A health history of Southampton

PUBLIC

HEALTH

SOCIETY OF MEDICAL OFFICERS OF HEALTH Telephone: EUSton 3 9 2 3

TAVISTOCK HOUSE. TAVISTOCK SQDARE, LONDON, W .C.1

Telegrmns: Epidauros, Westcent

No. 5. Vol. LXIII

FEBRUARY, 1950 CONTENTS EDITORIAL

Thoughts from a F u l l C a r e e r . . . A H e a l t h H i s t o r y of S o u t h a m p t o n . . The E p i d e m i o l o g y of C o r o n a r y Disease The Products of Fission Recent R e s e a r c h in N u t r i t i o n ii

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75 75 76 77 77

SPECIAL ARTICLES 78 S0 81 84 85 87

CORRESPONDENCE Organisafion of Child H e a l t h Services (T. M. C l a y t o n )

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BOOK REVIEWS The E x a m i n a t i o n of W a t e r s a n d W a t e r S u p p l i e s (~. W i n d l e - T a y l o r l Meet Yourself a t the D o c t o r ' s ( " M a s s - O b s e r v a t i o n " )

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EDITORIAL Thoughts from a Full Career Our ubiquitous and esteemed Chairman of Council, Sir Allen Daley, was last year elected to the presidential chair of the Section of Epidemiology and State Medicine of the Royal Society of Medicine. His presidential address, delivered on May 2nd last, has now been published in the September, 1949, P r o c e e d i n g s * of the R.S.M., under the title " I Remember." Few members of the public health service have had such varied urban experience as Sir Allen, although he himself confesses that he has not done public health work in a rural county. He was first for nine years M.O.H. of Bootie, then for five years of Blackburn, then for five of Hull, all leading up to his 20 years at County Hall, London, first as deputy to the late Sir Frederick Menzies, and for the last ten years as County Medical Officer of Health. His colleagues will be glad that Sir Allen, rather than composing a presidential address on some particular subject, has instead turned to the fruits of his long experience and the records he has kept in his various appointments, and as a result produced a fascinating medley of reminiscences which, incidentally, contains a wealth of wisdom on various topics. For instance, he wrote a paper on " Home Helps " in 1920, and records that, in the first instance, he chose those ladies on the basis of smartness and good looks. The experience gained from that showed that women did not want other smart, good-looking women in their houses but preferred them plain if their husbands were likely to be about the house as well. We gathered that although good looks were at first grounds for disqualification, once the scheme had got going they could again be chosen irrespective of their appearance. Under " Health Education," Sir Allen records his discussions with philosophers, the clergy and others, whether the young adult is more influenced in propaganda against VD by lurid pictures of the personal risks he is running or by an appeal to avoid exposure because of possible effects on his future wife and children, and the unanimous view that the latter is the more fruitful approach. He has some interesting recollections of controlling smallpox, including a reference to the first appearance in this country of variola minor. Later he turns to the scrutiny of public health costs which resulted from the 1921 Geddes Axe, when he discovered that in county boroughs the expenditure of health departments varied from 2s. 3d. to 9s. 4d. per head of the population and from 3]d. to 2s. 6d. in the £ of rateable value. At that time, of every £100 spent by the health departments, £26 was on work against infectious diseases, £30 on anti-tuberculosis work (in both cases the most part being on hospital or sanatorium maintenance); £13 on M. & C.W. ; £9 on school health; (1949.) 42, 687.

REPORTS

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V i t a l Statistics (ProvisionalL S e p t e m b e r Q u a r t e r , V . ) 4 9 A n a l y s e s of General a n d M e n t a l H o s p i t a l Statistics C l a i m s to Sickness B e n e f i t Nnffield F o u n d a t i o n Fellowships

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THE SOCIETY OF MEDICAL OFFICERS OF HEALTH

The Services H y g i e n e Group. By H . D. C h a l k e , o m . r . , T.D., -~LR.C.S., D.P.H. Public H e a l t h in the A r m y , 19~9-45. B y W . R. M a r t i n e , O.B.E., T.9., D . V . H . . . Dental A u x i l i a r y Workers. B y J . F. P i l b e a m . F.D.S., R.C.S. (ENG.) .. The Value of S w a b b i n g in E p i d e m i o l o g i e a l P r a c t i c e - I. B y C. Milliken Smith, M.D., D.P.~ . . . . . . . . . . . . . ]I. B y R o b e r t C r u i c k s h a n k , M . D , F.R.C.P., t).P.H . . . . . A Comprehensive I n d n s t r i a l H e a l t h Service M e m o r a n d m n nf E v i d e n c e i ) y flw Society for the D a l e C o m m i t t e e . . . . . .

*Proc. R. Soc. Med.

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Notices A n n u a l G e n e r a l Meeting"-.. East Anglian Branch .... Home Counties Branch . . . . Metropolitan Branch .... Northern Blanch . . . . North-Western Branch .... Scottish B r a n c h . . . Welsh Branch \V~st of E n g l a n d B r a p c h . D e n t a l Officers' G r o u p M & C . W . G r o o 9 .. North-Western MC.W. &SH2g Tuberculosis G r o u p . .

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£5 on V.D. ; £2 on food and milk control; and £15 on general sanitary work and administration. He records his conclusions on the distribution of the total monies at that time and suggests that, as financial stringency is again beginning to appear, the time may have arrived for another similar review. His passages on administrative work and research reflect his intensely exacting period in the planning of the L.C.C. hospital service, which he said gave him as a medical administrator the greatest satisfaction of knowing that he could still serve the sick, although he had a deep-rooted adherence to the importance of preventive medicine. Under " Medical Education," he reminds us of the foundation of the British Postgraduate Medical School at Hammersmith, and under " Local Government " he again records his disagreement with those who suggest that medical officers of health should become State officers. " Their work," he says, " in the environmental health services and the school health services is too inextricably mixed with duties which must remain in the field of local government for any separation to be possible without lessening materially the efficiency of the service." Speaking of unified administration, he wisely points out that " when administrations are separate and independent, everyone is sensitive about his dignity and develops a loyalty to his own administration, coupled, it would appear, particularly in the lower ranks, with a distaste for, and suspicion of, other administrative bodies and their officers." H ow true this thought is when one considers the difficulties experienced during the last 18 months in establishing contacts even at officer level between the various forms of administration under the National Health Service. In his final reference to his experience of the war years, he again pays tribute to local government when he says " I have been more and more impressed by the zeal and devotion to the cause of their fellow citizens which animates those who serve the public, quite voluntarily, as members of local authorities. T h e y receive little thanks and much abuse. T h e public health services of this country could never have shown such astounding success as is evident in recent vitat statistics if they had not listened to the advice of their medical officers. of health and found the necessary cash to implement that advice." Nor, we may add, if they had not attracted to the Local Government Medical Service men of the calibre of Sir Allen Daley.

A Health History of Southampton Dr. H. C. Maurice Williams, O.B.E., this year's President of the Society, includes in his Annual Report for 1948 the first part* o f a historical survey of public health in Southampton, * Available~' ,000." / ~ ,

Public Health in Southampton, IS50"(~\

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PUBLIC HEALTH, February, 1950

covering the years 1850-1900. He proposes to deal with the second 50 years in his next report. T h e advertisement for the appointment of Southampton's first health officer, in 1850, specified his duties as follows : " T h e gentleman appointed is expected to report periodically on the sanitary conditions of the town generally, to ascertain whether any contagious epidemic affecting the public health exists, and to take charge of the common lodging-houses." Dr. Francis Cooper was appointed at a salary of £75 per annum, with permission to continue in private practice. When he died of Asiatic cholera in 1865, the advertisement for his successor appears not to have stipulated medical qualifications in the candidates, for they included a plumber, one applicant of independent means, one " strongly supported by his father, Mr. Spooner," and three doctors. However, the choice fell on Dr. McCormack, at a salary of £150, w i t h o u t permission to engage in private practice. He moved on, in 1871, to become M.O.H., Lambeth, no doubt stimulated by the glaring contrast of his salary with that of the then Town Clerk, who received £400 as Clerk to the Council and £400 as Clerk to the Local Board of Health. Dr. Henry Osborn, ~.a.c.P., the next in the line, was appointed in 1874 at a salary of £250 per annum, of which the exchequer repaid half on condition that he did not engage in private practice, and there was a separate part-time port sanitary officer (Dr. Harry Bancroft), on whose death, in 1884, the two posts were merged. Dr. Wellesley Harris succeeded Dr. Osborn in 1890, and was still in office in 1900. From the epidemiological aspect the big event of the period covered, apart from steady environmental improvements, was the cholera outbreak of 1866, well described by Dr. Williams, which caused 100 deaths. Such historical surveys compiled from the records of the time have a more than local interest. We hope that other medical officers of health may find time to extract the local history of the public health service which, in so many towns, now extends over at least 75 years.

the sexes. Social Classes 1 and 2 are very much in excess of the average, Class 1 males being 137% in excess and Class 2 males 46%. Wives join in this excess in the two upper groups but with a much lower incidence. Within the same social groups the sex ratios of men and wives showed an excess for the men at the age group 45 to 55 amounting to ten times for Class 1, five times in Class 3 and three in Class 5 ; in contrast no such gradient was found for myocardial disease. Whatever the cause may be, it operates especially in the first two social classes, affecting men more than wives, and most potently in the 45 to 55 age group when men exceed wives by ten times. As to geographical incidence, the report can say little because of our ignorance of the differences in social structure in different areas, but for what it is worth there is an excess of 21% above the average in Greater London, 11% excess in the residual south-eastern counties and 3% m North I ; with North IV, Midlands I and II, and South Wales with 15% below the average, and North Wales with defect of 3%. Ryle's own cases totalled 243 (164 males and 79 females). I n age of onset there was a greater male preponderance in early and middle life. Where it was possible to indicate the occupation clearly, the main professions for 100 men included 39 men engaged in business, 19 physicians and surgeons, six clergy, six officers of the armed forces, six justices, judges or solicitors, and four engineers. Among 47 women, eleven were single, of whom five were gainfully occupied, a n d there were 36 housewives, four being also gainfully occupied. Ryle's entries about associated illnesses yielded a suggestion of the association of cholecystitis and gallstones; 9% of the males gave such a history. Other conditions, e.g., migraine, duodenal ulceration, obesity and diabetes, were not recorded sufficiently often to suggest anything more than a chance relationship. About half had a raised blood-pressure, either systolic and diastolic or systolic alone, but a history of associated vascular lesions occurred in only 4% males and 7% females, and the reader is left with the impression that Ryle has considered the possibility that coronary disease may be due in part to some local selective effect.

The Epidemiology of C o r o n a r y Disease

What is the precise aetiology ? Obviously, Ryle does not pretend to give the answer in full. He makes it plain, however, that he regards both his own experience and the evidence provided by Russell's figures as pointing clearly to nervous strain as an important influence. I n social Clas#~ 1, and particularly at age 45 to 55, the workers included " have usually reached the peak of their professional careers and are exposed to the maximal strain associated with their particular responsibilities." Physicians and surgeons head the standardised mortality list (368), proprietors of wholesale businesses come a bad second (235), judges, barristers and solicitors third (227), and clergymen of the Anglican Church fourth (218). These four occupations with the greatest liability to death from coronary disease are those " requiring not only a high degree of mental activity, but also involve considerable anxiety and stress in their performance." T h e weight of evidence is such that there is no longer any reasonable doubt that the changes in the coronary vessels take place as a result of physiological and intrinsic biochemical processes which a r e s e t in operation predominantly by nervous action. Heredity predisposition also plays its part, but the " multiple factor," in which age, sex, occupation, genetics and mental stress are all contributory, is, at present, the most rational. More than this, and this in itself is a lot, cannot at present be stipulated. Smoking and alcohol could not be certainly incriminated. There is the possibility to which Cassidy called attention in his Harveian Oration (1946) that the remarkable sex incidence is due to chemical processes having their origin in maleness, but this is offset by the indications contained in Russell's analyses and Ryle's cases that women do themselves suffer when the processes of mental stress are sufficiently in evidence. T h e possibility that cholesterol metabolism may be involved at some point in the chain cannot be wholly excluded. Infection and nutrition are ruled out by the authors, perhaps a little summarily. Readers will remember that Geiringer's study of blood vessel walls in relation to age, published in the B r i t i s h J o u r n a l o f S o c i a l M e d i c i n e (1948),

Prof. John Ryle, of the Oxford Institute of Social Medicine, has given a valuable impetus to the study of the degenerative diseases by his analysis of the epidemiology of coronary disease. Readers will recall that his book, " Changing Disciplines," contained a reference to this subject in illustration of his main thesis that the scope of social medicine should extend to cover the whole range of man's afflictions. A further study, undertaken in collaboration with W. T. Russell, the statistician of the Institute, bas now appeared in the B r i t i s h H e a r t J o u r n a l . * This combines a statistical study of the incidence of coronary disease for England and Wales (as shown in the RegistrarGeneral's mortality figures between 1926 and 1945), with an analysis of Ryle's own clinical experience during a similar period of 23 years in consulting practice. T h e official figures reveal an increase in standardised mortality amounting to 12 or 13 times. In a critical analysis of this occurrence, the study first suggests that even when allowance is made for an ageing population, a definite and steeply rising incidence is still present. This is followed by evidence that this rise cannot be wholly due to " a transference of deaths from other forms of circulatory disease " ; in particular, the possibility of transference having taken place from a myocardial group is examined. A third important analysis reveals that the increase has been fairly uniform throughout life and that a transference of deaths from " old age " does not offer an adequate explanation of the increased mortality from coronary disease. Thus, we arrive at a measure of certainty that coronary disease has been rapidly increasing, and the question is--why ? When we examine this question of why, the first important point to note is that the incidence in men is much higher than in women (at age 40 to 50 five times greater) and in a way which is demonstrably absent in myocardial disease. T h e second point is that there is a correlation with social class which must be read in conjunction with the difference between * Oct~ 1949, 11, 4370