Article VIII.

A permanent section of the Council is instituted with the object of giving advice on all questions submitted to it either by the Minister or by the Council.

Article IX.

The Council shall be provided with a general secretariat which shall be in contact with Public Relief and Welfare services.

Article. X.

A departmental commission on Birth-rate and Child Welfare shall be instituted in each "département." These commissions shall investigate questions pertaining to child welfare and the increase of Birth-rate, submitted by the Prefect, or by one of its members in agreement with the Prefect. They can formulate resolutions to be submitted to the Minister of Public Health and, through him, to the Supreme Council. Meetings of these Commissions shall be called by the Prefect at least once every three months.

THE UNSOLVED PROBLEMS OF PREVENTIVE MEDICINE.

The following is a summary of an article by Prof. Aaron Arkin, which appeared in the "American Journal of Public Health.”

7HEREAS the infection transmitted by insects, the waterborn diseases and certain diseases for which we possess methods of specific immunisation have been well conquered, we are still unable to control the high mortality from degenerative diseases of the heart, bloodvessels, and kidneys, from pneumonia and other acute respiratory infections, cancer, and, to a less extent tuberculosis. "

The above statement serves as text to the following.

It is only within the last half century that the world has possessed any scientific knowledge of causes of disease and of their prevention and treatment. We are, in fact, only just emerging from a past in which superstition and mysterious influences were invoked to explain the spread of disease. Even to-day only about 1 % of the population of the world is provided with proper medical care and sanitation. This in itself is sufficient to explain the existence of epidemic diseases and their spread in time of war.

Necessary as it is to insure a proper comprehension of the importance of hygiene and sanitation, it is even still more urgent that the public should be educated to combat those diseases which have still escaped the control of modern science.

These are the unsolved problems of preventive medicine: degenerative diseases of heart kidney and blood vessels; tuberculosis; cancer; acute respiratory diseases (pneumonia, scarlet fever, measles, influenza, etc.); venereal diseases; and metabolic diseases (diabetes, dietary diseases).

One of the great difficulties in the control of contagious diseases consists in the "germ carriers," people who are apparently well, but harbor and

spread disease germs. The control of these germ carriers, as well as of the diseased individual, is the most difficult problem in the prevention of communicable diseases. Unless we can discover the germ and develop an effective preventive vaccination, the only line of attack which remains in certain recurring epidemic diseases, like influenza, poliomyelitis, and epidemic encephalitis, is the eradication of their endemic foci in various parts of the world. It is the opinion of the author that such work could only be accomplished "by some international organisation such as the League of Red Cross Societies."

A result of the progress which medical science has made in the control of many communicable diseases has been that more people reach middle life than was formerly the case, and as a consequence there are at present more cases of cancer, of cardiac, vascular and renal disease. Whereas formerly only highly resistent persons survived, it is a fact that now many weak individuals reach advanced age. This explains why the average expectation of life at ages beyond 60 is not as high as it was in former centuries.

cancer,

It is a fact that the chronic diseases of the latter half of life, nephritis, organic heart disease, are increasing in most civilised countries and present the major problem in preventive medicine. In this connection Dr. Arkin notes the interesting fact that Dr. Pearl found from his statistical studies on influenza, that the mortality from the influenza epidemic was closely related with three great causes of death: tuberculosis, disease of the heart, and diseases of the kidneys.

The victims of the great epidemic were chiefly those subject to the constitutional diseases involving the three fundamental organ systems of the body.

In this connexion, it is significant that of the several million men in the prime of life examined for military service in the United States, 37 % were found unfit by reason of physical or mental defects. Of these defects, 88 % can be classified as follows:

Before the influenza epidemic and the war, the principal causes of death in the Registration Area of the United States in 1916 were as follows:

As this area included only 70 per cent of the total population of the United States and only 44 per cent of the total land area of the country, the deaths from the above causes for the entire country were approximately as follows:

Regarding cancer, Dr. Arkin, makes the following interesting statement: "While 77,000 American soldiers gave their lives for their country during the two years of our participation in the Great War, about 180,000 people died of cancer in the United States. Few people realise the great toll of life taken by this disease. Cancer causes at present one out of every ten deaths in people past the age of 40. It is responsible for one in every eight deaths in women, and one in every thirteen in men above that age. More people over 40 are killed by cancer than by tuberculosis or pneumonia. About 95 per cent of deaths from cancer occur in people above 35. Between the ages of 35 and 45 three times as many women as men die of cancer. It is estimated that in 1920 the cancer mortality in the United States was close to 100,000.

The tragic fact concerning cancer is that its vital effects are nearly always due to unconscious ignorance on the part of patients. The frequent painlessnes of the early symptoms is one of the reasons why the disease is not detected in time and cured as it could be.

Referring to the annual deaths in America due to cancer, Dr. Arkin finds the organs affected are the following:

He suggests that there are probably many exciting influences which stimulate the cell proliferation. In certain sarcomas of lower animals a filterable virus has been obtained, and a bacillus has been found in plant cancer, but in the case of human neoplasms, no micro-organism has so far been shown to cause the disease.

As our hope to-day, in the case of cancer, is its early recognition and proper surgical and radium treatment, it is clear that the education of the public in this matter is of primary importance. This task is naturally that of the physician, the health officer and the nurse, who can receive aid from the Societies for the Control of Cancer. The rôle of the former should be the following: "The surgeon must make use of the trained pathologist and cooperate with him in the diagnosis of his cases. The physician must recognise the cases in the pre-cancerous stage, or early stage of malignancy, or begnignancy. The public health nurse is best able to advise women regarding the early symptoms and proper treatment of hard lumps in the breast, disease of the nipple, menstrual disturbances, etc."

Tuberculosis.

About I per cent of the population of the United States is afflicted with tuberculosis, there being over a million active cases and probably another million of inactive ones. The annual mortality is 130,000, representing one tenth of the entire death rate and about 30 per cent of preventable deaths. It has been ascertained that at least 30 per cent of children had been infected at the age of 10 and that about 93 per cent of the adult population become infected without developing active forms of the disease; they thus acquire a degree of immunity which protects them against subsequent infections, unless this infection be massive or oft-repeated.

To solve the Tuberculosis problem, we must discover either an effective vaccination which would protect against subsequent infections, or a specific drug which would cure the disease. With regard to vaccination, the methods applied by Shiga and Calmette, are considered very promising. Very good results have been obtained with the vaccine of tubercle bacillus employed by Shiga, while Dr. Calmette's successful experiments on cattle are now to be extended to anthropoid apes. We must be satisfied for the present with the reduction of active tuberculosis by increasing body resistance and avoiding massive or oft-repeated infection. Some of the methods for reducing the disease are the following: periodic physical examination, strict supervision of children, proper diet, sanitary homes, pasteurisation of milk and tuberculin-testing of cows, free dispensary and clinic treatment, and sanatorium treatment of advanced cases.

Arteriosclerosis and Cardiovascular disease.

These two diseases, although closely related, are by no means identical there being many instances in which both occur simultaneously in varying combination. Referring to Dr. Ophüls' clinical and anatomic studies of this question, Dr. Arkin states that preceding infection was determined by clinical and careful examination for old inflammatory lesions in tonsils, heart valves and other known foci of chronic infection. Where there were no signs of previous infections, chronic arterial disease was almost entirely absent, but it appeared early and frequently when infection existed.

The arterial injuries usually begin in early life and progress slowly even after disappearance of the focal infection. It was found that chronic pulmonary tuberculosis and syphilis were rarely related to arteriosclerosis and associated conditions unless a chronic rheumatic condition was also present.

This statement does not apply to aortic or cerebral arterial disease. At times there may be severe functional derangement of the cardiovascular system, at other times marked anatomic lesions, or both may coexist. They are the results of the action of toxic bacterial substances which may at times attack the arteries, at other times the kidneys, or both.

If these observations of Dr. Ophüls are correct, asks the writer, do we not have further evidence of the dangers of the focal infection of teeth, tonsils, adenoids, middle ear, appendix, etc.?

Nephritis.

Careful studies of large groups of human cases indicate the importance of a focal infection, usually streptococcus, as the cause of the disease. In child

hood nephritis usually follows scarlet fever, tonsillitis, erysipelas, endocarditis, rheumatic fever or chorea, in all of which the streptococcus undoubtedly plays the most important part. But the nephritis may also present itself months or years after a focal infection when the focus may no longer be present and when, if present, its removal may be of slight value. As preventive measure against renal disease, Dr. Arkin advises the removal of recognised foci of infection as early as possible, prompt and efficient treatment of all acute infectious fevers, and dietary restrictions to decrease the amount of renal work.

Pneumonia.

The annual death rate from pneumonia in the United States is about 100,000, half that number succumbing to pneumonia and influenza during the 4 months of the great epidemic (September to December 1918). Mixed pneumococcus vaccine has already been shown to be of decided value for preventing pneumonia. The necessity of isolation of all cases and identification of carriers is also well recognised.

Diabetes.

It is estimated that there are half a million diabetics in the United States. The relation of obesity to diabetes has been pointed out by Joslin, who found in the case of 1,000 diabetics, that the disease largely results from obesity, persons of overweight being more liable to the disease than those of average weight. It is therefore necessary that the medical profession impress upon the public the importance of maintaining average weight; early dietetic treatment is essential.

Conclusions.

Dr. Arkin's conclusions are the following: "Better medical service rendered to the public through the establishment of fully equipped health centers in every community and available to the family physician for the diagnosis and treatment of disease, and periodical physical examinations; the organisation of group medical clinics in larger centers of population for more expert diagnosis and treatment; further development of federal and State forces in disease prevention; and the promotion of scientific research and investigation, will do much toward solving these problems in the future.

"Modern medicine is becoming more and more a social service concerned with the prevention of disease, prolongation and betterment of life, improvement of physical healt and efficiency through organised community efforts. The physician must uphold his reputation as the leader in this work. He can do this only by constantly acquiring knowledge. He must have the spirit of scientific investigation.

"Let us adopt as our motto: 'Every ill that can be relieved shall be removed '. "