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The Paris international exhibition
1937 excessive prevalence rather than increased virulence seems to have accounted for the high number of deaths. Nutrition is given the place of prominence it deserves and the value of milk emphasised ; the report commends properly operated milk-bars and gives evidence to support the contention that there is no significant difference in nutritive values between raw and pasteurised milk. The facetious observer might remark that cosmetics are nowadays considered more essential than clothes ; and it is certainly a sign of a rapidly advancing era that a detailed section is given to the risk of skin diseases which may follow the use of lipstick, hair dye, face creams and the various appurtenances of modern beauty. But despite the universality of this hard-worked cosmetic art, there are few untoward results; although there is a timely warning about measures for slimming, with a severe condemnation of at least one drug the existence of which might well be forgotten. The whole report is good, and shows an eminently satisfactory range of services; it only remains to ensure that these facilities are fully understood and adequately utilised by the people for whom they were created, and then preventive medicine can continue to go hopefully forward conquering and to conquer.
Tests of Vitamin A Deficiency While we seem to be no nearer to the discovery of a reliable measure of the state which we call under-nutrition of a kind which will eliminate subjective errors arising from personal impressions, progress is being made in the quantitative detection of specific deficiencies. The oldest and simplest of these is, of course, the estimation of h~emoglobin in the blood. Intensive work on vitamins, their chemical constitution and their effect on metabolism or other physiological processes, has brought further tests within the range of practicability and is giving us a clearer conception of the derangements which may arise from minute but Continued shortage of these dietetic constituents. For instance, an excess of blood phosphates is now generally accepted as an indication of shortage of vitamin D, and urinary excretion tests are available as apparently reliable measures of deficiency of vitamins Bx and C. Since Jeans and Zentmire in the U.S.A. investigated vitamin A deprivation by a photometer test in 1933 further work has been done on this important subject, the latest of which has recently been carried out in London and Cambridge by Maitra and Harris.* The test depends on the determination of the rate of restoration of visual purple in the retina after exposure to strong light and the instrument *Lancet, 1937, g, 1009.
PUBLIC HEALTH used was the Birch-Hirschfeld photometer. The results confirm previous findings in America and indicate t h a t vitamin A deficiency is relatively common in elementary school children, especially among the younger children. Some of the previous work on the subject is reviewed in a leading article in the same issue of the Lancet* which deals also with the pathological results of vitamin A deficiency. Investigations of this kind, if they are scientifically reliable and not too elaborate, offer a valuable field of work in the school health and child welfare services. No other group of practitioners has such a ready access to so great a body of material lending itself to research. It offers an opportunity to get away from the sterile routine which may be one of the causes of the present diminished field of applicants for entry to the service. It is, therefore, desirable that local authorities should encourage and afford facilities for local enquiries on these lines. If, however, any departmental officer should contemplate an investigation into vitamin A deficiency he should note a recent publication to which reference is not made in the Lancet. Palmer and Blumbergt have repeated in schools over a wide area of Maryland and around Washington Jeans' work with a modified instrument, recently adopted by Jeans himself and called the " biophotometer," and their findings are somewhat disconcerting. Briefly they conclude that the test " does not appear to be a reliable method for application to the routine survey of school children " and that " more data concerning the quantitative relationships between vitamin A nutrition and dark adaptation tests are needed."
The Paris International Exhibition It is good news that although the Paris Exhibition closed at the end of last month it may be reopened in 1938. Much has been written of its glories, glories that appeal to all, e.g., its magnificent lay-out on both banks of the Seine, with the Eiffel Tower as its pivotal point ; its brilliant illuminations, its aquatic displays of fireworks and sky-high coloured fountains, the attractiveness and variety of its many pavilions. Indeed, the danger is that amidst so veritable an embarrassment of riches one may miss two pavilions of outstanding professional interest and instructiveness--especially as they are both situated rather off the beaten track and at some distance from the resplendent main (Trocadero) entrance to the Exhibition. These are the Palace of Discovery and the Pavilion of Hygiene. In the Palace of Discovery, as in the Exhibition *Lancet, 1937, 2, 1025. "]"United States Treasurery Department, Pub lic Health Reports, 52, 1403. 63
PUBLIC HEALTH as a whole, there is so much to see and learn that, without unlimited time at one's disposal, specialisation is essential. The hygienist will turn naturally to the sections of biology, of microbiology (" The work of Pasteur and its consequences ") and, if time, of medicine. In the section of biology is a host of good things, but dominating all is a huge model designated to demonstrate the theory of evolution, which, indeed, it does most effectively, from atoms and molecules to man. Next, perhaps, in impressiveness for its power to instruct so that all may understand are the models that illustrate the laws of Mendel. From there is but a step to the study of sex and eugenics, with living fowls whose sex has been changed by gland grafts. Having thus acquired in the basement a " biological background," it is proper to ascend to the first floor and examine the section of microbiology. Here, as one would expect, Pasteur dominates all, but Jenner is given a place of high honour--rather higher, it would seem, than in his native country. Below his bas-relief is an imposing statistical table which shows the decline in smallpox since vaccination was introduced, and here is no treating with the enemy, no meeting the anti-vaccinationists half-way, no half-hearted admission that perhaps after all other factors may have played their part in stamping out smallpox from the civilised world ; for, at the foot of the table it is stated most emphatically that in proportion as vaccination is neglected so will increase the danger of a return of virulent smallpox. Indeed, there breathes through the section of microbiology in the Palace of Discovery as also in the Pavilion of Hygiene an atmosphere of passionate belief in the efficacy of immunisation of all kinds, an atmosphere most refreshing to the English believer in such things who, comparing the clarity here with the confusion at home is inevitably reminded of the continental legend that in England there is always fog. The other outstanding impression to be derived from the microbiological section is one of insistent emphasis on animal experimentation as an essential factor in the conquest of human disease--an impression all the more readily received after previous study of the wonderful evolution model nearby, whose peak towers up intview from the floor below. From the Palace of Discovery to the Pavilion of Hygiene may take half-an-hour's j o u r n e y - a parable of the time-lag between research and its application. The best method of approach is by the River Seine over which the Pavilion of Hygiene is mounted entirely on piles, its layout following the bend of the river at this point. The building, which has a most striking design, consists of a central body with two rounded 64
DECEMBER wings and from the river looks rather like a huge biplane, the space between the upper and lower wings being filled in almost from the lower plane upwards by glass windows. In the central block is a spacious entrance hall and a cinema (200 places) with a continuous performance of good, silent films. There are no " talkies " - - i n a local health exhibition, an omission, but in an international one, a virtue. The cinema is welcome, not only for instruction, but to sit down and rest for exhibitions can be very tiring. The wall space over the entrance to the cinema is occupied by an enormous map of France which is divided up into " Departments," and shows by symbols the degree to which the essential health services have been provided M maternity and child welfare, tuberculosis, venereal diseases and hospitals. From the Central Hall there is one-way traffic, round the two wings of the pavilion, which house the stands in order as follows: The Unhealthy and the Healthy Dwelling, Pure Water Supply, Health Education, Refuse Disposal, Anti-Malaria Campaign and Destruction of Mosquitoes, Food Inspection, The Hygienic and the Unhygienic Food Stall, PreMarital Medical Consultation, Pre-Natal Medical Consultation, The Social Assistant (Health Visitor), School Medical Inspection, Hygiene of the Teeth and Dental Inspection, The Open-air School, The Return from Holiday Camps, Nursing the Infectious Disease Patient at Home, The Public Health Laboratory, The Anti-Tuberculosis Dispensary, The Preventorium, The Sanatorium, The Venereal Diseases Dispensary, The Anti-Rheumatism Campaign, The Campaign against Cancer, The Health Centre. All the stands are arranged most skilfully; they have the maximum popular appeal and convey their message with the utmost clarity. Thus between the " life size" rooms of the unhealthy and the healthy dwelling is a small stretch of wall, of which half is dilapidated and has the housebreaker's pick embedded in it, the other half being obviously new built with clean, red bricks and gleaming mortar. All available wall space between stands or groups of stands is utilised by posters of compelling health propaganda (one of the posters even has a message of hope for drug addicts) and, needless to say, the stands are arranged against the inner wall of the pavilion so that there is no interruption of the light that comes streaming through the almost wholly windowed outer wall on the riverside aspect. Ventilation is by conditioned air, the efficiency of which was proved under very different conditions, on a mid-week morning when the pavilion was almost empty, and on the afternoon of a national holiday when the place was
PUBLIC HEALTH
1987 packed with people. (How many one-week health exhibitions m England are ever packed with people ? And this one had been going on for months !) In addition to the main cinema, three small projectors and screens were at work, mounted high up on the stands so that those going round in the one way traffic could interrupt their progress to watch excellent little films shows--also silent. On one tour three films were seen, one about venereal disease, one about cleanliness and one about tuberculosis. The Pre-marital Medical Consultation is an interesting innovation. At present, it is entirely voluntary, but it is expected that its ever-growing popularity will in time create a public opinion favourable to making it compulsory. Sixteen per cent. have been found unfit to marry. The " Social Assistant " in France has a much wider field of work than her English equivalent, the health visitor. Her primary function is to teach the ways of health especially for infants, but she acts also as school nurse and tuberculosis nurse, she advises what to do in case of infectious disease, and, above all, when any member of the family falls ill, she acts as supervisor and teacher of sick nursing. Holiday camps : here is a truly remarkable photograph of children returning from a holiday camp in glowing health. In 1936, 200,000 school children spent seven million days at holiday camps. The Preventorium takes infants away from the risk of continued infection by a tuberculous parent and at the same time builds in the open-air life under medical supervision its resistance against the disease. Only those infants are received that have doubtful or initial signs, including positive tuberculin reactors, but in any case, non-infectious and non-progressive cases. The Venereal Diseases stand draws special attention to the international organisation for continuing treatment of venereal disease in seamen whatever part Of the world they may find themselves. The ship's surgeon is shown talking to a nice-looking young sailor boy and explaining the system to him. Ite really does talk--by means of a selfrepeating gramophone record ! Rheumatism : in France, not merely are juvenile, but all forms of rheumatism are being energetically tackled by organised schemes, organised on lines similar to those of tuberculosis and orthopaedic schemes in this country. The general practitioner, the dispensary, the consultant, the assistant, the laboratory and various forms of treatment (ultraviolet light and other physical agents, heat, baths) and, last but not least, re-education ; all have their place in the scheme. The Cancer stand is also well done. It conveys the impression of vigour and optimism. Immunisation: there is no special stand but in various ways there is insistent
propaganda on the value of immunisation of all kinds of diseases, including " B.C.G. " for tuberculosis. The infant may be immunised against diphtheria, typhoid and tetanus, at one and the same time. It is fitting to conclude with the Health Centre, which, in France, seems to cater for everything. The main divisions of its coordinating activities are as follows : (1) MaternitY and child welfare, (2) Pre-school and school child, (3) Adolescents and adults, (4) Teaching mothercraft and domestic science to mothers and young girls, (5) Breathing and orthopaedic exercises, (6) Vocational guidance, mental hygiene, training of the deaf and dumb, (7) Social scourges --syphilis, cancer, tuberculosis. The Centre is always open with the object of assuring the co-ordination of activities which have no other end than to maintain the individual in good health. The visitor leaves the Pavilion with a free collection of cleverly worded and illustrated pamphlets of all kinds. At least three hours should be devoted to the Palace of Discovery and even longer to the Pavilion of Hygiene, but having thus done his duty, the visitor is justified in making all speed to the " Pavilion de Champagne."
Past and Future We commend to our readers the two presidential addresses to Branches which appear as special articles in this issue of PUBLIC HEALTH. The address by Dr. E. Stanley Robinson to the Midland Branch might have been entitled " O n e Man Against the World." Dr. Robinson has modestly disclaimed any pretension to edify his audience and has said that he hoped merely to entertain them, but his graphic picture of the conditions with which a medical ot~cer of health had often to contend 40 years ago is at the same time an education in that important side of an ? [.O.H.'s duty, which is to urge reform and progress in the face of apathy and self-interest and despite many rebuffs and failures. This paper reads so well that one can almost hear Dr. Robinson talking and one envies the Midland Branch for having listened to so delightful an address. Dr. Shinnie's presidential address to the Metropolitan Branch must have given equaI p easure to his hearers, and he not only gives a picture of the concerns of the first borough M.O.sH. in London but also looks to the future with a discerning eye as to the new interests of the public health service. Such reviews of progress are most useful and aptly delivered from a presidential chair. 65
Tests of Vitamin A Deficiency While we seem to be no nearer to the discovery of a reliable measure of the state which we call under-nutrition of a kind which will eliminate subjective errors arising from personal impressions, progress is being made in the quantitative detection of specific deficiencies. The oldest and simplest of these is, of course, the estimation of h~emoglobin in the blood. Intensive work on vitamins, their chemical constitution and their effect on metabolism or other physiological processes, has brought further tests within the range of practicability and is giving us a clearer conception of the derangements which may arise from minute but Continued shortage of these dietetic constituents. For instance, an excess of blood phosphates is now generally accepted as an indication of shortage of vitamin D, and urinary excretion tests are available as apparently reliable measures of deficiency of vitamins Bx and C. Since Jeans and Zentmire in the U.S.A. investigated vitamin A deprivation by a photometer test in 1933 further work has been done on this important subject, the latest of which has recently been carried out in London and Cambridge by Maitra and Harris.* The test depends on the determination of the rate of restoration of visual purple in the retina after exposure to strong light and the instrument *Lancet, 1937, g, 1009.
PUBLIC HEALTH used was the Birch-Hirschfeld photometer. The results confirm previous findings in America and indicate t h a t vitamin A deficiency is relatively common in elementary school children, especially among the younger children. Some of the previous work on the subject is reviewed in a leading article in the same issue of the Lancet* which deals also with the pathological results of vitamin A deficiency. Investigations of this kind, if they are scientifically reliable and not too elaborate, offer a valuable field of work in the school health and child welfare services. No other group of practitioners has such a ready access to so great a body of material lending itself to research. It offers an opportunity to get away from the sterile routine which may be one of the causes of the present diminished field of applicants for entry to the service. It is, therefore, desirable that local authorities should encourage and afford facilities for local enquiries on these lines. If, however, any departmental officer should contemplate an investigation into vitamin A deficiency he should note a recent publication to which reference is not made in the Lancet. Palmer and Blumbergt have repeated in schools over a wide area of Maryland and around Washington Jeans' work with a modified instrument, recently adopted by Jeans himself and called the " biophotometer," and their findings are somewhat disconcerting. Briefly they conclude that the test " does not appear to be a reliable method for application to the routine survey of school children " and that " more data concerning the quantitative relationships between vitamin A nutrition and dark adaptation tests are needed."
The Paris International Exhibition It is good news that although the Paris Exhibition closed at the end of last month it may be reopened in 1938. Much has been written of its glories, glories that appeal to all, e.g., its magnificent lay-out on both banks of the Seine, with the Eiffel Tower as its pivotal point ; its brilliant illuminations, its aquatic displays of fireworks and sky-high coloured fountains, the attractiveness and variety of its many pavilions. Indeed, the danger is that amidst so veritable an embarrassment of riches one may miss two pavilions of outstanding professional interest and instructiveness--especially as they are both situated rather off the beaten track and at some distance from the resplendent main (Trocadero) entrance to the Exhibition. These are the Palace of Discovery and the Pavilion of Hygiene. In the Palace of Discovery, as in the Exhibition *Lancet, 1937, 2, 1025. "]"United States Treasurery Department, Pub lic Health Reports, 52, 1403. 63
PUBLIC HEALTH as a whole, there is so much to see and learn that, without unlimited time at one's disposal, specialisation is essential. The hygienist will turn naturally to the sections of biology, of microbiology (" The work of Pasteur and its consequences ") and, if time, of medicine. In the section of biology is a host of good things, but dominating all is a huge model designated to demonstrate the theory of evolution, which, indeed, it does most effectively, from atoms and molecules to man. Next, perhaps, in impressiveness for its power to instruct so that all may understand are the models that illustrate the laws of Mendel. From there is but a step to the study of sex and eugenics, with living fowls whose sex has been changed by gland grafts. Having thus acquired in the basement a " biological background," it is proper to ascend to the first floor and examine the section of microbiology. Here, as one would expect, Pasteur dominates all, but Jenner is given a place of high honour--rather higher, it would seem, than in his native country. Below his bas-relief is an imposing statistical table which shows the decline in smallpox since vaccination was introduced, and here is no treating with the enemy, no meeting the anti-vaccinationists half-way, no half-hearted admission that perhaps after all other factors may have played their part in stamping out smallpox from the civilised world ; for, at the foot of the table it is stated most emphatically that in proportion as vaccination is neglected so will increase the danger of a return of virulent smallpox. Indeed, there breathes through the section of microbiology in the Palace of Discovery as also in the Pavilion of Hygiene an atmosphere of passionate belief in the efficacy of immunisation of all kinds, an atmosphere most refreshing to the English believer in such things who, comparing the clarity here with the confusion at home is inevitably reminded of the continental legend that in England there is always fog. The other outstanding impression to be derived from the microbiological section is one of insistent emphasis on animal experimentation as an essential factor in the conquest of human disease--an impression all the more readily received after previous study of the wonderful evolution model nearby, whose peak towers up intview from the floor below. From the Palace of Discovery to the Pavilion of Hygiene may take half-an-hour's j o u r n e y - a parable of the time-lag between research and its application. The best method of approach is by the River Seine over which the Pavilion of Hygiene is mounted entirely on piles, its layout following the bend of the river at this point. The building, which has a most striking design, consists of a central body with two rounded 64
DECEMBER wings and from the river looks rather like a huge biplane, the space between the upper and lower wings being filled in almost from the lower plane upwards by glass windows. In the central block is a spacious entrance hall and a cinema (200 places) with a continuous performance of good, silent films. There are no " talkies " - - i n a local health exhibition, an omission, but in an international one, a virtue. The cinema is welcome, not only for instruction, but to sit down and rest for exhibitions can be very tiring. The wall space over the entrance to the cinema is occupied by an enormous map of France which is divided up into " Departments," and shows by symbols the degree to which the essential health services have been provided M maternity and child welfare, tuberculosis, venereal diseases and hospitals. From the Central Hall there is one-way traffic, round the two wings of the pavilion, which house the stands in order as follows: The Unhealthy and the Healthy Dwelling, Pure Water Supply, Health Education, Refuse Disposal, Anti-Malaria Campaign and Destruction of Mosquitoes, Food Inspection, The Hygienic and the Unhygienic Food Stall, PreMarital Medical Consultation, Pre-Natal Medical Consultation, The Social Assistant (Health Visitor), School Medical Inspection, Hygiene of the Teeth and Dental Inspection, The Open-air School, The Return from Holiday Camps, Nursing the Infectious Disease Patient at Home, The Public Health Laboratory, The Anti-Tuberculosis Dispensary, The Preventorium, The Sanatorium, The Venereal Diseases Dispensary, The Anti-Rheumatism Campaign, The Campaign against Cancer, The Health Centre. All the stands are arranged most skilfully; they have the maximum popular appeal and convey their message with the utmost clarity. Thus between the " life size" rooms of the unhealthy and the healthy dwelling is a small stretch of wall, of which half is dilapidated and has the housebreaker's pick embedded in it, the other half being obviously new built with clean, red bricks and gleaming mortar. All available wall space between stands or groups of stands is utilised by posters of compelling health propaganda (one of the posters even has a message of hope for drug addicts) and, needless to say, the stands are arranged against the inner wall of the pavilion so that there is no interruption of the light that comes streaming through the almost wholly windowed outer wall on the riverside aspect. Ventilation is by conditioned air, the efficiency of which was proved under very different conditions, on a mid-week morning when the pavilion was almost empty, and on the afternoon of a national holiday when the place was
PUBLIC HEALTH
1987 packed with people. (How many one-week health exhibitions m England are ever packed with people ? And this one had been going on for months !) In addition to the main cinema, three small projectors and screens were at work, mounted high up on the stands so that those going round in the one way traffic could interrupt their progress to watch excellent little films shows--also silent. On one tour three films were seen, one about venereal disease, one about cleanliness and one about tuberculosis. The Pre-marital Medical Consultation is an interesting innovation. At present, it is entirely voluntary, but it is expected that its ever-growing popularity will in time create a public opinion favourable to making it compulsory. Sixteen per cent. have been found unfit to marry. The " Social Assistant " in France has a much wider field of work than her English equivalent, the health visitor. Her primary function is to teach the ways of health especially for infants, but she acts also as school nurse and tuberculosis nurse, she advises what to do in case of infectious disease, and, above all, when any member of the family falls ill, she acts as supervisor and teacher of sick nursing. Holiday camps : here is a truly remarkable photograph of children returning from a holiday camp in glowing health. In 1936, 200,000 school children spent seven million days at holiday camps. The Preventorium takes infants away from the risk of continued infection by a tuberculous parent and at the same time builds in the open-air life under medical supervision its resistance against the disease. Only those infants are received that have doubtful or initial signs, including positive tuberculin reactors, but in any case, non-infectious and non-progressive cases. The Venereal Diseases stand draws special attention to the international organisation for continuing treatment of venereal disease in seamen whatever part Of the world they may find themselves. The ship's surgeon is shown talking to a nice-looking young sailor boy and explaining the system to him. Ite really does talk--by means of a selfrepeating gramophone record ! Rheumatism : in France, not merely are juvenile, but all forms of rheumatism are being energetically tackled by organised schemes, organised on lines similar to those of tuberculosis and orthopaedic schemes in this country. The general practitioner, the dispensary, the consultant, the assistant, the laboratory and various forms of treatment (ultraviolet light and other physical agents, heat, baths) and, last but not least, re-education ; all have their place in the scheme. The Cancer stand is also well done. It conveys the impression of vigour and optimism. Immunisation: there is no special stand but in various ways there is insistent
propaganda on the value of immunisation of all kinds of diseases, including " B.C.G. " for tuberculosis. The infant may be immunised against diphtheria, typhoid and tetanus, at one and the same time. It is fitting to conclude with the Health Centre, which, in France, seems to cater for everything. The main divisions of its coordinating activities are as follows : (1) MaternitY and child welfare, (2) Pre-school and school child, (3) Adolescents and adults, (4) Teaching mothercraft and domestic science to mothers and young girls, (5) Breathing and orthopaedic exercises, (6) Vocational guidance, mental hygiene, training of the deaf and dumb, (7) Social scourges --syphilis, cancer, tuberculosis. The Centre is always open with the object of assuring the co-ordination of activities which have no other end than to maintain the individual in good health. The visitor leaves the Pavilion with a free collection of cleverly worded and illustrated pamphlets of all kinds. At least three hours should be devoted to the Palace of Discovery and even longer to the Pavilion of Hygiene, but having thus done his duty, the visitor is justified in making all speed to the " Pavilion de Champagne."
Past and Future We commend to our readers the two presidential addresses to Branches which appear as special articles in this issue of PUBLIC HEALTH. The address by Dr. E. Stanley Robinson to the Midland Branch might have been entitled " O n e Man Against the World." Dr. Robinson has modestly disclaimed any pretension to edify his audience and has said that he hoped merely to entertain them, but his graphic picture of the conditions with which a medical ot~cer of health had often to contend 40 years ago is at the same time an education in that important side of an ? [.O.H.'s duty, which is to urge reform and progress in the face of apathy and self-interest and despite many rebuffs and failures. This paper reads so well that one can almost hear Dr. Robinson talking and one envies the Midland Branch for having listened to so delightful an address. Dr. Shinnie's presidential address to the Metropolitan Branch must have given equaI p easure to his hearers, and he not only gives a picture of the concerns of the first borough M.O.sH. in London but also looks to the future with a discerning eye as to the new interests of the public health service. Such reviews of progress are most useful and aptly delivered from a presidential chair. 65