THE HEALTH OF A NATION
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27 THE HEALTH OF A NATION THE LANCET LONDON: SATURDAY, JULY 4, 1936 DURING the present century, and especially since the war, there has been a great increase in the amount of energy and public money expended in this country on measures designed to protect the health of the community and from time to time various inquiries have been made to ascertain whether the expenditure has secured the best possible results. One important inquiry was made ten years ago by the Royal Commission on National Health Insurance. More comprehensive, however, is that recently completed by the Committee on Scottish Health Services, which was appointed by the Secretary of State for Scotland in June, 1933 ; and the Committee’s report, which has just been published by the Department of Health for Scot- land, is a remarkable document of special in. terest to medical practitioners. The Committee was appointed to review the existing Scottish health services in the light of modern conditions and to recommend such changes in policy and organisation as might be considered necessary. The task was begun with a study of the various agencies now at work, the circumstances in which they originated, their development, successes, and shortcomings. It was found that in Scotland, as elsewhere, health services sprang from the fear of pestilence, and that this fear was long the main motive for nearly all organised health effort in Scotland. With the beginning of the century, however, there came a wider outlook. It was due to several causes, chief among which were the growing public concern for the continuance of a high infant mortality with all its implications, the declining birth-rate, and the unsatisfactory physical conditions revealed by the examination of army recruits during the South African war. Evidently it was not enough to remove specific conditions inimical to health ; a more positive policy was needed-a policy that should not only impose safeguards against disease, but should actively promote the health of the people and seek to realise for all the full possibilities of healthy living. The pathological conception of disease as a basis for health measures gradually gave place to the wider concept in which medicine, both in its preventive and curative aspects, is regarded as applied biology. This view has inspired much of the progress made in recent developments of health services-in maternity and child welfare, for example, and in school hygiene and industrial hygiene-and the Committee adopt it in their study of what has already been achieved and in their recommendations for future action. The record of achievement is impressive ; the Scottish health services have certainly justified their existence by remarkable results. But there is still much to be done. The services in many points are ill-adapted to modern conditions ; there are gaps in the health front, and effort and money are being spent in attempts to ameliorate defects that might have been prevented. Further develop- ments are necessary to enable the services to yield a full return for the expenditure upon them. The recommendations (some of which are transcribed on p. 36 of this issue) cover a wide field, and perhaps the most important are those relating to the extended provision of general medical services. The Committee find that large numbers of people are unable to secure the aid of a general medical practitioner, and that this, especially where women and children are con- concerned, seriously impairs the efficiency and development of some of the services provided by the local authorities. They contemplate a complete and coordinated medical service in which the general practitioner, in his capacity as family doctor, will work in liaison between the homes of the people and the different statutory and other agencies. As a step in this direction they recom- mend that the provision made for the medical attendance of persons insured under the health insurance system should be extended to their dependants and other persons in similar economic circumstances. The Committee attach great importance to the function of a family doctor in a modern community and think that the State must depend increasingly on the general prac- titioner for the medical contribution to further progress in public health, rather than on an extended employment of whole-time medical officers for clinical work. Nevertheless they are inclined to the view that at the present time the " pathological conception " plays a less prominent part in the statutory health services than in private medical practice, and that if the general practitioner is adequately to fulfil his function as a family adviser, through whom the people may most effectively be instructed in the essentials of healthy living, he should be more imbued with the preventive idea of health and disease. It is recognised that this may involve some modifica- tion of the training of medical students. Dealing with the cost of extending insurance medical practice to the dependants of the insured, the Committee estimate the number of dependants at 1,600,000 ; these, together with the 1,900,000 insured persons, represent some 70 per cent. of the total population of Scotland. They think that for the dependants a capitation fee of 6. would afford reasonable medical remuneration, being probably considerably more than doctors are now receiving for such attendance, and this together with allowances for drugs, mileage, and adminis- tration would bring the total annual cost to 98. per person, or about &:720,000 in all. It is proposed that this sum should be raised by increasing the weekly insurance contribution by 3d. for men and Id. for women, to which would be added the usual Exchequer grant. It is proposed also that the general practitioner service so extended should undertake the domiciliary treatment of the necessitous class, the local authority paying into the insurance fund the contributions required to
Transcript of THE HEALTH OF A NATION
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THE HEALTH OF A NATION
THE LANCET
LONDON: SATURDAY, JULY 4, 1936
DURING the present century, and especiallysince the war, there has been a great increase inthe amount of energy and public money expendedin this country on measures designed to protectthe health of the community and from time totime various inquiries have been made to ascertainwhether the expenditure has secured the best
possible results. One important inquiry was madeten years ago by the Royal Commission on NationalHealth Insurance. More comprehensive, however,is that recently completed by the Committee onScottish Health Services, which was appointed bythe Secretary of State for Scotland in June, 1933 ;and the Committee’s report, which has just beenpublished by the Department of Health for Scot-land, is a remarkable document of special in.terest to medical practitioners. The Committeewas appointed to review the existing Scottishhealth services in the light of modern conditionsand to recommend such changes in policy andorganisation as might be considered necessary.The task was begun with a study of the variousagencies now at work, the circumstances in whichthey originated, their development, successes, andshortcomings. It was found that in Scotland, aselsewhere, health services sprang from the fear ofpestilence, and that this fear was long the mainmotive for nearly all organised health effort inScotland. With the beginning of the century,however, there came a wider outlook. It was dueto several causes, chief among which were the
growing public concern for the continuance of ahigh infant mortality with all its implications, thedeclining birth-rate, and the unsatisfactory physicalconditions revealed by the examination of armyrecruits during the South African war. Evidentlyit was not enough to remove specific conditionsinimical to health ; a more positive policy wasneeded-a policy that should not only imposesafeguards against disease, but should activelypromote the health of the people and seek torealise for all the full possibilities of healthy living.The pathological conception of disease as a basisfor health measures gradually gave place to thewider concept in which medicine, both in its
preventive and curative aspects, is regarded asapplied biology. This view has inspired much ofthe progress made in recent developments of healthservices-in maternity and child welfare, for
example, and in school hygiene and industrialhygiene-and the Committee adopt it in their
study of what has already been achieved and intheir recommendations for future action. Therecord of achievement is impressive ; the Scottishhealth services have certainly justified theirexistence by remarkable results. But there isstill much to be done. The services in many points
are ill-adapted to modern conditions ; there are
gaps in the health front, and effort and money arebeing spent in attempts to ameliorate defects thatmight have been prevented. Further develop-ments are necessary to enable the services to yielda full return for the expenditure upon them.The recommendations (some of which are
transcribed on p. 36 of this issue) cover a widefield, and perhaps the most important are thoserelating to the extended provision of generalmedical services. The Committee find that largenumbers of people are unable to secure the aidof a general medical practitioner, and that this,especially where women and children are con-
concerned, seriously impairs the efficiency anddevelopment of some of the services provided bythe local authorities. They contemplate a completeand coordinated medical service in which the
general practitioner, in his capacity as familydoctor, will work in liaison between the homes ofthe people and the different statutory and otheragencies. As a step in this direction they recom-mend that the provision made for the medicalattendance of persons insured under the healthinsurance system should be extended to their
dependants and other persons in similar economiccircumstances. The Committee attach greatimportance to the function of a family doctor ina modern community and think that the Statemust depend increasingly on the general prac-titioner for the medical contribution to further
progress in public health, rather than on an
extended employment of whole-time medicalofficers for clinical work. Nevertheless they areinclined to the view that at the present time the"
pathological conception "
plays a less prominentpart in the statutory health services than in
private medical practice, and that if the generalpractitioner is adequately to fulfil his function asa family adviser, through whom the people maymost effectively be instructed in the essentials ofhealthy living, he should be more imbued withthe preventive idea of health and disease. It is
recognised that this may involve some modifica-tion of the training of medical students.
Dealing with the cost of extending insurancemedical practice to the dependants of the insured,the Committee estimate the number of dependantsat 1,600,000 ; these, together with the 1,900,000insured persons, represent some 70 per cent. ofthe total population of Scotland. They think thatfor the dependants a capitation fee of 6. wouldafford reasonable medical remuneration, beingprobably considerably more than doctors are nowreceiving for such attendance, and this togetherwith allowances for drugs, mileage, and adminis-tration would bring the total annual cost to 98.
per person, or about &:720,000 in all. It is proposedthat this sum should be raised by increasing theweekly insurance contribution by 3d. for men andId. for women, to which would be added the usual
Exchequer grant. It is proposed also that thegeneral practitioner service so extended shouldundertake the domiciliary treatment of thenecessitous class, the local authority paying intothe insurance fund the contributions required to
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discharge its obligations in respect of this class,and of persons in economic circumstances similarto those of the insured. All persons comingwithin the scope of the scheme would have freechoice of doctor, and medical remuneration wouldbe on the capitation method. It will be seen thatthe Committee seek to retain the contributoryprinciple for medical benefit and its proposedextensions, but in this they are not unanimous.Of the eighteen members, seven have submitteda memorandum giving reasons why they regardsuch an arrangement, under the new conditionscontemplated, as neither logical nor capable of
being maintained for any length of time.The extension of general practitioner services is
the basis of the Committee’s scheme of reform,but many other important recommendations aremade. Some are highly controversial, but all meritcareful study by those in any country who havepublic health progress at heart ; for healthproblems transcend national frontiers and havein them much that is common to all countries.
THE INTERACTIONS OF ADRENALS ANDTHYMUS
THE evolution of thymic tissue in Addison’sdisease is perhaps the only well-known patho-logical manifestation of the interaction betweenthe adrenals and the thymus glands. A funda-mental relation between the two glands has beenrecently demonstrated by Dr. HANS SELYE,1working in COLLIP’S laþoratory. Using some
1500 female rats from one colony, he has con-
ducted a series of experiments designed to
clarify the reaction of the thymus and adrenalsto trauma, various intoxications, and fasting. In
particular he has devoted attention to the so-called" accidental " involution of the thymus that isknown to follow injury. By drawing his con-clusions from the averages of large experimentalseries he has been able to overcome the difficultyarising from the considerable variations found inthe weights of organs even in animals of the sameage-group. A striking decrease in the weight ofthe thymus follows fasting for periods of four
days or longer in one group of experiments. It isof course familiar to pathologists that at autopsythe amount of lymphadenoid tissue in the bodyreflects the state of general nutrition, but thediminution in thymic weight in SELYE’S rats
appears to be disproportionately greater than theloss in body-weight, which indeed is hardly appre-ciable, according to his figures, over the shortperiods of the experiments. Amongst the drugsused atropine, morphine, and formaldehyde, givenby subcutaneous injection, are particularly activein producing thymic involution. Atropine andmorphine in doses of 2 c.cm. of a 1 per cent.solution and formaldehyde in doses of 0’5 c.cm.of a 4 per cent. solution, injected twice daily,will produce severe degrees of involution in48 hours from the first dose. The histologicalchanges in the thymus, which are said to beginas early as six hours after the first dose, are first
1 Brit. Jour. Exper. Path., 1936, xvii., 234.
an cedema, accompanied by a little fluid exudatein the pleural cavity and occasionally in the
retroperitoneal tissues, followed in 24 hours bydegeneration of the thymic cells and in 48 hoursby subsidence of the cedema and gradual removalof the cell debris resulting from the degeneration.At the same time the adrenals show an increasein size which is proportionate to the decrease inthe thymus, accompanied by loss of lipoid fromthe cortex. This change is interpreted as evidenceof increased activity. The increase in size isattributed to cortical hypertrophy, an importantstatement which we should like to see confirmed
by careful histological studies.This combined thymic and adrenal change was
also produced by extensive skin lesions, bonefractures, peritoneal injuries, or by exciting theanimal and simultaneously preventing its freemovement. In further series of experimentsSELYE goes on to show that in adrenalectomisedanimals thymic involution is not obtained withthese different damaging agents ; and he concludesthat an adrenal secretion is essential for suchinvolution. This has an important bearing on theapparent evolution of the thymus both in Addison’sdisease and in experimental adrenalectomy. SELYE,after considering all the evidence, doubts whetherthe thymus really undergoes hyperplasia in thesecircumstances. The results of controlled animal
experiments, at any rate, seem to suggest that theapparent enlargement of the thymus after adrenal-ectomy is due rather to a failure of the glandto undergo normal involution. If this view iscorrect it follows that the adrenal ordinarilysecretes some hormone which induces involutionof the thymus and in the absence of which thethymus will retain its juvenile character. Infurther experiments SELYE failed to demonstratethat this hormone is either adrenaline or cortin.Thus adrenaline failed to induce thymic involutionin the adrenalectomised animal. It is of interestto note that sodium chloride, while greatlyimproving the general condition of such animalsand almost completely restoring their resistanceto drugs, also failed to induce thymic involution.Although adrenaline is apparently not the hormoneconcerned, the conservation of the medulla appearsto be essential. Again, in a series of hypophys-ectomised animals, in which, as is well known,the adrenal cortex undergoes atrophy, it was
found that the thymus did not respond normallyto the agents known to produce pronouncedinvolution. It would thus appear, then, that thepresence of the hypophysis also is necessary forthe normal secretion of the adrenal hormone
responsible for thymic involution. SELYE’s resultsin this respect are however susceptible to criticismon the grounds that the crucial experiments werecarried out only eight days after hypophysectomy,a period which may be insufficient for the establish-ment of the remote effects of this procedure.The meaning of this complex reaction on the
part of the thymus and adrenals is still obscure.SELYE regards it as a defence reaction, pointingout that it is most noticeable when the damaginginfluence acts on the organism for the first time.
