t r a o r d i n a r y t h a t after all the tonsillectomies t h a t have b e e n done n o definite answer can yet be given. It w o u l d seem to be very timely, therefore, t h a t t h e r e s h o u l d b e systematic advance i n f o r m a t i o n , recording, a n d follow-up in regard to every tonsillectomy done and that this s h o u l d be done in c o n j u n c t i o n with, b u t also i n d e p e n d e n t l y of, t h e surgical specialty. Incidentally, if the average stay in hospital is five days, a n d the average cost p e r child b e d is taken as s 10s. 0d. per day, t h e r e would b e a saving of s in hospital costs for every 100,000 tonsillectomies not p e r f o r m e d .

Rheumatism R h e u m a t i s m , b e i n g s o m e w h a t of a diagnostic rag-bag, is n o t so simple of a p p r o a c h f r o m t h e epidemiological angle. I t is only 14th in the Causes of D e a t h , b u t it is responsible for a vast a m o u n t of invalidism. It has b e e n estimated t h a t it was responsible in one year for the loss of 3,000,000 w o r k i n g weeks, an e x p e n d i t u r e of s on sickness benefit, a n d caused o n e - s i x t h of the total industrial invalidism.

T h e epidcmiological aspect s h o u l d certainly be i n c l u d e d in any review of the r h e u m a t i c p r o b l e m .

P r e v e n t i v e W o r k i n the H o s p i t a l s So m u c h for an outline of some of the p r o b l e m s to bc tackled or c o n s i d e r e d for action. N o w what existing m a c h i n e r y in any of the medical services can be e x t e n d e d or adapted so t h a t the practice of p r e v e n t i o n is as m u c h t a k e n for g r a n t e d b y the hospital service, even if only in a small way initially, as is the necessity for any form of curative t r e a t m e n t r e q u i r e d for any sick p a t i e n t ? A n extension of notification to include the n o n - i n f e c t i o u s diseases is one step w h i c h has b e e n p r o p o s e d b y some. D r . D i x o n has said that " if the Medical Officer of H e a l t h qf the f u t u r e is to be c o n t i n u o u s l y aware of the state of the public health, he m u s t be able to evaluate the medical, social and e c o n o m i c p r o b l e m s of m a n y diseases. H e c a n n o t do this w i t h o u t figures. I n the case of cancer of the l u n g we are obviously in the early stages of an e p i d e m i c process of u n k n o w n d u r a t i o n ; a n d as w i t h o t h e r diseases, the m o s t suitable t i m e to s t u d y cause is d u r i n g an e p i d e m i c phase. As history shows, the causative factors can be postulated w i t h some accuracy b y epidemiological study, a n d some degree of control achieved w i t h o u t k n o w i n g the specific cause. I f it were tackled in this way we s h o u l d have t h e greatest c h a n c e of achieving some control. " A t first sight, notification m a y a p p e a r an attractive, obvious, a n d relatively s i m p l e m e t h o d of o b t a i n i n g the i n f o r m a t i o n required, b u t would it really suffice ? T o b e g i n with', all t h a t n e e d be i n c l u d e d in the p r e s e n t notification f o r m is the n a m e , address, age, sex, date of onset a n d disease f r o m w h i c h the p a t i e n t is suffering. These particulars w o u l d obviously b e insufficient even as a basis for the epidemiological recording and evaluation of l u n g cancer, peptic ulcer, etc. Secondly, we are all aware of the difficulties we e n c o u n t e r f r o m the hospitals, even w i t h the simple Infectious Disease Notification s t a t u t o r i l y required, a n d w h i c h s h o u l d b e traditional b y now. Is it n o t likely t h a t t h e difficulties a n d delays w o u l d b e considerably greater w i t h notification of the n o n - i n f e c t i o u s diseases, especially if m o r e i n f o r m a t i o n were r e q u i r e d t h a n for infections ? F o r m a n y reasons, a domiciliary visit b y t h e Medical Officer of H e a l t h ' s staff to fill the lacunae m i g h t be unprofitable, undesirable or unnecessary, especially as m u c h , if not all, of the data r e q u i r e d is already available in the p a t i e n t ' s caseh i s t o r y a n d hospital records. W h a t w o u l d b e r e q u i r e d for this p u r p o s e is, therefore, an extract f r o m the p a t i e n t ' s r o u t i n e h i s t o r y sheets, s u p p l e m e n t e d b y such f u r t h e r enquiries as experience showed to be desirable, and w h i c h could be o b t a i n e d at the p a t i e n t ' s hospital attendance. Domiciliary visiting w o u l d be done to amplify sociomedical data, b u t n o t necessarily as a routine. I f this line of a p p r o a c h is correct, t h e n it follows t h a t t h a t part of t h e p a t i e n t ' s history w h i c h has epidemiological significance s h o u l d be separately d r a w n u p a n d be available or extractable for use a n d r e t e n t i o n b y the Medical Officer of Health. H e will have to work in close cooperation w i t h t h e hospital consulting a n d senior medical staff, and his status is therefore i m p o r t a n t . It m i g h t also b e b e t t e r for t h e records to be kept at the hospital instead of in the p u b l i c h e a l t h d e p a r t m e n t , a n d to be associated w i t h the general hospital records. A n alternative to notification is therefore t h a t medical records in an a p p r o v e d a n d agreed f o r m be t r a n s m i t t e d to or extracted b y the Medical Officer of Health, w h o will be m a d e formally responsible for this part of the work in respect of s u c h n o n - i n f e c t i o u s diseases as m a y b e statutorily specified. T o carry out this f u n c t i o n effectively will p r o b a b l y necessitate the a p p o i n t m e n t of t h e Medical Officer of H e a l t h to t h e hospital staff as a c o n s u l t a n t epidemiologist in its widest sense (or p e r h a p s c o n s u l t a n t aetiologist). H e w o u l d not, of course, have any hospital beds, b u t the i m p o r t a n t n a t u r e of his responsibility s h o u l d be recognised b y c o n s u l t a n t status, not only for equality in dealing w i t h

20 his rnost senior colleagues, b u t also as a p u b l i c indication of t h e i m p o r t a n c e of this f u n c t i o n b y t h e State. T h e a p p o i n t m e n t s h o u l d not, of course, bo w h o l e - t i m e a n d t h e principal a p p o i n t i n g a u t h o r i t y s h o u l d r e m a i n t h e local authority. T h e p r e s e n t f u n c t i o n s of the M . O . H . have still to be carried out, b u t apart f r o m this, if t h e hospital b e c a m e the principal employer, it m i g h t well t e n d to s u b merge, in the course of time, t h e i m p o r t a n c e of the preventive objective 9 M y suggestion t h a t the M e d i c a l Officer of H e a l t h m i g h t be a p p o i n t e d on t h e hospital staff has some points of similarity w i t h the r e c o m m e n d a t i o n m a d e b y Prof. Leslie Banks in his address o n " T h e F u t u r e of Local A u t h o r i t y H e a l t h Services " in 1952. Prof. Banks believes t h a t the p r e v e n t i o n a n d cure of diseases are no longer to b e r e g a r d e d as d i s t i n c t entities to b e retained in separate adminigtrative a n d technical c o m p a r t m e n t s , b u t t h a t p r e v e n t i o n , diagnosis, t r e a t m e n t a n d after-care n o w f o r m one cont i n u o u s process, a n d t h a t we s h o u l d revise o u r u n d e r g r a d u a t e a n d p o s t g r a d u a t e t e a c h i n g accordingly. H e also s t a t e d t h a t the first step w h i c h w o u l d allow t h e M e d i c a l Officer of H e a l t h to c o - o r d i n a t e the local medical services, if h e h a d the full a n d active s u p p o r t of his colleagues, w o u l d be to give h i m an h o n o r a r y c o n t r a c t on the staff of t h e local g r o u p of hospitals as H o m e - c a r e Physician. It w o u l d t h e n b e his d u t y to e n s u r e t h a t all existing resources were u s e d to p r e v e n t disease arising in the individual, as well as to encourage t h e m e d i c a l care of patients in t h e i r o w n homes, etc. Since t h e Medical Officer of H e a l t h will have n o beds, h e will n o t require, as d o o t h e r consultants, a registrar, senior a n d j u n i o r h o u s e m e n , a l m o n e r , etc. H e will, however, in all probability, require t h e services of a statistical assistant, w h o m a y or m a y n o t b e already available o n t h e hospital staff. I t m i g h t well be a logical d e v e l o p m e n t t h a t e v e n t u ally t h e whole of t h e hospital m o r b i d i t y recording, w h e n developed, s h o u l d pass u n d e r t h e aegis of t h e M . O . H . as c o n s u l t a n t epidemiologist. Initially, however, only a very l i m i t e d n u m b e r of selected conditions, such as l u n g cancer a n d p e p t i c ulcer, n e e d b e singled o u t for epidemiological treatment. W i t h regard to the possible n u m b e r of s u c h a p p o i n t m e n t s , t h e r e are 378 H o s p i t a l M a n a g e m e n t C o m m i t t e e s in E n g l a n d a n d Wales, a n d 136 B o a r d of G o v e r n o r s , m a k i n g a total of 414 hospital groups. H o w e v e r , t h e special hospital groups, e.g., mental, need not b e considered for this purpose, a n d t h i s w o u l d therefore leave s o m e t h i n g u n d e r 400 hospital g r o u p s available for t h e m a k i n g of preventive a p p o i n t m e n t s . T h e r e are obviously m a n y aspects w h i c h w o u l d have to b e c o n s i d e r e d before a r r i v i n g at a decision on general hospital epidemiologists. H o s p i t a l epidemiology s h o u l d be linked w i t h n e i g h b o u r h o o d epidemiology, b u t hospital g r o u p areas m a y cover m o r e t h a n one local a u t h o r i t y area, each w i t h a n M . O . H . I n s u c h cases s h o u l d each M . O . H . b e a p p o i n t e d to the same g r o u p to link respectively w i t h his o w n area, or s h o u l d only one a p p o i n t m e n t be made, the p e r s o n a p p o i n t e d referring domiciliary investigations to his colleagues for t h e area ? C o n s i d e r a t i o n of this factor leads to t h e possible suggestion t h a t each local h e a l t h area shall b e b a s e d u p o n the local hospital group, b u t i m p o r t a n t implications such as this m u s t r e m a i n p a r t of l o n g - t e r m policy. T h e i n t r o d u c t i o n of p r e v e n t i v e practice into t h e hospitals s h o u l d n o t be delayed for s u c h settlements, since hospital e c o n o m y calls for m o r e i m m e d i a t e steps. I n any case, t h e a p p o i n t m e n t of medical officers of h e a l t h to the hospitals f r o m existing local a u t h o r i t y areas will provide valuable i n f o r m a t i o n a n d experience for some time to come~ before f u r t h e r d e v e l o p m e n t s are likely to take place in h e a l t h a u t h o r i t y areas in the years to come. T h e setting u p of a small, b u t distinct, general e p i d e m i o logical-statistical d e p a r t m e n t in t h e hospital w o u l d have a f u r t h e r very i m p o r t a n t advantage, especially in t h e t e a c h i n g hospitals. T h e medical s t u d e n t , in t h e course of his t r a i n ing, is so t a k e n u p w i t h p a t h o l o g y a n d the diagnosis a n d t r e a t m e n t of disease t h a t he can h a r d l y be m a d e aware of p r e v e n t i o n . A n d yet if t h e p r a c t i t i o n e r of the f u t u r e is

PUBLIC HEALTH,

November, 1953

ever to have a different outlook a n d play a larger p a r t in t h e h e a l t h services a n d the p r o m o t i o n of h e a l t h t h a n h e does at present, it is absolutely essential t h a t he be t a u g h t p r e vention in his s t u d e n t days 9 C a n p r e v e n t i o n of disease a n d its practice be e m p h a s i s e d in any b e t t e r way w i t h i n the hospital t h a n b y m a k i n g each s t u d e n t serve for a s h o r t period in the p r e v e n t i v e d e p a r t m e n t u n d e r the c o n s u l t a n t epidemiologist, j u s t as he does his medical clerking a n d surgical dressing. Incidentally, the t e a c h i n g of s t u d e n t s should also serve as a m o r a l a n d intellectual s t i m u l u s to t h e epidemiologist himself. Additional a p p o i n t m e n t s of epidemiologists a n d statistical staff m a y a d d a little in the first place to the hospital salaries bill. I t would, however, be a relatively m i n o r item, b u t unless t h e s t a n d a r d of hospital care a n d a t t e n t i o n is substantially lowered, t h e r e is n o p r e s e n t h o p e of w o r t h while reductions in t h e cost of the hospital service. O n the contrary, w i t h the c o n t i n u e d complexity of m e d i c i n e on the one h a n d , and the necessity sooner or later for m a j o r capital e x p e n d i t u r e on old hospital b u i l d i n g s - - a n d this c a n n o t be p o s t p o n e d i n d e f i n i t e l y - - t h e r e is every likelihood that hospital costs will go u p a n d n o t down. Since no one really desires t h a t sick p e r s o n s shall be t r e a t e d o n the cheap, l o n g - t e r m r e d u c t i o n in curative service costs can only be b r o u g h t a b o u t sensibly b y r e d u c i n g the necessity for medical a n d especially hospital t r e a t m e n t . From the economic p o i n t of view, therefore, a small p r e m i u m p a i d n o w on i n s u r a n c e b y the p r e v e n t i v e service m a y be r e t u r n e d m a n y f o l d in t h e future, as has already o c c u r r e d w i t h d i p h t h e r i a a n d t h e p r i m i t i v e hygiene diseases w i t h w h i c h we are n o longer afflicted in this country. I am well aware of m a n y difficulties a n d snags w h i c h m a y be e n c o u n t e r e d in trying to i m p l e m e n t the suggestions I have p u t forward. B u t the p r o b l e m s to b e dealt w i t h w h i c h I have m e n t i o n e d are generally accepted as r e q u i r i n g to b e tackled urgently. P r e v e n t i o n is f r e q u e n t l y m e n t i o n e d , b u t o n h o w to b e g i n to make it work t h e r e has b e e n singularly little discussion, a n d I have therefore felt s o m e w h a t i m p e l l e d to step i n w h e r e others, p r o b a b l y wiser, have n o t trodden 9 Finally, m a y I say t h a t p e r h a p s t h e p r e v e n t i v e service has b e e n too m o d e s t a b o u t itself in the p a s t - - a n d also t h e present. W e have m a d e insufficient i m p a c t o n the p u b l i c a n d the politicians. " P r e v e n t i o n is b e t t e r t h a n cure " has become too familiar a saying, b e i n g so generally accepted t h a t it is automatically ignored. I t h i n k if I were going to p u t a n alternative title to this talk it w o u l d b e " P r e v e n t i o n is cheaper t h a n cure ! " I f this b e c a m e publicised it m i g h t p e r h a p s make a little m o r e i m p r e s s i o n o n the politicians, w i t h benefit b o t h to the public a n d the p r e v e n t i v e service. BIBLIOGRAPHY

BANKS, A. LESLIE. (1952.) Brit. Med. J., 2, 1007. BOMFORD, R . R . (1(.)53.) Ibid., I, 633. Children in Road Accidents. (1953.) Lancet, i, 1032. Civil Estimates, 1952-53, Class V. Civil Estimates, 1,(}53-54, Class V. COHEN, SIR HENRY. (1951.) Proc. Roy. Soe. Med., 4o, 443. DALLY, SIR ALLEN. (1953.) Croonian Lectures. Brit. Med 9 J., 2, 163 and 243. DIXON', C . W . (1952.) Lancet, 2, 1131. DOLL, RICHARD, & AVERYJONES, F. (1951.) Occupational factors in the aetiology of gastric and duodenal ulcers. Spec. Rep. Ser. Medical Research Council, No. 276. H.M.S.O. DOLL, RICHARD, • BRADFORD}][ILL. (1952.) Brit. Med.ff., 2, 1271. 9 (1953.) 1bid., I, 505. Epidemiology of accidents. (19539 Lancet, I, 730. Epidemiology of virus hepatitis. (1952.) Brit. Med. ]., I, 1399. GEARY. (1952.) Ibid., 2, 625. Health Service Costs. (1953.) Ibid., x, 723. LAYTON, T . B . (1948.) Ibid., 2, 310. MACKAY, DONALD. Hospital Morbidity Statistics, General Register Office. McNEE, SIR JOHN. (1952.) Brit. Med. ft., r, 1367. MINISTRY OF HEALTH. (1950.) National Health Service, Development of Consultant Services. H 9 (1953.) National Health Service, Hospital Costing Returns for March 31st, 1952. H.M.S.O. Report for year ended March 31st, 1949. Report for year ended March 31st, 1950, Part II.

PUBI,IC HEALTH, November, 1953 Ministry of Health. Report of, Part I, March 31st, 1950. Report of, Part I, 1950. Report of, Part III, 1951. Report of, Part II, April to December, 1951. 9 Report of, Part I, 1952. Notification of Disease. (1952.) Brit. ~Ied. ft., x, 474. Nuffield Provincial Hospitals Trust, Report, 1948-51. OGILVIE, SIR HENEAGE. (1952.) Lancet, 2, 820. PEMBERTON, JOHN. (1953.) Lancet, 2, 469. Political and Economic Planning, Cost of Social Services, 1932-52. Registrar-General's Statistical Review, England and Wales, Part I, 1948. Ibid., Part I, 1951. Removal of children's tonsils. (1948.) Brit. Med. ~., 2, 564. Smoking and lung cancer. (1952.) Ibid., 2, 1299. STOCKS, PERCY. (1952.) Munic. Eng., I3o, 168. Tasks for the M.O.H. (1952.) Lancet, x, 87. The Times, March 27th, 1952. , February 25th, 1953. , February 26th, 1953. TOPPING, A. (1953.) Roy. San. Inst. ft., 73, 520. VINES. (1953.) Brit. Med. ~., I, 1104. WINSLOW, C. E . A . (1951.) W.H.O. Monograph Series. T h e Cost of Sickness and the Price of Health. Geneva.

RECENT A D V A N C E S IN T H E T R E A T M E N T OF THE R H E U M A T I C DISEASES* By G. D. KERSLEY, T.D., M.D., F.R.C.P. D u r i n g the last few years t h e r e have b e e n several recent advances in t h e t r e a t m e n t of the r h e u m a t i c disease, b u t n o " cures." T h e n e w t r e a t m e n t s wilt only be advances, h o w ever, if used in c o n j u n c t i o n w i t h t h e already e s t a b l i s h e d principles of t r e a t m e n t . Rheumatoid Disease I n r h e u m a t o i d a r t h r i t i s - - o r b e t t e r r h e u m a t o i d disease, as t h e joints a r e only one small part of the tissues affected - - r e l i e f f r o m stress, care of the general health, m e n t a l a n d physical rest, t r e a t m e n t of anaemia, removal of obvious sepsis, care of affected j o i n t s a n d possibly aurotherapy, are t h e first considerations. I n addition A . C . T . H . , cortisone, h y d r o c o r t i s o n e a n d b u t a z o l i d i n e m a y be valuable adjuvants to t r e a t m e n t in selected cases. F i r s t it w o u l d be in o r d e r to consider cortisone a n d A . C . T . H . a n d t h e i r practical value. T h e y are antiphlogistic or a n t i - i n f l a m m a t o r y r a t h e r t h a n a n t i - r h e u m a t i c a n d they m a y b e u s e d as an " asbestos suit " to protect t h e p a t i e n t t e m p o r a r i l y f r o m the fire of t h e disease, b u t t h e y will n e i t h e r p u t out the fire n o r deal w i t h the ashes. T h e dosage n e e d e d varies very greatly f r o m p a t i e n t to patient a n d this factor, a n d t h e .length of t i m e for w h i c h " cover " is required, largely define t h e i r value. I n r h e u m a t o i d arthritis t h e y m a y b e used w i t h advantage (1) to cover a s u d d e n e m e r g e n c y or acute exacerbation of t h e disease ; (2) to assist in r e d u c t i o n s of d e f o r m i t y b y splintage a n d m a n i p u l a t i o n ; (3) for those cases t h a t flare u p after surgery ; (4) to rehabilitate b o r d e r l i n e cases w h o are almost b u t n o t quite fit for light work or almost a m b u l a n t ; a n d (5) for l o n g - t e r m t r e a t m e n t w h e r e a very small dosage of cortisone, 25 to 50 rag. p e r day, makes a very great clinical i m p r o v e m e n t . I n choice of h o r m o n e to be used, cortisone is best for Iong-tema t r e a t m e n t , h y d r o c o r t i s o n e used locally for r e d u c tion of deformity, especially of knees, a n d w h e n t h e condition affects few joints or there is a c o n t r a - i n d i c a t i o n to general use. A . C . T . t I . , especially as t h e long acting get, is of great service given b y injection once a day, or even o n alternate days, as a s t i m u l u s for s h o r t - p e r i o d t r e a t m e n t . T h e c o n t r a - i n d i c a t i o n s a n d dangers can be g r o u p e d as (1) the i n h e r e n t result of t h e antiphlogistic e f f e c t - - m a s k i n g of s y m p t o m s , r e d u c t i o n of reaction against infection a n d l e n g t h e n i n g of time of healing ; (2) p r o d u c t i o n temporarily, while a large dose is b e i n g taken, of a C u s h i n g s y n d r o m e w i t h m o o n i n g of the face, hirsutes, a m e n o r r h o e a , etc. ; a n d (3) upset of salt a n d water m e t a b o l i s m , w i t h o e d e m a usually controlled by restriction of salt. Occasionally,

21 p o t a s s i u m deficiency m a y result. T h e general use of these h o r m o n e s is as a rule inadvisable in d i a b e t e s - - t h e y cause a t e m p o r a r y diabetogenic t e n d e n c y as well as lowering the renal t h r e s h o l d to s u g a r - - i n active tuberculosis unless used with s t r e p t o m y c i n a n d carefully controlled, in cardiac failure because of salt and water r e t e n t i o n a n d in psychoneurosis a n d psychosis because of their e u p h o r i c effect, w h i c h is often followed b y irritability or depression. P h e n y l b u t a z o n e (butazolidine) rivals the pituitary adrenal h o r m o n e s in the controversy it has raised. I n some r h e u m a t o i d cases, the effect on pain a n d h e n c e spasm, m o b i l i t y a n d indirectly o n the general health is so d r a m a t i c t h a t some almost b e d r i d d e n patients can be got back to light work. T h e effect o n t h e s e d i m e n t a t i o n rate is, however, slower a n d less c o n s t a n t t h a n w i t h cortisone. T h e use of b u t a zolidine carries dangers, the m o s t serious of which, b u t least c o m m o n , is agranulocytosis. Gastric irritation a n d s o m e t i m e s h a e m o r r h a g e are not unusual, rashes are c o m m o n b u t n o t severe, a n d oedema, due to salt r e t e n t i o n b u t n o t to damage to the kidneys, is, as a rule, of little i m p o r t a n c e . Agranulocytosis, however, occasionally arises even o n small dosage and w i t h n o w a r n i n g - - r o u t i n e w h i t e c o u n t s arc valueless. Butazolidine s h o u l d be used only w h e n r h e u m a t o i d disability is severe a n d w h e r e there is a response to small d o s a g e - - 2 0 0 to 600 mg. (one to three tablets) p e r day. I n t e r m i t t e n t a d m i n i s t r a t i o n s h o u l d be avoided as it m a y increase the risk of sensitisation a n d the patient should be told to report at once if he or she feels ill, r u n s a t e m p e r a t u r e for n o obvious cause, or gets a sore t h r o a t or m o u t h . Daily w h i t e counts s h o u l d t h e n b e carried out a n d a screen of antibiotics c o m m e n c e d . Transfusion and A.C.T.H. may b e indicated. Sternal m a r r o w e x a m i n a t i o n will show evidence of c h a n g e before t h e peripheral blood. Osteoarthritis I n osteoarthritis t r e a t m e n t has altered little the principles of rest, exercises a n d heat, b u t r a d i o t h e r a p y has p r o v e d of benefit in some 5 0 % of cases a n d s u r g e r y has a d v a n c e d a great deal. T h e J u d e t acrylic head is c o m p e t i n g w i t h the vitellium cup in t h e t r e a t m e n t of the osteoarthritic hip. T h e i r results in relief of pain a n d usually i m p r o v e m e n t in m o b i l i t y are good, p r o v i d e d the degree of disability a n d the p a t i e n t ' s age justify these m a j o r operations. T h e J u d e t operation entails a little less t r a u m a a n d is indicated for the aged, b u t it is certainly less d u r a b l e t h a n t h e cup. Ankylosing Spondylitis I n ankylosing spondylitis the preservation of p o s t u r e is t h e key t~ t r e a t m e n t - - p o s t u r a l a n d b r e a t h i n g exercises, b e d b o a r d s or plaster bed, a light brace a n d especially radiot h e r a p y are of p r o v e n value. Cortisone a n d A . C . T . t t . p r o d u c e t e m p o r a r i l y d r a m a t i c results, as in m a n y cases of r h e u m a t o i d arthritis, b u t t h e effect 'of r a d i o t h e r a p y is longer lasting. H o r m o n e t h e r a p y s h o u l d be used for correction of posture in w o m e n of the c h i l d - b e a r i n g age when' r a d i o t h e r a p y is e o n t r a - i n d i c a t e d a n d w h e n t h e p a t i e n t has already received the m a x i m a l safe dosage of radiation. Gout G o u t is a partially hereditary a n d g o n a d controlled dyscrasia of uric acid m e t a b o l i s m , fired off b y stress or allergy. Basic t r e a t m e n t is still t h e same, b u t A . C . T . H . m a y be u s e d for rapid control of s y m p t o m s to he followed i m m e d i a t e l y b y colchicine to p r e v e n t a " reb o u n d " attack. Cortisone m a y s o m e t i m e s be of value in severe t o p h a c e o u s gout o n a longer t e r m basis. Butazolidine m a y also have a very powerful t h e r a p e u t i c effect. B e n a m i d in a dose of 0.5 to 2 gm. p e r day has b e e n used in gout. It causes a very m a r k e d increase in the uric acid excretion a n d fall in plasma uric acid, b u t it m a y actually provoke a n attack of gout. Its place in t r e a t m e n t is n o t really yet established. I t seems h o w e v e r t h a t it m a y b e of value if c o n t i n u e d for long periods, a year or m o r e . Colchicine is still the m a i n - s t a y of d r u g t r e a t m e n t in this disease, t h o u g h it affects n e i t h e r the b l o o d level n o r ex* A paper read to the West of England Branch, Society of M.O.H., May, 1958.