Cancer statistics—Cancer and diet

1926.

PUBLIC

newly qualified dentist was not quite the person to t r e a t school children. W i t h r e g a r d to the anmsthetist, t h o u g h a man m i g h t be skilled in one b r a n c h of the medical profession he m i g h t not be sufficiently g o o d to give an anaesthetic for the p u r p o s e s of school dentistry. The m a t t e r had been b r o u g h t f o r w a r d at YVillesden, and it had been r e c o g n i s e d t h a t the dentist m u s t have t h o r o u g h confidence in his anaesthetist, and t h a t the anaesthetist should be able to procure for the dentist the e x a c t period of anaesthesia required within the limit of the anaesthetic. An i n t e r e s t i n g point raised by Mr. Breese was in r e g a r d to the large p r o p o r t i o n of sound teeth found in the children of p o o r law i n s t i t u t i o n s - - a m a t t e r that had been reiterated by other speakers. Mr. "~Vallis s u p p l e m e n t e d his r e m a r k s on the subject of dental inspections carried out at the school and at the t r e a t m e n t centre. A dentist m a k i n g an inspection at a school was w o r k i n g at a d i s a d v a n t a g e , and consequently school dental inspectors were advised not to c o m m i t themselves at such an inspection as to w h a t needed to be done. It also had to be borne in mind t h a t it s o m e t i m e s h a p p e n e d that the dentist m a k i n g the school inspection w a s not the dentist who would t r e a t the child, and some considerable time m i g h t elapse between the dental inspection at the school and at the centre. W i t h r e g a r d to the point raised by Dr. N a s h concerning children classed as " b l e e d e r s , " he was ready to a d m i t that there w a s a g r e a t a m o u n t of looseness in the description t h o u g h it had to be r e m e m b e r e d that m a n y complaints in t h a t connection were received, and the blame was i n v a r i a b l y placed on the dentist. Dr. N a s h had also d r a w n attention to the methods of p a y m e n t of the dentist. In London they were paid at the rate of ~600 per a n n u m for 44 school weeks in the y e a r ; if half-time were w o r k e d the pay w a s g 3 0 0 per annum. In the p a s t there had been trouble with dentists in the g i v i n g of p r o p e r sessional time, but there was now at each centre an a t t e n d a n c e b o o k which the dentists themselves were required to sign. As to e l e m e n t a r y school chiIdren b e i n g t r e a t e d in the s u r g e r i e s of private dentists, he did not believe in the method. T h e r e were several d r a w b a c k s , including the possibility t h a t some of the children m i g h t be suffering from i m p e t i g o and other conditions. In r e g a r d to the use of anaesthetics, there was a g r e a t deal of nonsense in the g i v i n g of anmsthetics in every case. A l a r g e n u m b e r could be dealt with quite s a t i s f a c t o r i l y with an ethyl chloride spray. On the whoIe it had been found that the use of injection anaesthetics was not g o o d at centres, the

HEALTH.

167

ethvi chloride s p r a y b e i n g p r e f e r a b l e in cases in which a g e n e r a l anaesthetic could be avoided. W i t h respect to ethyl chloride, there were a certain number of people who were afraid of it, but if they were p r o p e r l y instructed as to its use there was not the s l i g h t e s t difficulty and it had a g r e a t a d v a n t a g e in the case of children. As to minor regulations, the m e t h o d of " j u d i c i o u s e x t r a c t i o n " w a s p r o b a b l y well known, but it w a s absolutely necessary in such cases that the m a t t e r should be fully explained to the p a r e n t s , as the extraction of perfectly healthy teeth m i g h t be involved. In London it was quite easy to send children to one of the b i g dental hospitals for m i n o r regulations to be carried out, the p a t i e n t b e i n g sent with a personal note to the house s u r g e o n of the hospital. \ V i t h r e g a r d to p e r s u a s i o n of difficult mothers, Mr. Vv~allis had found it a g o o d plan to show the mother the condition of the child with its mouth shut. The child m i g h t have, for example, a skin eruption and e n l a r g e d g l a n d s . A f t e r w a r d s she would be asked to look into the c h i l d ' s mouth and see the cause of the trouble, and it was usually found that the m o t h e r would a g r e e to dental t r e a t m e n t being carried out. CANCER STATISTICS--CANCER AND DIET. ~ By M. HIXDHEDE,M . D . , Copenhagen. W h a t has especially led me to study the Etiology of cancer has been the u n c a n n y fact that of all countries D e n m a r k t a k e s the lead as r e g a r d s the death rate from cancer, and t h a t moreover, the disease is i n c r e a s i n g apace. In 1900 the death rate from cancer was 120 per 100,000 i n h a b i t a n t s in Danish towns, but in 1915 and 1916 is was 151. In Swedish towns in the same period it fluctuated between 100 and 108. In 1908-1912 it was, a c c o r d i n g to Hoffman, 112 in London, 111 in Paris, 77 in New York, 12 in C a l c u t t a . In the whole of D e n m a r k about 17% of'all the persons that have c o m p l e t e d their 45th y e a r have every p r o s p e c t of d y i n g of c a n c e r ; a dismal thought, c o n s i d e r i n g t h a t it is the d i s e a s e most dreaded by all of us. It is b e y o n d d o u b t that the fact of our being d i s t i n g u i s h e d in such a sad m a n n e r must have a cause. But w h a t ? W h e n , t h r o u g h my i n v e s t i g a t i o n s into p e o p l e ' s mode of living in various countries, I have come to the result that D e n m a r k p r o b a b l y is the country in the world where the daily fare is " b e s t , " and where consequently the g r e a t e s t number of fat Paper read before the Medical Association of Copenhagen.

168

PUBLIC H E A L T H .

people are to be met w i t h ; when it is further known that stout people are particularly liable to die of cancer, it is but reasonable to suppose that here may be a causation. P r e p a r a t o r y to my investigations I have gone over the l i t e r a t u r e t to learn what is k n o w n about the death rate fror~ cancer t h r o u g h o u t the world. As is well known, this question is much disputed, and the conclusions arrived at differ widely. I c a n n o t enter on discussions here, but shall c o n t e n t myself with g i v i n g a short s u m m a r y of the results at which I have arrived. It appears that natives of the torrid zones who live on a mild unspiced v e g e t a r i a n diet have practically no cases of cancer of the internal organs. Cancer of the stomach and the intestinal tube especially, which occur so very frequently in civilized countries, are almost unk n o w n a m o n g those people. The same applies to ulcers of the stomach and intestines, catarrh of the small and large intestines, ailments which often lie at the root of cancer. But when uncivilized peoples become "civilized" and adopt the E u r o p e a n mode of living their cancer death rate also becomes " n o r m a l . " In all civilized countries d u r i n g the last 50 years this disease has been very greatly increasing. Attempts, which to me appear entirely unsuccessful, have indeed been made to explain away these u n c a n n y facts. As regards the uncivilized peoples it has been proposed that the apparently slight diffusion of the disease was not due to its non-existence, but to its not c o m i n g to the knowledge of the physicians. E n g l i s h and German cancer-students have made every effort to find cases of cancer a m o n g uncivilized peoples. They have succeeded in finding a few, but the figures are so very small that they not only do not refute, but, on the contrary, e m i n e n t l y support the assertions r e g a r d i n g the slight diffusion of cancer with the peoples in question. To this rule the Japanese are an e x c e p t i o n ; with them cancer of the stomach is of rather c o m m o n occurrence. But the explanation is not far to seek : the Japanese use large quantities of very p u n g e n t spices and, to a great extent, half-decayed plant products. The increase of the disease in civilized countries has also been questioned, comfort havin K been taken in the t h o u g h t that the probable cause of the a p p a r e n t increase was the g r o w i n g ability of medical men to diagnose the disease. See Journal of Cancer Research, Bulletin de L'Association fruncaise pour l'etude du Cancer, Zeitschrift fur Krebsforsehung, Scientific Reports of the Imperial Cancer Research Fund, the books of Roger Williams, Rollo Russell, Hoffinan, Jakob Wolff, etc., etc.

MARCH,

But this supposition far from explains the whole increase, and is besides contradicted by the fact that the increase is as high for the external easily recognizable varieties as for the internal ones. \.Ve now pass on to our revision of the D a n i s h cancer statistics. The results are represented in the charts I - V , which show deaths from cancer per every 100,000 individuals past the age of 85. The figures are standardized according to standard population 1901. Each figure represents the average for 5 years. Fig. 1. shows all deaths from cancer. F o r men the crude as well as the standardised figures are

+ I .....

g~e~j

~e.,.,,.,.~¢. O'6a.~
4~'r

I

I

.oi

!

i

e°F

,

' . T TJZ

)'{a~

j~Zea

"...

\

I

II

,oi ue

//

i ~

9.;,'

~;rO~

Od

il

~6

gt

stated. F o r women only the l a t t e r . . It shows the heavy increase succeeded by decrease d u r i n g the last 5-10 years. Fig. II. shows in the lower section deaths from cancer of the stomach. It will be noted that the death rate of men here exceeds that of women by far. In the upper section are shown deaths from all other varieties of cancer. F o r women, c a n c e r of the uterus and cancer of the breast are, however, not included. Fig. II[. shows deaths from cancer of men in C o p e n h a g e n and provincial towns. Noticeable-is the considerably higher death rate in the capital. Fig. IV. shows deaths from cancer ventrieuli and all other varieties of cancer (cancer uteri and cancer m a m m m excluded} in provincial towns.

PUBLIC HEALTH.

1926.

169

X

~,e~

3b'- ~00

i~e, ,.5~'-IO0. I

/ gw /po

<...

/

qB~

\

\,/,

z<. / % 89

~y IgSo

90

9~"

19,;}"

06

tO

gt

IO0, D O 0 .

~.~_~.

I~8o

90

9J,"

/;,c,~

o#

If

fO

li

decrease, which it would have been reasonable to expect from the fact t h a t s u r g e o n s d u r i n g the last 20 years very p r o b a b l y have saved m a n y of these p a t i e n t s from death by radical operations. Fi K. V. shows deaths from cancer of the breast. Noticeable is the heavy increase despite the inc r e a s i n g n u m b e r of radical operations. This

£

~.e~

rio4,,, e , . ~ . ~

.~o~...

wo.ooo.

~.,9.e 3 5 - 400.

~,~.

..~.

~f,~.:~ ~ . ~ . . F

F /'2,:.o

T h e lower curves show d e a t h s from cancer of the uterus in the capital and the provincial towns. Here is no increase, but neither is there any

90

~,,~"

/;'~t

~".~

H

if'

~l

increase of an e x t e r n a l v a r i e t y of cancer which the physicians 40 y e a r s a g o could have had no difficulty in d i a g n o s i n g , shows with g r e a t certainty t h a t the increase m u s t be a real fact. Now, w h a t m a y be deduced from these figures ? Do they tend to prove t h a t the rich daily diet (over-feeding) by which D e n m a r k is distinguished, not only as r e g a r d s the upper classes but, as comp a r e d with other countries, even more a m o n g the

w o r k i n g classes, can be in any w a y connected with the cancer death r a t e ? It seems to me that they point s t r o n g l y that way. If cancer of the p a r t i c u l a r female o r g a n s be excepted, w o m e n have a far lower death rate than men. A n d there can be no doubt that men fare richer than women, and t h a t men in C o p e n h a g e n indulge in richer fare than men in the provincial towns. YVe k n o w that d u r i n g the last 50 y e a r s the p o p u l a t i o n has inc r e a s i n g l y turned from v e g e t a b l e diet to animal foodstuffs. The causes m a y be p a r t l y the higher w a g e s , p a r t l y the medical p r o f e s s i o n ' s v i g o r o u s a g i t a t i o n for a " s t r o n g e r " fare, one richer in protein. Only in the last 10-15 ),ears the tide has b e g u n to turn o w i n g to the intense a g i t a t i o n , more intense here, p r o b a b l y , than in any other country, a g a i n s t the p r e v a l e n t over-feeding and for a return to the old, plainer diet. D u r i n g the time of the r a t i o n i n g 1917-'1919, it was left to the c h a m p i o n s of the new doctrine to calculate the d i e t a r y of the D a n i s h population, with the result t h a t the stock of p i g s was reduced to one-fifth, while the normal nutrients of the pig, barley and p o t a t o e s , were reserved for man. ~ T h a t medical men here raised no objection to this c h a n g e of fare floes to show the recently c h a n g e d views on the m a t t e r . The highly improved s a n i t a r y conditions also, in those classes of the population where the restriction on alcohol could be of no consequence,j- made a s t r o n g impression, and are p r e s u m a b l y the reason why a g r e a t m a n y people have g o n e on u s i n g more v e g e t a b l e s than formerly. T h e c o n s u m p t i o n of p o t a t o e s , particularly, has u n d o u b t e d l y much increased. The decrease of deaths from cancer, especially d u r i n g the last 5 years, accords very well with the theory of o v e r - f e e d i n g as its cause. T h a t the restriction on alcohol c a n n o t be its sole cause is also proved by the m a r k e d increase d u r i n g the last 30 y e a r s before the war, despite the steadily d e c r e a s i n g c o n s u m p t i o n of alcohol. Fig. VI. shows the death rate from cancer per 100,000 individuals (for all ages) in all Swedish and Danish towns. H e r e the figures are not standardized. It is shown t h a t the death rate is by far the higher in D a n i s h towns, although the statistics in the two related, n e i g h b o u r i n g countries m u s t be p r e s u m e d to be equally exact. In the towns all the death certificates are m a d e out by qualified doctors. \ V h a t dan be the cause of * M. ing War

Hindhede.

"The

on Mortality

E f f e c t of F o o d in C o p e n h a g e n . "

the Am. Med. As.~., F e b . 7th, 1920.

Restriction The

Dur-

]ournal of

V o l . 74, pp. 881 a n d

382. "1" M.

MARCH,.

PUBLIC HEALTH.

170

Hindhede,

"AlcoboI

Restriction

Brit. Med. Journal, A u g u s t 12th, 1922.

and

Mortality."

this difference? T h e explanation will p r o b a b l y be found in the two following charts. Fi K. V I I . gives an account of the g e n e r a l death rate in Stockholm and C o p e n h a g e n . It will be seen that before the w a r the death rates from all diseases were about equal, but the Swedish death rate from tuberculosis was a b o u t twice as high

~e~.~,

~'

.r~.. to.o0o.

(aCe.

""

.'

~\

~-,'.~

'5.,~1\ t I

r \

I..

\

/

:....

,,,

I \

/N" I \

, \ W~

', A,~gZ

I\

,

't

",,/,.,..,jl\ "

'~

,

I"--.1

-

',l\l

I \'

';.,

t\

24:

\ [

t /% ~

IN

\

\

__LJ t'17o$ ¢:9

,'o

t!

ffd,

¢3

,,to

/i¢

/6

f~'

,'it

,-~'

t~

:Jr"

as the Danish. If the figures for tuberculosis (and from 1916 also those for influenza) be deducted, the death rate from all other diseases up to 1918 was far lower in Stockholm. H o w is this c o n t r a s t to be explained ? As r e g a r d s the tuberculosis, one would n a t u r a l l y seek the cause in a lower s t a n d a r d

1926.

PUBLIC

of l i v i n g , p o o r e r h a b i t a t i o n s , e x t r e m e l y s p a r e diet --factors which impirically cause higher death rate from tuberculosis, but often a lower death rate from other diseases. This surmise becomes a l m o s t c e r t a i n t y w h e n it is c o n s i d e r e d t h a t d u r i n g t h e r a t i o n i n g , w h e n we w e r e p u t o n p o o r m a n ' s f a r e , o u r d e a t h r a t e d e c r e a s e d t o t h e level of t h a t of S w e d e n . B u t , of c o u r s e , t o t h i s r e s u l t t h e restriction on alcohol has been eminently conducive.

Finally, I have drawn a parallel with England. D i r e c t l y f r o m t h e official s t a t i s t i c s ~ I h a v e t a k e n t h e f o I l o w i n g f i g u r e s f o r s t a n d a r d d e a t h r a t e in 18 t y p i c a l p r o f e s s i o n s , a r r a n g e d in s e q u e n c e a c c o r d i n g to t h e r a t e of c a n c e r m o r t a l i t y . A t t h e s a m e t i m e is s t a t e d t h e a g g r e g a t e d e a t h r a t e , a n d the death rates from alcoholism, phthisis and apoplexy. TABLE I. ENGLAND, 1910-12.

Fig. VIII. Here the figures for the death rate f r o m all d i s e a s e s e x c e p t i n f l u e n z a a n d t u b e r c u losis a r e r e p e a t e d . B e l o w is s t a t e d t h e s i m u l t a n e o u s c o n s u m p t i o n of s t r o n g s p i r i t s in l i t e r p e r inhabitant.

I t is c u r i o u s

to

watch

the

I.

x. xooz.)

...

528

Physicians ... Cotton manufacturers Shopkeepers ... Shoemakers ... Iron goods makers ... Carpenters ... Clerks . . . . . . Av_era_ge . . . go

Inn-keepers ... Dock Labourers ... Inn-servants ... Butchers ... Chimneysweeps ... Brewers ... Beer-bottlers ..

t0 8 6¸

Average t~)

lq

Ill

16

1~

15

:y

d i f f e r e n t effects of t h e r e s t r i c t i o n o n s p i r i t s in Sweden and Denmark. In the latter country the d e a t h r a t e d e c r e a s e d s t r o n g l y , w h i l e in S w e d e n a t the same time a slight increase was observable. Is it r e a s o n a b l e to s u p p o s e t h a t t h e t w o n e i g h b o u r i n g p e o p l e s c a n r e a c t so d i f f e r e n t l y o n t h e s a m e poisons? Hardly! T h e e x p l a n a t i o n is p r o b a b l y t h i s , t h a t t h e S w e d i s h f o o d - r a t i o n i n g failed. T h e Swedes were actnally underfed; therefore the death rate rose. If r e a l u n d e r f e e d i n g h a d n o t frustrated the plan the Swedish death rate would probably also have been conslderablv lower during t h e t i m e of t h e r a t i o n i n g .

1

45

30

45

1 4 3 2

71 70 57 76

16 27 23 51

54 57 58 6l

2.2

64

29

:

55

]

70

5

65

37

811 708 820

3 5 3

120 117 222

48 33 39

71 72 79

837 694 742

3 2 4

131 128 154

43 30

80 82

35

I

s3

763

3.6

t40

40

I

78

...

High Cancer Mortality.

1,265

39

198

68

85

1,I27 1,173 885

14 21 l0

232 294 127

39 47 45

98 99 105

1,015 1,023 968

10 10 12

202 181 201

41 50 47

107 125 128

1,065

17

207

48

107

4

142

36

78

i

i

All men ... I 993 i 51 Copenhagen !1877-19!22 1877-81 "i)" ... 1,242 1887-91 "'" ... i 1,162 1sgs-1902

1908-12 .1918-22 .....

Cancer.

693

All men ... 790 J Copenhagen 1908-121

g,-_.

ADO -

plexy.

~edium Cancer MortahO,.

IIL

tg

MEN,

Low Cancer Mortality.

Priests . . . . . 443 Agricultural Labourers ... 1 470 Teachers ... 506 Farmers ,,. 495 Coal Miners 727

II.

to

MORTALITY,

All Alco- Phthicauses, holism sis.

very

verage

ottqof o9

STANDARD

AcE 25 - 65.

~.~e¢~ ,~,~. iaooo.

(a4e..

171

HEALTH.

~025

"" I '993 2- . . .653 .

[

60 ;6

I

52

i 51 ~= 4

181 39 139 All m e n , age ;5-65 ] 362 I 320 1 212 ! lsl lO7

41 33 41

94) ] 12 119

39 ! 241

139 11 !.....

* All causes except influenza. T h e f i g u r e s tell t h e i r o w n tale. A c o m p a r i s o n of g r o u p I w i t h g r o u p I I I l e a v e s a s t r o n g i m p r e s r

* Mortality of men in certain occupations. Supplement to the 75th Annual Report of the Registrar General for England and \Vales,

172 sion

PUBLIC of

the

professions

high the

cancer

members

death of

rate

which

HEALTH.

MARCH,

among

indulge

in

TABLE I I.

ENGLAXD 1910-]2.

S'rANnARD-MORTALITY, MeN, AcE 25-65.

a b u n d a n t food and alcoholic drink. A t t h e f o o t of t h e c h a r t I h a v e s t a t e d t h e c o r r e -

•2 3 1 Cirrho- Other i Brg'ts 1 4- 2 -q- 3 Cancer. sis of diseases disease liver. of digestive system

s p o n d i n g f i g u r e s f o r C o p e n h a g e n , c a l c u l a t e d anti s t a n d a r d i z e d ill t h e s a m e w a y figures.

as

the

English

O f c o u r s e , it is m i s l e a d i n g to c o m p a r e

t h e f i g u r e s for o n e D a n i s h c i t y w i t h t h o s e of a whole country, the death rate always being lower o u t in t h e c o u n t r y ;

bht as 80%

of t h e E n g l i s h

p o p u l a t i o n live in t h e t o w n s , t h e d e v i a t i o n is n o t very wide.

If 2 0 % of t h e p o p u l a t i o n h a v e a c a n c e r

d e a t h r a t e of o n l y 5 4 + 5 8 = 5 6 , t h e d e a t h r a t e for 2 t h e r e m a i n i n g 8 0 % will b e 85, w h i c h m e a n s t h a t

3

42

27

72

45

4 8 11 7

25 30 29 28

15 27 22 20

42 65 62 55

54 57 58 61

30

22

59

55

22

60

44

126

70

11 18 10

33 33 33

41 43 34

85 94 77

71 72 79

10 1,5

32 32 37

29 32 36

7I 73 88

80 82 83

14

37

37

88

78

Inn-keepers ... 117 Dock Labourers ... 16 Inn-servants ... 30 Butchers ... _ 34 Chimneysweeps .,. 31 Brewers ... 39 Beer-bottlers 46

57

79

253

85

39 38 38

40 52 47

95 120 119

98 99 105

26 40 42

49 35 32

106 114 120

I

107 125 128

]

107

Priests ..... Agri cultural Labourers ... Teachers ... Farmers Coal Miners'[[

Average

...

7

]

t h e d e a t h r a t e in C o p e n h a g e n is 6 5 % h i g h e r t h a n in

English towns.

seeing the huge

How

explain this?

difference as r e g a r d s

Well,

t h e alco-

h o l i s m d e a t h r a t e o n e m i g h t b e led t o t h i n k t h a t t h e e x p l a n a t i o n lay h e r e . B u t t h i s will h a r d l y bear investigation. The English figures here must be false. In 1906-1910 t h e a g g r e g a t e c o n s u m p t i o n of p u r e a l c o h o l in g i n , b e e r , a n d w i n e p e r indivi-

Physicians ... Cotton l manufacturers] Shopkeepers ... Shoemakers ... Iron goods makers ... Carpenters ... Clerks . . . . . Average

...

d u a l a n d y e a r w a s 6'82 L f o r D e n m a r k , b u t 9"67 L for g r e a t B r i t a i n .

T h e e x p l a n a t i o n is p r o b a b l y

that E n g l i s h physicians are less inclined than the D a n i s h to put this certificate.

diagnosis

into

the

death-

Below I have stated the corresponding figures for death rates from causes

which

probably

il

w o u l d be j u s t i f i a b l e t o t e r m n u t r i t i o n d e a t h - c a u s e s , most physicians being

presumably

willing

to

...

45

40

48

113

All men ... Copenhagen

13 1911

34

33

80

20

33

52

105

Average

a d m i t t h a t t h e y a r e likely to be c l o s e l y c o n n e c t e d with w r o n g nutrition (food and drink).

If w e look

78

a t t h e a v e r a g e f i g u r e s in t h e c h a r t s f o r t h e t h r e e g r o u p s w e find a c o n s p i c u o u s a g r e e m e n t b e t w e e n t h e f i g u r e s for 1 + 2 + 3 ~ a n d t h o s e

for

cancer.

T h i s w o u l d i n d i c a t e t h a t if 1 + 2 + 3 c a n be t e r m e d nutrition d e a t h - c a u s e s , cancer m u s t be put under the same head.

All men

...

133

c o n t e n t m y s e l f w i t h q u o t i n g a f e w of his c l o s i n g remarks :--iBut

of all p r o f e s s i o n s , t h e s e p o o r ,

underfed

l a b o u r e r s h a v e b y f a r t h e l o w e s t f i g u r e s for t h e

T o m e t h e f i g u r e s for t h e E n g l i s h f a r m l a b o u r e r s have been of special interest.

Rowntree has made

a c l o s e s t u d y of t h e i r m o d e of l i v i n g . here

a

pronounced

under-nourishment.

H e finds I

shall

* Of course, there are exceptions. Most strildng is the enormously high death rate from the three nutrition deathcauses among innkeepers, whereas the death rate from cancer is not correspondingly high. May not the explanation to some extent be sought in erroneous diagnosis, I wonder. The death rate from all known causes of death is so high among innkeepers that the death rate from cancer to some extent may be obscured. When a physician finds a tumour in the abdomen of a highly alcoholised innkeeper, he may not unnaturally feel a certain inclination to write "cirrhosis hepatis" (observe the very high figures for this cause), whereas it may be cancer heatis or ventriculi,

"[" B. Seebohm Rowntree, "How the Imbourer Lives." London: 1913, Nelson and Sons.

"Meat of some description figures in all but one of the dietaries, but as already explained, it often represents a flavourlng rather than a substantial course. ' For the man only ' is a remark found in many of the menus." " O f milk, a~aln, the under-consumption, especially in the households with many small children, is very serious . . . " After showing that the deficiency was ,lot great as regards the whole food-energy value, but that it was the protein-especially the animal protein--which was mostly wanting, Rowntree continues : "But as an adequate supply of protein is an essential of physical efficiency, it is not incorrect to say that on the average the forty-two families investigated are receiving not much more than three-fourths of the nourish~nent necessary for the maintenance of physical health,"

PUBLIC HEALTH.

1926.

a g g r e g a t e d e a t h rate from the three nutrition diseases. Medical m e n ' s death rate from the s a m e diseases is e x a c t l y three times higher. It would hardly be possible better to illustrate the falsity of the old nutrition theories. A c c o r d i n g to these facts it looks as if the high p r o t e i n - s t a n d a r d is not only u n n e c e s s a r y but directly harmful, not only in g e n e r a l but also as r e g a r d s the development of cancer. On the basis of all facts here stated, I b e g to conclude t h a t there is a p r o b a b i l i t y of the main causes of cancer b e i n g : - 1. Irritation of the digestive tube. (Decayed, s t r o n g l y salted and spiced nutrients, alcoholic drinks, tobacco, etc.) 2. Over-nourishment, most frequently caused bv a too varied, too savoury food. 3. A food too rich in animal protein. To escape cancer, we m u s t return to the more frugal h a b i t s of our ancestors. THE VALUE OF THE ISOLATION HOSPITAL IN THE PREVENTION OF INFECTIOUS DISEASE. BY

T. \V. N. BARLOW, O . B . E . , M . R . C . S . , D . P . H . , F . R . S . (Ed.), B a r r i s t e r - a t - L a w , Medical Officer of Health, W a l l a s e y .

Dr. Barlow's paper, which was the opening contribution to the discussion on this subject by the North-f,17estern Branch, on January 8th, 1926, considers at length the question as to whether or not full use is made of the existing accommodation in Infectious Diseases Hospitals, and offers a suggestion. Since Infectious H o s p i t a l s were first founded un(ler the provisions of the Public H e a l t h Act, 1875, our k n o w l e d g e of the diseases c o m m o n l y dealt with in these has w i d e n e d ; of the diseases themselves, some have c h a n g e d in type, e . g . , Scarlet F e v e r ; others, as in the case of T y p h o i d , have p r a c t i c a l l y d i s a p p e a r e d ; our m a n n e r of dealing with them has in some d e g r e e c h a n g e d . Other infectious diseases have a s s u m e d p r o m i n e n c e ; g e n e r a l conditions have c h a n g e d , and y e t we still m a n a g e our Infectious H o s p i t a l s in a c c o r d a n c e with the same ideas as those which prevailed when they were founded, and use them for the s a m e purposes. I, therefore, i m a g i n e you would wish me to link up the titular discussion with one e m b r a c i n g the question as to w h e t h e r full use is made, at the moment, of the h u n d r e d s of Infectious H o s p i t a l s dotted all over the coun-

173

try, and, if not, can any fuller use be made of them, and in w h a t d i r e c t i o n s ? I propose first to discuss the question in its n a r r o w sense s e p a r a t e l y in relation to each disease commonly dealt with in these Institutions. SCARLET FEVER.

Let me state some facts in relation to this disease, upon which p r o b a b l y all will be in a g r e e ment, and all of which have a b e a r i n g on the subject under discussion. (1) Type of D i s e a s e . - - I n the three years, 1863, ] 864 and 1869, no fewer than 9 0 , 0 0 0 d e a t h s o c c u r r e d from Scarlet F e v e r ; in the y e a r s 1923 and 1924 there were 993 and 888 deaths, respectively, so it is evident that within the last 60 y e a r s the type of disease has very distinctly c h a n g e d . Moreover, it is a t t e n d e d with fewer c o m p l i c a t i o n s , probably the result of the milder t y p e which the disease has assumed. All of us k n o w that m a n y of the cases removed to H o s p i t a l n o w - a - d a y s are never ill at all, and do not w a r r a n t the e x p e n s e incurred by isolating them in H o s p i t a l . It is an interesting m a t t e r for speculation as to how far s e g r e g a t i o n of the worst cases in H o s p i t a l m a y have been a f a c t o r in p r o d u c i n g a milder t y p e of the disease, but in this connection it is w o r t h while p o i n t i n g out that in r e g a r d to D i p h t h e r i a , a n o t h e r disease which has been isolated in H o s p i t a l to an equal e x t e n t as Scarlet, s e g r e g a t i o n of cases in Hospital does not seem to have been a c c o m p a n i e d by any c h a r g e lot the b e t t c r ir the type of disease p r e v a i l i n g now, as c o m p a r e d with t h a t p r e v a i l i n g in former years. In \ ¥ a l t a s e y the t y p e of Diphtheria at the m o m e n t is distinctly more severe than has ever prevailed before in my experience. It would seem, therefore, that, while Scarlet F e v e r is b e c o m i n g milder, D i p h t h e r i a is b e c o m i n g more virulent. I was interested to read the following from the Annual R e p o r t of the M e t r o p o l i t a n A s y l u m s B o a r d : " F r o m these figures it is seen t h a t Scarlet Fever may now be r e g a r d e d as a disease which normally is unlikely to end fatally. W i t h i n 30 y e a r s the case m o r t a l i t y has fallen from 3 to l ' l l per cent. A l t h o u g h , in c o m m o n with all forms of infectious disease it is costly in time, labour, and money, and it interferes with education, it t a k e s little toll in the form of h u m a n life " ; and with r e g a r d to Diphlheria the s a m e R e p o r t conrains the following : " T h e r e is a m p l e justification in round figures for the s t a t e m e n t that, seeing t h a t the incidence of D i p h t h e r i a in children under 10 y e a r s of a g e is a b o u t t w o - t h i r d s of the total incidence, the likelihood of a child under that age b e c o m i n g infected with the disease is now approximately twice as g r e a t as it was in the period