Chronic Illness in the United States: Volume I Chronic Illness in the United States, Volume I: Prevention of Chronic Illness [Reprint 2014 ed.] 9780674497474, 9780674497467


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Table of contents :
COMMISSION ON CHRONIC ILLNESS
Preface
Introduction
Contents
PART I. Prevention: Its Role and Objectives
Chapter 1. Prevention
Chapter 2. Promotion of Health
Chapter 3. Primary Prevention
Chapter 4. Secondary Prevention through Periodic Health Examinations
Chapter 5. Secondary Prevention through Screening Examinations
Chapter 6. Personnel and Education
Chapter 7. Community Planning for Prevention
Chapter 8. Conclusions and Recommendations
PART II. Summaries of Information on Prevention of Selected Chronic Diseases and Contributory Factors
Chapter 9. Arthritis and Rheumatism
Chapter 10. Blindness
Chapter 11. Cancer
Chapter 12. Cardiovascular Diseases
Chapter 13. Cerebral Palsy
Chapter 14. Diabetes Mellitus
Chapter 15. Epilepsy
Chapter 16. Impaired Hearing
Chapter 17. Mental Illness
Chapter 18. Multiple Sclerosis
Chapter 19. Poliomyelitis
Chapter 20. Late Manifestations of Syphilis
Chapter 21. Tuberculosis Chapter
Chapter 22. Chronic Disease in Industry
Chapter 23. Dental Health and Chronic Disease
Chapter 24. Emotional Factors in Chronic Disease
Chapter 25. Heredity as a Factor in Chronic Disease
Chapter 26. Malnutrition and Obesity as Factors in Chronic Disease
APPENDICES
Appendix A. Brief History of the Commission on Chronic Illness
Appendix B. Articles of Incorporation and Bylaws
Appendix C. List of Publications
Appendix D. Definitions
Appendix E. Largely Controllable, Partially Controllable, Largely Uncontrolled Chronic Illnesses
Index
Recommend Papers

Chronic Illness in the United States: Volume I Chronic Illness in the United States, Volume I: Prevention of Chronic Illness [Reprint 2014 ed.]
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CHRONIC ILLNESS IN THE UNITED STATES

Prevention of Chronic Illness

COMMISSION ON CHRONIC ILLNESS June 1949-June 1956

AN

INDEPENDENT THE

NATIONAL

PROBLEMS ILLNESS,

OF AND

AGENCY

CHRONIC

TO

DISABILITY

FOUNDERS A M E R I C A N HOSPITAL ASSOCIATION A M E R I C A N MEDICAL ASSOCIATION AMERICAN PUBLIC H E A L T H AMERICAN PUBLIC W E L F A R E

STUDY

DISEASE,

ASSOCIATION ASSOCIATION

CHRONIC ILLNESS IN THE UNITED STATES VOLUME I

Prevention of Chronic Illness COMMISSION ON CHRONIC ILLNESS

Published for The Commonwealth

Fund

BY HARVARD UNIVERSITY PRESS Cambridge,

Massachusetts 1957

© 1957 BY THE COMMONWEALTH F U N D

Published for The Commonwealth Fund By Harvard University Press Cambridge, Massachusetts For approximately a quarter of a century THE COMMONWEALTH FUND, through its Division of Publications, sponsored, edited, produced, and distributed books and pamphlets germane to its purposes and operations as a philanthropic foundation. On July 1, 1951, the Fund entered into an arrangement by which HARVARD UNIVERSITY PRESS became the publisher of Commonwealth Fund books, assuming responsibility for their production and distribution. The Fund continues to sponsor and edit its books, and cooperates with the Press in all phases of manufacture and distribution. Distributed in Great Britain By Oxford University Press London

LIBRARY OF CONGRESS CATALOG CARD NO.

56-10165

MANUFACTURED IN THE UNITED STATES OF AMERICA

COMMISSION ON CHRONIC ILLNESS OFFICERS Chairman LEONARD W . MAYO ( 1 9 4 9 - 1 9 5 6 ) , New

York

Director, Association for the Aid of Crippled Children Vice-Chairman EDWIN S. HAMILTON, M.D. ( 1 9 5 0 - 1 9 5 6 ) , Kankakee,

III.

Member, Board of Trustees, American Medical Association Secretary J . D . COLMAN ( 1 9 4 9 - 1 9 5 6 ) ,

Baltimore

Vice-President, Johns Hopkins University and Hospital Treasurer THEODORE G . KLUMPP, M.D. ( 1 9 4 9 - 1 9 5 6 ) , New

York

President, Winthrop Laboratories, Inc. MEMBERS CREIGHTON BARKER, M.D. ( 1 9 4 9 - 1 9 5 6 ) , New

Haven

Executive Secretary, Connecticut Medical Society S. BRUCE BLACK ( 1 9 4 9 - 1 9 5 6 ) ,

Boston

President, Liberty Mutual Insurance Co. SARAH GIBSON BLANDING ( 1 9 4 9 - 1 9 5 6 ) ,

Poughkeepsie

President, Vassar College *LESTER BRESLOW, M.D. ( 1 9 5 4 - 1 9 5 6 ) ,

Berkeley

Chief, Bureau of Chronic Diseases, California Department of Public Health DAVID BROCK, D.D.S. ( 1 9 5 2 - 1 9 5 6 ) , St.

Louis

Chairman, Council on Dental Health, American Dental Association MRS. W . DONALD BROWN ( 1 9 5 0 - 1 9 5 6 ) ,

Minneapolis

Attorney LEROY E . BURNEY, M.D. ( 1 9 5 3 - 1 9 5 6 ) ,

Washington

Assistant Surgeon General, Deputy Chief, Bureau of State Services, Public Health Service S. D E W I T T CLOUGH ( 1 9 4 9 - 1 9 5 5 ) ,

Chicago

Managing Director, Chicago Heart Association WARD DARLEY, M.D. ( 1 9 4 9 - 1 9 5 3 ) ,

Denver

President, University of Colorado JOSEPH W . FICHTER ( 1 9 4 9 - 1 9 5 6 ) , Oxford,

Ohio

Chairman, Ohio Farmers Union GEORGE A . HABERMAN ( 1 9 4 9 - 1 9 5 0 ) ,

Milwaukee

President, Wisconsin Federation of Labor E . L . HARMON, M.D. ( 1 9 5 4 - 1 9 5 6 ) , Valhalla,

N.Y.

Director, Grasslands Hospital MARK H . HARRINGTON ( 1 9 5 0 - 1 9 5 5 ) ,

Denver

Past President, National Tuberculosis Association CHARLES H . HOUSTON ( d e c e a s e d ) ( 1 9 4 9 - 1 9 5 0 ) ,

Washington

Attorney *RUTH HUBBARD, R.N. ( d e c e a s e d ) ( 1 9 5 3 - 1 9 5 5 ) ,

Philadelphia

General Director, Visiting Nurse Society of Philadelphia •Served previously as technical adviser.

MRS. R . LIVINGSTON IRELAND ( 1 9 4 9 - 1 9 5 6 ) ,

Cleveland

Chairman, Committee on the Chronically 111, Welfare Federation of Cleveland ANDREW C . IVY, PH.D., M.D. ( 1 9 4 9 - 1 9 5 1 ) ,

Chicago

Vice-President, University of Illinois MRS. HUGH KIRKLAND ( 1 9 4 9 - 1 9 5 1 ) , Santa Barbara LEONARD W . LARSON, M.D. ( 1 9 5 1 - 1 9 5 4 ) , Bismarck,

N.D.

Member, Board of Trustees, American Medical Association SAMUEL L . LATIMER, IR. ( 1 9 4 9 - 1 9 5 6 ) , Columbia,

S.C.

Editor and Publisher of The State THOMAS A . MCGOLDRICK, M.D. ( d e c e a s e d ) ( 1 9 4 9 - 1 9 5 2 ) , KARL P . MEISTER ( 1 9 4 9 - 1 9 5 6 ) , Chicago

Brooklyn

Executive Secretary, Methodist Board of Hospitals and Homes JAMES R . MILLER, M.D. ( 1 9 4 9 - 1 9 5 6 ) ,

Hartford

Connecticut Commission for the Care and Treatment of the Chronically 111, Aged and Infirm * HENRY B . MULHOLLAND, M.D. ( 1 9 5 0 - 1 9 5 6 ) ,

Charlottesville

Professor, Department of Internal Medicine, University of Virginia School of Medicine MOST REV. WILLIAM T . MULLOY ( 1 9 4 9 - 1 9 5 4 ) , Covington,

Ky.

Bishop of Covington THOMAS P . MURDOCK, M.D. ( 1 9 5 1 - 1 9 5 6 ) , Meriden,

Conn.

Member, Board of Trustees, American Medical Association PETER H . ODEGARD ( 1 9 4 9 - 1 9 5 3 ) ,

Berkeley

Chairman, Department of Political Science, University of California THOMAS PARRAN, M.D. ( 1 9 4 9 - 1 9 5 6 ) ,

Pittsburgh

Dean, Graduate School of Public Health, University of Pittsburgh ELLEN C . POTTER, M.D. ( 1 9 4 9 - 1 9 5 6 ) ,

Trenton

Advisory Council on the Chronic Sick, New Jersey Department of Health *OLLIE A . RANDALL ( 1 9 5 3 - 1 9 5 6 ) , New

York

Vice-Chairman, National Committee on the Aging WALTER P . REUTHER ( 1 9 4 9 - 1 9 5 5 ) ,

Detroit

President, Congress of Industrial Organizations DEAN W . ROBERTS, M.D. ( 1 9 4 9 - 1 9 5 6 ) ,

Baltimore

Director, Commission on Chronic Illness EDWARD S . ROGERS, M.D. ( 1 9 4 9 - 1 9 5 6 ) ,

Berkeley

Professor of Public Health and Medical Administration, University of California School of Public Health MEFFORD R . RUNYON ( 1 9 5 3 - 1 9 5 6 ) , New

York

Executive Vice-President, American Cancer Society MRS. RAYMOND SAYRE ( 1 9 4 9 - 1 9 5 2 ) , Ackworth,

Iowa

President, The Associated Women of the American Farm Bureau Federation SIDNEY L . SCHWARZ ( 1 9 4 9 - 1 9 5 3 ) ,

Chicago

Industrialist MRS. LUCILLE M . SMITH ( 1 9 4 9 - 1 9 5 6 ) ,

Washington

Chief, Health Services Organization Branch, Division of Public Health Methods, Public Health Service ALBERT W . SNOKE, M.D. ( 1 9 4 9 - 1 9 5 4 ) , New

Haven

Director, Grace-New Haven Community Hospital ERNEST L . STEBBINS, M.D. ( 1 9 5 2 - 1 9 5 6 ) ,

Baltimore

Director, Johns Hopkins School of Hygiene and Public Health R T . REV. CHARLES A . TOWELL ( 1 9 5 4 - 1 9 5 6 ) , Ludlow,

Ky.

Diocesan Director of Hospitals WILLIAM C . TREUHAFT ( 1 9 5 4 - 1 9 5 6 ) ,

Cleveland

President, Tremco Manufacturing Co. THOMAS J . S. WAXTER ( 1 9 4 9 - 1 9 5 6 ) ,

Baltimore

Director, Maryland State Department of Public Welfare * Served previously as technical adviser.

TECHNICAL ADVISERS Washington Assistant Chief, Division of Special Health Services, Public Health Service DONALD B . ARMSTRONG, M.D., Scarborough, New York DANIEL G . BLAIN, M.D., Washington Medical Director, American Psychiatric Association Ε . M . BLUESTONE, M.D., New York Consultant, Montefiore Hospital ERNST BOAS, M.D. (deceased), New York ROBERT ANDERSON, M.D.,

I. JAY BRIGHTMAN, M.D.,

Albany

Assistant Commissioner for Welfare Medical Services, New York State Department of Social Welfare CHARLES S. CAMERON, M.D., New York Medical and Scientific Director, American Cancer Society A. L . CHAPMAN, M.D., New York Regional Medical Director, U.S. Department of Health, Education and Welfare MARTIN CHERKASKY, M.D., New York Director, Montefiore Hospital ELEANOR COCKERILL, Pittsburgh School of Social Work, University of Pittsburgh N I L A COVALT, M.D., Winter Park, Florida DONALD H . DABELSTEIN, Washington Assistant Director, Office of Vocational Rehabilitation, U.S. Department of Health, Education, and Welfare THOMAS D . D U B L I N , M.D., Bethesda, Md. National Institutes of Health R U T H F R E E M A N , R.N., Baltimore Associate Professor of Public Health Administration, Johns Hopkins University School of Hygiene and Public Health VLADO A . GETTING, M.D., Ann

Arbor

Professor of Public Health Practice, University of Michigan School of Public Health E n GINZBERG, New York Graduate School of Business, Columbia University BELL GREVE,

Cleveland

Director, Cleveland Department of Health and Welfare MARY JARRETT, New York FRODE J E N S E N , M.D., New York T . D U C K E T T JONES, M.D. (deceased), New York Medical Director, Helen Hay Whitney Foundation ALBERT KAISER, M.D. (deceased), Rochester, N.Y. Health Officer, Health Bureau, Department of Public Safety A. B. C. KNUDSON, M.D.,

Washington

Director, Physical Medicine and Rehabilitation Service, Veterans Administration MARCUS D. KOGEL, M.D., New York Dean, Albert Einstein College of Medicine, Yeshiva University WILLIAM B. KOUNTZ, M.D., St.

Louis

Division of Gerontology, School of Medicine, Washington University ARNOLD KURLANDER, M.D., Washington Medical Director, Chief, Chronic Disease Program, Division of Special Health Services, Public Health Service GRANVILLE W . LARIMORE, M.D., Albany Director, Office of Public Health Education, New York State Department of Health MORTON L . LEVIN, M.D.,

Albany

Assistant Commissioner, New York State Department of Health

Washington Chief, Bureau of Medical Services, Public Health Service EDNA NICHOLSON, Chicago Executive Director, Institute of Medicine of Chicago JAMES E . PERKINS, M.D., New York Managing Director, National Tuberculosis Association G E O R G E S T . J . PERROTT, Washington Chief, Division of Public Health Methods, Public Health Service MARIAN RANDALL, R.N., New York Executive Director, Visiting Nurse Service of New York HOWARD A. R U S K , M.D., New York Associate Editor, The New York Times EDWARD J . STIEGLITZ, M.D., Washington E U G E N E J . TAYLOR, New York The New York Times E L L A Μ . T H O M P S O N , R.N., New York Secretary, National Association for Practical Nurse Education H A R T E . V A N R I P E R , M.D., New York Medical Director, National Foundation for Infantile Paralysis JACK MASUR, M.D.,

STAFF

American Dental Association

American Hospital

A L L E N O . G R U E B B E L , D.D.S.

American Medical

P H I L I P W . PHAIR, D.D.S.

American Public Health

Association

MAURICE J . N O R B Y

R . H . FRIEDRICH, D.D.S.

Association

G E O R G E W . COOLEY

Association

American Nurses

JONAS N . M U L L E R , M.D.

Association

M R S . MARGARET F . CARROLL, R.N.

M I L T O N TERRIS, M.D.

National League for Nursing

American Public Welfare Association

R U T H F I S H E R , R.N.

PEARL BIERMAN LOULA D U N N

DORO-ΙΉΥ RUSBY, R.N.

STAFF

DEAN W . ROBERTS, M.D., Director MORTON L . LEVIN, M.D., Director PETER G . MEEK, Assistant BEATRICE BOSSERT SARA BOWDITCH, M.D. M R S . MARGERY R . CUNNINGHAM CHARLES M . W Y L I E , M.D.,

* On detail from Public Health Service

(1952-1956) (1950-1951) Director

MARVIN GLASSER MARY H I R O N S DEAN E . KRUEGER* CH.B., DR.P.H.

CONTRIBUTORS A M E R I C A N CANCER SOCIETY A M E R I C A N D E N T A L ASSOCIATION A M E R I C A N H E A R T ASSOCIATION A M E R I C A N HOSPITAL ASSOCIATION A M E R I C A N MEDICAL ASSOCIATION AMERICAN PSYCHIATRIC ASSOCIATION A M E R I C A N PUBLIC H E A L T H ASSOCIATION ARTHRITIS AND R H E U M A T I S M FOUNDATION JOHNS H O P K I N S UNIVERSITY MUSCULAR DYSTROPHY ASSOCIATIONS OF A M E R I C A NATIONAL FOUNDATION FOR INFANTILE PARALYSIS NATIONAL M U L T I P L E SCLEROSIS SOCIETY NATIONAL SOCIETY FOR C R I P P L E D CHILDREN AND A D U L T S NATIONAL TUBERCULOSIS ASSOCIATION N E W Y O R K FOUNDATION P U B L I C H E A L T H SERVICE

CONTRIBUTORS FOR SPECIAL

STUDIES

T H E COMMONWEALTH FUND T H E EQUITABLE L I F E ASSURANCE SOCIETY T H E LIBERTY M U T U A L INSURANCE C O M P A N Y E L I L I L L Y AND C O M P A N Y T H E METROPOLITAN L I F E INSURANCE C O M P A N Y T H E NATIONAL H E A L T H C O U N C I L T H E N E W YORK L I F E INSURANCE C O M P A N Y T H E ROCKEFELLER FOUNDATION

Preface volume is the first of a series of four on the subject of chronic illness. The series is based on the work of the Commission on Chronic Illness, the national voluntary group which, from 1949 to 1956, studied the chronic illness problem in the United States. The Commission on Chronic Illness published a number of reports during its existence, both under Commission auspices and jointly with other organizations. At the conclusion of a 7-year program, the Commission authorized the preparation and publication of a general report on Chronic Illness in the United States. This, the first volume, deals primarily with prevention. Volume II, Care of the Long-Term Patient, is the Commission's report on care and rehabilitation of patients with prolonged illness. Volume III, Chronic Illness in a Rural Area, is the report of a study made under the joint auspices of the Commission and the Hunterdon Medical Center. The study presents estimates of the prevalence of chronic illness and of care needed in a rural community —Hunterdon County, New Jersey. Volume IV, Chronic Illness in a Large City, reports on a similar study in Baltimore. THIS

For the achievement of the Commission's undertakings and the successful realization of its founders' hopes, credit goes to many individuals and groups. A share of the credit belongs to each organization and agency which has aided and supported the Commission: American Cancer Society American Dental Association American Heart Association American Hospital Association American Medical Association American Psychiatric Association American Public Health Association American Public Welfare Association Arthritis and Rheumatism Foundation Commonwealth Fund Equitable Life Assurance Society Johns Hopkins University Liberty Mutual Insurance Company xi

xii

PREFACE

Eli Lilly and Company Metropolitan Life Insurance Company Muscular Dystrophy Associations of America National Foundation for Infantile Paralysis National Health Council National Multiple Sclerosis Society National Society for Crippled Children and Adults National Tuberculosis Association New York Foundation New York Life Insurance Company Public Health Service Rockefeller Foundation The Commission was fortunate to have as members during various periods of the 7-year program, the 46 persons listed on pages v-vi. The Commission members contributed their services, and they were most generous in devoting time and energy to a highly complex problem. The thoughtful and considered judgment of the members is reflected in all the work of the Commission, but especially in Part I of this volume and in Volume II which are built around conclusions and recommendations expressing the Commission's own views with regard to major questions concerning the prevention of chronic disease, illness and disability, and the care of long-term illness. I wish to mention one member in particular and to acknowledge here his contribution in launching and sustaining the Commission in its early days. If I had a citation to give for vision and leadership in the field of chronic illness, for devotion to the community as well as to the individual patient, I would give it to Dr. James R. Miller, of Hartford, Connecticut, chairman of the Interim Commission that set up and organized the Commission on Chronic Illness. Fortunately, Dr. Miller was fully supported by other individuals and groups, including the sponsoring organizations and the members of the Interim Commission. Thanks, too, are due the 41 experts who served as technical advisers to the Commission, providing to the members the expert knowledge of the various facets of the broad problem that was so essential. Another equally valuable service was performed by the 7 staff associates who provided skillful liaison with the organized fields of activity which they represented, i.e., dentistry, hospitals, medicine, nursing, public health, public health nursing, and public welfare. The ability and willingness of these latter individuals to bring a sympathetic understanding to consideration of problems broader than their own immediate sphere of

xiii

PREFACE

interest but common to all contributed greatly to the happy combination of professional interests which the Commission's program represented. I cannot stress too much the value of the staff services from which the Commission benefited. Dr. Dean W. Roberts, Director from 1952 to 1956; Peter G. Meek, Acting Director from 1951 to 1952; Dr. Morton L. Levin, Director from 1950 to 1951; and Mrs. Lucille M. Smith, who was Acting Executive Secretary during 1949 pending Dr. Levin's assumption of his duties—all made contributions of the highest order in organizing, conducting, and giving leadership to the Commission. The entire staff admirably served the development of the Commission's program. Finally, we are deeply grateful to the Commonwealth Fund which, in addition to generous support of our research projects in Baltimore and in Hunterdon County, New Jersey, has made possible the publication of the four volumes of this report. LEONARD W .

MAYO

Chairman, Commission on Chronic Illness November 1956

Introduction Chronic disease is a problem whose scope is as great as the total population of the country. Each member of the population is a potential victim and, to the extent that control is possible, the key to individual control lies with the individual. While all are possible targets of chronic disease and the largest number of victims are under 65 years of age, older persons are more likely to be disabled by chronic conditions. In a population such as ours in which the proportion of older persons is growing, the chronic diseases, unless they are controlled, will become an increasing problem. In 1950, an estimated 28 million Americans were suffering from disabling and nondisabling chronic disease or impairment. There is no reason to think that this number has decreased. All 169 million Americans are concerned with the control of chronic disease for, to the extent that we know what to avoid, each of us must make his own moves of avoidance. Chronic disease poses a mosaic of problems. The subject of vast and diversified current effort, its many facets must be studied from many different angles. Two major aspects are: the prevention, either of occurrence or of progression; and the care and rehabilitation of those who are ill or disabled. Prevention is the subject of this, the first volume of the Commission's four-volume report, Chronic Illness in the United States. Dr. Leonard A. Scheele, formerly Surgeon General of the Public Health Service, has said: Of all the medical and social aims in the field of chronic disease, prevention is probably the most difficult of achievement. At the present time, the body of scientific knowledge on prevention is smaller than that on any other aspect of chronic disease except etiology. And . . . prevention is so dependent upon a knowledge of causes—both primary and secondary—that the two can scarcely be considered separately. The formidable gaps in scientific knowledge, however, are not the sole or even the most important obstacles to a large-scale preventive effort. We do have some fundamental knowledge and a few measures proved to be preventive in some chronic diseases. The great obstacle to prevention is the development of methods for complete application XV

xvi

INTRODUCTION

of the knowledge and measures we possess. The difficulties of application affect both research and practice. 1 Clinical and public health practices still lag in utilizing the existing knowledge and measures for the prevention of chronic disease. To bring about maximum utilization poses problems of professional education, of organization, and of administration. How can the concept of prevention be instilled in students of medicine, nursing, social work, health education, and related disciplines? What organizational patterns will be most effective for the administration of preventive programs? How can the public be moved to adopt and support preventive measures? Answers to these and many other questions are essential if the prevention of chronic disease is ever to be more than an intellectual concept. Human beings are moved by experience. At present, prevention is largely an idea in the minds of a small proportion of professional and public leaders. Prevention has little of the motivating reality of pain. And pain not only sends patients to the physician; it also sends to professional schools and to laboratories students and investigators who are moved by a desire to relieve or avert pain such as they have felt themselves or witnessed in their families or friends. The medical and related professions must acquire a persistent and insistent awareness of the asymptomatic forms of chronic disease, of the chronic complications of disease in general, and of the biological, social, and environmental factors that cause chronic disease. The entire population needs not only an awareness of the biological, social, and environmental causes of chronic disease; but even more, an awareness of those physical and mental deviations from the normal that should be studied and evaluated by a physician. The creation of professional and public awareness is not an easy task. There are so many apparently conflicting facts about chronic disease, and so much difficulty in assessing the results of early detection and treatment or of social and environmental controls. Moreover, the range of human sensitivity is incredibly wide. In a London study a significant proportion of the persons examined had signs of chronic disease so severe that the examiners were amazed that the patients had sensed no marked discomfort. An even larger proportion of persons had various defects which health agencies commonly warn are predisposing to 1 Proceedings of the Conference on Preventive Aspects of Chronic Disease. March 12-14, 1951. Baltimore, Commission on Chronic Illness, pp. 31-32. (Out of print.)

INTRODUCTION

xvii

chronic disease. Yet these people also had no sense of ill health.2 The most ardent proselyte for wearing protective goggles in certain occupations is the man who has been saved from blindness and can display the cracked lens that stopped the sliver of steel. But the man who has had a benign tumor removed can scarcely display the specimen nor can he be sure that he has been saved from cancer. In educating the public for prevention, a psychological equivalent for experience is needed until such time as more persons can have vivid, first-hand experiences with prevention. At present, the prevention of severe forms of many chronic diseases depends largely upon early detection. Usually, this implies the discovery of asymptomatic cases by means of screening procedures, examination, and diagnosis. Good evidence exists that the severe forms of chronic disease and of chronic complications can be averted by early treatment. The difficulty is that the majority of cases which come to treatment are already in severe or advanced forms. The medical profession and the health agencies have wrestled with this problem for many years without notable results—except in the control of tuberculosis and syphilis, and, more recently, of rheumatic and congenital heart disease and of poliomyelitis. Since prevention must become the basic approach to chronic disease, it is logical that the first volume of a comprehensive presentation of the problems of chronic illness should be concerned with preventing the occurrence or the progress of disease. Part I of this volume presents 21 conclusions and recommendations concerning prevention which were adopted by the Commission in February 1956. The supporting text draws upon the Commission's many activities in regard to prevention, especially its first endeavor in that field—the National Conference on the Preventive Aspects of Chronic Disease, held in Chicago on March 12-14, 1951.3 The National Health Council and the United States Public Health Service cosponsored the Conference; 43 other organizations "participated," thus bringing together a wide range of private and public agencies concerned with chronic diseases. The Conference brought together 198 persons from 22 states. The delegates included physicians, dentists, nurses, social workers, teachers, ' Pearse, I n n e s H., M . D . , and C r o c k e r , L u c y H . The Peckham Experiment; A Study in the Living Structure of Society. L o n d o n , G e o r g e Allen a n d U n w i n , 1943. s Proceedings of the Conference on Preventive Aspects of Chronic Disease, loc. cit.

xviii

INTRODUCTION

health educators, statisticians, and other persons engaged in health work. The Conference operated through 12 working committees arranged in 5 sections. These sections and committees and their chairmen were: Evaluation of Scientific Data Primary Prevention—T. Duckett Jones, M.D., Helen Hay Whitney Foundation, New York Early Detection and Screening—David D. Rutstein, M.D., Harvard University Medical School, Boston Prevention in Medical Practice Primary Prevention—David Seegal, M.D., College of Physicians and Surgeons, Columbia University, and Goldwater Memorial Hospital, New York Early Detection and Screening—Martin Cherkasky, M.D., Montefiore Hospital, New York Professional Information and Training—Edward J. Stieglitz, M.D., Washington, D.C., Section Chairman Education of Physicians and Dentists—Ward Darley, M.D., University of Colorado School of Medicine, Denver Education of Nurses—Irene L. Beland, R.N., Wayne University School of Nursing, Detroit Education of Social Workers—Dora Goldstine, University of Chicago School of Social Service Administration, Chicago Education of Teachers and Health Educators—Frank Stafford, Ph.D., Office of Education, Federal Security Agency, Washington, D.C. Community Organization and Services Primary Prevention—John W. Ferree, M.D., American Heart Association, New York Early Detection and Screening—Lester Breslow, M.D., California Department of Public Health, Berkeley Public Education Primary Prevention—Beryl J. Roberts, Harvard University School of Public Health, Cambridge Early Detection and Screening—Granville W. Larimore, M.D., New York State Department of Health, Albany The Conference was organized to meet eight major objectives: To focus national attention on prevention and early detection and screening as the basic long-range approach to the chronic disease problem.

INTRODUCTION

xix

To stimulate the preparation of authoritative summaries of existing scientific knowledge applicable to the prevention and early detection of some of the most important chronic diseases. To find ways to utilize this knowledge more fully. To emphasize the common denominators in the problems to be overcome in the prevention and early detection of the chronic diseases. To provide a means for simultaneously directing the attention of experts, in each professional and community group concerned, to the problem of prevention and early detection of chronic disease. To set up guideposts for cooperative community planning of prevention and early detection programs, and to encourage working agreements between agencies on methods for coordinating their efforts. To delineate areas and problems which seem most important for scientific and administrative research. To summarize in a published report the Conference proceedings and recommendations regarding prevention and early detection of chronic disease. Part I was prepared under the direction of an editorial committee composed of Lester Breslow, M.D. and Henry B. Mulholland, M.D., members of the Commission; and Arnold B. Kurlander, M.D., a technical adviser to the Commission. Edward B. Kovar was given a leave of absence by the Subcommittee on Chronic Disease and Rehabilitation of the American Public Health Association to do much of the original drafting of this part of the book. Mrs. Lucille M. Smith, assisted by Miss Martha D. Ring, took responsibility for editing the original draft and preparing the manuscript for the publisher. Part II is a series of summaries on the preventive aspects of most of the major chronic diseases and impairments and on several of the most important factors contributing to them. These summary statements, prepared originally for the National Conference on the Preventive Aspects of Chronic Disease, were revised in 1956 by the individuals or organizations originally responsible for their preparation. This section of this book was developed for the Commission under the editorial direction of Alice M. Waterhouse, M.D., Division of Public Health Methods, Public Health Service, Department of Health, Education, and Welfare. She also assisted the editorial committee in planning and reviewing the entire manuscript. Working with Dr. Waterhouse on Part II were the national voluntary health agency concerned with each disease and the appropriate administrative arm of the Public Health Service. In a few instances, a nationally recognized authority not officially asso-

XX

INTRODUCTION

dated with either a voluntary health organization or a governmental agency in the field prepared the summary statement. Appendix A describes the origin and history of the Commission on Chronic Illness, included here primarily to provide a permanent record of the activities of the temporary national organization responsible for the total report. D E A N W . R O B E R T S , M.D.

Director, Commission on Chronic Illness November 1956

Contents Page Preface

xi xv

Introduction Part I Prevention: Its Role and Objectives CHAPTER

1

Prevention

3

CHAPTER

2

Promotion of Health

8

CHAPTER

3

Primary Prevention

CHAPTER

4

16

Secondary Prevention through Periodic Health Examinations

28

CHAPTER

5

Secondary Prevention through Screening Examinations 45

CHAPTER

6

Personnel and Education

69

CHAPTER

7

Community Planning for Prevention

88

CHAPTER

8

Conclusions and Recommendations

104

Part II Summaries of Information on Prevention of Selected Chronic Diseases and Contributory Factors CHAPTER

9

CHAPTER

10 Blindness

Arthritis and Rheumatism

111 120

CHAPTER

11 Cancer

126

CHAPTER

12 Cardiovascular Diseases

144

CHAPTER

13 Cerebral Palsy

159

CHAPTER

14 Diabetes Mellitus

166

CHAPTER

15 Epilepsy

172

CHAPTER

16 Impaired Hearing

182

CHAPTER

17 Mental Illness

191

CHAPTER

18 Multiple Sclerosis

199

CHAPTER

19 Poliomyelitis

205

CHAPTER

20 Late Manifestations of Syphilis

217

CHAPTER

21 Tuberculosis

222

CHAPTER

22 Chronic Disease in Industry

229

xxi

xxii

CONTENTS

Page CHAPTER

23

Dental Health and Chronic Disease

236

CHAPTER

24

Emotional Factors in Chronic Disease

243

CHAPTER

25

Heredity as a Factor in Chronic Disease

251

CHAPTER

26

Malnutrition and Obesity as Factors in Chronic Disease

267

Appendices APPENDIX

A

Brief History of the Commission on Chronic Illness

285

APPENDIX

Β

Articles of Incorporation and Bylaws

312

APPENDIX

C

List of Publications

318

APPENDIX

D

Definitions

320

APPENDIX

Ε

Largely Controllable, Partially Controllable, Largely Uncontrolled Chronic Illnesses

Index

322 327

PART I

Prevention: Its Role and Objectives

Chapter

1 Prevention WHAT IS IT, TO WHOM APPLICABLE, WAYS TO EXTEND IT

"The basic approach to chronic disease must be preventive. Otherwise the problems created by chronic diseases will grow larger with time, and the hope of any substantial decline in their incidence and severity will be postponed for many years." 1 This idea was still fairly novel when adopted in 1947 by four major national organizations as their credo for planning for the chronically ill. It attracted immediate and widespread interest which increased and took on new meaning even during the short life of the Commission on Chronic Illness (19491956). In addressing the final meeting of the Commission in February 1956, Surgeon General Scheele summarized this progress most dramatically. For his presentation Dr. Scheele drew upon the information presented in Part II of this volume—the statements summarizing present knowledge concerning prevention of the major chronic conditions. In Dr. Scheele's analysis of the salient points in these statements, he stressed four concepts that are evident in the rapidly changing preventive approach to chronic disease:2 Unity of service—viewing medicine as a whole fabric rather than as separate preventive-curative-restorative "services for any type of illness, acute or chronic, infectious or noninfectious, local or systemic. . . ." Recognition of the multiple causation of most chronic disorders . . . the interplay of "genetic factors, stress reactions, metabolic and endocrine factors, and the interaction of the host—under various conditions and at different times of life—with a wide variety of exogenous agents, including viruses, poisons, drugs and radioactive substances." 1 "Planning for the Chronically 111." A Joint Statement of Recommendations by the American Hospital Association, American Medical Association, American Public Health Association, and American Public Welfare Association. See Journal of the American Medical Association 135:343, October 11, 1947; American Journal of Public Health 37:1257, October 1947; Public Welfare 5:218, October 1947. 'Scheele, Leonard Α., M.D. "Progress in Prevention of Chronic Illness, 1 9 4 9 1956." Journal of the American Medical Association 160:1114-1117, March 31, 1956.

3

4

P R E V E N T I O N OF C H R O N I C ILLNESS

New vistas in maintenance and promotion of health—recognition that, although we should not relax our efforts to prevent chronic illness among older people, we should greatly intensify our efforts for groups thought to be the "healthiest." Prevention must start with infants and their mothers, children, and young people. New goals in treatment incorporating new medical and psychological concepts, avoiding methods of the past that contributed to chronicity and disability. PREVENTION AND CHRONIC DISEASE DEFINED

Early in its history the Commission decided that prevention, in its narrowest sense, means averting the development of a pathological state; more broadly it includes also all the measures which halt progression of disease to disability or death. Under the broader definition, all definitive treatment of disease may be considered preventive. In this volume, however, treatment will be discussed only in its relationship to prevention, reserving fuller discussion of treatment for Volume II. The definition of chronic disease adopted by the Commission—like that of prevention—is a broad one. Chronic disease comprises all impairments or deviations from normal which have one or more of the following characteristics: are permanent; leave residual disability; are caused by nonreversible pathological alteration; require special training of the patient for rehabilitation; may be expected to require a long period of supervision, observation, or care. EXPANDING OPPORTUNITIES FOR PREVENTION

Challenging opportunities appear on every hand in the practice of modern medicine for using known preventive measures against chronic disease. Dr. David Seegal in 1951 described these prospects in the following terms: In my student days medicine had very little to offer the patient with severe diabetes mellitus, pernicious anemia, congenital heart disease, Addison's disease, rheumatoid arthritis, or cirrhosis of the liver, to name a few chronic illnesses. Today the situation is much different as you well know. With this fine record over the past 40 years and the present pace of research, is it not possible that the medical student of 1975 or 2000 may add hypertension or arteriosclerosis or cancer or all three to the list of preventable or controllable chronic diseases?3 3 See Appendix Ε for excerpts from Proceedings of the Conference on Preventive Aspects of Chronic Disease. March 12—14, 1951. Baltimore, Commission on Chronic Illness. (Out of print.)

PREVENTION

5

The 1951 Conference on Preventive Aspects of Chronic Disease presented a list of long-term diseases and conditions which could be largely controlled if our present knowledge were fully applied. These diseases are: diabetes mellitus, pernicious anemia, syphilis, hyperthyroidism, myxedema, hyperparathyroidism, sprue, "alcoholic" neuritis, pellagra, beri-beri, scurvy, rickets, hookworm infestation, malaria, amebiasis, thrombocytopenic purpura, and familial hemolytic jaundice. Another 27 diseases and conditions with long-term manifestations were listed as being "only partially controllable." A third group of 7 illnesses—each, however, with a tremendous potential for causing longterm disability and premature mortality—was described as still in the "largely uncontrollable" category. These were: certain congenital defects, certain neurological diseases, certain psychoses, certain neoplasms, chronic glomerular nephritis, hypertension, and arteriosclerosis. We cannot relax our efforts to find new and more effective ways of preventing all these diseases. The present challenge to the health professions is, first, to see that what is already known concerning prevention becomes part of the knowledge of all the health professions, and indeed of all the people. This volume of the Commission's series is dedicated to that purpose, for the Commission is convinced that full application of what is presented in this volume "would so reduce the burden of chronic disease that the effects on the economic, social, and health status of the American people could be likened to the first great triumphs of preventive efforts against epidemic diseases."4 Second, we must add to the list of diseases for which primary prevention is effective. Simultaneously, knowledge must be acquired and applied to reduce the number of diseases that still must be labeled "largely uncontrollable" or "only partially controllable." Recent years have seen great expansion in the recognition, in the United States and other countries, of the importance of research which will increase our knowledge of how to prevent chronic disease. Vast sums of money are being expended for the conduct of this research and, more recently, for the training of research personnel and the construction and improvement of research facilities. New patterns of education for health personnel—emphasizing prevention—are also emerging, as is shown in Chapter 6 of this volume and in Chapter 5 of Volume II; and the journals of the professional medical associations are replete with articles designed to extend concepts of prevention. Comparatively less effort, however, is being made to bring to the 4

Scheele, op. cit., p. 1117.

6

PREVENTION OF CHRONIC ILLNESS

attention of the general public appreciation of each individual's role in this preventive effort. Environmental hygienists can fluoridate the water supply to protect the community against dental caries and pasteurize the milk supply to prevent milk-borne infections. The physician can vaccinate against poliomyelitis. But only the individual can control his own food intake, rest, exercise, consumption of alcohol and cigarettes, home accident hazards, and many other factors which we are learning play a role in chronic illness. Emphasizing the importance of each individual's responsibility for controlling chronic illness, the Commission adopted as its first recommendation on prevention the following: 1. Individual initiative is vital in the prevention of chronic disease. The public — a l l of us—should incorporate in our daily lives the recognized precepts of preventive medicine a n d should cooperate fully in practical programs of preventive medicine once they have been worked out by the professions concerned.

STEPS TOWARD PREVENTION

Prevention of chronic illness and disability requires mobilization of individual and public resources, in all aspects of health protection and health care. Freedom from chronic illness can be achieved only through united efforts: (1) toward health promotion; (2) toward averting the occurrence of illness; and (3) toward early detection of disease through health examinations and mass screening programs to assure treatment in the early stages that will prevent disability or premature death. The chapters that follow discuss the opportunities and responsibilities for prevention in each of these stages as well as the need for continuing effort toward education and community organization. The chapter on promotion of health is directed particularly to the general public; and that on primary prevention to the general public as well as the health professions. The two chapters on secondary prevention—through periodic health examinations and through screening examinations—will be of most interest to health personnel and to organized agencies and industries that are concerned with developing these types of preventive measures. The chapter on personnel and education is designed to stimulate curriculum changes, to underscore the need for great increases in health personnel, and to present some important concepts concerning public education for prevention. The chapter on community planning discusses why and how the many organizations that must be involved can work together to achieve the preventive objective.

PREVENTION

7

Throughout Part I the Commission presents the common denominator approach which it strongly endorses. This approach, of course, must rest on a knowledge of the causes and measures for preventing the diseases and conditions which account for the bulk of chronic illness and disability, and for which some measures of prevention and control are known. These today are the subject of extensive research and much still needs to be learned about them. The fact remains, however, that what is known is not being fully applied. Accordingly, Part II presents for the use of educators, practicing health personnel, community health and welfare agencies, and the general public what is currently known about preventive aspects of the following major chronic illnesses and impairments and certain factors influencing their occurrence: Arthritis and rheumatism Blindness Cancer Cardiovascular diseases Cerebral palsy Diabetes mellitus Epilepsy Impaired hearing Mental illness Multiple sclerosis Poliomyelitis

Late manifestations of syphilis Tuberculosis Chronic disease in industry Dental health and chronic disease Emotional factors in chronic disease Heredity as a factor in chronic disease Malnutrition and obesity as factors in chronic disease

Chapter

2 Promotion of Health Health is defined in the World Health Organization's basic charter as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. For the vast majority of mankind in the world today, health, thus defined, is obviously a goal to aspire to, rather than a condition that is realistically attainable. War, international rivalry, revolutions, widespread poverty and disease, and widely prevalent social and economic dislocations are major barriers to the achievement of positive health for people in many parts of the world. Even in a country as prosperous as the United States, health in this sense is far too rare. The promotion of positive health, however, is an increasingly important motivation underlying all our health activities. RELATIONSHIP TO OTHER FORMS OF

PREVENTION

A precise distinction between the concept of "promotion of health" and that of "primary prevention" of chronic illness is impossible. In one sense, "promotion of health" may be viewed as general primary prevention. It helps to avoid the occurrence of illness by encouraging achievement and maintenance of an optimum level of health throughout a person's life. Specific primary prevention, on the other hand, is usually related more directly to prevention of particular diseases. Despite the fact that health promotion and primary prevention are closely related, they differ materially in basic orientation. Health promotion is "health-oriented"; it emphasizes maintenance of health rather than prevention of disease. Primary prevention, on the other hand, is basically "disease-oriented"; its major emphasis is on averting the occurrence of disease. The Commission on Chronic Illness has recognized the key importance of promotion of health in its second recommendation on prevention which adds specific factors to the first that emphasized individual responsibility: 8

PROMOTION OF HEALTH

9

2. Proper nutrition, mental hygiene, adequate housing, an appropriate balance between work and play, rest and exercise, and a useful and productive place in society, are among the best recognized factors contributing to maintenance of optimum health. Attention to these factors, both in the formative years and throughout adult life, will do much to create attitudes of zest and purposefulness in living, and positive physical and mental health generally. A primary goal of community agencies concerned with health problems should be to promote appreciation of the value of these factors.

SOME COMPONENTS OF HEALTH PROMOTION

The average pediatrician spends less than half his time treating major or minor illnesses; more than half his activities are divided between prevention of illness through immunization and promotion of health through advice and counsel.1 With the current and expanding medical knowledge of ways to maintain health among adults as well as children, promotion of health will assume ever greater significance in preventing chronic illness. What are the most important components of healthful living? Among them are: Nutrition—adequate, safe, and well-distributed food supplies as well as appropriate levels of personal nutrition. Mental hygiene—beginning at an early age, it is important that the individual develop an equanimity in the face of the natural and inevitable frustrations of living; appreciation of the values of family life; acceptance of oneself and one's limitations. Adequate housing—including proper safeguards against accidents for persons of all ages, and particular safeguards for children and for the aged and handicapped. Moderate and well-balanced personal habits—restraint in use of alcohol and tobacco, sufficient rest and an appropriate amount of exercise, careful attention to personal hygiene. A useful and productive role in society. General education and education specifically for health. A safe and healthful working environment. Recreation, including access to recreational opportunities and facilities on the one hand, and proper balancing of recreational activities against satisfying work on the other. A sense of personal security, related to such things as access to health services; legalized provisions for minimum wages and some sort 1 Supplement to Child Health Services and Pediatric Education. Report of the American Academy of Pediatrics. New York, The Commonwealth Fund, 1949, Table 35. (Now published by Harvard University Press, Cambridge, Massachusetts.)

10

P R E V E N T I O N OF C H R O N I C ILLNESS

of job security; provision for income maintenance during illness or following retirement. This list is not exhaustive. Yet it is clear from its scope that promotion of health calls for both individual and social action. It shows that individuals must take considerable responsibility for maintaining their own health—for example, by obtaining sufficient rest and exercise. It also shows that society must provide certain prerequisites for healthful living —for example, nonhazardous working conditions. On a narrower front, but still within the broad framework of social action to assure healthful living conditions, are the responsibilities of health personnel and health agencies whose functions may include programs for health education (Chapter 6) or arrangements to give economically disadvantaged groups of the population ready access to health services of all kinds (Chapter 7). Health promotion aims to achieve the kind of health status for the individual described in the following quotation: A steady, glowing health is the goal. Cheerful people, full of vital strength and practicing the decorum of kindly behavior, accomplish more than grumblers and grouchers who snarl at each other. A completely healthy person meets trouble with equanimity. He has time and inclination for sociability and recreation. [He has been described as] a well-integrated individual, both as to his physical structure and as to his physiological and psychological functioning.2 Not only long-term disability, but even acute illnesses of short duration, clearly diminish the ability of an individual to attain the personal health level thus described. Moreover, the short-term illnesses that occur throughout life may result in the subsequent development of chronic conditions. Avoidance of short-term illness, to the extent possible, through the health-promotional approach is, therefore, one method of preventing chronic illness. At the other end of the health scale, among the obviously ill, healthpromotional efforts can also be effective. Even people for whom a state of "glowing health" is a remote and virtually unattainable goal retain some health potentials which should be maximized; such patients offer to the physician "an opportunity for advice not only concerning treatment of that illness and prevention of further disability from it, but also as to how the remaining health potential of that person may be 2 Building America's Health. America's Health Status, Needs and Resources. Vol. 2. A Report to the President by the President's Commission on the Health Needs of the Nation. Washington, D.C., Government Printing Office, 1953, p. 13.

PROMOTION OF HEALTH

11

maintained. Such advice extended to the remainder of the patient's family may have considerable effect in promoting health for a larger circle of individuals."3 Measures for the promotion of health should be applied, desirably, to all age groups of the population. All the components of health promotion listed earlier in this chapter are relevant in some degree to infants, young children, adolescents, young adults, middle-aged persons, and the elderly. Assurance of a "useful and productive place in society," for example, applies to children as well as to adults. A child can develop a well-balanced personality only if he feels himself to be a participating and productive member of the family group through his achievements in school or at play and through his contributions to a happy and harmonious family life. Health promotion is also important to the aged members of society. The health-promotional effect of an economically productive job (even if it is not as good as the one he has been used to) is of paramount value for the older person who is able and willing to keep on working. Many elderly persons, although basically in good health, are handicapped by the minor infirmities that often accompany old age. Correcting these minor defects helps such persons maintain a stable health status; health promotion for them, therefore, may involve such relatively simple things as dentures, spectacles, hearing aids, or canes. Often, for lack of dentures, for example, a relatively healthy older person avoids necessary food elements; with the decline in his nutritional level, his mental faculties may begin to deteriorate or he may develop some chronic physical infirmity. Health-promotional activities directed toward the older age groups should also include recreational facilities that will afford old people opportunities for enjoyable and psychologically satisfying expenditure of their time and energy. Among such facilities are social centers; "golden age" groups; public, voluntary, or union-sponsored activity or day centers; summer camps; hobby clubs and handicraft exhibits; and library (including music library) services. Examples of each of these facilities can be found throughout the United States,4 but there are still all too few of them. 'Leavell, Hugh R., M.D., and Clark, E. Gurney, M.D. Textbook of Preventive Medicine. New York, McGraw-Hill Book Company, 1953, p. 13. 4 Examples of existing facilities of this type are described in The States and Their Older Citizens. A Report to the Governors' Conference. Chicago, Council of State Governments, 1955, pp. 83-85.

12

PREVENTION OF CHRONIC ILLNESS

Nutritional Services Like so many other aspects of health promotion, nutrition is involved at all levels of prevention of chronic illness. Prevention of obesity, of underweight, and of vitamin deficiencies are ways in which nutritional management can play a significant role in promotion of health as well as in primary prevention of certain specific chronic illnesses (e.g., diabetes). As Brightman has pointed out, if the concept of "genetotrophic disease" is established "for even one disease, dietary management would have the potentiality for preventing chronic illness in a large number of persons." 5 This concept, described by Williams and others, suggests that some persons, because of their genetic constitution, need unusually large amounts of one or more specific nutrients to prevent disease.6 In secondary prevention, nutritional management may retard or arrest a disease process either directly as in diabetes or peptic ulcer, or indirectly, through prevention or correction of nutritional deficiencies caused by or associated with the disease. In addition, maintenance of adequate nutrition during acute illness may prevent development of a subsequent chronic condition. Finally, restoration of the individual to an optimum state of nutrition, with emphasis on avoidance of obesity, is a key factor in rehabilitation and may have direct bearing on ambulation, use of prostheses, and ability to provide self-care.7 In a study of the nutritional status of more than 500 healthy individuals over the age of 50, relationships were found between nutrition and general health and life expectancy in what was essentially an aging and aged population group. Among the pertinent findings of this study were: (1) further evidence of the association between overweight and increased mortality from cardiovascular disease; and (2) indications that the mortality rate of older persons with low intake of vitamin A, niacin, and ascorbic acid is higher than that of persons with greater intake of these substances.8 Health-promotional efforts need to be expanded through research, health education, and community action regarding several aspects of nutrition, chief among which are: s See Brightman, I. Jay, M.D. "Prevention of Chronic Illness—The Role of the Dietitian and Nutritionist." Journal of the American Dietetic Association 28:813, September 1952. "Williams, Roger J. "Concept of Genetotrophic Disease." Nutrition Reviews 8:257-260, September 1950. 7 Brightman, op. cit., pp. 809-814. ' Chope, Harold D., M.D., and Breslow, Lester, M.D. "Nutritional Status of the Aging." American Journal of Public Health 46:61-67, January 1956.

PROMOTION OF HEALTH

13

Improving the nutritional value of foods—There is need for more emphasis on, and research in, methods used in growing, processing, and preparing foods, so that maximum nutritive value is retained. Correcting individual dietary habits—Availability of essential foods, and even ability to buy them, does not necessarily assure adequate individual nutrition; individual instruction in dietary habits should be emphasized, particularly for adolescents (adolescent girls especially are a malnourished group) and pregnant women; practicing physicians should receive better training than most of them now have in this field and should take greater responsibility for providing such instruction. Recognizing cultural connotations of food—Cultural patterns prevalent in various regions of the country or among certain population groups should be respected in the provision of nutrition services; suggested menus for an adequate diet should be set up in line with the dietary predilections of the particular community or group concerned. Meeting nutritional needs for special groups—Among community efforts to improve nutritional status through maternal and child health programs are the provision of vitamins A, C, and D and milk for infants; school lunches and other nutritional services for children of families in marginal economic circumstances; instruction and assistance in maintenance of a balanced diet for expectant mothers; educational efforts in helping assistance recipients to obtain the maximum nutritional value from their expenditures for food; and the initiation of efforts to bring prepared meals to aged persons living alone. Mental

Hygiene

Programs

Stresses and strains threaten the average individual's mental and emotional equilibrium. Both social and personal efforts directed at maintaining equilibrium are important aspects of health promotion. 9 Little is now known about the many factors influencing mental and emotional health and the way in which they affect different personality structures. More knowledge is needed concerning the normal curve of personality growth and development, and the patterns of stress and tension during childhood and adolescence and their effect on personality structure during later life. Yet it is known that certain groups of the population are subject to greater stress than others: infants, because of their complete dependency on adults; adolescents, because of their adjustments to life outside the home; certain occupational groups, because of the continual strain arising from the nature of their work; and persons in the older age groups, because they face retirement and removal from the productive scene. Empirical knowledge of the groups in which mental and emotional equilibrium is most threatened gives a • See Chapter 24, "Emotional Factors in Chronic Disease."

14

PREVENTION OF CHRONIC ILLNESS

basis for stimulating and organizing community action and individual initiative to remove or palliate existing stresses and strains. Housing

Programs

An essential component of any program to promote health in the family and in the community is the provision of adequate and healthful homes. Proper housing promotes health in several ways: Sanitary facilities—Adequate sanitary facilities are an important factor in protection against conditions which produce disease and in promotion of individual cleanliness and hygiene. Space—Psychological as well as physical health is promoted by enough housing space to avoid overcrowding, to give each member of the family some privacy, and to reduce the possible spread of infection. Safety—Especially for children and aged persons, the home is often a collection of booby-traps; elimination of conditions in the structure of homes (steep stairways, insufficient lighting, etc.) and in their maintenance (fire hazards, slippery floors, etc.) which may lead to accidents are examples of active health promotion. Several studies, among them the National Health Survey of 19351936, have emphasized the significance of housing in relation to health status. Overcrowding—as well as other unfavorable conditions associated with low income—was demonstrated in the National Health Survey to be associated with a high rate of pneumonia, influenza, tuberculosis, and rheumatic ailments. Many improvements in present housing construction have been suggested by various groups and agencies to make modern homes more safe and comfortable for the elderly. The implementation of many of these suggestions would undoubtedly contribute immensely to maintenance of health among older persons in the population. One reason why these suggestions have not been more widely adopted, however, is that the housing needs of individual older people differ widely. A wellknown architect discussing this situation remarked that "housing projects must be designed for an entirely hypothetical and theoretical tenant who is at one and the same time completely healthy, and ridden by a variety of characteristic ailments. Housing for the elderly must accommodate the healthy and in this respect is no different from any housing but it must also accommodate the infirm." 10 "Kennedy, Robert Woods. Quoted in Housing for the Aged, Staff Report to the Subcommittee on Housing, Committee on Banking and Currency, United States Senate, 84th Congress, 2nd Session, Committee Printing, January 4, 1956, p. 18.

PROMOTION OF HEALTH

15

Education for Health Two phases of health education specially deserve emphasis in connection with promotion of health. One is the role of the family physician in educating parents and children in healthful living. The second is the role of professional leadership in community health activities as discussed in Chapters 6 and 7. Economic

Security

Good health and prosperity are closely correlated. Inadequate food, apathy toward participation in community life, emotional disturbances, poor housing, and lack of medical attention are often associated with low income and with economic insecurity. As long as adequate family income is maintained, most essentials for healthful living are normally within reach. A reasonable degree of economic security—today acknowledged to be a general responsibility of society—is therefore a health-promotional measure of the first order. One of the essentials of healthful living is easy access to health services. Large groups of our population still face an economic barrier to full use of health and medical resources. A physician may advise a patient in one of the economically disadvantaged groups to get more rest, to change occupation, to undergo surgery, or to take expensive medicine. Such advice is obviously of little preventive or therapeutic value if the cost of the steps recommended is far beyond the individual's resources or if neither physician nor patient knows about or has access to the community resources ready to supply these needs.

Chapter

3 Primary

Prevention

In setting the framework for its Conference on Preventive Aspects of Chronic Disease, the Commission adopted definitions to distinguish between two major types of prevention-—primary and secondary. Primary prevention means averting the occurrence of disease, for example, averting lung cancer by preventing human exposure to certain Chromate ore operations. Secondary prevention—discussed in the two succeeding chapters—means halting the progression of a disease from its early unrecognized stage to a more severe one and preventing complications or sequelae of disease.1 Within the narrow limits of the present definition of primary prevention, we are perhaps inclined to think only in terms of the techniques used to stamp out many acute communicable diseases after the infective agent was discovered. We fail at times to realize that preventive measures were successful even before the precise cause was identified. In 1854, removing the handle from the Broad Street pump in London was a general measure of primary prevention of cholera.2 Identification of the cholera vibrio and tracing its source to water supplies contaminated by sewage later led to more specific primary prevention through environmental sanitation. Immunization against cholera was a further step in primary prevention, protecting the immunized person from serving as a favorable host for the cholera vibrio. Reducing the reservoirs of actively infective cases prevents the spread of communicable diseases to other susceptible persons. Reducing the number of persons infected reduces the number of people suffering in later years from the chronic sequelae of many of the acute communicable diseases—hearing loss, heart involvement, and sometimes other irreversible damage to body, mind, and even offspring. 1

See Appendix D, pp. 320-321, for definitions of terms used in this volume. ' Snow on Cholera: A Reprint of Two Papers by John Snow, M.D. New York, The Commonwealth Fund, 1936. (Now published by Harvard University Press, Cambridge, Massachusetts.) 16

PRIMARY PREVENTION

17

Opportunities for primary prevention in its strictest sense are, of course, quite limited until research discloses the intricate interrelations among the various causes that seem to be involved in nearly all chronic illnesses. When the cause of a disease is identified, measures can be taken to protect human beings. For example, since silica dust has been found to be the cause of silicosis, measures can be taken to prevent its entry into the lungs, either by removal of the dust from the air or by use of masks and other protective devices when exposure is unavoidable. These measures parallel the environmental sanitation and immunization techniques in control of infectious diseases. Environmental sanitation— as developed through occupational health programs, and through measures to prevent pollution of air, water, and soil by harmful chemical, biological, and radiological products of our factories and mines—serves as primary prevention against several chronic illnesses and against congenital malformations and handicaps of future generations. The goals of primary prevention extend, on the one side, toward health promotion—increasing human resistance to the various forces that induce disease. On the other side primary prevention goals extend toward those of secondary prevention. For example, early surgical or radiological treatment of a malignant neoplasm before it starts to invade or metastasize to other organs and tissues is a means of preventing disseminated cancer. In application to chronic illness, the strict traditional definition of primary prevention must be widened because it is impossible to determine the exact point in time that signals the inception of the illness. When, for example, does schizophrenia start? or diabetes? or rheumatism? Each of these disorders, before a frank attack occurs or pain or disability is evident, has gone through a long, silent phase. It may even stem, in part, from hereditary factors. We still know little about the role of nutrition in these disorders, or about the emotional factors preceding them. Preventive measures against chronic diseases and disabilities must, of course, include sanitation, control of communicable diseases, and reduction of accidents. Preventive efforts run the gamut of medical supervision of pregnancy, attention to problems of child growth and development, and health promotion for adolescent, adult, and aged persons. Preventive efforts include also the paramount essential of individual responsibility for habits and precautions that promote continued health. The Commission thus expresses its conviction that primary prevention is a job for all of us:

18

PREVENTION OF C H R O N I C ILLNESS

3 . M a n y elements of society—particularly the health professions, the people, a n d their government—are involved in primary prevention of disease. All should strive for the fullest application of what we now know a n d for the development of new means for primary prevention.

Prospects for dramatic progress in the application of the preventive approach to long-term illness depend on research in scientific laboratories or, through the use of epidemiological techniques, in the larger laboratory of society itself. New discoveries are constantly opening up new vistas for primary prevention. Among the major disease entities and conditions to which the 1951 Conference on the Preventive Aspects of Chronic Disease devoted special attention were 10 for which, the conferees agreed, no certain method of primary prevention was yet known. These were (1) alcoholism; (2) arteriosclerosis; (3) degenerative joint disease; (4) diabetes mellitus; (5) epilepsy (inherited); (6) essential or primary hypertension; (7) multiple sclerosis; (8) primary glaucoma; (9) rheumatoid arthritis; and (10) poliomyelitis. If the Conference on the Preventive Aspects of Chronic Disease were to be reconvened now, poliomyelitis would be removed from the 1951 list. As Chapter 19 indicates, the favorable results of the field trials open "the vista of improved vaccines ultimately eliminating paralytic poliomyelitis." Given the cooperation of patients, physicians, dentists, and other personnel and agencies concerned with health, prompt and continuing application of known measures of primary prevention will result in a substantial reduction in the amount of chronic disease and impairment due to: s Blindness—resulting from retrolental fibroplasia in premature infants, from ophthalmia neonatorum, and from glaucoma. Paralytic poliomyelitis. Cardiovascular diseases—rheumatic, syphilitic heart disease, and certain types of congenital malformations. Cancer—particularly those forms associated with cancerigenic substances in industry. Deafness—particularly the forms resulting from infections and from occupational exposure to noise. Dental caries. E X A M P L E S OF MEASURES FOR PRIMARY

PREVENTION

Many examples can be cited to show how control of causative factors effectively prevents chronic illness or disability. Many of the hazards " See Chapter 5 for parallel lists of diseases that can be controlled by secondary prevention.

PRIMARY PREVENTION

19

against which current preventive attacks must be directed are those which arise from exposure to new or highly concentrated substances or to sources of accidental injury that were unknown a generation or more ago. Similarly, some therapeutic agents can play a part in primary prevention that parallels immunization in the control of communicable disease. Blindness In an earlier era, few premature babies survived their first few hours of existence. To prevent this unnecessary loss of life, centers for premature babies were established to give these infants the greatest possible chance for survival. At the Conference on the Preventive Aspects of Chronic Disease, attention was called to the fact that blindness from retrolental fibroplasia was reported by these centers as afflicting 7 per cent of the babies who weighed less than 1,500 grams at birth. The cause was then recorded as unknown; no form of treatment had proved successful though some hope was felt that vitamin Ε or A C T H therapy might help prevent the condition. Three years later, however, a dramatic series of investigations identified excessive amounts of oxygen as the major cause of retrolental fibroplasia in this group of babies. A primary preventive measure was thus revealed: administration of oxygen only when there was evidence of respiratory distress and, even then, careful restriction of the concentration of oxygen and the length of the period of administration. The significance of this new primary preventive technique cannot be overestimated. Retrolental fibroplasia was rapidly increasing as a cause of blindness and, moreover, destroyed vision at such an early age that many serious problems for the family and the community were involved in educating and training the child. Primary prevention of blindness is also possible in other instances. Many congenital cataracts can be avoided if German measles in expectant mothers is prevented through acquired immunity or through administration of gamma globulin. Protective goggles and other safety precautions can prevent the cataracts caused by exposure to radiation and the cataracts that result from eye injuries. Safeguards against such poisons as wood alcohol, arsenic, and quinine can prevent other forms of accidental blindness. Blindness due to glaucoma can also be prevented by early treatment of that disease, even though no measures are known for preventing glaucoma itself. Treatment of gonorrhea in expectant mothers and required administration of prophylactic drops to all newborn babies have already greatly reduced the prevalence of ophthalmia neonatorum.

20

PREVENTION OF CHRONIC ILLNESS

Poliomyelitis Measures to prevent the spread of poliomyelitis through environmental sanitation have thus far proved ineSectual. Much remains to be learned, of course, about the duration of the immunity conferred by the Salk vaccine. This new way to strengthen resistance to infection, however, marks significant progress in the long search for a protective vaccine. Search for new and even more effective means of protection cannot be abated. Yet this initial breakthrough in the struggle against a crippling disease of grave social and economic consequences heralds advances that can be hoped for in many other disabling illnesses of infectious origin. Cardiovascular Diseases Primary prevention of rheumatic heart disease is another striking recent gain in the struggle to avert the occurrence of a crippling chronic illness. Use of penicillin in the treatment of infections caused by the group A hemolytic streptococcus is now a preventive measure of great significance, particularly among persons and families with a previous history of rheumatic fever. Environmental sanitation, as applied in control of food-borne epidemics of the streptococcal infection and in improvement of housing conditions, is also an important step in preventing rheumatic heart disease. Association of atherosclerosis with high fat and high cholesterol intake points to the probable importance of dietary control as a form of primary prevention as well as an essential for health maintenance and health promotion. Syphilitic heart disease can be successfully averted by prompt and adequate treatment of early syphilis. Certain congenital heart disorders can be prevented by good prenatal care. Cancer Primary prevention of cancer, as pointed out earlier, involves eliminating or greatly reducing human contact with the substances implicated in cancer etiology. In industry these procedures may require closed methods of production, secondary conversion of substances to noncancerigenic materials, or safe disposal of wastes that might pollute the air, water, soil, or other environment. Studies demonstrating the association of cigarette smoking and cancer of the lung suggest as possible preventive measures the avoidance of excessive smoking or removing cancerigenic

PRIMARY PREVENTION

21

substances from cigarettes. Avoidance of overexposure to sunlight is important as a means of preventing skin cancer in people with fair complexions. Medicinal use of ionizing radiation, arsenicals, tars, and benzol should also be accompanied by special precautions to prevent cancer. The cancers of the bladder caused by exposure to some of the substances used in the dye industry can be prevented by other means of occupational and environmental sanitation. One does not need a phenomenally long memory to recall the occupational hazard discovered among persons employed in illuminating watch dials with radium paint. Cancer of the scrotum was an occupational disease among chimney sweeps in the days when human brooms were used to clean out the soot residues clogging smoke stacks. Changes in industrial and labor practice were the forms of primary prevention needed to avert the occurrence of that disease. Deafness

Syphilis, German measles and other virus diseases, and toxic conditions during pregnancy can cause impaired hearing as well as blindness in the child. Modern prenatal and obstetrical management have minimized the occurrence of both these conditions. The incidence of ear infections secondary to acute diseases of childhood has been greatly reduced by the tremendous strides in the control of infections by means of antibiotics. Removal of excessive lymphoid tissue in the nasopharynx of children is another means of preventing deafness. Rupture and other damage to the eardrum and ossicles can be prevented through protection against head injuries and through the use of ear plugs or muffs to shield the ear from explosion blasts and excessive noise. Dental

Caries

Dental caries is an important chronic disease—important not only in terms of widespread prevalence and destruction of useful tissue but also important in the sense that resulting loss of teeth may complicate the lives of aged persons suffering other disabling conditions. Two measures have been developed which have a high potential for preventing dental caries: fluoridation of the water supply; and, in the absence of fluoridated water, the topical application of fluoride for children. Fluoridation of community water supplies has been undertaken by many communities and has been endorsed by leading professional organ-

22

PREVENTION OF CHRONIC ILLNESS

izations in the field. The Commission has expressed its endorsement in these terms: 4 . American communities are urged to adopt fluoridation of water supplies, a public health measure which is a positive step in the prevention of dental caries. NEW ENVIRONMENTAL HAZARDS

New products and processes appear in rapid succession in our generation. Increase in the concentration of dust, fumes, and irritating gases in the air has presented new threats to well being. Catastrophic smogs, such as those in the industrial valley of the Meuse, in London, and in Donora, Pennsylvania, are dramatic evidence of our need to safeguard the cleanliness of the air. The fumes and dust from incinerators, gasoline engines, coal and oil furnaces, and from plants producing various chemicals are potential if not actual caiises of cancer of the lung and other chronic diseases of the respiratory system. The increasing concentration of ionizing radiation in the air, water, and soil arising from the extensive use of radiant energy in industry, medicine, and research poses other problems of safeguarding the environment. Ragweed control and further study of the pollens and other irritants that cause allergies will also reduce chronic respiratory disorders. The fact that the National Institute of Microbiology has been expanded to constitute the National Institute of Allergy and Infectious Diseases indicates that increasing attention is to be given to allergies in laboratory as well as in clinical research. Accidents rank high among causes of death in all age groups and are responsible for disability and distress among large numbers of people. Control and reduction of traffic accidents require governmental action in constructing and maintaining safe roads and highways as well as in maintaining and enforcing ordinances on the safety of automotive vehicles, the qualifications of those who run them, and the speed at which they are driven. The automobile industry, as well as the government, is increasingly concerned also with the problems of building safety devices into automotive equipment that will offset the hazards of the increased congestion of vehicles on our roads and the increased speed at which they can and do move. Poisoning—another form of accident—is assuming greater prominence than in the past as a cause of illness and death. In the medical practice of the past half century, chronic anemia, neuritis, colic, and mental depression resulting from lead poisoning were frequent, especially among painters and among young children. Environmental safe-

PRIMARY

23

PREVENTION

guards restricting exposure to lead in paint have greatly reduced these chronic conditions. The large number of new and potentially lethal products used in our farms and homes raises further problems. To aid in making the necessary information on identification and treatment available to the medical profession and to others concerned with emergency aid, poison centers have been established in Chicago, Boston, New York City, Cincinnati, Phoenix, Washington, D.C., and other cities. These centers are open day and night to provide data on the various new poisons and their antidotes.4·5 The public has recently become aware of the extent to which young children are poisoned by aspirin and other drugs in the family medicine chest and by kerosene, ammonia, lye, and other substances used in the home. Prevention of the serious effects of these accidents requires care in keeping all potentially harmful chemicals out of reach of children. Other accidents in homes can be avoided only by eternal vigilance. Sound construction of floors, stairs, roofs, walls, and furniture, adequate lighting, appropriate insulation of heating and electrical equipment rank high in essentials of home safety. Good housekeeping is equally important. When toys, tools, and other movable objects are in their places they seldom are responsible for falls, cuts, and bruises. The falls, particularly among the aged, may mean months of hospitalization for treatment of fractures; in many instances the patient may never regain use of the fractured leg or arm. RESPONSIBILITY

FOR PRIMARY

PREVENTION

People working together through government have vast resources for primary prevention of chronic illness. An important role of government in prevention of chronic illness lies in the extension of the earliest function of public health services—environmental sanitation—to some of the increased health hazards of our highly urbanized, highly industrialized, and highly motorized civilization. 5 . G o v e r n m e n t has a n important role to p l a y in p r i m a r y prevention

both

in supporting the voluntary efforts of others a n d in t a k i n g direct action in those a r e a s where o r g a n i z e d public effort is needed. It should pursue p r o g r a m s of regulation a n d

control of environmental

vigorously

and

human

factors k n o w n to contribute to disease a n d disability. A m o n g these p r o g r a m s are air pollution control, r a g w e e d control, h i g h w a y safety, home 1

accident

P r i c e , J u l i a n P., M . D . " A c c i d e n t s a n d P o i s o n i n g s in C h i l d r e n . " Public Health Reports 7 0 : 8 9 4 , S e p t e m b e r 1955. 6 " M a n and Chemicals—Poisoning Control Programs." Editorial. American Journal of Public Health 4 5 : 5 0 4 - 5 0 5 , A p r i l 1955.

24

PREVENTION OF CHRONIC ILLNESS

prevention, and fluoridation of water supplies. Government also should eng a g e in continuing research to identify other suspect or as yet unknown environmental and human factors.

Physicians and dentists in public and voluntary health organizations are the agents of society in establishing and enforcing the safeguards that rank high as measures of primary prevention. The physicians and dentists in industry have additional responsibilities: they not only maintain health supervision of the employees of industrial firms but also are in the forefront of efforts to promote safety measures that reduce the frequency and severity of occupational accidents and diseases and thus the social and economic consequences of these health hazards in the community as a whole. Physicians and dentists in private practice are equally concerned with measures of primary prevention. Summing up the responsibilities of physicians and dentists in all forms of practice, the Commission on Chronic Illness has declared: 6 . The medical and dental professions should encourage physicians and dentists to practice preventive medicine and dentistry aggressively and enthusiastically. a. In health supervision of their patients, they should provide such services as: appropriate immunizations; judicious use of antibiotic drugs in the early treatment of streptococcal infections to prevent rheumatic fever and, possibly acute nephritis; individual health education directed toward cultivation of personal habits and practices that are conducive to good health such as maintenance of optimum weight and avoidance of excessive smoking. b. In treating patients, they should be alert to the hazards of procedures which may lead to development or exacerbation of chronic disease, such as: use of certain mydriatics for older persons, administration of excessive oxygen to premature infants; and use, without specific indication, of modern therapies in general—particularly such agents as antibiotics and hormones. c. A s members of the community, they should play a leading role in stimulating organizations and individuals (1) to embrace the concepts of primary prevention and (2) to support its practical application by voluntary and public agencies. RESEARCH

Etiology and Natural History of Chronic Disease Research into the causes and natural history of disease in general, and of specific chronic diseases in particular, merits high priority as a means of augmenting our knowledge about methods of primary prevention of

PRIMARY

PREVENTION

25

long-term ailments. In the following recommendation the Commission on Chronic Illness has emphasized the need for this kind of research: 7 . Since the prevention of illness a n d d i s a b i l i t y is of i m p o r t a n c e b o t h to ind i v i d u a l s a n d to the strength of the nation, investigations of diseases a n d their origins, a n d studies of the methods a n d resources for prevention should c o m m a n d a high priority in the s p e n d i n g of research funds.

Many questions relating to the etiology and natural history of chronic disease require answers. Are there, for example, basic common factors in chronic illness that are clearly definable? The suspected presence of common biological factors in a wide variety of chronic diseases suggests that fundamental research directed toward uncovering any such factors will help solve the mysteries of the separate diseases themselves. Some common denominators that might be investigated are: The interaction between heredity and environment in relation to disease processes. The relationship between functional and physical disability. The influence of metabolic and endocrinal reactions on bodily structure and function. The social factors (including those related to economic, occupational, cultural, and family status) linked with the causes of illness. Environmental factors have been implicated as causative agents in a number of chronic diseases. Establishment of a clear causal or definite associative relationship between such factors and particular diseases will depend on concentrated research directed to this end. Environmental influences that may be causally related to certain long-term diseases include: air pollution in chronic respiratory disease; dietary deficiencies and excesses in hypertension, atherosclerosis, diabetes, and gout; and occupational exposures in cancer. Research is now going forward in many of these areas and we may anticipate that more definite information on the relationships between environmental agents and various chronic conditions will be forthcoming in the near future. At the same time, much fundamental investigation of this type remains to be undertaken. A special responsibility rests upon official public health agencies for conducting and supporting research in the etiology and natural course of chronic illness. Development of some of the tools and skills for this type of research has been an important contribution of public health to the health sciences in general, and many health departments are equipped with the trained staff needed for this kind of investigation. The epidemiological techniques that have proved to be so effective in

PREVENTION OF CHRONIC ILLNESS

26

preventing communicable disease show promise of producing similar results in preventing chronic disease. Epidemiology is the study of all factors which affect the occurrence and course of health and disease in a population—the causative agents, and the biological, physical, and social environment. The major objective of epidemiological research is to discover the causes of a given disease and to determine the points in its natural history where interruptions may be accomplished in man's favor. It can be of great help in solving many problems of chronic disease. A British epidemiologist has listed these important uses for the epidemiological method in health research: Historical study; estimating the individual risk of contracting a disease; estimating the community dimensions and distributions of health problems; in operational research; in the identification of causes of disease, and thus of pointers to prevention; in completing the clinical picture of disease; and in the definition of clinical and pathological processes and syndromes.® Social Science

Research

Knowledge of the specific motivations of individuals who make use of preventive facilities and services can be obtained through social science research. The question of individuals' attitudes toward preventive measures is of major concern to the health field; determination of the reasons for and the basic drives governing such attitudes is a task for which sociologists, psychologists, and other social scientists are particularly well equipped. A multidisciplinary approach, in which professional health personnel would necessarily play an important role, is essential for fruitful research in this field.7 In view of the importance of fundamental research in the life sciences, foundations and other fund-granting agencies should pay particular attention to the development of research potential in these areas. They should endeavor, as a matter of policy, to increase the quantity and strengthen the quality of investigators in these fields. Of prime significance in this connection is the inauguration of studies in health departments, schools of nursing, schools of social work, schools of public health, and similar institutions. At present, the major share of " Morris, J. N., M.D. "A Social-Medical Reconnaissance of Coronary Disease," in Sheps, Cecil G., M.D., and Taylor, Eugene E. Needed Research in Health and Medical Care. Chapel Hill, The University of North Carolina Press, 1954, p. 193. 7 See Recommendations Nos. 58, 59, and 64 in Care of the Long-Term Patient, Vol. II of this series, Chronic Illness in the United States.

PRIMARY PREVENTION

27

funds for research in chronic disease allocated to institutions is going to medical schools. Medical schools should, of course, continue to receive needed grants for the support of many different types of investigations of chronic illness. What is also obviously required for research on chronic disease is, as the Commission on Chronic Illness has indicated in its Recommendation No. 76 on care of the long-term patient, that all "private and public expenditures for research should be expanded." 8 It is not only a substantial increase in the total amount of money devoted to such research that is needed, but also improved methods of distributing existing funds for research in chronic disease. • Care of the Long-Term United States.

Patient, Vol. II of this series, Chronic Illness in the

Chapter

4

Secondary Prevention through Periodic Health Examinations Secondary prevention means halting the progression of a disease from its early unrecognized stage to a more severe one and preventing complications or sequelae of disease. Complete diagnosis and treatment will often prevent further progression of disease and incapacitating conditions. Thus, secondary prevention frequently merges into treatment as, for example, in provision of dentures as a means of preventing serious oral defects; early treatment of syphilis to prevent general paresis and other complications of syphilis; and early and adequate treatment of diabetes as a preventive measure against blindness and gangrene. Persons who go to the doctor because they have symptoms or feel ill are candidates for secondary prevention, especially since persons with one chronic disease often have other undetected chronic diseases. The physician can establish a diagnosis and institute prompt treatment for suspected disease and simultaneously look for unsuspected disease, thus making a substantial contribution to secondary prevention in both instances. Secondary prevention, however, would have limited potential as a means of controlling chronic illness if it placed under medical management only persons with noticeable symptoms of disease. A fundamental aspect of secondary prevention is case-finding, that is, the search for early signs of disease among seemingly healthy people. Case-finding is the active search for and pursuit of cases of chronic disease and disability in both asymptomatic and more advanced stages— in order to provide, for the patients concerned, available techniques of secondary prevention appropriate to the stage of the disease, and thus stop further progression of the disease or disability to a more severe, complicated, or disabling stage. The purpose of case-finding is to detect unsuspected disease in the apparently well population and to search for other unsuspected disease among persons with known or suspected illness. Case-finding is carried 28

SECONDARY P R E V E N T I O N — H E A L T H EXAMINATIONS

29

on wherever health examinations are made—in the offices of private physicians, in clinics, hospitals, industrial medicine facilities, health centers, and organized health plans. As the succeeding chapter indicates, case-finding is also the objective of large-scale community programs for screening and detection, in some of which the process may be initiated —but not completed—by persons other than physicians. Ideally the search for early signs of chronic illness among apparently healthy people should be conducted by means of a periodic health examination by a physician. Such examinations are now available to some individuals and to certain population groups in the United States. In addition to those individuals who obtain regular preventive examinations in private doctors' offices, a few special groups, such as executives of some corporations, officers in the military services, and eligible subscribers of some voluntary prepayment plans, also receive this type of medical service. The fact remains, however, that the number of persons to whom such examinations are available is woefully small in proportion to the total national population. The technique of the comprehensive periodic health examination cannot do much to reduce the prevalence of chronic illness until the number of persons to whom this kind of preventive service is available is greatly enlarged. As early as 1925 the American Medical Association published a manual on the periodic health examination "in the hope that by correcting and modifying the procedure more satisfactory results and more universal utilization may be attained." 1 The Commission believes that it is incumbent on all individuals, agencies, and groups with professional or community interest in the chronic disease problem to do what they can to encourage dissemination of the idea of the preventive examination and provision of the facilities and personnel for performing it. 8 . All persons should have a careful health examination including selected laboratory tests at appropriate intervals. The medical and dental professions must specify the desirable scope and frequency of this examination, taking into account age, sex, and other biosocial factors. Such examinations must then be made practical and realistic, and be incorporated in the day-by-day practice of modern medicine and dentistry.

Dr. J. D. Mortensen of the Mayo Foundation has reported a study that illustrates the value of "a carefully performed physical examination, a medical history, and a few routine laboratory procedures in detecting 1 American Medical Association. Periodic Health Examination: A Manual for Physicians (3rd revision). Chicago, American Medical Association, 1947, p. 7.

30

PREVENTION OF CHRONIC ILLNESS

medical abnormalities in supposedly normal, healthy persons. These examinations were performed by a single general practitioner in a rather isolated community [Stibnite, Idaho]. . . ."2 There the Bradley Mining Company offered routine medical examinations to all employees and their dependents. Three hundred and ninety supposedly well persons were examined during a 19-month period in 1948-1949. Forty-one per cent were new employees, the remaining 59 per cent being dependents or employees who had been living in Stibnite for a year or more. According to Dr. Mortensen's report: The high incidence of abnormal findings, the relatively large number of unsuspected disorders, the frequency of treatable and improvable abnormalities, and the occasional serious or unusual diagnosis uncovered were all something of a surprise to the patients and to the community from which they came. Less than a fourth of those examined were considered entirely free from physical or mental abnormalities. Approximately a fourth had a single abnormal condition, while approximately half had two or more detectable abnormalities. Seven hundred and thirteen abnormalities were diagnosed, 534 of which had not been detected previously. Three hundred and two abnormalities (42 per cent of those detected) were treated, with improvement in 261 conditions, representing 180 patients. . . . The cardiovascular system was the site of the highest number of abnormalities of any bodily system. . . . Twenty patients (5.1 per cent of those examined) with moderate elevation of blood pressure (160 to 180 systolic or 96 to 105 diastolic) are worthy of note because the hypertension was completely unknown to all but six of them. These patients should be candidates for intensive treatment in an attempt to control their hypertension before complicating vascular, renal, or cardiac sequelae develop. Nine patients had advanced hypertension with pressures that were more than 180 systolic or 105 diastolic, and four of these persons did not know that their blood pressure was elevated. Orthopedic abnormalities were noted in 18.1 per cent of the persons examined. . . . More than half of the persons with orthopedic conditions were treated, most of these showing definite improvement. About a fifth of the persons in this group were referred to an orthopedist for care. . . . Among the gastrointestinal abnormalities, there were thirteen peptic ulcers. Four ulcers were gastric in location, two being subjected to surgical treatment because they would not heal on medical management. Treatment of the patients with duodenal ulcer was very satisfactory, with eight of the nine patients experiencing excellent relief of symptoms. Twenty-six persons were found to have uncomplicated silicosis, which ' Mortensen, J. D., M.D. "Examination of Subjectively Normal Persons." GP 8:60, July 1953. (Published by the American Academy of General Practice.)

SECONDARY PREVENTION—HEALTH EXAMINATIONS

31

is not unusual in a group of men, many of whom had been hard-rock miners for several years. One man had silicotuberculosis, and four other persons had proved early active pulmonary tuberculosis. Bronchiogenic carcinoma was not demonstrated in this group of patients, although 320 were men, many of whom were in the age group susceptible to cancer of the lung. Gynecologic abnormalities were detected in two-thirds of the women examined. This observation was of particular interest, since most of the women were young and active. Nearly two-thirds of the women with abnormal conditions were treated, with improvement being reported by nearly all who were treated. Thus about half the women reporting for a routine examination, all without symptoms, were improved in health and comfort by treatment for gynecologic conditions that they had not previously known existed. . . . Seven proved malignant lesions were detected. Five of the patients were treated definitively, one having a lesion that was beyond eradication but regressing on medical treatment with hormones, and another being given surgical palliation. Seventeen patients had conditions definitely considered to be precancerous; the lesions of ten of these were eradicated, the other patients being observed carefully at regular intervals for early changes demanding treatment. An incidental finding of interest was the fact that eight persons feared that cancer was present in some organ. After the examination and laboratory studies, they were assured that no malignant disease was present, thus being relieved of their anxiety. The relative importance of the various methods of examination and reaching diagnoses in this study is of interest. The medical history represented the chief diagnostic procedure in eighty-five instances, and it was an important contributory method in 306 instances. The physical examination itself was the basis for the diagnosis in 229 cases, and a contributory tool in 302. The laboratory was of prime importance in only twenty-six cases, and contributed to the diagnosis in ninety additional cases. X-ray examinations were the chief means of diagnosis in forty-two instances, and contributed to correct diagnosis in 140 instances. It thus appears evident that none of these methods of investigating the patient's condition could be omitted justifiably.3 Somewhat similar testimony in favor of the periodic health examination is given by Franco and Gerl. In a 5-year period, 1,816 examinations were given to 648 persons. About half of these persons had conditions of medical significance, major in themselves or as precursors of potentially serious disease. One-third had conditions revealed to them for the first time, and over half of these cases were without symptoms of any kind. Further proof of the value of periodic examinations "is indicated by the fact that of the medical conditions revealed by examination, 'Ibid., pp. 60-62.

32

PREVENTION OF CHRONIC ILLNESS

17 per cent were entirely corrected and 31 per cent were improved by treatment. In addition, in almost all of the 34 per cent whose condition remained unchanged, medical supervision enabled these individuals to carry on their usual business activities. Deterioration occurred in 12 per cent, and the mortality rate was 6 per cent at the end of the fiveyear period." 4 A program of cancer detection in rural practice has demonstrated what can be done through periodic examinations for a specific condition. The program was initiated by the Lorain County (Ohio) Medical Society in 1946 with a detection center in Elyria and a diagnostic clinic in Lorain. In 1950 the program was modified "to make every physician's office a cancer detection center" and 42 physicians agreed to cooperate. During 6 years of the detection program, 1,650 examinations were done on 950 presumably well women. Thirteen malignant conditions were discovered; 255 benign lesions were revealed and treatment given or advised.5 Although it manifestly represents the first line of attack in casefinding with respect to chronic illness, the periodic health examination is no panacea. Definite limitations of the health examination as a preventive measure are inherent in the relative imprecision of available techniques for detecting the presence of asymptomatic disease and in lack of knowledge of the cause of certain chronic conditions. Other limitations arise from the attitudes of physicians and patients toward such examinations. Some physicians who discount the value of these examinations perform them in a perfunctory manner. Of equal or perhaps even greater importance are the laymen's attitudes based on fears, cultural patterns, lack of information, and concern with the cost and inconvenience of such examinations.® These attitudes frequently cause postponement of medical services or failure to follow the advice given when services are utilized. FACTORS AFFECTING SCOPE OF THE HEALTH EXAMINATION

The frequency and content of the health examination should vary depending upon such factors as age and sex, occupation and residence, and 4 Franco, S. Charles, M.D., and Gerl, A. J., M.D. "The Periodic Health Examination—A Five-Year Survey." Industrial Medicine and Surgery 24:163, April 1955. 5 Siddall, A. C., M.D. "Cancer Detection in Rural Practice. Report of 1,650 Ex-

aminations." Journal

of the American

Medical

Association

3, 1951. * See Chapter 6, "Personnel and Education," pp. 77-86.

1 4 5 : 3 1 4 - 3 1 7 , February

SECONDARY PREVENTION—HEALTH EXAMINATIONS

33

socioeconomic status. Other factors that will affect the nature of the examination are specific diseases or conditions suspected and the setting in which the examination is done. The periodic health examination should be started, desirably, in infancy, and carried through adult life into old age. Although the health examination is equally applicable as a preventive measure at all ages, chronic diseases are more threatening in some age groups than in others. For all persons over 40, the regular health examination procedure is obviously of even more importance than for the rest of the population. Age and Sex Most authorities in this field consider age and sex to be the most important factors in determining the frequency and content of health examinations. The American Medical Association has suggested the following desirable intervals for periodic health examination of normal individuals, subject to modification where special reasons exist for more frequent examinations: Prenatal: monthly to bi-weekly. Two to 5 years: semi-annually. First 6 months: bi-weekly. Five to 15: every 2 to 3 years. Second 6 months: monthly. Fifteen to 35: every two years. One to 2 years: quarterly. Thirty-five to 60: annually. Above 60: semi-annually. 7 In examining infants and young children the physician will focus on immunity status, presence or absence of congenital defects, nutrition, progress of growth and development, emotional well-being, and the like; for older persons, emphasis will be placed on detecting cardiovascular disease, diabetes, cancer, glaucoma, mental disorders, and other long-term ailments whose incidence increases with age. Occupation and Residence The ever present danger for miners of developing silicosis or tuberculosis will have a direct bearing on the frequency and type of health examination provided in mining regions. Employment in particularly hazardous jobs, such as those involving continuous contact with radioactive substances, will also affect the frequency and content of the examination. Periodic health examinations might well include microscopic exami'American Medical Association, op. cit., p. 7.

34

PREVENTION OF CHRONIC ILLNESS

nation of the fresh stool of persons living in or coming from regions where hookworm, amebic dysentery, or other tropical or subtropical intestinal diseases are prevalent. Socioeconomic

Status

The physician will also vary somewhat the tests included in the health examination in accordance with a particular patient's socioeconomic status; persons in low-income groups are likely to show higher rates for such ailments as tuberculosis, anemia, and syphilis. He will take cognizance of the implications of family medical history. Rheumatic heart disease, diabetes, hypertension, arteriosclerosis, and epilepsy should have special consideration when these diseases occur in other members of the patient's family. In such cases, the physician will want to incorporate into the periodic examination special procedures for these diseases. COMPONENTS OF THE HEALTH

EXAMINATION

A good periodic health examination should have four main sections: (1) a careful medical and social history (including attention to family history); ( 2 ) a comprehensive examination; ( 3 ) appropriate laboratory, x-ray, and other special procedures; and (4) health counselling and follow-up. The Medical

History

Members of the medical profession who have evaluated the effectiveness of the periodic examination in promoting health and preventing serious long-term illness attach great importance to the history. A review of the patient's diet, work environment, and general living habits helps the physician to understand the patient's personality and life situation. The family history may indicate which laboratory, x-ray, and other specialized studies are needed to discover the earliest signs of disease with a familial tendency. It is desirable for the physician to record a "history in depth" the first time a patient comes to him for a health examination; the history to be brought up to date at each subsequent periodic visit. A good medical history is more than a mechanical search for evidence of specific disease. It is an evaluation of growth and development in the younger age groups and of functional capacity and performance among older persons. The following summary of the suggested areas for em-

SECONDARY PREVENTION—HEALTH EXAMINATIONS

35

phasis in the physician's exploration of a patient's medical history may be cited: The physician inquires into the activities of the various organs of the body, seeks manifestations of disturbed function, asks about reactions to stress and strain. He notes patterns of physiological and psychological reaction, the nature of routine activities, such as diet, sleep, and exercise, medications, smoking and drinking habits. The "past history" elicits the record of significant illnesses, injuries, operations, etc., while the "family history" indicates those conditions known to have hereditary tendencies which should be watched more carefully. "Social history" delves into the important factors of occupation, residence, hobbies, social activities, travel, economic status and the like. The current recognition of the psychological and emotional factors in health is reflected in careful evaluation of personality patterns, family and other relationships, sexual difficulties, areas of fear and hesitancy, etc. Such an evaluation of an individual's functional capacity and over-all health status is, obviously, a demanding goal.8 The Comprehensive

Examination

The basic components of a comprehensive examination—to be supplemented by laboratory, x-ray, and other tests—are: Determination of: Temperature Pulse and blood pressure Height and weight Visual and hearing acuity Intraocular pressure

Examination of: Skin Eyes, ears, nose, and throat Oral cavity and teeth Extremities, including reflexes Heart and, lungs Abdomen Breast and pelvis (for women) Rectum Spine

The physical examination should be, literally, a physical survey and analysis of the entire body, from head to toe. It should include systematic exploration of all major organs and body systems, as well as the simple tests (pulse, weight, etc.) for physical status. In addition, it should include an over-all evaluation of such things as general body development and nutritional state, obvious physical defects, posture, agility, and alertness. The examining physician will wish to use all the standard methods of physical observation during a systematic periodic examination, including 8 Weinerman, E. Richard, M.D. "The Periodic Health Examination." (Publication in process.)

36

PREVENTION OF CHRONIC ILLNESS

palpation, percussion, and auscultation. He will need, in addition to the standard equipment in most offices (e.g., sphygmomanometer, vaginal speculum, proctoscope, otoscope, and ophthalmoscope), a number of specialized instruments (e.g., tonometer for ocular tension and sigmoidoscope for inspection of the lower bowel). Recently acquired knowledge of body functions and reserves has led to the development of tests to measure physiological status in dynamic terms; among them are the various tests for heart function, for evaluation of muscle strength, and for estimating lung capacity. Basically, such tests relate the functioning of a specific organ at rest to its performance under stress. Laboratory, X-Ray, and Other Specialized

Tests

A basic list of laboratory procedures ordinarily used in a comprehensive health evaluation would include: Urinalysis Blood glucose level Hemoglobin determination determination Serologic test for syphilis Chest x-ray Cervical cytology test (Papanicolaou smear) When indicated, the following procedures or tests may also be included: Blood Complete blood count Sedimentation rate determination Hematocrit determination Special determinations, e.g., urea nitrogen, nonprotein nitrogen, calcium, phosphorus, cholesterol, vitamins Heart and lungs Laryngoscopy Electrocardiography Electrokymography Cardiovascular exercise tests Fluoroscopy

Gastrointestinal Gastric acidity test Gastrointestinal x-ray series Sigmoidoscopy Examination of feces for occult blood and parasites Liver and gallbladder Liver and gallbladder function tests Examination of urine for bile Kidney Urea clearance test Urine concentration tests

Specialized psychological tests Many of the tests mentioned above will be used by a physician only if he finds specific indication for them from the physical examination or from factors in a patient's life situation. Some of these procedures will be more appropriate for the evaluation of the health of persons in one age group than another, or of one sex than the other. The physician who devotes himself predominantly to care of elderly persons, for ex-

SECONDARY PREVENTION—HEALTH EXAMINATIONS

37

ample, is likely to view the relevance and efficacy of certain tests quite differently from his colleague who deals mainly with younger people. One physician with particular interest in geriatric medicine has stated: The proper medical evaluation of the geriatric patient consists of three principles. One, careful medical and social history . . . two, thorough physical examination, and three, laboratory studies designed primarily to detect any functional weakness of the body. The laboratory tests are of prime importance in understanding the functional weaknesses thereby enabling the geriatric physician to control or possibly prevent body degeneration.9 He has further underscored this conviction by suggesting that "perhaps no other field of medicine requires such exacting and 'reckless' use of laboratory procedures. . . ." 10 In a different setting, two industrial physicians who, over the 5-year period from 1949 to 1953, made periodic health examinations of employees (including top executives) of a large utility company, expressed the opinion that: Nothing is gained by undertaking a barrage of laboratory and x-ray examinations as a routine procedure. This only adds to the cost of the examination and is unwarranted. Urinalysis, sedimentation rate, and blood serological examination are the only laboratory tests that need to be done routinely. Blood count, blood sugar analysis, other blood chemical examinations and basal metabolism are done only on specific indications as revealed by individual history and physical examination. In those who are overweight, routine post-prandial blood sugar, blood cholesterol and blood uric acid determinations at times have yielded valuable information. Routine electrocardiograms in persons over 40 years of age have disclosed evidence of unsuspected disease of the coronary arteries. Routine x-ray of the chest is advocated by some examiners, but it has been our experience that, with a careful physical examination, fluoroscopy of the chest may be adequate to uncover disease processes. In fact, the two lung cancers in this group were detected on fluoroscopic examination. Routine x-ray of the gastrointestinal tract is not advocated in the light of our present medical knowledge. . . , u Some physicians believe that all the procedures considered as required in the first health examination should be repeated in subsequent periodic evaluations. In their view, "a man is just as likely to have an asymptomatic cancer of the stomach on his fifth examination as on • Kountz, William B., M.D. "Medical Evaluation of the Geriatric Patient." Medical Record and Annals (Houston) 47:554, June 1953. "Ibid., 11

p. 553.

Franco and Gerl, op. cit., p. 162.

38

PREVENTION OF CHRONIC ILLNESS

his first; if a barium meal x-ray study was done as a routine when he was first seen, it should be done as a routine on every subsequent examination."12 Others believe that the most important phase of periodic examinations after the first one is the consultation between the examinee and the physician, at which the medical history is brought up to date. This will provide clues to specific disease and any malfunction developed in the interval between examinations for which more detailed laboratory investigation is needed to supplement a "basic minimum" of laboratory tests.13 Health Counselling

and

Follow-Up

The physician counsels his patients on many occasions and he has a particularly advantageous opportunity to do so in the periodic health examination. Real gains for prevention can result if the findings are brought together for the patient in a meaningful pattern. Counselling helps to give these examinations the quality of true "health inventories." The examination is the prelude to a discussion in which the patient receives helpful instruction and advice on his general health status. Explanation and interpretation of findings will undoubtedly increase the patient's health consciousness, improve his health habits, and increase his willingness to accept the follow-up procedures necessary for definitive diagnosis and prompt treatment. During the counselling session the physician can stress such things as the importance of maintaining good oral hygiene or of avoiding obesity; he can emphasize the desirability of breast self-examination for women as an aid in the early detection of cancer, and can instruct female patients in the technique of self-examination; he can estimate the patient's work capacity and recommend any necessary adjustments with regard to employment. Furthermore, the counselling session will usually help to establish desirable rapport between physician and patient, thus laying the basis for subsequent examinations at regular periodic intervals. The way in which health counselling may be integrally related to the examination that has preceded it is well demonstrated in the following account from the report of a health examination program in an industrial setting mentioned earlier in this chapter: 12 Baker, J. P., M.D., Ballou, H. C., M.D., Hall, W. Thomas, M.D., Lemon, Willis E., M.D., and Morhous, Eugene J., M.D. "Executive Health Examinations." Southern Medical Journal 46:984, October 1953. "Shillito, Frederick, M.D. "Periodic Health Examinations." Annals of Internal Medicine 39:7-14, July 1953.

SECONDARY PREVENTION—HEALTH EXAMINATIONS

39

At the termination of the examination, the significance of the findings is discussed with the person examined. . . . Experience shows that this health counseling is the most important part of the periodic examination because it gives the best opportunity to correct errors of habit and diet which seem to play some role in the development of the degenerative diseases. This is a good time for the physician to give advice about mental hygiene and outline a program for reasonable living to each individual, even to those with normal findings. In discussing the presence of organic disease, such as cardiac involvement, the accent is on reassurance. Experience indicates that even severe cardiacs rarely get into trouble on the job if they are under adequate medical supervision. While some persons may prefer a written report, we feel that discussion of the findings is advisable because a surprising variety of personal problems can be brought up by such an interview even after a detailed history. The follow-up examination to check on correction of defects is important. Equally important is the establishment of health consciousness so that the individual does not delay in seeking medical advice in the event of development of new symptoms. This was particularly evident . . . among those individuals who subsequently developed neoplastic lesions.14 PERIODIC HEALTH EXAMINATIONS IN DIFFERENT SETTINGS

In

Industry

Many internists are actively engaged in performing periodic health examinations, especially the so-called "executive" examinations. One practicing internist has said that: "As a minimum, urinalysis, serologic test for syphilis, complete blood count, sedimentation rate, x-ray of chest, nonprotein nitrogen, cholesterol, stool guaiac and electrocardiograph are suggested. The incidence of peptic ulcer or gastroduodenitis is high enough in this group to consider the inclusion of gastrointestinal x-rays. Sigmoidoscopy to detect papillomata is another valuable procedure." 15 These tests are to be given as supplements, of course, to the medical history and complete physical examination. In the periodic examination program inaugurated at the Consolidated Edison Company of New York in 1949, health evaluations were provided over a 5-year period to 648 men out of the 954 who were eligible for the service. The majority of these examinations were given annually and participation was on a voluntary basis. Those examined represented all occupational levels from assistant foremen to top executives, and ranged in age, in the main, from 40 to 65 years. The basic component "Franco and Gerl, op. cit., pp. 162-163. Shillito, op. cit., pp. 12-13.

15

40

PREVENTION OF CHRONIC ILLNESS

of these examinations was a careful history and physical examination, on the assumption that the " 'dragnet' method which routinely undertakes a wide scope of x-ray and laboratory studies did not allow a personalized approach and was more expensive and time consuming."16 The tests provided routinely in the course of these examinations included: Urinalysis Electrocardiography Fluoroscopy of the chest The Group Practice

Serologic test for syphilis Blood sedimentation rate determination

Framework

The periodic health evaluation provided for patients in a group practice setting has great potential significance. A medical service plan based on group practice, particularly when it is combined with the principle of prepayment, affords a promising situation for a program of health maintenance and early detection of chronic disease based upon a comprehensive periodic health inventory. By bringing together under one roof the general practitioner, various medical specialists, and all the necessary laboratory equipment and technicians, the group practice method of organizing medical services offers an excellent opportunity, from the technical standpoint, for thorough health examination. However, most group practice plans (including those that provide comprehensive medical services on a prepayment basis) have not yet incorporated into their benefit structure provisions for offering health examinations to their members on a regular basis. Moreover, many of the plans that provide these examinations need to expand the range of the tests given as well as the health counselling aspects of their preventive programs. Other Special

Forms of Health

Examination

Many health examinations for special purposes are provided for various segments of the population in the United States. They include: Well baby conferences, School medical examinations, Premarital health tests, Preemployment examinations in industry, Life insurance examinations, Military service examinations, preinduction and periodic, Other special examinations, including cancer detection tests and antepartum and postpartum check-ups. "Franco and Gerl, op. cit., p. 161.

SECONDARY PREVENTION—HEALTH EXAMINATIONS

41

Many of these special purpose examinations provide only partial evaluations of a person's total health status; they offer, nevertheless, valuable opportunities for early detection of chronic illness, depending upon the comprehensiveness of the examination. At present, the range of procedures provided in these special examinations varies greatly— from the fairly complete evaluations in well baby conferences and in examinations required for prospective clients by some life insurance underwriters, to the token premarital health test, which usually consists merely of a blood test for syphilis and a cursory inspection for obvious signs of venereal disease. These special examinations reach relatively large numbers of people. Much of the best experience available to us in the field of health testing has been developed in special examination programs of this kind. This experience, in turn, has stimulated the development of the more comprehensive type of regular health examination performed by the physician for individual patients. If these various specialized programs were broadened to focus on the examinee as an individual and if the findings were explained to each individual and he were referred for appropriate medical follow-up, these programs could well become an important measure for prevention of chronic illness. POTENTIALS OF THE HEALTH EXAMINATION ASSESSED

However desirable as an ideal, the periodic health examination still represents only a partial solution to the problem of early detection of chronic disease. This chapter has stressed the significance of such examinations in leading to the discovery of asymptomatic illness among the relatively few persons in the nation who today receive them regularly under optimum conditions. Without minimizing that significance, the weaknesses and limitations of the health examination as a currently practical method of secondary prevention of chronic disease can be assessed realistically. Time, Cost, and Personnel

Limitations

The average practitioner of medicine is an exceedingly busy man. The pressure of caring for the sick in the home, office, clinic, and hospital makes it difficult for physicians to devote any substantial amount of their time to health maintenance work. The comprehensive evaluation of a person's health status is time-consuming. It is an expensive process, not only because of the time actually spent by the physician in history taking, performing the physical examination, and health counselling,

42

PREVENTION OF CHRONIC ILLNESS

but also because of the laboratory and x-ray procedures required. Even were all other problems connected with the health examination resolved, there are not enough physicians in the United States at present, as a number of studies have shown, to provide this type of service for the majority of the American people. Additional methods of disease detection, such as those discussed in the following chapter, must therefore be improved and extended to conserve the physician's time and to reduce the cost of the examinations. Cursory Nature of Some

Examinations

Many physicians are not positively oriented toward the idea of health conservation as a basic technique in medicine. Health examinations are frequently performed in a sketchy and superficial manner and much incipient chronic illness remains undiscovered by the physician. The important health counselling aspect of the examination is also often slighted, with resultant failure of the patient to take the necessary steps to prevent progression of the disease. Greater emphasis on preventive medicine is required in all stages of education for the health professions, as shown in Chapter 6. Moreover, as health counselling becomes an increasingly important function of the family physician, both he and his patients will recognize the value of scheduling appointments for periodic check-ups. In this regard, lessons for medical practice in general can be learned from pediatrics and obstetrics as well as from dentistry. Physicians should feel no reticence in having their office nurses or receptionists notify patients that the time for a review of health status has arrived. Poor Public Acceptance of the Health

Examination

Despite the considerable amount of emphasis that has been placed on health maintenance in recent years through educational campaigns of various types, only a relatively small proportion of the adult population of the country has become sufficiently interested in the concept to seek health examinations on a regular basis. One of the reasons for the poor public response to the idea is probably economic. Nevertheless, even when the economic problem is obviated, there appears to be considerable resistance on the part of the public to the health examination. The few prepayment health plans providing comprehensive medical services have not been notably successful in getting their subscribers to take advantage of such examinations. In the household study of needs for long-term care conducted in Baltimore by the Commission on

SECONDARY PREVENTION—HEALTH EXAMINATIONS

43

17

Chronic Illness, a substantial number of persons interviewed refused the free comprehensive health evaluation offered them, despite the persistent efforts of the Commission's staff to persuade them to participate in this important phase of the study. The experience was similar in the study of the needs for long-term care in Hunterdon County, New Jersey.18 The excuse most frequently given by participants in the Hunterdon study for not reporting for the clinical evaluation was, in essence, that "if there is something wrong with me, I don't want to know it." Whether or not this comment represents the typical attitude of the public toward health examinations is not certain. The pervasiveness of this attitude among persons involved in both the Baltimore and the Hunterdon County studies, however, is a challenge to health educators to reanalyze assumptions on which efforts to "sell" the periodic health examination have been grounded. Accuracy and Predictive Value of the Health

Examination

Even a comprehensive examination of first-rate quality provides no guarantee either that all incipient disease will be discovered in a patient, or that he is definitely free of unsuspected disease. Some of its more ardent exponents exaggerate its precision. However, progressive improvement is being made in the techniques of detecting incipient chronic diseases in their earliest stages. At the same time, clinical and epidemiological studies are slowly revealing the patterns of development in many of the chronic conditions and should result in greatly improved accuracy in detection and in the ability to predict outcomes. Facilities for Diagnosis and Treatment Provisions for adequate follow-up procedures, so that health problems revealed by the periodic examination can be definitely diagnosed and promptly treated, will need to be expanded to increase the effectiveness of the health examination as a preventive procedure. When diagnostic and therapeutic medical services are widely available to all segments of the population, regardless of economic, geographical, or ethnic status, the advantages of early detection of incipient disease can be vastly augmented. In the meantime, physicians, health departments, voluntary agencies, and welfare authorities can make greater use than is now customary of existing follow-up services. 1T See Chronic the United States, 18 See Chronic the United States,

Illness in a Large City, Vol. IV of this series, Chronic Illness in for a full report of this study. Illness in a Rural Area, Vol. I l l of this series, Chronic Illness in for a full report of this study.

44

PREVENTION OF CHRONIC ILLNESS

A comprehensive personal health inventory under optimum conditions is unquestionably a desirable procedure, and with appropriate follow-up has tremendous potential, both for health maintenance and for detection of incipient chronic illness. But it cannot now be applied to the population at large. Other mechanisms must be sought for and employed, in addition to the health inventory, in the achievement of secondary prevention of chronic disease.

Chapter

5 Secondary Prevention through Screening Examinations Since time, costs, and personnel shortages preclude the possibility of regular, comprehensive health examinations for the majority of the population, relatively simple and inexpensive procedures of other types are needed to sort out persons with probable evidence of chronic disease in order to refer them for diagnosis and medical care. In recent years increasing numbers of physicians and other health personnel have come to the conclusion that screening tests—most of them given by technicians under general medical supervision—can be an effective device in secondary prevention of chronic illness. The Commission's 1951 Conference defined screening as the presumptive identification of unrecognized disease or deject by the application of tests, examinations, or other procedures which can be applied rapidly. Screening tests sort out apparently well persons who probably have a disease from those who probably do not. A screening test is not intended to be diagnostic. Persons with positive or suspicious findings must be referred to their physicians for diagnosis and necessary treatment.1 Whether conducted for individuals or for large groups of people, whether directed toward the discovery of one particular disease or of several diseases simultaneously, screening examinations represent a practical supplement—and, for the present, a practical alternative for many people—to the comprehensive periodic health examination as a method for early detection of several chronic ailments. The Commission on Chronic Illness has strongly endorsed screening: 9. Screening tests for early case-finding are an essential device in prevention. Used discriminately, these tests should be undertaken in physicians' offices, hospitals, industrial health services, schools, and health centers. 1 Proceedings of the Conference on Preventive Aspects of Chronic Disease. March 12-14, 1951. Baltimore, Commission on Chronic Illness, p. 14. (Out of print.)

45

PREVENTION OF CHRONIC ILLNESS

46

Local health departments especially should foster efficient screening programs for large groups of the population. 10. The medical and dental professions should continue their collaboration with insurance companies, voluntary prepayment plans, industrial health plans, union health plans, and appropriate tax-supported agencies to find the most satisfactory methods for financing screening and examinations.

The key value of the screening technique lies in the fact that presumptive identification of an unrecognized disease can be accomplished through simple measurements or laboratory procedures performed by nurses or technicians. All such presumptive evidence of disease, however, must be confirmed or ruled out subsequently by appropriate diagnostic procedures which require the knowledge and skill of the physician himself. Screening is thus one—but not the only—method that may be used for detection of incipient illness. The great advantage of screening is that it affords a means of bringing the benefits of early detection to large groups of the population. A screening program, designed as an auxiliary mechanism for the practicing physician, can help him find among his patients and their families persons who are apparently well but who in reality may need medical care. For example, Surgeon General Burney has stressed the value of screening as a measure to prevent blindness from glaucoma: It is estimated that 2 per cent of all persons over 40 years of age suffer from glaucoma and, with the increasing proportion of aged persons in our population, the number of persons included in that 2 per cent is constantly growing. With early detection and treatment, glaucoma seldom progresses to blindness; yet at present, 12 per cent of all blind people are blind as a result of glaucoma. Obviously, we are not detecting and treating cases in time. Encouraging progress has been made in the development of tonometry and other detection techniques. However, there are 59 million Americans over 40 years of age who, ideally, should be examined annually for glaucoma. The task is formidable, but a promising start is being made in a few communities through the use of mass screening, comparable to the mass casefinding programs that have proved so successful in the control of tuberculosis and venereal disease.2 Screening tests can shorten the time and reduce the cost involved in establishing a subsequent diagnosis by giving the physician certain preliminary findings which guide him in determining the diagnostic pros

Address by L. E. Burney, M.D., Surgeon General, U.S. Public Health Service, Department of Health, Education, and Welfare, before the House of Delegates, Indiana State Medical Association, Indianapolis, Indiana, October 18, 1956, pp. 5-6.

SECONDARY PREVENTION—SCREENING

47

cedures appropriate for a particular individual. Thus, screening conserves professional resources and time and increases the likelihood that physicians' care will be available to a large number of people when they can derive the most profit from it. TYPES OF

SCREENING

The screening method has been applied to case-finding in a number of ways. Each may have an appropriate place in a detection program, depending on the specific purpose of the program. Individual screening may be performed by physicians in their offices, both for presumably well patients who come in for health evaluations and for patients who present symptoms of disease. A physician or his nurse or technician often conducts certain routine screening tests in the course of a well-person health evaluation. Individual screening tests also, of course, may be done in clinics and hospitals. Mass screening consists of the application of screening tests rapidly and economically to large population groups, to identify persons who probably have abnormalities so that they can be referred for diagnosis and, if indicated, for medical care. Single-test screening is the application of a simple laboratory or related test to groups of people in an effort to detect a particular unrecognized disease, e.g., blood sugar level determination for diabetes. Multiple screening is the application of two or more screening tests in combination to large groups of people. Applying a battery of laboratory and related procedures simultaneously to presumably well population groups is a relatively rapid and effective method of presumptively identifying major chronic impairments and conditions such as tuberculosis, syphilis, diabetes, certain forms of cardiovascular disease and cancer, vision and hearing defects, obesity, and anemia. Laboratory and technical tests which are relatively simple to perform, reliable, and convenient for mass application are already available for screening for these conditions. CRITF.RU FOR EVALUATING MASS SCREENING

PROCEDURES

Two committees of the 1951 Conference on Preventive Aspects of Chronic Disease gave special attention to evaluation of tests and mass

48

PREVENTION OF CHRONIC ILLNESS

programs for early detection and screening.3 As the chairman of one of those committees has pointed out: The combined experience from mass surveys for such diseases as tuberculosis, syphilis, cancer and heart disease has made it possible to define . . . certain principles which govern the use of screening tests in case finding in the general population. These principles are general and apply to the use of screening tests in mass surveys for any disease.4 This Conference committee identified five criteria for evaluation of tests and programs: reliability, validity, yield, cost, and acceptance. The first two apply specifically to evaluation of tests, the remaining to both tests and programs. Another committee of the Conference suggested a sixth criterion, follow-up services, which is applicable to programs. The succeeding paragraphs discuss each of these six criteria, utilizing the report of the original Conference,5 refinements suggested by numerous later articles on the subject, and the Commission's own experience with mass screening and detection in the Hunterdon County, New Jersey, and Baltimore studies.8 Reliability

The reliability of any given test is evaluated in terms of (1) its reproducibility in repeated use of the same techniques; (2) the ability of technicians of average training to use these techniques; and (3) the range of variation to be expected among specimens collected from, or physical or physiological reactions recorded for, a given individual at different times under the same conditions. Two distinct stages are normally involved in determination of the reliability of a screening procedure: (1) the "laboratory" stage, during which reliability is checked under closely controlled laboratory conditions; and (2) the "field trial" stage to discover whether the laboratory results can be duplicated when the test is given on a mass basis. As Rutstein has pointed out, "Properly qualified personnel must be available for interpretation of the test." 7 s

Proceedings

of the Conference

on Preventive

Aspects

of Chronic

Disease.

4

Rutstein, David D., M.D. "Screening Tests in Mass Surveys and Their Use in Heart Disease Case Finding." Circulation 4:659, November 1951. ' Proceedings

of the Conference

on Preventive

Aspects

of Chronic

Disease,

pp.

63-68. 6 See Chronic Illness in a Rural Area and Chronic Illness in a Large City, I l l and I V of this series, Chronic Illness in the United States.

7

Rutstein, op. cit., p. 660.

Vols.

SECONDARY PREVENTION—SCREENING

49

Scientific Validity The validity of a screening test is measured by the frequency with which the result of that test is confirmed by an acceptable diagnostic procedure. The ideal screening test would yield only true positives and true negatives, but none of the tests available thus far can claim this degree of accuracy. When screening test determinations are compared with the results of complete diagnostic examinations, the persons screened fall into four groups: (1) true positives—persons whose diagnostic evaluation subsequent to the screening procedure confirms presumptive identification of the disease; (2) true negatives—persons in whom screening results as well as diagnostic results are negative insofar as presence of the disease is concerned; (3) false positives—persons selected by the screening procedure as showing signs of a disease who are found not to have it on subsequent diagnostic evaluation; and (4) false negatives —persons not selected by the screening procedure as showing signs of disease, but who are found to have the disease in the course of the diagnostic evaluation. According to Kurlander and his associates,8 a valid test will be highly sensitive, that is, it will identify a large percentage of the cases of disease present in the population. A valid test will also be highly specific, that is, it will identify a large percentage of the population who are free from the disease. Sensitivity and specificity are useful factors in the evaluation of screening tests since these measures are independent of the prevalence of the condition being screened for in the population. Yield The yield of a screening test or program may be measured by: (1) the number of previously unknown and subsequently verified cases of disease discovered among the population group tested; (2) the number of persons with previously unrecognized verified diseases who are benefited by referral to medical care as a result of the screening procedure; (3) the number of persons with previously known disease who are returned to medical supervision as a result of the screening experience; (4) the number of individuals who believe they have the disease, have 8

Kurlander, Arnold B., M.D., Hill, Elizabeth H., M.D., and Enterline, Philip E. "An Evaluation of Some Commonly Used Screening Tests for Heart Disease and Hypertension." Journal of Chronic Diseases 2:427—439, October 1955.

50

PREVENTION OF CHRONIC ILLNESS

a positive screening test, but are found not to have the disease by subsequent diagnostic examination; and (5) the number of persons with communicable disease who are prevented, as a result of their participation in the screening program, from spreading the disease to their families or to the community at large. In 1949, Chapman 9 observed: The productiveness of a multiphasic screening program can be estimated by a study of prevalence statistics. Based on national estimates, a screening examination of 1,000 apparently well people over the age of 15 for syphilis, diabetes, glaucoma, anemia, tuberculosis, obesity, vision defects, hearing loss, hypertension, and heart disease would result in finding 976 cases of these diseases or pathological physical conditions. Some of the 1,000 people screened probably would have two or more of these diseases or conditions, whereas others would have none. For example, one person might have syphilis and diabetes; another might have a significant refractive error and glaucoma; and still another might be obese and hypertensive. . . . Many of these [persons] ordinarily may not come to the attention of physicians until definite signs or symptoms have developed. In every community today many people with a chronic disease or a remediable disability, such as faulty vision or a progressive aural disease, are going about their work unaware of the fact that there is anything seriously wrong with them or that they will eventually become hopelessly ill, or permanently disabled. By the time signs and symptoms, which send them to their physician, do develop, much valuable time has been lost and irreversible pathology has been established. Costs Costs may be calculated per test given, per person screened, or per case found (often per new case found). The two major elements in determining costs are: (1) the amount of regular payroll and other costs that should be charged to the screening project, and (2) additional expenditures for payroll, instruments, and reagents. Two factors that will strongly influence costs are: (1) accessibility of population group to be screened and (2) number of diseases screened by the same test or procedure, or by using singly-collected specimens for multiple determinations. For example, a chest x-ray is actually a very economical screening device, inasmuch as it can indicate the pre' Chapman, A. L., M.D. "The Concept of Multiphasic Screening." Public Health Reports 64:1313, October 21, 1949.

51

SECONDARY PREVENTION—SCREENING

sumptive presence of pulmonary neoplasm and some cardiovascular disease as well as tuberculosis. Wherever feasible, the chest x-ray should be used to detect evidence of all three of these conditions. The fact that relatively few professional personnel, particularly specialists, can be assembled at any one time and place makes it mandatory that screening programs use technicians and other nonprofessional personnel to as great an extent as possible. The costs of any screening procedure will rise, of course, with increased use of professional personnel. To arrive at a complete determination of the cost of any program, cost accounting and job analysis studies must be conducted. An American Medical Association study of multiple screening programs has documented variations in cost, which further emphasize the need for studies on cost: The range in the 18 surveys reporting costs was from $1.03 to $39 per person. Of these 5 were less than $2.00; 3 were from $2.00 to $5.00; 3 from $5.00 to $10.00; 6 from $10.00 to $15.00; and 1 was over $15.00. 10 Acceptance Acceptance of a screening program may be measured by the percentage of the population participating; the extent to which the positive results of the test lead to recommended action for diagnosis and therapy; the willingness of physicians and other professional groups to collaborate in the program; and the degree of responsibility taken by official and voluntary community agencies to increase funds and facilities for care of patients discovered by the screening programs. Follow-Up

Services

The availability of adequate follow-up services is another measure for evaluating screening programs. Follow-up services should include diagnosis and therapy for all persons in the community in whom disease is presumptively detected through screening procedures. Lack of existing facilities for prolonged care of the chronically ill, however, should not in itself preclude undertaking a community screening program; the important thing is willingness on the part of all community health and related resources to cooperate in providing the diagnostic and follow-up services that will assure the productivity of the screening program. 10

A Study

of Multiple

Screening.

Descriptive

Data

on 33 Screening

Surveys.

(Revised). Chicago, American Medical Association, Council on Medical Service,

1955, p. 13.

52

PREVENTION OF C H R O N I C ILLNESS CONTENT OF SCREENING

EXAMINATIONS

Mass screening—on both a single-test and multiple basis—has been conducted in a variety of situations and communities in the United States since the late 1940's. Beginning with the early 1950's, interest in and emphasis on multiple screening have greatly increased. Multiple screening surveys have been undertaken in widely scattered communities, including Boston, Atlanta, Richmond, San Francisco, Los Angeles, Indianapolis, Washington, D.C., Akron, Hunterdon County, New Jersey, and Baltimore.11

Tests and Procedures Commonly Used Some screening and detection methods are suitable for use by the private physician for individual screening in his office; some for singletest screening programs; some for multiple programs; and some in all situations. Some 24 procedures are fairly representative of the screening tests that have been developed in recent years. All of them have been reported by the Council on Medical Service of the American Medical Association as having been used in one or more of the 33 multiple screening surveys conducted in various sections of the United States since 1948.12 The 33 surveys, while not including all multiple screening programs that have been carried out in this country, represent all for which the Council on Medical Service could obtain the information required for its study. Of the 24 procedures listed below, the 3 most commonly used in the programs studied were blood sugar determination, serologic test for syphilis, and x-ray for chest pathology. Some programs included procedures denoted as "complete general physical examination" and "complete medical history." Inasmuch as neither of these is, properly speaking, a "screening" procedure, they have not been included in the following list: Evaluation of Physical Status Height, weight, and body build Pulse and respiration Temperature Blood pressure

Eye Tests Visual acuity determination Intraocular pressure determination

11 See Chronic Illness in a Rural Area and Chronic Illness in a Large City, Vols. I l l and I V of this series, Chronic Illness in the United States, f o r descriptions of the two last n a m e d . " A Study of Multiple Screening, pp. 15-91.

SECONDARY PREVENTION—SCREENING

Blood Tests Hematocrit determination Buffy coat test Blood count Hemoglobin determination Serologic test for syphilis Blood group and Rh factor determinations Sedimentation rate determination Blood sugar level determination Urine Tests Albumin Sugar Acetone

53

X-Ray Procedures Dental x-ray Chest x-ray (read for evidence of lung and/or heart pathology) Miscellaneous Procedures Electrocardiography Cervical cytology test (Papanicolaou smear) Hearing test (audiometry) Self-screener history (done by the patient or a clerk, as distinguished from a complete medical history) Stool examination (for occult blood)

It is obviously not practicable to provide all these 24 tests and examinations in every multiple screening program. The usefulness of individual tests in a screening program will depend on a number of factors, including the specific objectives of the program; characteristics of the population groups being screened; and available funds, facilities, personnel, and time. "Streamlined" Medical Examinations and Screening Great emphasis has always been placed in medical education on the need for meticulous and detailed history-taking and physical examination.13 In adapting the idea of the comprehensive examination to presumably well persons, the medical profession has tended to retain this general approach. However, if the techniques of modern medical science are to have widespread application in detecting chronic disease, use of the "streamlined" or survey type of physician's examination must be expanded. White and Geschickter, for example, developed a streamlined health examination consisting of a group of 18 questions in the medical history, 28 indications of abnormality detectable by physical examination (including 5 indications of psychiatric abnormality), and 6 essential laboratory tests. They believe that this battery of procedures provides a sufficient basis for detection of the 200 common disorders which they estimate account for 98 per cent of all illness in the United States. A sensible screening examination, they contend, must concentrate on 13

See Chapter 6 for discussion of the need to reorient medical training toward the preventive approach to chronic illness.

PREVENTION OF CHRONIC ILLNESS

54

detecting evidence of these 200 conditions, rather than attempt to track down the rarer disease that may concern an individual diagnostician in an occasional case. White has suggested that if the laboratory procedures and the medical history are performed as a separate "packaged" service by public health units or other community agencies, the remainder of the simplified examination can be carried out by the physician in about 15 minutes.14 Other physicians might select a different list of indicators for use in detecting major diseases, but the White-Geschickter examination outline provides a good example of the use of the screening method in private medical practice. Most cancer detection clinics have adopted a similar approach and an occasional multiple screening program has also made use of the technique. The simplified checklist medical history form known as the Cornell Medical Index, or "self-screener," is another example of the selective approach to the health examination.15 It is one of several standardized history forms developed in recent years which may be completed by the patient with simple "yes" or "no" answers. In the Cornell Index, the patient is asked to answer approximately 200 relatively simple questions, arranged in 18 groups. These questions relate to symptoms, past or present, rather than to clinical entities of which most patients have only vague knowledge. If a patient fills out the questionnaire before his visit to the doctor, much time can be saved in the historytaking procedure. The physician's attention may be quickly directed toward symptoms that require special attention. Self-administered histories of this kind have been helpful to physicians who see patients referred from mass screening programs. Diseases

to which Screening

Tests Are Now

Applicable

The discussion which follows presents some of the more useful screening tests and procedures that have been developed for presumptive identification of several of the major chronic conditions and diseases. In most cases, these tests have demonstrated their ability (in terms "White, Benjamin V., M.D., and Geschickter, Charles F., M.D. Diagnosis in Daily Practice. Philadelphia, J. B. Lippincott Company, 1947. 693 pp. 15 Brodman, K., M.D., Erdmann, A. J., Jr., M.D., Lorge, I., and Wolff, H. G., M.D. "The Cornell Medical Index: An Adjunct to Medical Interview." Journal of the American Medical Association 140:530-534, June 11, 1949; also Brodman, Erdmann, Lorge, and Wolff. "The Cornell Medical Index-Health Questionnaire: II. A s a Diagnostic Instrument." Journal

145:152-157, January 20, 1951.

of the American

Medical

Association

SECONDARY PREVENTION—SCREENING

55

of a relatively high rate of confirmed diagnosis upon subsequent medical follow-up of the persons tested) to reveal evidence of disease while it was still in an asymptomatic phase. Newer and more experimental procedures which have been suggested as appropriate techniques for screening but which require further study are discussed on pages 67-68, 16 which also point up the need for extensive study of the effects on humans of relatively low level radiation exposure. As further information is developed, it may be necessary to modify existing practices and recommendations to assure that the potential risk from radiation exposure does not exceed the probable benefit. Tuberculosis. At present, the tests for tuberculosis considered suitable for general application to the population are the tuberculin skin test and the chest x-ray. The types of x-ray test most frequently employed are the miniature photofluorogram and the 14-by-17 inch roentgenogram. Further refinement of both procedures is still desirable, although they are already appropriate for general use. Vision defects (including glaucoma). Many types of vision defects (such as refractive errors and cataracts) may be detected by visual acuity tests and ophthalmoscopic examinations in the screening program. Primary glaucoma cannot yet be prevented, but its end result —which is blindness—can be prevented in a large percentage of cases through early detection and treatment, with the aid of such screening techniques as visual-field tests and tonometry. The tonometer is a suitable device for presumptive identification of glaucoma. Hearing dejects. Early detection of hearing loss, especially in children, may reverse the process of impairment or prevent progression to a point where problems of communication arise. Suitable screening tests for hearing loss consist of the "individual test" with a pure-tone audiometer; and the "group test" for screening 5 or more persons. Syphilis. Latent syphilitic infection may be discovered before serious organic damage occurs by means of any one of a number of accepted serologic testing procedures.17 Tests employing treponemal antigens may be used to resolve some of the borderline cases. 10 See also Part II of this volume for a more extensive discussion of some of these procedures in relation to specific conditions. 17

These tests are listed in the Manual

of Serologic

Tests for Syphilis,

lication No. 411. Washington, D.C., Government Printing Office, 1955.

PHS Pub-

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Diabetes. Early detection has a twofold preventive significance in the case of diabetes: if adequately treated after detection, patients with the disease will have less danger of incurring infection or lapsing into coma; and proper therapy during the asymptomatic stage is likely to inhibit the progress of the disease process, and may even reverse some of the changes that have already taken place. Tests considered suitable for general application as case-finding devices for diabetes are measurements of blood sugar and urine sugar. Until recently, the principal method for early discovery of diabetes was urinalysis, based on the theory that substantially all early diabetics displayed evidence of glycosuria. Urinalysis is a useful indicator of the possible presence of diabetes, but experience in community-wide surveys has shown that about 1 out of 3 diabetics whose disease is in the asymptomatic stage escapes detection if dependence is placed upon analysis of a urine specimen alone.18 A newer and generally more accurate screening procedure for diabetes is the blood sugar level determination. A relatively rapid method for determining blood sugar level, widely used in mass screening situations, is the Wilkerson-Heftmann test which is automatically performed by the Clinitron. Cancer. Authorities have estimated that one-third of the deaths from cancer could be avoided through application of present knowledge of prevention and treatment. In the United States, this would mean saving approximately 75,000 lives annually. Accomplishment of this goal depends upon early detection and prompt, adequate treatment. The cost of comprehensive cancer detection examinations has led to the development of modified clinical examinations limited to a few accessible sites of the disease, such as the skin, buccal cavity, rectum, breast, and cervix. These 5 sites can be checked for evidence of cancer quite rapidly; they account for more than one-half of all cancer in women and a substantial amount of it in men; and they are also, generally speaking, "the ones most amenable to cure in the present state of our knowledge."19 In screening programs, the most effective current procedures for the discovery of early evidence of cancer are radiography and cytology. The radiographic technique has been applied particularly to discover lung cancer. The photofluorogram of the chest taken in the course of a screening survey may be read for evidence of lung cancer and heart 13 Rosenau, Milton Joseph, M.D. Preventive Medicine and Hygiene (7th edition). New York, Appleton-Century-Crofts, 1951. u Ibid.

SECONDARY PREVENTION—SCREENING

57

pathology as well as for tuberculosis. Mass application of radiographic techniques for discovery of cancer of the upper gastrointestinal tract is now also being evaluated. Cytology appears to be the most useful procedure at present for cancer detection. The cytologic method of cancer detection is based on changes in cell specimens removed from body areas and depends upon the fact that most cancers begin at an early stage to exfoliate cells with malignant characteristics. If recovered, these cells constitute presumptive evidence of the existence of carcinoma long before any symptoms of the disease occur. The vaginal cytology test (Papanicolaou smear) for cancer of the cervix is suitable at present for general use in screening. A cytologic technique for the detection of pulmonary cancer has also been developed and studies are under way to determine the applicability of the technique in screening for gastric and prostatic cancer. The appropriateness of the cytologic procedure as a method for early detection of cancer of the uterine cervix has been demonstrated in several screening programs. The findings of a 3-year project conducted by the National Cancer Institute of the Public Health Service in Shelby County, Tennessee, in 1951-1954, place the peak of incidence of intraepithelial cancer at age 33; and of early invasive cancers at age 52. Eighty-eight per cent of cases of intraepithelial cancer and 29 per cent of cases of invasive cancer were unsuspected by either physician or patient. This suggests that cancer of the cervix may exist for varying periods of time in a noninvasive form—a stage at which it is curable. This study, which is being followed by others, emphasizes the value of the cytologic technique as a screening device.20 Cardiovascular diseases. The two major forms of cardiovascular disease affecting the American people today are coronary artery disease and hypertensive heart disease. Recent advances in therapy of these conditions justify greater attention to early detection of them. Blood pressure determination, for example, is a simple screening test for hypertensive disease which often reveals the disease process before cardiac enlargement is visualized on x-ray film. The chest x-ray, so commonly used for lung disease detection only, also serves to disclose hypertensive heart disease—after the heart begins to enlarge in response to the disease process. As yet, no fully satisfactory screening devices have been developed 20

Erickson, Cyrus C., M.D., et al. "Population Screening for Uterine Cancer

by Vaginal Cytology." Journal

September 15, 1956.

of the American

Medical

Association

162:167-173,

PREVENTION OF CHRONIC ILLNESS

58

for coronary artery disease. Brief self-questionnaires to determine heart pain; electrocardiography, with and without exercise; physical-chemical tests for certain blood constituents; and other means proposed for the early detection of coronary artery disease are now being explored by many investigators. Research along these lines will hasten the day when we can reduce the toll of this disease which now accounts for about half of all deaths among men in the United States. 21 SELECTION OF POPULATION GROUPS FOR SCREENING PROGRAMS

Coverage of the entire population by screening programs is far beyond the realm of possibility at present. Very effective screening programs, however, can be directed toward groups relatively accessible to existing facilities for health services and toward groups likely to give a high yield of positive findings. Among these groups are hospital inpatients and outpatients; employees of industrial and commercial organizations; members of labor unions; students in schools and universities; persons receiving social services; and members of organized medical care programs. Hospital Patients Hospitals in the United States report approximately 20 million inpatient admissions annually and about 65 million outpatient visits.22 General and special hospitals and their clinics can appropriately use screening procedures to detect unsuspected chronic illness and to initiate early treatment. The criteria outlined on pages 47-51 for evaluating mass screening programs are equally applicable in determining which tests can be effectively used for hospital and clinic patients. Members of Industrial and Labor Groups The large industrial corporations that have organized comprehensive health plans for their employees include such services as preemployment examinations, routine periodic health evaluations, nursing services in the homes, and so forth. Other industrial organizations may offer no more than inplant first-aid services for job-connected disabilities. Regardless of the size and scope of their health programs, industrial plants have both the incentives and the opportunities to reach many apparently healthy individuals, through screening tests, "well adult" health clinics, 21 U.S. Department of Health, Education, and Welfare. Vital Statistics of the United States, 1953. Vol. II. Washington, D.C., Government Printing Office, 1955, pp. 164, 168. 22 American Hospital Association. Administrators Guide Issue of Hospitals 29:7, 57, August 1955, Part II.

SECONDARY PREVENTION—SCREENING

59

and other case-finding devices to discover unrecognized chronic illness. Approximately 18 million persons were trade union members in the United States at the beginning of 1955 ;23 therefore, labor unions, through expansion and direction of their health programs, have an outstanding opportunity to promote case-finding and screening for chronic illness. Students in Schools and Universities From the viewpoint of prevention, children constitute perhaps the most important group in the population. Comprehensive preventive measures against chronic illness applied to school children throughout the period of school attendance could significantly reduce the incidence in later life of chronic and crippling diseases such as mental illness and rheumatic heart disease. One of the common requirements for admission to colleges and universities is a health examination. Such examinations vary widely in scope and adequacy, as do the follow-up services available through health facilities for students. Screening and other case-finding programs could be profitably conducted among the several million students currently attending colleges and universities. Screening programs of this type in schools and universities should be organized so as to be available to faculty members and other employees of these institutions as well. Recipients of Social and Welfare Services Approximately 4 per cent of the total national population are estimated to be under the care of public and private welfare agencies at any one time. Agencies giving financial assistance and other social services could discover much unknown chronic disease and arrange for initiation of early medical treatment when necessary, if their clients received appropriate screening tests and were referred for thorough examination and medical care. Social agencies should encourage community medical care facilities to offer, and their clients to accept, detection services for chronic disease. Members of Group Health Plans Medical service plans usually have facilities for selected screening tests as well as for comprehensive health examinations. The total combined membership of these plans is sizable and growing. They are particularly " U.S. Department of Labor. Directory of National and International Labor Unions in the United States, 1955. Bulletin 1185. Washington, D.C., Government Printing Office, 1955, p. 1.

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well equipped for screening services oriented toward diseases in which familial patterns of incidence appear, inasmuch as they usually emphasize medical care of entire families rather than single individuals. In group practice prepayment plans, the reduction in cost of treatment that might result from early detection and secondary prevention of chronic illness should encourage routine screening services for all members. Other Special Groups Approximately 2 million persons are employed by hospitals, and thousands more are on the staffs of public and private health and welfare agencies across the nation. Furthermore, some 7 million persons are employees of federal, state, and local governments.24 Early detection of much unrecognized chronic disease would undoubtedly result from screening tests for all these personnel. Preemployment examinations could be converted into more meaningful preventive procedures, from the standpoint of the individual examined, if the agencies involved would also arrange appropriate referral services for those found to have conditions needing medical attention. Medical examinations and medical services for members of the Armed Forces and for veterans would yield many opportunities for secondary prevention of chronic illness were emphasis placed on early detection and prompt treatment. Mechanisms should be developed to insure that men rejected under the Selective Service System for health reasons are referred for adequate diagnosis and early treatment of their defects. SCREENING IN ACTION

Chronic Illness in a Rural Area and Chronic Illness in a Large City, Volumes III and IV of this series,25 detail the methods and present the findings of the Commission's two community surveys. Both studies included screening and detection procedures. Millions of persons undergo screening procedures of various kinds each year. Physicians screen their private patients for one chronic condition or another in the course of health evaluations or diagnostic examinations. Although multiple screening programs are still relatively new, several million persons have participated in such programs since 1948. About 2.5 million were screened in the 33 multiple screening programs 24 U.S. Department of Commerce. Bureau of the Census. Statistical Abstract of the United States, 1954. Washington, D.C., Government Printing Office, 1954, p. 419. Included in this figure of 7 million, of course, are the employees of public hospitals and school systems, and of the official health and welfare agencies referred to in the previous sentence. 25 In preparation.

SECONDARY PREVENTION—SCREENING

61

described by the Council on Medical Service of the American Medical Association in its report in 1955. A good general idea of the manner in which multiple screening programs are organized and administered can be obtained from a brief review of some of the characteristics and results of this group of 33 programs.26 General Characteristics—A Review of 33 Projects Coverage. Geographically, the programs described in the American Medical Association's report covered a wide area. They were located in 14 states and the District of Columbia. Two of the 33 surveys were conducted on a state-wide basis; 17 involved entire communities; 14 were limited to certain groups of the population, such as employees in a given industry. Three of the programs screened more than 200,000 people each, the largest number for any single program being the nearly 1.4 million who participated in the state-wide Georgia project in 1953— 1954. A majority of the projects attempted to cover the entire population in a given area. In 9, however, only the workers in a single industry were included; in 1 only Negroes participated; and in another only hospital outpatients. Sponsorship. The number of sponsoring and collaborating organizations and agencies varied widely among surveys, ranging from a single health department in 3 instances to 11 community agencies and groups in the 1951 survey in San Francisco. Local and state health departments either sponsored or conducted 23 of the programs, often in cooperation with voluntary health agencies, while the United States Public Health Service cooperated in 11. Medical societies sponsored and actively collaborated in 16 of the projects and approved most of the others. The list below indicates the wide variety of community organizations that sponsored, cosponsored, or actively participated in one or more of the 33 multiple screening programs described by the American Medical Association: 27 Voluntary Health Agencies State cancer society State heart association Community health council Local tuberculosis association Local visiting nurse association State diabetes association State mental hygiene association Commission on Chronic Illness

Community Welfare and Civic Agencies Local chapter, Young Men's Christian Association Local chapter, American Red Cross Veterans' organization Community social service organization " A Study of Multiple 21 Ibid.

Screening,

loc. at.

62

Government Agencies Local health department State health department Public Health Service Tennessee Valley Authority U.S. Children's Bureau Public general hospital School of medicine Medical-Service Organizations Organized medical care plan Voluntary hospital Private diagnostic clinic Ad hoc group of local physicians University student health center County medical center Professional Organizations Medical school department of public health

PREVENTION OF CHRONIC ILLNESS

County medical society State medical society City academy of medicine Local chapter, state-wide association of medical laboratory technicians Committee of professional health consultants County dental society Women's auxiliary, county medical society Labor and Management Groups Labor union welfare fund Industrial corporation Labor union local Insurance company Employer-employee collective bargaining group

Objectives. One or more of the following objectives were identified: to test the general feasibility of the multiple screening approach; to test certain specific techniques of multiple screening procedures; to discover cases of particular chronic conditions in the population; and to provide health education. Tests and findings. The number of tests ranged from 2 to 15 among the 33 programs investigated. Fewer than 6 tests were used in 10 surveys. Twelve programs used between 6 and 10 tests and the remaining 11 used between 11 and 16. As would be expected, there is a direct correlation between the number of screening procedures used in a given survey and the percentage of positive findings recorded among the individuals participating. Those programs including 11 or more procedures reported positive findings for 48 to 67 per cent of the persons screened. Administration, personnel, and costs. Typical multiple screening programs were arranged so that the various procedures were performed in one convenient place, and were organized to permit examinations of 15 to 20 persons per hour. Technical, clerical, and auxiliary personnel, working under medical supervision, constituted the basic staff; except for procedures such as eye and pelvic examinations, physicians did not ordinarily perform tests. Results of each individual's examinations were subsequently summarized and recorded. Confidential reports indicating

SECONDARY PREVENTION—SCREENING

63

presence or absence of suspicious findings were sent to each participant, and persons whose findings were positive were referred to their own physicians for follow-up. Nine of the surveys had one or more physicians in the examining or testing line. The other programs had medical supervision with physicians available when they were needed. Results of many of the tests in the 33 programs were interpreted by technicians. However, in all cases physicians interpreted chest films, electrocardiograms, significant points in individual medical histories, and other procedures needing clinical judgment. The time spent per person and the cost per person varied greatly from survey to survey, and in some programs could not be estimated. Rough estimates of time spent ranged from 3 minutes to 2 hours per person, depending on the number and types of tests used; 16 of the 24 programs for which the time factor could be calculated required 30 minutes or less to screen each participant. Follow-up. The loose control over the follow-up phase characterizing most of these projects points up dramatically one of the major problems in current screening efforts. To be successful in bringing incipient chronic conditions to early detection and prompt treatment, screening programs must have the cooperation of both the person screened and his physician regarding referral for follow-up services. The American Medical Association's Council on Medical Service emphasized this point in the following terms: Probably the greatest obstacle in any evaluation of multiple screening is the lack of data on diagnosis resulting from follow-up on persons with positive indications of disease. In only 15 of the 33 surveys were such follow-up data available, and even in these instances there was no way of knowing how many of the positive screenees actually went to their own physicians for further examination. Figures on the percentage of positive screenees found to have positive diagnoses cannot be compared until the percentages of persons seeking follow-up are known.28 With careful arrangements for follow-up services built into a screening program, however, the latter becomes an excellent technique for bringing unsuspected chronic disease to definitive diagnosis and early treatment and, thereby, for promoting secondary prevention in its true sense. 28

Ibid., p . 14.

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The San Francisco Survey A multiple screening project which was among the first to demonstrate the importance of organized medical follow-up for all screened individuals was the 1951 survey in San Francisco, in which 3,994 longshoremen participated.29 The fact that the screening procedures in this case were organized within the framework of an operating prepayment health plan offering comprehensive medical services provided every inducement for union members participating in the screening phase to take advantage of follow-up services. Medical care was easily available to them through the prepayment plan and a convenient means of checking on the number of union members reporting for such services was also available. A high proportion of participants received follow-up services, and a high percentage of confirmed diagnoses was recorded for diseases presumptively identified through the screening tests. The 3,994 men screened in this program were relatively well paid manual laborers, with a median age of 49 and an average annual income of about $5,000. The time spent in examining each individual averaged 55 minutes, and 18 persons were screened per hour on the average. The examinations took place at a single location—a clinic set up for the project in the union hiring hall on the San Francisco waterfront. A battery of 12 screening procedures was used: height and weight determination; vision test; hearing test; chest x-ray; electrocardiography; blood pressure determination; serologic test for syphilis; hemoglobin determination; blood sugar level determination; urine sugar and urine albumin tests; and medical history. All persons with positive findings for one or more tests were routinely referred to a health plan physician for medical follow-up. Of the total number of 3,994 men screened, 2,521 (63 per cent) were found to have positive results on one or more tests. Seventy-two per cent (1,820 persons) of those with one or more positive tests reported for follow-up medical services within 4 months; of this group, 78 per cent (1,413 persons) had one or more positive diagnoses confirmed. Of the total number who reported for follow-up, 19 per cent (773 persons) had at least one diagnosis of a previously unknown condition confirmed. M Weinerman, E. R., M.D., Breslow, Lester, M.D., Belloc, Nedra B., Waybur, Anne, and Milmore, Benno Κ., M.D. "Multiphasic Screening of Longshoremen with Organized Medical Follow-Up." American Journal of Public Health 42:15521567, December 1952.

SECONDARY PREVENTION—SCREENING

65

Eighty-one per cent of the longshoremen with subsequently confirmed diagnoses were not under a physician's care when they were screened. An important by-product of the screening project was the establishment of medical supervision for many men with conditions which, though previously known to them, had been neglected. Instances of newly discovered disease detected by the battery of tests included cardiovascular disease (339), active or possibly active pulmonary tuberculosis (6), diabetes (46), and syphilis (28)—all potential long-term illnesses. In addition, many other important conditions not related to the screening tests were first discovered during the examination which was done after the individual had been referred because of some test. These included 4 malignant neoplasms, 50 nervous system disorders, 47 respiratory conditions, and numerous other important diseases. FUTURE

PROSPECTS

The screening technique, particularly as applied in multiple mass screening programs, represents a major extension of the concept of preventive medicine into the chronic disease field. The major considerations that led the Commission on Chronic Illness to recommend extension of screening programs can be summarized as follows: Screening is one way of detecting early signs of disease that may lead to diagnosis when the patient is subsequently examined by a physician. A positive screening test suggests a high "index of suspicion" for the disease or abnormality at which the screening test was directed. Multiple screening, by combining several disease-detection tests, is a streamlined process assuring speed, efficiency, and economy. Multiple screening contributes to good medical practice. It constitutes a practical means for early detection of a number of important chronic diseases and impairments. Since a complete health examination for everyone is not practicable at present, screening—while definitely not a substitute for a health appraisal by a physician—performs a useful function in facilitating discovery of disease in asymptomatic stages for many persons not now reached by periodic health appraisals. Multiple screening provides an excellent opportunity for health education. Through participation in a screening program, individuals may receive worthwhile information on health practices, and many will be motivated to seek medical attention. Multiple screening, nevertheless, should not be regarded as a panacea. Smillie, one of its critics, while recognizing the advantages attributed to it, believes multiple screening to be inferior medicine. In its stead, he proposes "that the health department shall develop facilities for a

66

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series of standard and acceptable diagnostic tests which would be available to all physicians and to all patients who have been referred by physicians; and that these tests shall be free of cost." 30 The position taken by the Commission on Chronic Illness, however, is essentially that taken by one of its members who has pointed out that screening "will not solve all the health problems of the people. To ensure even its appropriate contribution in the health field, technical and organizational aspects . . . should be improved. It does, however, carry us a step forward in the early detection of chronic disease."31 The Commission further believes that the major needs for improvement are: To develop and refine valid tests and procedures. To maintain continuing facilities for multiple screening, as opposed to the present largely episodic or "demonstration" programs. To acquire and disseminate facts on the number of suspected cases of disease that will be revealed by particular screening procedures. To assure adequate arrangements for medical follow-up, through referral to physicians for definitive diagnosis and needed care, for persons in whom disease is suspected on the basis of screening test findings; and to analyze costs of the various tests and follow-up procedures; and to develop methods of financing the programs. Kurlander and Carroll offer the following balance sheet on its future prospects: Although much progress has been made, multiple screening is still in an evolutionary stage. Screening and followup programs for syphilis and tuberculosis have been highly developed, but this is not true of screening for other diseases or for groups of diseases. Much remains to be learned through evaluation of multiple screening, in terms of accomplishments and costs of procedures to be followed at various stages from the original screening through the entire followup. In the final analysis, of course, screening can be evaluated only by its results, such as reduced morbidity, disability, or mortality. Its ultimate value in the local community will be achieved as it becomes an integral part of a well-rounded chronic disease program, but on a limited scale multiple screening can serve to stimulate and guide the evolution of such a program. 32 M Smillie, W. G., M.D. "Multiple Screening." American Journal of Public Health 42:258, March 1952. 21 Breslow, Lester, M.D. "Multiphasic Screening in California." Journal of Chronic Diseases 2:383, October 1955. 32 Kurlander, Arnold B., M.D., and Carroll, Benjamin E. "Case Finding Through Multiple Screening." Public Health Reports 68:1042, November 1953.

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EXPANSION OF RESEARCH

Major areas in which research should be started or extended are development of more precise screening tests for early detection of illness and development of administrative methods for the more efficient organization of services for secondary prevention. Greater Precision in Screening and Early Detection Despite the great strides that have been made in recent years in the development of techniques for early detection of chronic illness, many of the tests and procedures used should be improved in reliability, validity, and yield. In addition, many proposed screening tests and procedures for possible detection of disease in asymptomatic stages need to be evaluated. Examples of procedures awaiting further evaluation are: For cancer Tests based on measurement of host changes, such as blood protein changes, serum enzyme activity changes, and specific immunological reactions. Abnormal steroid urinary excretion patterns as possible portents of cancer. Cytologic tests for bronchogenic, prostatic, and gastric cancer. Use of the microfluorometric scanner (an electronic device) as an aid in cytologic detection of cancer. Practical methods for selecting a high prevalence group for gastrophotofluorography, using such prescreening findings as anemia, achlorhydria, and family history. For diabetes mellitus Glucose tolerance tests (the need here is for attainment of greater uniformity in preparation for, and interpretation of, the tests). Administration of cortisone or ACTH to persons suspected of having subclinical diabetes (substances may make latent diabetes sufficiently manifest to be clinically apparent). For rheumatoid arthritis Differential sheep cell agglutination test. For cardiovascular diseases Exercise tests. Anoxemia tests. Tests for cholesterol and cholesterol fractions. Single blood pressure determinations. Cold pressor tests.

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For glaucoma Validation of simple screening tonometer. Validation of rapid visual field screener. Before their potential value can be determined, the procedures just mentioned and many others as well must be evaluated, 33 including extensive study of the effects of radiation. When the limits of its safe use are established, screening and diagnostic tests now in use may be subject to changes comparable with those introduced following discovery of the effects of overuse of oxygen in the care of premature infants. This underscores the need for research conducted on a systematic and comprehensive scale. Frequency Distribution

of Chronic Diseases

Epidemiological studies are needed to determine the concentration of specific chronic diseases in various demographic groups. Research has already revealed the high prevalence of tuberculosis among patients in mental hospitals, or among single, homeless, elderly men; of cancer of the cervix among women in the lower income groups and particularly among those who have borne children early in life; of lung cancer among men who smoke cigarettes and among men in certain occupations; and of diabetes among the obese and the relatives of diabetics. Special screening programs to reveal demographic factors like these in the distribution of illness and detailed reporting and analysis of results of such studies will yield data that will be of great value in planning future programs of maximum productivity and minimum unit costs. Recognizing the importance of greatly expanded research, the Commission concluded: 1 1 . The successful operation of programs for making screening tests available to large groups of the population cannot be accomplished until a number of problems are solved. Administrative research is needed to seek solutions to such questions as: the appropriate relationship of mass screening programs to the practice of medicine, the creation of a demand for services after screening which cannot be fulfilled with existing resources, a n d a standard of reasonable cost for screening. There are other similar questions stemming from present-day traditions a n d attitudes about which administrative research should be undertaken. 12. The Public Health Service is urged to use its leadership position and its resources to bring about the development a n d refinement of valid and feasible screening tests, to disseminate information about them, and to stimulate their prompt incorporation into general use. 33

See Part II of this volume for further examples of such procedures.

Chapter

6 Personnel and Education1 The same shortages of adequately trained personnel that hinder provision of optimum services in other health areas also retard progress in prevention of chronic illness. The personnel problem is not only a matter of shortages of people but also one of reorientation in education. The need for reorientation is not limited to any one of the health professions but is found in varying degrees in the educational programs for physicians and dentists, for nurses and social workers—in fact, for all the health disciplines. These groups need emphasis in their training on the preventive aspects of chronic illness. They need to become "prevention-minded." The broad implications of this attitude are well described in the report of the Conference on Preventive Medicine in Medical Schools, held in 1952 in Colorado Springs: If preventive medicine's challenge is to protect man from the hazards to his health, students must study man, in all his complexity, both in order to measure and to best fortify his resistance. They also must be prepared to recognize the varied kinds of hazards and stresses which impinge on man's health; disease agents; factors in man's hereditary constitution and in his personality; and circumstances in his physical and in his social environment, all of which—in combination or singly— may strain the individual's resistance beyond the limits of tolerance and bring disease or malfunction. If the success of prevention depends first upon the knowledge of causes, it depends next on the opportunity to use this knowledge to help man successfully counteract the stresses he encounters. The student should come to have a view of the natural history of disease, so that as a physician he may continually seek opportunities to interrupt its course most promptly for his patient's benefit. He should be aware that before the pathologic process is recognizable, the causes may be operating in man himself or in his physical, biological or social environment. He should understand the evolution of disease, from the first factors which lead to its initiation through changes in man's form and function lead1 See also Chapter 5, "Personnel and Education," in Care of the Patient, Vol. II of this series, Chronic Illness in the United States.

69

Long-Term

70

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ing to eventual defect, disability or death. In short, the central core of preventive medicine is an appreciation of the natural history of man and the natural history of disease. With such a view, the student should come to see that in any individual, from the period of his apparent health through the course of any disease or disorder, the physician has opportunities to "come before" the event. (To prevent, in modern usage, means to stop. The Elizabethan connotation of the word, to "come before," expresses more exactly the purposes of preventive medicine as we see it.) In some instances, depending on existing knowledge and opportunity, complete prevention is possible; in others, only intervention is possible, to prevent development of further disorders. But preventive opportunities of some degree or other are never lost until the patient himself is lost. A student can most easily visualize his opportunities to practice preventive medicine if he sees these opportunities in relation to the whole scope of comprehensive health care. . . . We believe that the student can look at the entire range of health service in terms of what have been called "levels of prevention." At these various levels, measures may be applied to the agent, the host, or the environment at some stage or another of the natural history of disease. . . . A student who gets the impact of this point of view will be the kind of physician who continually asks himself not only "What is wrong with this patient and how can I help him?", but also "Could his disease have been prevented?" 2 A great stride forward in efforts to control long-term illness will have been made when the attitude exemplified by this quotation becomes characteristic of the professional education and training of physicians and dentists, and of members of the other health professions as well. The cultivation of "prevention-mindedness," moreover, should be extended beyond the health professions. Intelligent cooperation from (1) the patient and his family and (2) the general public is needed before the attempts that physicians, dentists, nurses, and other professional health workers make to prevent chronic illness can have lasting and widespread effect. Such a reorientation will come about only if the cue for it is first given by practitioners of medicine and the other health disciplines. Inevitably, therefore, major emphasis must be placed initially on providing students in the various health fields and at all levels of training with greater knowledge of, and skill in applying, preventive techniques. This should be the first line of attack in the area of education for prevention. * Clark, Katharine G. Preventive Medicine in Medical Schools. Report of Colorado Springs Conference, November 1952. Chicago, Association of American Medical Colleges, 1953, pp. 13-15.

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EDUCATION

REORIENTING CURRICULA FOR ALL HEALTH PROFESSIONS 1 3 . Medical schools a n d other professional training resources should reorient their curricula so that graduates will have a n appreciation of the potentialities of chronic disease prevention a n d will develop the skills to translate the available knowledge a n d techniques into everyday practice. 1 4 . Associations which are directly concerned with curriculum improvement can be important instruments in reorienting professional education to bring to students modern concepts for prevention of chronic disease a n d long-term illness. W e urge these organizations to continue a n d e x p a n d their efforts to be of assistance in bringing about the necessary changes. 3

What is required today in the education of all health personnel to fit them for the role they should play in the prevention of chronic disease? Emphasis on Concepts and Methods of Preventive

Medicine

Significance of "health," as distinct from "disease." Students in all the health professions need to understand the significance of "health," as distinct from "disease." During his first two years of medical school, in the classroom and laboratory, the [medical] student is taught systematically the precise anatomical, physiological and biochemical knowledge painstakingly accumulated over the last four centuries to describe and measure the "normals" of bodily structure and function. Less frequently is he asked to study systematically the "normals" of living people as distinguished from those of the cell. . . . The scientific approach to health promotion and maintenance is possible only with a more exact understanding of what constitutes health, and with a better understanding of the nature of the adaptive devices which enable man to maintain health.4 Importance of comprehensive care. Interest in a comprehensive approach to health care may be stimulated by exposure, as a carefully planned part of the curriculum, to experience in programs "which provide continuous care of the patient in all the various circumstances of sickness and health and which offer opportunities to demonstrate a more comprehensive view of health services than is usually possible within the walls of a hospital." 5 ' F o r discussion of the role associations can play in reorienting curricula, see Care of the Long-Term Patient, Vol. II of this series, Chronic Illness in the United States, pp. 2 5 4 - 2 7 1 , 2 7 6 - 2 8 2 . 1 Clark, Katharine G., op. cit., pp. 1 7 - 1 8 . '•Ibid., p. 20.

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Influence of emotional factors on general health status. Emotional factors play a significant role in all disease, and in the development and progress of chronic disease in particular. Continued emotional disturbances, for example, directly affect a person's physiological state, and often lead to alteration in organic function and structure. They also may result in refusal on the part of a patient with a chronic ailment to follow the therapeutic regimen prescribed for his condition, and thus may contribute to its exacerbation. Influence of environmental factors on general health status. Since "from the world in which the individual lives come certain influences which may aggravate and perpetuate a disorder, and others which may be purposefully used to alleviate or correct it," 6 students should learn to pay attention to the physical and social environment of their patients, and to relate these factors to each patient's state of health or disease. Use of specific preventive measures. Students should be alerted to look constantly for opportunities and ways to apply the principles and practices of preventive medicine in the widest variety of situations for individual patients. Epidemiological approach to disease. Epidemiology may be defined as "the study of health and disease of populations in relation to their environment and ways of living."1 The pertinent factors in any epidemiological investigation include: characteristics of the host population; the causative agents of the disease being studied, whether they be predisposing, precipitating, or perpetuating agents; and the total environment —biological, physical, and social. The major objective of an epidemiological approach to a disease is to discover the cause or causes and to determine the points in its natural history where interruptions may be accomplished in man's favor. Epidemiological principles may be validly applied to analysis of the natural history of long-term disorders and conditions, as well as to the acute communicable diseases in relation to which they were first worked out. Some examples of the use of epidemiological techniques to discover methods for control of certain noncommunicable conditions are determination of the roles played by iodine in prevention of goiter, by fluorides in prevention of dental caries, 'Ibid., p. 18. ' Morris, J. N., M.D. "Uses of Epidemiology." British Medical Journal No. 4936, p. 396, August 13, 1955.

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and by vitamins in prevention of certain nutritional deficiencies and diseases. In a society that is changing as rapidly as our own, epidemiology has an important duty to observe contemporary social movements for their impact on the health of the population, and to try to assess where we are making progress and where falling back—an activity in line with the classic descriptions of famine and pestilence, of the relations of health and disease to social dislocations, wars, and crises.8 Medical and dental students, particularly, should learn about both the basic approach of epidemiology to health and disease and the techniques for determining the epidemiology of a particular disorder if they are to make a full contribution, in their professional practices, to prevention of chronic illness.9 The Contribution

of Public

Health

The public health discipline has much to contribute to the education of all health personnel in "prevention-mindedness," particularly with respect to the epidemiological approach to disease and the influence of environmental factors on health status. The primary emphasis of public health has traditionally been on prevention, and this approach remains a natural one for public health personnel as they take on greater responsibilities in combating chronic disease. The great achievement of public health, in the nineteenth and early twentieth centuries, in learning how to control most of the serious communicable diseases through the application of preventive measures is directly traceable to the special proficiency of public health personnel in relating environmental factors to disease processes and in using epidemiological methods to attain mastery over these factors. Physicians

and

Dentists

In order for physicians and dentists to be prepared to apply principles and techniques of prevention in their everyday practice, there must be a reorientation in the content of the training they receive at every level of education, from the preprofessional to the postgraduate. The study of man in his totality—recognizing that he is constantly interacting with his environment—embodies concepts that are not as easy to teach as the basic factual and clinical material of modern medi• Ibid. ' Epidemiological methods are discussed in somewhat greater detail in Care of the Long-Term Patient, Vol. II of this series, Chronic Illness in the United States, Chapter 7, pp. 331-341.

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cine and dentistry. There are specific methods of getting at this problem, however, which are being used successfully and which are cited in Volume II of this series.10 Nurses

Nurses can be effective in prevention of chronic disease whether they work in hospitals, clinics, home care programs, nursing homes, schools, industries, or in public health programs. They can recognize premonitory symptoms of disease in patients and members of their families, and encourage early medical attention; they can teach patients and their families the principles and practice of good nutrition and healthful living in general; and they can, by recognizing the emotional aspects of illness, often forestall or reduce the psychological trauma of the illness for the patient. Education of the nurse for her vital role in the prevention of chronic illness presupposes a well-prepared faculty, clinical situations conducive to effective learning, and a sympathetic attitude on the part of other members of the health team. Emphasis should be placed especially on improving the curriculum of the basic professional program, although attention should also be paid, of course, to postgraduate and refresher programs for graduate nurses and to educational programs for practical nurses. The attitude of the student nurse is of paramount importance in any attempt to inculcate the newer concepts of prevention of chronic illness in the nursing profession as a whole. Suggestions for improvement in curriculum content are presented in Volume II of this series.11 Social

Workers

To the extent that social workers aid in alleviating social stress and strain or in minimizing deprivation, they may contribute substantially also to disease prevention. To the extent that they recognize the need for preventive services at the time of their initial contact with individuals and promptly institute the team work necessary to bring preventive services to their clients, social workers can be an important means of establishing "prevention-mindedness" in a group especially in need of this attitude. Education of social workers, therefore, should emphasize the role that they play in secondary prevention of chronic illness; that is, by early case-finding, prompt and effective referral, and 10 n

Ibid., Chapter 5, pp. 253-262; and Appendix E, pp. 538-540. Ibid., Chapter 5, pp. 262-266; and Appendix E.

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continuing casework service to prevent the progression of disease, to minimize disability, and to promote rehabilitation. In professional schools of social work, the teaching of medical and psychiatric principles and facts should be expanded and coordinated more closely with other parts of the curriculum, to the end that students will become more aware of the significance of early indications of physical and emotional dysfunction and of the possibilities of initiating preventive efforts at this point. Some of the means through which this reform of the social work curriculum might be achieved are: Revision of present medical information courses in schools of social work to include principles and methods applicable to prevention and control of chronic illness. Revision of psychiatric information courses to emphasize early deviations from normal personality development and behavior (particularly in children) which could lead to serious emotional disturbances. Inclusion of college courses in physiology and hygiene among the preprofessional requirements for admission to schools of social work. More and better utilization, during professional social work training, of opportunities—in casework courses and in field work—for extending the student's knowledge of chronic disorders, of their early symptoms, and of measures for preventing their progression. Outside the professional schools, the educational device of the shortterm "institute," which has helped considerably in making postgraduate educational opportunities available to practicing physicians, might well be adopted as a means of providing social workers with necessary knowledge about prevention. Institutes of this kind might be used to stimulate an interest among faculty members of schools of social work in revising present methods of instructing social work students in medical and psychiatric data. Organized on a regional basis and employing consultants from other health fields, such institutes might also prove worthwhile as educational mechanisms for executives of social welfare programs—especially family service and child guidance programs. Teachers and Health Educators The general classroom teacher, the special health teacher, and the professional health educator have important responsibilities in preventing long-term illness. Accordingly, their professional education requires instruction designed to fit them for exercising these responsibilities. The classroom teacher. By demonstrating his appreciation of the value of good health and by exemplifying in his own behavior desirable

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health habits and practices, the classroom teacher can suggest an appropriate pattern of healthful living for children to emulate. He will need instruction in techniques for observing and screening children in order to note deviations from normal health and to give particular attention to changes in attitudes and behavior as well as gross physical appearance. When definite deviations from the normal among members of his class become apparent, the teacher should know how to make the proper referrals to community health resources. Moreover, he can play an important part in preventing disability by his own attitude toward handicapped children. Many parents tell heartbreaking tales of their efforts to gain admission to school for very bright children who have some obvious handicap such as a left hand missing or a leg in a brace. Besides undertaking in his classes the kind of observation and rough screening described, the teacher may contribute to prevention of chronic illness by providing specific instruction directed at fostering development and maintenance of positive health. Such instruction should include emphasis on personal hygiene, proper nutrition, prevention of communicable disease, and community health in general. The special health teacher. In addition to receiving the same training in basic health observation as the ordinary classroom teacher, the health teacher should have special instruction in health education. His professional education should also provide him with the following knowledge and skills: Knowledge of accepted concepts concerning the cause, prevention, and treatment of long-term illness. Familiarity with, and ability to use effectively, services of other school health personnel, such as the physician—especially the psychiatrist— the guidance specialist, dentist, nurse, and nutritionist. Knowledge of the organization and services of community health and welfare agencies. Appreciation of educational methods appropriate to community organization and public relations activity. The professional health educator. The health educator working in the community applies the principles and techniques of education to health. His task is to work with individuals or groups in the community to aid in discovering the problems in chronic illness and restorative services and to help the community to work out its own solutions to these problems. Thus, basically, the same education in health is needed as is suggested for the classroom and special health teacher. In addition, graduate work emphasizing public health and its implications for chronic

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77

disease is required to augment the undergraduate training which may have been in education or related fields. An essential ingredient of the training of prospective teachers and health educators is the opportunity for field experience of adequate length to acquaint them with some of the situations which they may expect to meet on the job. The instructors of potential teachers, too, should be regularly exposed to field activities on a "refresher" basis, and should be urged to participate actively in community health affairs. Training for teachers and health educators, if conducted on a personalized basis, will do much to encourage proper motivation on their part. This motivation, if strongly inculcated in them, will enable them to perform their own educational functions in a manner that, in itself, will stimulate individuals to change their attitudes toward health. Colleges and universities can help potential teachers acquire this kind of motivation toward their profession by insuring a status for the teaching of health education equivalent to that of other special areas of education. Since the teacher and the health educator can materially help to reduce the lag between the development of new knowledge about prevention of chronic illness and its application by individuals in their own daily lives, it is important that current scientific information be provided on a continuing basis in the training curriculum for teachers and health educators. Along those lines, there is still no general agreement as to what are the "essentials" concerning health and the chronic illnesses that teachers and health educators should be prepared to teach in order to persuade persons to live healthfully. Intensive research should be undertaken to determine some of these, with special attention being given to the influence of social, economic, geographical, cultural, and similar factors. 12 INFORMATION AND EDUCATION FOR THE GENERAL PUBLIC

1 5 . General Interest in prevention of all illness has been aroused. Vigorous a n d more effective public education is needed, however, if individuals a r e to take the initiative a n d responsibility necessary for the most rapid extension of this general interest.

The primary objective of an educational program for the public in chronic disease prevention is to provide useful information and profitable learning experiences which will motivate individuals and groups to use preventive services and information for the benefit of the individual and his family. A secondary but almost equally important objective is "Ibid., pp. 331-341.

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to motivate groups and communities to provide, strengthen, and organize the personnel and facilities needed for preventive services and for research in prevention. Public education for the prevention of chronic disease takes the form of individual guidance, group teaching, and mass education. Changing patterns of disease which have accelerated during the past ten to fifteen years have brought changing patterns in the demand for preventive services and for programs to teach people what can be prevented and how. As Dr. Leonard A. Scheele told the American Academy of General Practice in 1956, ". . . four changing patterns of disease directly affect the general practice of medicine in the United States. These are: (1) the pattern of mortality and morbidity; (2) the pattern of diagnosis; (3) the pattern of therapy and follow-up; and (4) the pattern of community services."13 With effective immunizing agents at their disposal, doctors are now able to prevent many communicable diseases; a wide choice of effective therapeutic agents enables them to control such diseases as scarlet fever, streptococcal sore throat, meningococcal meningitis, measles, and whooping cough. The cumulative effect of these changing patterns of disease upon the demand and use of preventive service is tremendous, and accounts for much of the increased public interest in prevention. According to a study by the American Academy of Pediatrics, 55 per cent of visits to pediatricians are made by well children coming for preventive services.14 This may well foreshadow the day when the bulk of patients in the offices of the general practitioner and the internist will be adults seeking preventive tests and examinations for the more insidious chronic diseases. To accelerate this interest will require programs of health education that are soundly conceived and intelligently executed. THE "COMMON DENOMINATOR" CONCEPT OF CHRONIC ILLNESS

Authorities on the prevention and control of chronic illness place increasing emphasis on the necessity for a broad preventive approach to the chronic diseases as a whole. Basic to this concept are the "com13 Scheele, Leonard Α., M.D. "The Changing Patterns of Disease." Speech delivered at a general session of the 8th Annual Scientific Assembly of the American Academy of General Practice, Washington, D.C., March 19, 1956. 11

Supplement

to Child Health

Services

and Pediatric

Education.

Report of the

American Academy of Pediatrics. New York, The Commonwealth Fund, 1949, Table 35. (Now published by Harvard University Press, Cambridge, Massachusetts.)

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79

mon denominator" aspects of the major chronic diseases. The public, however, has not yet been exposed to this idea. But since people seem to respond more favorably to one idea at a time, it appears highly desirable to substitute this single concept for the prevailing pattern of health education directed toward preventing each single disease. The traditions of medical practice as well as the appeals of fund-raisers and the actions of budget experts have combined to thwart the development and testing of the generic approach which appears to have so much value. In relation to care of the chronically ill, the common denominators are readily accepted. As Dr. Morton L. Levin wrote in the Proceedings of the 1951 Conference on Preventive Aspects of Chronic Disease: . . . persons suffering from different chronic ailments may all require similar kinds of help or services, such as financial assistance, rehabilitation services, special help to enable them to continue to live at home, or care in a substitute home. They may encounter equal difficulty in obtaining or in paying for prolonged hospital care. They may also experience and need help in solving the same kind of trouble in their family relationships, the same type of emotional disturbances, or the same obstacles to obtaining employment, even though the "diseasecause" of their difficulties may vary. These are all "common denominators" from the individual's as well as the community's standpoint, in chronic disease control.15 The readiness with which people have accepted these as common problems in all of the chronic illnesses is a strong argument for using the common denominator approach in education for prevention. People can easily grasp the idea of common causative factors or settings. Emotional disturbances, or stress in its wider sense, are now known to play an important part in causing or at least precipitating many chronic diseases; obesity is considered to be an important factor in heart disease, hypertension, diabetes, and some types of arthritis. A number of chronic diseases may have their origin in environmental hazards associated with occupation; many chronic diseases apparently have a significant genetic (or at least familial) component. Thus, principles of emotional hygiene, good nutrition, industrial hygiene, and the hygiene of procreation are common factors underlying many chronic diseases.16 We now have a common method of prevention because modern medical techniques enable us to detect several chronic diseases simul15

Proceedings

of the Conference

on Preventive

Aspects

of Chronic

Disease.

March 12-14, 1951. Baltimore, Commission on Chronic Illness, pp. 10-11. "Ibid., pp. 11-12.

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taneously. Furthermore, prevention through detection, i.e., identifying chronic disease before the individual has any reason to consider himself diseased, is a method applicable to the entire population. Research is needed to determine how best to interpret the common denominator concept to the public, but the Commission on Chronic Illness believes that the logic for doing so is irrefutable. Provision of Valid Information on Prevention In educating the general public to appreciate the potentialities of prevention, those responsible for conducting educational programs should exercise great care to impart only information which is accurate and scientifically valid, and which will be understood by the ordinary person. As the 1951 Conference on Preventive Aspects of Chronic Disease was told: We need in the entire medical and related professions a persistent and insistent awareness of the asymptomatic forms of chronic disease, of the chronic complications of disease in general, and of the biological, social, and environmental factors that cause chronic disease. We shall not have large-scale prevention until every private physician's office, every dentist's office, every clinic, hospital, and health agency is a "listening post" for chronic disease. We need in the entire population a healthy awareness of the biological, social, and environmental causes of chronic disease; and even more, a healthy awareness of those physical and mental deviations from the normal that should be studied and evaluated by a physician. We shall not have large-scale prevention until every adult makes himself a sensible "listening post" for possible chronic disease in himself and his family.17 Valid and scientifically accurate facts concerning the causes of chronic disease, its asymptomatic forms, and the tendency of some to occur more frequently among family members can be taught to the general public. The Need To Outline Specific Action People always do what they want to do—within the limits of each individual's situation. Moreover, we do whatever we do because of our feelings, which frequently are opposed to our intelligence. And we appear to respond best to one idea at a time—and a specific one at that. For these reasons the educational program will need to outline specific action that is both desirable and feasible. Vague general recom" Ibid., pp. 34-35.

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81

mendations should be avoided in favor of specific suggestions to people to undertake action which has clear preventive implications. Such exhortations, for example, as "avoid colds and virus infections," and "keep happy to reduce attacks of disease X" have little meaning for members of the public; on the other hand, positive action is more likely to result if people are urged to "get a regular health check-up from your doctor" or to "have your child inoculated against poliomyelitis." In addition, the end result of the action recommended needs to be one that people can as well as should take. Few adherents for the preventive approach are gained, for example, from attempts to "sell" the concept of cancer prevention too strongly in a community unless facilities for a good diagnostic examination and any necessary treatment are available. Of course, if resources in the community are not adequate to handle the demands for health services that proposed public educational programs may create, the created demand can be used effectively as a device for stimulating action to provide the necessary resources. Averting Unrealistic Expectations A vigorous educational or promotional campaign aimed at obtaining wide participation in preventive programs or procedures may—unless well planned—engender unrealistic expectations or erroneous ideas in the public mind. The public is being constantly barraged, through the press and other media of mass communication, with much inaccurate and misleading information on health matters in general, and on the chronic diseases in particular. As a result, many people with chronic ailments (and their families, relatives, and friends as well) in whom unfounded hopes for cure are aroused, become disillusioned and suspicious of all claims made by scientific medicine. They may become indifferent to the possibilities that do exist for preventing chronic disease or ameliorating its effects; or they may resort to quacks and charlatans. Health education specialists and community agencies, therefore, should be extremely wary of "over-selling" preventive programs. This is a particular danger with respect to programs for early detection and screening. The public needs careful schooling on the purpose and limitations of a projected screening program so that it will be clearly understood that exact diagnosis and treatment are not part of the screening. Furthermore, the experimental status of many screening procedures can be frankly acknowledged in educational efforts directed to the public. Screening tests whose validity has not yet been firmly established

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should not be employed in mass screening programs, until they have been tested and further refined in a research or evaluation context. Also to be guarded against, as has been pointed out in Chapter 5, is the danger that "screening" may lead to a sense of self-complacency on the part of the individual screened; a person whose battery of tests has been negative may believe that he has been proved to be "in perfect health." The obverse, of course, is also true; fear and hysteria may be caused by positive screening results—whether such results are "true" or "false." Promotional programs for screening procedures can point out both to prospective screenees and to the medical profession what a screening program does not do, as well as what it does do; the public needs to be fully prepared for "false negative" as well as "false positive" results. And where "true positive" results are obtained for any person who has participated in the screening procedure, the program administrators should be prepared not only to refer him for appropriate clinical diagnosis, but to provide such reassurance and psychological support as are necessary. A word on the use of fear in connection with education for prevention is appropriate here. While creation of an atmosphere of outright fear is not recommended as a method for health education personnel to employ in urging people to participate in preventive programs, stimulation of some concern and even anxiety appears to be necessary in certain instances to motivate individuals to action in this area. Anxiety, injudiciously stimulated, may, however, be a two-edged sword; if it becomes too threatening, it may lead a person to seek protection in a denial of the existence of any health problem he may have, or to become so panicky that complete inaction may result. If anxiety is to be used as a goad to action, good methods for handling the apprehensions created must be available. Motives and Obstacles to Public Acceptance The public educational aspects of preventive programs must be based upon sound concepts of the motives that are likely to be involved. Similarly, the obstacles likely to be encountered in gaining public acceptance and support must be recognized. The motives that are likely to be involved in consumer reaction to preventive programs include: Desire to conform to group pattern. Desire to seek relief from fear of disease because of family history, symptomatology, etc.

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Screening is a convenient, quick, inexpensive, and usually painless method of examination. Curiosity. Hypochondriasis. Desire for maintenance of optimum health and therefore to stay "on the job." Compulsion—of legal, economic, or social nature. Various personal motives including the individual's desire to find a disease present and through it the avoidance of responsibility. The obstacles to getting a person to become a consumer include: Fear of a particular disease itself and its accompanying physical effects, as in the case of cancer. Fear of the economic consequences of discovering that one has tuberculosis (e.g., loss of job, cost of care, inability to continue supporting one's family). Fear of social stigma still attached to certain diseases, such as epilepsy and syphilis. Religious or cultist beliefs. Traditions of medical practice (i.e., attachment to personal relationship with a family physician, as against the impersonality of a mass screening procedure, for example, in which examination may be by unknown physicians and technicians). Misinformation or lack of information. Lack of confidence in the effectiveness of a particular procedure. Inconvenience as to time and place at which a preventive service is offered. Indifference (which may often be a cloak for unstated fears with respect either to a particular procedure, or to the disease or diseases to which it relates). Cost of the procedure (for the individual). Emphasis of a particular preventive procedure on common aspects of chronic illness rather than on specific disease entities. Cultural and social patterns of ethnic and other subgroups in the population. Groups To Be Reached in Educational Programs While the whole population capable of being educated, from high school age up, could benefit from an educational program in chronic illness prevention, it will usually be found necessary to select certain groups for special attention if limited resources are to be used most effectively. Among such groups are: School children—Junior and senior high school students, especially, need to be reached, and vigorous attempts made to create favorable attitudes toward prevention, to dispel needless fears, and to counteract

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superstitions and misinformation. A well-organized program of school health education will have important long-range effects on education of the public as a whole, inasmuch as there is a great deal of carry-over to the home of facts and attitudes picked up at school. Community leaders—As molders of public opinion, leading citizens of the community obviously have high priority for attention from health education personnel. Certain sections of the adult public—Certain sections of the adult public warrant special attention in public health educational programs. These include: parents; young married couples; labor and management in certain occupational groups; the economically and socially productive age groups; and other groups (including specific ethnic, low-income, and age groups) with high rates of chronic disease incidence and prevalence. Research

in Public

Education

As in other areas, research is needed in public education for prevention and in the sciences basic to it—psychology, anthropology, sociology. Workers in this field need to know the amount and kind of information people have concerning chronic diseases, their attitudes toward chronic disease and methods of prevention, and the motivations that encourage and discourage people's participation in preventive programs. Reference has been made earlier to the need for studies to determine how best to use the "common denominator" approach in these educational programs. Other studies are needed to evaluate the quantity and content of educational programs and their effect on motivation of various population groups. The impact of a program can be measured in terms of imparting information, changing attitudes, and influencing responses. Imparting information—This measure can be applied by use of questionnaire or interviews with those who responded and those who did not, both before and after the educational program. Changing attitudes—The degree to which an educational program has changed attitudes can be measured by "depth" interviews which should be conducted both before and after the program and with those who did not respond as well as with those who did. Attitudes of professional groups as well as of the screenees should be measured. Influencing responses—"Volume of sales" or response of individuals and of the community can be used to measure the influence of an educational program. Response in turn may be divided into quantitative (e.g., how many came to the screening clinic) and qualitative (e.g., did the right people come). Evaluation should also include response to

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PERSONNEL AND EDUCATION

suggested follow-up. The influence of a program on the community can also be measured by the extent to which the community develops the resources for medical care that the program reveals to be needed. The Patient

and His

Family

Most of what has been said in this chapter on education of the general public regarding prevention of chronic illness applies equally to individual patients and to their families. Educational efforts for the latter two groups should be directed toward: Changing their attitudes toward greater optimism for the control of chronic disease, and inculcating a greater receptivity to preventive concepts. Providing accurate and valid information to them on the possibilities of prevention of more severe developments through treatment and rehabilitation, and on the virtues and limitations of particular preventive techniques. Encouraging them to take specific actions with implications for prevention, such as participating in screening programs and obtaining periodic health inventories. When "patient" is defined more narrowly to mean a person who already has a chronic ailment, there is still much that can be done for him along educational lines to demonstrate the idea that preventive techniques are applicable to chronic illness even after the disease process has become functionally or organically apparent. Many persons with long-term illness have several diseases or impairments. This fact highlights the importance of frequent general examinations to discover conditions not yet recognized, as well as prompt treatment and rehabilitation of known conditions. When the home environment of a patient is suitable and members of his family are receptive to the idea, the advantages of home care as a technique for preventing some of the unfavorable psychological and social sequelae of chronic illness may well be stressed. A few institutions for the care of the chronically ill are making great progress in giving to their patients knowledge about the nature and progression of their condition and of the possibilities that exist for amelioration.18 Educational programs whose purpose would be to provide this information to patients and to help them cultivate their remaining capacities to the fullest extent possible, would be of inestimable value to many patients in arresting the progress of disease to invalidism or 18

See Care of the Long-Term

Patient,

Vol. II of this series, Chronic

Illness

the United States, Chapter 3, pp. 134-149 and Chapter 4, pp. 172, 206-208.

in

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PREVENTION OF CHRONIC ILLNESS

premature death. There are widespread opportunities in hospitals, outpatient departments, nursing homes, and other institutions for development of personnel and methods to carry out this kind of patient education for prevention on an appropriate scale. SHORTAGES OF Q U A L I F I E D

PERSONNEL

16. There are serious shortages of trained, qualified personnel to staff existing official and voluntary programs for the prevention of chronic disease and disability. The expansion of preventive services recommended by the Commission cannot be accomplished unless and until training and recruitment programs are designed to alleviate current personnel shortages and to avoid even more serious future deficits.

Shortages of qualified personnel to care for long-term patients and measures to reduce these deficiencies are discussed at length in Volume II of this series.19 On the "care" side of the problem—which, of course, includes prevention of disability—the need for additional personnel is staggering. On the "prevention" side, more people are also needed but how many and what kind are not known. If the kinds of preventive programs described in Chapters 4 and 5 are to be developed widely, however, the demand for some kinds of personnel would increase materially, both in official and voluntary agencies. Many more physicians, nurses, and laboratory technicians would be needed if every doctor's office were a "listening post" for chronic disease. In the official agencies, we will need first sufficient staff to install local health units in the remaining one-third of the counties without departments. In addition, the 1,365 full-time units already established will need more staff. In 1953, for example, 380 or 28 per cent of these units lacked the top health officer.20 A multifold increase in paramedical personnel will be required, especially administrators, medical laboratory technicians, x-ray technicians, nurses and nurses' aides, social workers, health educators, nutritionists, and medical record technicians and librarians. In spite of the tremendous increase in some of these classes of personnel, even the current demand is far in excess of the supply. A study made by the American Hospital Association in 1952 showed a total of 143,912 persons employed in hospitals as dietitians, laboratory technicians, medical record librarians, social workers, occupational and " Ibid., pp. 239-253. Directory of Full-Time Local Health Units, 1953. PHS Publication No. 118. Washington, D.C., Government Printing Office, 1953, p. 58.

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physical therapists, practical nurses, and technicians. Forty-six thousand nine hundred twenty-seven jobs were vacant! Additional personnel needed in 5 years was estimated to be about 77,000. 21 A study conducted by the Public Health Service in 1951 for the Health Resources Advisory Committee of the Office of Defense Mobilization revealed that 16,000 paramedical workers were employed in state and local health departments and 5,000 more in other state departments. Vacancies in budgeted positions totaled 1,500 in health agencies alone.22 As is pointed out in Volume II, 23 it is indeed fortunate that in 1954 a nationwide project was launched to enlarge the pool of health manpower, to increase the numbers in some 150 health careers. Unless this project is successful, the prospect is dim that prevention will become the cornerstone of the nation's chronic disease program. Yet, as Dr. James R. Miller wrote in February 1949 in the Prospectus for the Commission, ". . . fundamental changes are required if we are to avoid repeating our present dilemma in regard to the mentally ill, whose treatment even today is mainly limited to custodial care." The numbers of persons with long-term disabling illness are still small enough to replace the overemphasis on institutional care with emphasis on prevention— given an adequate supply of trained personnel. ""Critical Shortages of Personnel—Results of a Survey." Hospitals April 1952. 22

Building

America's

Health.

America's

Health

Status,

Needs

and

26:70,

Resources.

Vol. 2. A Report to the President by the President's Commission on the Health Needs of the Nation. Washington, D.C., Government Printing Office, 1953, pp. 177, 190. 23 Care of the Long-Term United States, pp. 2 4 5 - 2 4 6 .

Patient,

Vol. II of this series, Chronic

Illness

in the

Chapter

7 Community Planning for Prevention 17. Inasmuch as the basic approach to chronic disease must be preventive, and prevention and care are inseparable, it follows that prevention is inherent in adequate medical care. Practitioners, institutions, and programs, therefore, have an obligation to apply early diagnosis and prompt and comprehensive treatment of the whole patient to prevent or postpone deteriorations and complications which may produce or aggravate disability.

This point of view is at the core of suggestions in previous chapters that providers of both preventive and treatment services for the chronically ill should consider each individual patient in terms of his total personality and total environmental situation. It is also the rationale for the emphasis placed on the obligation of each person to participate actively in protecting himself against chronic illness. But this kind of individualized approach to the problem represents only one side of the coin. Many of the factors which predispose to or perpetuate chronic illness are either not at all, or only with difficulty, under the control of the individual patient or the individual provider of medical service. This highlights the urgent need for community organization and planning for prevention of chronic illness. The community has a stake in all aspects of prevention of chronic illness. It plays a vital role in insuring that the services and facilities needed for prevention are available and that they are coordinated; in providing financial support for research related to prevention; and in establishing a broad educational program to motivate the individual to take responsibility for his own health and that of his family. In the words of a 1955 study by the American Public Health Association, community organization is "the process by which official and voluntary agencies, professional and lay groups, and individuals develop together ways and means of pooling their knowledge, interests, and resources to meet specific community needs. The process can take place within a small local community, a larger geographic area or whereever families live, as in a city, town, or neighborhood. It can involve 88

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a limited interest or a broader field of service. The type of organization, action, and leadership is dependent on the problem being dealt with." 1 The cornerstone of community organization is knowledge and the translation of that knowledge into purposeful action by individuals working together as members of a group. Adequate knowledge of the causes of specific diseases in the hands of a few professional persons does not, however, assure that such knowledge will be applied to benefit large numbers of persons. The discovery that consumption of citrus juices, for example, would prevent scurvy was made many years before it began to have an appreciable effect in reducing the prevalence of this deficiency disease. The time lag between discoveries relating to prevention of chronic illness and their application has tended to be shorter in recent years, owing in part to the vast improvements that have taken place in communications and in the machinery for social planning in the health and welfare fields. But even today, there are thousands of communities in the United States, for example, that have made no move to use the important knowledge that fluoridation of drinking water is an efficacious preventive measure against dental caries.2 The number of health and welfare agencies in any one community varies widely, as does the scope of the services offered and the relationships that have developed among agencies. There may be enough physicians, nurses, social workers, nutritionists, and other professional workers who, as individuals and as members of their professional organizations, can provide the services, the leadership, and the technical knowledge that the community requires. In addition to the official health and welfare agencies, there are many voluntary health, welfare, civic, religious, business, labor, and other organizations and representatives of the consuming public which provide community health services. A community may, however, be able to point to a myriad of organizations and a long list of discrete activities in the field of prevention and still not have an adequate program. Agencies and professional personnel concerned with health and related problems usually tend to function as separate, isolated units, taking responsibility only for various fragments of the community's needs. They often serve distinct portions of the population only and there is no assurance that the needs of all are met. It is essential, therefore, for communities to look at their health services as a whole in order to 1 Services for Handicapped Children. New York, Committee on Child Health, American Public Health Association, 1955, p. 82. 2 See Chapter 23, "Dental Health and Chronic Disease."

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evaluate needs and the extent to which they are currently met by existing facilities and programs. Where community planning in the field of chronic disease has taken place in the United States, it has shown a regrettable tendency to concentrate on the problems of providing treatment and custodial facilities for those persons who are already chronically ill, or who are expected to become so. By the time most communities recognize the gravity of their chronic illness problem, lacks in treatment facilities and in institutional arrangements are apparent on every hand. Preoccupation with this urgent humanitarian problem has blinded the community to the implications of more long-range goals. The basic thesis of this chapter is that community planning for chronic disease must encompass prevention since the preventive approach offers the most promise today for solving the basic problem of chronic illness. Chapter 6 in Volume II of this series deals with community organization of services for treatment and rehabilitation. Both volumes call for a point of view on the part of the planning bodies which recognizes that prevention and care are so closely intertwined as to be inseparable, and that preventive thinking must permeate the entire program of chronic illness control. If the preventive approach to chronic illness is to be built into community health activities, new preventive as well as therapeutic services will probably need to be established in most local jurisdictions. Creation of a preventive climate surrounding the provision of all community health services, however, does not necessarily require establishment of new services. It may require rather that the community—public and professional—become imbued with the wisdom of prevention; and that the plethora of programs and facilities already in the community be related to each other in a rational and logical manner—in other words, that there be substituted coordinated and integrated program arrangements for the chaotic and fragmentary ones that characterize the current pattern of health services in most communities. COORDINATION AND INTEGRATION OF FACILITIES AND SERVICES 18. Coordination and integration of services a n d facilities are so valuable in promoting prevention that all concerned have an obligation to support and further arrangements to this end. 1 9 . Planning and programs must be directed to the needs of all a n d not limited to those of any special economic, racial, cultural, or other segment of the population. Planning must, however, take into account the services now available to veterans, a n d to fraternal a n d other special groups.

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Although "coordination" and "integration" are not precisely synonymous terms, they are used interchangeably in this discussion. The processes they describe have a similar effect in improving the efficiency and quality of health services for individuals in the community. The concepts they embody—although intangible and difficult to describe and demonstrate—are of vital significance to successful community health planning. An example of coordination in prevention might be something as simple as an informal case conference between a public welfare department social worker and a public health department nurse, for the purpose of discussing, from the different vantage points of the two professions and agencies, the problems of a family receiving public assistance whose wage-earner is suspected of having tuberculosis. Another example would be the combining of mass screening programs, previously conducted under separate auspices, into a multiple screening program "administered jointly by the agencies concerned. Such a program was carried out in Akron, Ohio, where the Summit County Tuberculosis and Health Association, the state and city health departments, and the American Social Hygiene Association joined forces to include testing for diabetes in the detection programs for tuberculosis and syphilis.3 There are three levels at which coordination can be applied with important implications for prevention: ( 1 ) coordination of action specifically directed to preventing chronic disease; (2) coordination of preventive and care services for chronic illness; and (3) coordination of programs in the health field with those in other areas. Coordination To Prevent Chronic Disease The same kinds of gaps and duplications that are typically present in the structure of community health services in general exist in the pattern of preventive services for chronic disease. Voluntary health agencies in the various categorical areas frequently establish screening services for the specific disease in which each is primarily interested without regard to the preventive possibilities of multiple programs conducted under joint auspices. Community detection services—perhaps for cancer-—are provided for different segments of the population by several agencies. Little attempt may be made to relate preventive services to similar ones provided in the offices of private practitioners of medicine. For example, community-wide chest x-ray • "Three-Way Detection Program in Akron, Ohio." Chronic Illness News August 1956.

Letter,

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programs for tuberculosis are conducted, but appropriate follow-up procedures, designed to insure that persons suspected of harboring the disease are encouraged to visit a physician for definitive diagnosis, are sadly deficient. These examples of the uncoordinated manner in which preventive services are often provided in the average American community can be multiplied without difficulty. They point up the fact that even within the relatively narrow area of established preventive programs, organized planning on a community-wide basis could do much to improve service for the individual. Coordination

of Services

for Prevention

and

Care

The structure of health services in the United States has developed in a manner which—in addition to erecting artificial barriers for various economic, racial, cultural, and diagnostic groups—encourages continued separation between prevention and therapy in the practice of medicine and between the community resources responsible for providing for the needs of individuals in these two areas. Coordination of services and facilities constitutes the mechanism through which this type of relationship may be achieved. As has been said in earlier chapters, in the physician's office lies the best opportunity for coordination of preventive and therapeutic services. But most physicians will need well-coordinated community services for some of their patients. Examples of ways to bring together preventive and treatment services in physicians' offices and in hospitals are found in the state grant-in-aid program of the New Jersey State Health Department. Nine local hospitals have been assisted in developing multiple screening services for hospital personnel and for all persons admitted to the hospital. Two hospitals are evaluating screening tests related to diabetes control. Four have made pilot studies of rheumatic fever prophylaxis. Money has been allotted to a medical center to provide screening services to patients of private physicians upon request. This incomplete list of the many local chronic disease projects in which the New Jersey Department is participating illustrates "how quickly and effectively a large number of institutions, agencies, and people can become involved in developing local services for the chronically ill through the expenditure of a relatively small amount of money."4 Other examples of ways in which a health center can assist the practicing physician in preventing chronic illness are cited later in this chapter. ' Chapman, A. L., M.D., and Bergsma, Daniel, M.D. "State Grants for Local Projects in Chronic Illness Control." Public Health Reports 71:339, April 1956.

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Coordination of Health Programs with Other Programs Concern with the community's health status is not limited to health agencies alone. Specific agencies are charged with direct responsibility in the health field, but many community activities and interests impinge on health. There may be a community housing program, for example, conducted under the auspices of a public or voluntary agency, but the intimate relationship of housing to the health of the population calls for involving health agencies in the planning and administration of the housing program. Similar relationships exist between the health field and such spheres of activity as law enforcement, family and child welfare, and education. The interests and responsibilities of health and welfare agencies have so much in common that one would expect to find many cooperative endeavors. Unfortunately, however, most of the patterns of cooperation, according to a field study conducted by the American Public Health Association and the American Public Welfare Association, ". . . relate to activities somewhat remote from the recipient of service, and few are vigorously directed at the prime goals of health. Moreover, cooperation is practiced relatively seldom and is rarely explicitly defined as policy. This is not to say that there is noncooperation between health and welfare staffs. There is often simply no relationship on the administrative level." 5 To stimulate coordinated program arrangements, the American Public Health Association and American Public Welfare Association have issued a joint policy statement. As this statement points out: "Pooling the knowledge and skills found in health and welfare departments . . . brings both added prestige and an expanded view to the development of [joint] projects and the utilization of their findings." The statement cites examples of an intensive joint review of "the long-neglected area of preventive medical services for public assistance recipients" in New York; and of the joint development of the food program in children's institutions in Illinois.® The field of dental care for children provides a good illustration of the manner in which coordinated programming by various community agencies can have a predictable effect in preventing development and 5 Muller, Jonas N., M.D., and Bierman, Pearl. "Cooperation Between Departments of Health and Welfare." Public Health Reports 71:834, September 1956. ""Strengthening Tax-Supported Health and Welfare Services: The Essentials of Effective Interdepartmental Relationships." Policy statement developed by the American Public Health Association-American Public Welfare Association Joint Committee on Medical Care. American Journal of Public Health 4 7 : 1 0 4 - 1 1 1 , January 1957; and Public Welfare 15:2-6, 28, January 1957.

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progression of chronic illness—in this case chronic tooth and mouth ailments. If we postulate a community with (1) a local health department, (2) a welfare medical and dental care program for needy persons, (3) a fluoridated water supply system in the department of water supply, (4) a school health program in the department of education, and (5) a number of private dental practitioners, we can be certain that considerable preventive dental care is being given to that community's children. On the other hand, we can be fairly certain that if no formal attempt is made to coordinate these different services, a few children whose families do not use the city water supply will not be reached initially by the basic program, and that many others who need followup and referral services will not get them. If, on the other hand, the community were able to set up an organized mechanism for relating to each other, on a case-by-case basis where necessary, the dental health education program of the health department, the welfare department's payments for dental care for the children of relief recipients, the dental aspects of the school health examination system, the services of the practicing dentists in provision of dental prophylaxis, and the fluoridated water supply program, there can be little doubt that the community's children would soon begin to show a markedly decreasing rate of dental disorders. A report of a recent study cites examples in which other types of preventive and therapeutic services are brought together by health and welfare departments. For example: In Wisconsin, . . . where the State anti-tuberculosis association and the State board of health cooperate in sending mobile X-ray units around the State, each county welfare department is informed, through the State welfare department, when the unit is coming. All possible channels are used to encourage county agency clients to use the service. The latest tuberculosis control report of the Wisconsin State Board of Health notes that nursing homes are receiving special attention. Oregon also reported special efforts in regard to nursing homes with indigent residents. In this State, representatives of both State boards confer to arrange care for tuberculosis patients.7 Another example is the comprehensive program of integrated services found in a combined local department of health and welfare in San Mateo, California. . . . This department is responsible for the county institutions as well as for the full range of public health and public welfare services. ' Müller and Bierman, op. cit., p. 837.

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The entire tuberculosis control program is under the medical director of the sanatorium, to assure continuity of service from casefinding and diagnosis through followup. A full-time public health nurse at the sanatorium keeps liaison with the field staff. Problems relating to the treatment plan for a patient are usually worked out in the district by frequent and informal meetings between the public health nurses and caseworkers. If difficulties require administrative consideration, the family is brought to the attention of the supervisors. Medical consultation is immediately at hand. The staff confers on patients under care twice each month. A representative of the social service division participates whether or not the patient receives public assistance. [Italics added.] Planning 2 to 3 months ahead in anticipation of discharge from the sanatorium applies to every public patient in San Mateo County. The sanatorium itself has a rehabilitation program in which a representative of the district office of the State bureau of vocational rehabilitation shares. Psychiatric services also are provided. Thanks in large part to the relationship established by the department in this program, an unusually low proportion of patients leave the sanatorium against medical advice.8 In Georgia an arrangement has been worked out between the state health and welfare departments and the state tuberculosis hospital. The hospital reviews patients 60 to 90 days prior to discharge. If the patient appears to be in need of financial assistance, the welfare department is notified immediately of the pending discharge and starts a determination of eligibility for Aid to the Disabled so that assistance can be available to the patient at the time of discharge. Within 90 days after discharge, the health and welfare departments share information on the medical progress of the patient and on the social situation, joining hands to prevent further disability, to help the patient to full recovery. VARIOUS

PATTERNS

WORK

2 0 . N o one pattern for organizing preventive services is satisfactory for all communities. Programs of necessity must be adapted to local situations taking full account of what is good in existing resources for prevention. Planning should be based on facts—both local and regional—as to needs, density of population, financial capacity, and types of illnesses and accidents likely to prevail.

The Commission on Chronic Illness has strongly endorsed the idea of necessary variations in the pattern of preventive programs from community to community, in terms of local resources, problems, and tradi"Ibid., p. 838.

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tions. No community, except by analogy, can serve as an example for any other. Decisions as to where emphasis can most appropriately be placed will usually have to be made in terms of funds, personnel, and facilities. Among the criteria that should carry great weight in aiding community planning groups to arrive at useful and practicable judgments on program emphasis are: the prevalence and seriousness of specific chronic and disabling conditions in the jurisdiction; availability of community resources for handling these conditions; total cost of the contemplated program to the community; the possibilities of applying preventive measures; and the effects of particular chronic and disabling conditions on the afflicted individuals, on their families, and on society in general. Decisions concerning where to locate responsibility for community planning will depend largely upon the fact that "leadership is where you find it." The health department is, of course, an important resource in community planning efforts to coordinate health services in general. The preventive orientation of public health and the traditional leadership role of health departments in organizing preventive activities in the community suggest that the health agency is the logical body to assume responsibility for relating the community's preventive activities to one another. It is impossible to predict, however, where the spark of community leadership may come from; it may, for example, be a community welfare or health council rather than the local health department that can provide the major stimulus for cooperative effort on the part of other local agencies and resources. It may be the medical society or one of the voluntary categorical health agencies. It may be an official agency other than the health department. The list of possible candidates for the leadership role is a long one. What is important is that a community accept leadership where it exists, and make use of it appropriately within the framework of the local situation. In the succeeding pages several alternative patterns are discussed. Welfare

Council

Activities

In urban communities, the welfare council or council of social agencies (of which there are 450) has proven a most valuable means for coordinating services and facilities for preventing and controlling chronic disease. In city after city, where studies have been made, new services established, old ones changed, and new patterns of coordination developed, the welfare council has been involved—Boston, New York,

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Cleveland, Cincinnati, Chicago, Minneapolis, San Francisco, Los Angeles—to mention only a few. The objectives toward which the council movement is directed make them a focal point for coordination: (a) a concern with a better ordering of health and welfare resources in relation to needs; (b) a mixture of management consultation and coordination; (c) the development of new skills and resources that will enable individuals to find satisfying opportunities for well-rounded living; and (d) action directed toward community improvement.9 As part of its fact-finding function, the Commission on Chronic Illness in 1951, together with Community Chests and Councils of America, Inc.,10 asked the welfare councils in what planning and coordination activities concerning chronic disease they had engaged during 19451949. Even though this was early in the era when concern with preventive chronic disease programs was developing, 21 of the 70 councils which reported some activity were engaged in studying or promoting programs for prevention and detection. The councils had studied the preventive programs of the health departments, voluntary health agencies, medical centers, and industrial health organizations. These programs included some directed to specific diseases or groups of diseases, such as diabetes, tuberculosis and heart, occupational, and mental diseases. More general programs concerned nutrition and dental health. Councils also had studied screening programs—single, multiple, and admission screening in hospitals—and programs of periodic physical examination in physicians' offices, in clinics, and in industries. Community Health Councils Independent community health councils also provide an excellent medium for achieving coordination in prevention. Like the health division of more broadly based community planning bodies, these organizations, of which there are more than 500, can be instrumental in bringing together and relating to each other the various community resources for both preventive and therapeutic health services. Coordination of Hospitals and Health Departments Coordination of the activities of hospitals and health departments represents another way in which care and preventive aspects of chronic • Danstedt, Rudolph T. "Councils in Social Work," in Kurtz, Russell H. (editor). Social Work Year Book 1954. New York, American Association of Social Workers, 1954, p. 142. 10 Now the United Community Funds and Councils of America, Inc.

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illness may be related to each other. A policy statement on this subject prepared jointly by the American Hospital Association and the American Public Health Association states: Hospitals and health departments have a common interest in providing the best possible technical facilities and administrative tools for the further development of both the preventive and therapeutic aspects of medical practice. The expression of this relationship in terms of greater coordination of the activities of hospitals and health departments has already occurred in some communities, but a great deal still remains to be accomplished in this direction.11 The statement strongly recommends that "wherever circumstances justify and permit, there should be joint housing of hospitals and health departments, and, if possible, the offices of physicians and dentists."12 Although seldom so regarded, a far-reaching instrument for coordination between hospitals and health departments exists in the Hospital Survey and Construction (Hill-Burton) Program. 13 Initiated in 1946, it provides a means whereby the health department, in all but 8 states, is the core for survey planning and construction of a network of medical facilities: public and voluntary nonprofit hospitals, public health centers, and related facilities. By May 1956, a total of 131,061 hospital beds, 619 public health centers, and many adjunct facilities had been provided. Of equal importance to the prevention of chronic illness and disability are the 20 per cent of total funds that have been made available to teaching institutions, including 37 university medical school hospital projects. The potential for coordination in this program, for which the 1957 appropriation was $123,800,000, cannot be overstated. The Health Center as a Coordinating

Mechanism

In some communities, joint use of facilities by hospitals and health centers in itself helps achieve coordination. Actually, existing health centers could play a larger role than most of them do now in programs designed to control long-term illness. The Hunterdon (New Jersey) Medical Center, for example, has incorporated in its program such activities as "multiple screening, rheumatic fever control, a limited public health dental program, parents' u "Coordination of Hospitals and Health Departments." Joint Statement of Recommendations by the American Hospital Association and the American Public Health Association. American Journal of Public Health 38:701, May 1948. 12 Ibid. 13 Cronin, John W., M.D. "Hospital and Medical Facilities Survey and Construction Program." Public Health Reports 71:932, September 1956.

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classes, in-service training for public health nurses, school health demonstrations, and weight control." 14 As Dr. Ray E. Trussell points out: A multiple screening program offers an ideal opportunity for cooperation to various community agencies. . . . It is a logical concern of health departments, heart associations, cancer societies, and tuberculosis associations and of any local group of citizens interested in promoting adult health.15 He cites the following ways in which the Hunterdon program was supported: 1. Sight-testing equipment and a Clinitron for blood-sugar tests have been lent by the U.S. Public Health Service through the State Health Department. 2. An electrocardiograph and a photofluorographic unit for chest x-rays on 70 mm. film have been donated by the State Health Department. 3. Serologic tests for syphilis are performed by the State Health Department. 4. Funds have been contributed by the County Heart Association toward the salary of a technician in the electrocardiographic service; by the local Public Health Association for chest x-rays; and by the State Health Department for technical, secretarial, and administrative services on a contract basis. 5. The U.S. Public Health Service and the State Health Department have assisted in the design and processing of records. 6. The U.S. Public Health Service lent a technician to train hospital personnel in new techniques for blood-sugar determinations and in the operation of the Clinitron. In other communities local agencies might be able to assign technicians, public health nurses, clerical assistants, and so forth to the screening program. 16 The Center's rheumatic fever control program was approved by the County Medical Society and cosponsored by the County Heart Association and the State Health Department. Each physician in and adjacent to the county "was encouraged to report any case of streptococcal infection, which came under his care, to treat the infections according to the recommendations of the Council on Rheumatic Fever, and to report the name of any individual with a history of rheumatic fever and possible rheumatic heart disease. Meetings were held with the County superin11 Trussell, Ray E., M.D. Hunterdon Medical Center. Published for the Commonwealth Fund by Harvard University Press, Cambridge, Massachusetts, 1956, p. 128. Ibid., p. 136. "Ibid., pp. 136-137.

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tendent of schools, local school administrators, public health nurses, school nurses, and others concerned. Such persons were asked to report the names of individuals who reputedly had had rheumatic fever, individuals in whom murmurs had been found by school physicians during routine examinations, and any other individuals in whom the diagnosis of rheumatic fever was suspected. They were indoctrinated in the importance of advising parents whose children had symptoms of streptococcal infection to seek early medical care. Considerable publicity was given to the program." 17 The identification and evaluation of individuals with suspected rheumatic fever or rheumatic heart disease were conducted on a basis which proved quite successful. During the first 14 months of the program, 74 persons were referred by family physicians, 22 by public health nurses, and 5 from other channels. After a thorough medical evaluation including a battery of tests and procedures, each patient was seen at the Center. All the physicians involved, including the family physician in many instances, the social worker, and the public health nurse reached a group judgment as to diagnosis, status, and recommendations. COORDINATION AND PLANNING RESPONSIBILITIES OF STATE GOVERNMENTS 2 1 . Each state government should assign to its health department responsibility for developing and coordinating programs for the prevention of chronic disease. This responsibility should include the provision of consultation and financial assistance to local communities for initiating and expanding their own services in prevention. A guide for the development of chronic disease services in state and local health departments will be an important contribution to this effort as it was in the control of the acute communicable diseases. It is urged that the appropriate national official a n d voluntary health agencies do everything in their power to expedite the preparation a n d wide distribution of such a guide.

Throughout this chapter references have been made to activities of state health departments directed to coordination and planning. The need for this kind of state leadership is highlighted by a 1955 survey of the chronic disease activities of 271 selected full-time local health departments. Of the 187 responding departments, almost 60 per cent reported that they considered activities in the chronic disease field to be one of the department's "major responsibilities"; 114 reported that the department had conducted or participated in community surveys of "Ibid.,

pp. 138-139.

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chronic disease problems, needs, services, or facilities. In over 90 per cent, the department's public health nurses referred for physical examinations or screening tests members of the families of patients visited at home. One-half or fewer of the departments had undertaken or been assigned responsibilities for maintenance or improvement of the care of chronically ill patients in community institutions; and 123 departments reported the provision of consultation service to local welfare authorities in connection with the health problems of public assistance recipients.18 First Annual Meeting of Directors of State Chronic Disease Programs Only recently have state health departments given specific recognition to the chronic diseases, although a few activities in this field were carried on as a general operation of the department. By 1944, for example, only 2 state health departments had developed a unit responsible for chronic disease. By 1956, however, 31 state health departments had such units. In response to the growing interest in chronic disease programs, the first annual meeting of directors of state chronic disease programs was held in September 1955 under the sponsorship of the State and Territorial Health Officers Association and the Public Health Service. Twenty-seven states, the District of Columbia, and Hawaii sent representatives.19 Primary prevention. Among the specific primary prevention activities recommended for state health departments by that conference were: Encouragement toward prevention and control of streptococcal infections. Expansion of programs to prevent rheumatic fever and rheumatic heart disease, including the provision of antibiotics through both public and private sources. Educational programs for all health department and hospital personnel concerning the use of oxygen in the care of premature infants. Mental health programs, particularly in connection with licensing of foster homes and children's institutions, and other child welfare activities, that would minimize the emotional privation. " Muller, Jonas N., M.D., and Kovar, Edward B. "Chronic Disease Services in Local Health Departments—Report of a Survey." American Journal of Public Health 47:352-362, March 1957. 19 Proceedings of First Meeting of State Chronic Disease Program Directors, September 28-29, 1955, Excelsior Springs, Missouri. Bureau of State Services, Public Health Service, Department of Health, Education, and Welfare. Mimeographed. 14 pp.

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Other suggestions involving a high degree of community planning had to do with health education programs for the general public, for all health personnel, and for industry. Secondary prevention. In relation to secondary prevention, this first conference of state directors of chronic disease programs urged the stimulation of screening programs in physicians' offices, hospitals, outpatient departments, industry, and voluntary programs, with plans for bringing the suspect to diagnosis and for providing necessary remedial services. Diseases marked for special community planning efforts were: Diabetes, with epidemiological follow-up of immediate blood relatives stressed. Heart disease, for which the full preventive potential of the chest x-ray has not been realized. Cancer, particularly cervical cancer for which the extended use of exfoliative cytology as a screening device was recommended. General administrative services for coordination. Several services much needed by physicians for their patients at home and in institutions were endorsed for expansion—nutrition, public health nursing, social services, laboratory and consultation services, and evaluation services for disabled patients. General Nature of State Responsibility This summary of specific activities which state chronic disease programs have undertaken or are trying to develop suggests the direction which community planning will take. In addition to consultation services on planning and coordination of preventive services, and financial assistance to help local communities get under way, state governments might appropriately provide the following types of assistance: Demonstration and promotion of specific methods which have been proved valuable in achieving coordination at the local community level.20 Temporary loans of health department personnel to local communities with active interest in improving coordination of preventive services. Promotion of the regional organization of health services in general on a state-wide basis, so that the resources of urban centers can be made more readily available to rural areas and small communities.21 Promotion of closer liaison, at the state level as well as in local jurisdictions, between the official health agency, and other governmental 10

See Muller and Bierman, op. cit., for examples of techniques. See Care of the Long-Term Patient, Vol. II of this series, Chronic Illness in the United States, pp. 295-298, for discussion of the objectives and values of regional organization in chronic illness control. 11

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agencies (e.g., mental health authorities, welfare department, vocational rehabilitation agency) and voluntary groups with interests in prevention of long-term illness. Stimulation of arrangements for the convening of state, regional, and local chronic disease conferences, for the purpose of providing interested agencies and individuals with a forum for discussion of common problems, including the problem of achieving better coordination and integration of preventive services. To expedite the work of state health departments, guides are needed to help communities select areas of activity on which to concentrate and to suggest sound ways in which to proceed. Something is needed comparable to the Control of Communicable Diseases in Man. The primary aim of this report, first issued in 1917, was to provide . . . an informative text for ready reference by public health workers of official and voluntary health agencies, to include physicians, dentists, veterinarians, sanitary engineers, public health nurses, social workers, health educators and sanitarians; and for physicians, dentists and veterinarians in private practice having a concern with the control of communicable disease. . . . A second general purpose is to serve public health administrators as a guide and as a source of materials in preparation of regulations and legal requirements for the control of the communicable diseases, in development of programs for health education of the public, and in the administrative acts of official health agencies toward management of communicable disease.22 At this stage in community planning, at least three types of guides are needed: For planning purposes—a guide on the role of health departments in controlling chronic disease. Such a guide should be developed nationally, thus permitting the broadest possible scope, and the greatest variety in kinds and combinations of activities. For clinical and administrative uses—a manual, describing for each of the diseases likely to become chronic, how it is recognized, its etiology, what is known concerning its prevention, important complications and measures to prevent them. In a sense, Part II of this volume constitutes the beginning of such a manual. For use of practicing physicians and community agencies—local directories, or source books telling where, under what circumstances, to whom, and when various services are available. Such a guide developed by the planning agency in each community would help patients, their families, and doctors find the services needed. The preparation of the guide, in itself, is a medium for bringing the agencies closer together and in identifying duplications and overlaps. 22 Control of Communicable Diseases in Man. An official report of the American Public Health Association (8th edition). New York, American Public Health Association, 1955, p. 2.

Chapter

8 Conclusions and Recommendations1 1. Individual initiative is vital in the prevention of chronic disease. The public—all of us—should incorporate in our daily lives the recognized precepts of preventive medicine and should cooperate fully in practical programs of preventive medicine once they have been worked out by the professions concerned. 2. Proper nutrition, mental hygiene, adequate housing, an appropriate balance between work and play, rest and exercise, and a useful and productive place in society, are among the best recognized factors contributing to maintenance of optimum health. Attention to these factors, both in the formative years and throughout adult life, will do much to create attitudes of zest and purposefulness in living, and positive physical and mental health generally. A primary goal of community agencies concerned with health problems should be to promote appreciation of the value of these factors. 3. Many elements of society—particularly the health professions, the people, and their government—are involved in primary prevention of disease. All should strive for the fullest application of what we now know and for the development of new means for primary prevention. 4. American communities are urged to adopt fluoridation of water supplies, a public health measure which is a positive step in the prevention of dental caries. 5. Government has an important role to play in primary prevention both in supporting the voluntary efforts of others and in taking direct action in those areas where organized public effort is needed. It should vigorously pursue programs of regulation and control of environmental and human factors known to contribute to disease and disability. Among these programs are air pollution control, ragweed control, highway safety, home accident prevention, and fluoridation of water supplies. 1 These Conclusions and Recommendations which have appeared in the text are presented in seriatim for the reader's convenience.

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Government also should engage in continuing research to identify other suspect or as yet unknown environmental and human factors. 6. The medical and dental professions should encourage physicians and dentists to practice preventive medicine and dentistry aggressively and enthusiastically. a. In health supervision of their patients, they should provide such services as: appropriate immunizations; judicious use of antibiotic drugs in the early treatment of streptococcal infections to prevent rheumatic fever and, possibly acute nephritis; individual health education directed toward cultivation of personal habits and practices that are conducive to good health such as maintenance of optimum weight and avoidance of excessive smoking. b. In treating patients, they should be alert to the hazards of procedures which may lead to development or exacerbation of chronic disease, such as: use of certain mydriatics for older persons, administration of excessive oxygen to premature infants; and use, without specific indication, of modern therapies in general—particularly such agents as antibiotics and hormones. c. As members of the community, they should play a leading role in stimulating organizations and individuals (1) to embrace the concepts of primary prevention and (2) to support its practical application by voluntary and public agencies. 7. Since the prevention of illness and disability is of importance both to individuals and to the strength of the nation, investigations of diseases and their origins, and studies of the methods and resources for prevention should command a high priority in the spending of research funds. 8. All persons should have a careful health examination including selected laboratory tests at appropriate intervals. The medical and dental professions must specify the desirable scope and frequency of this examination, taking into account age, sex, and other biosocial factors. Such examinations must then be made practical and realistic, and be incorporated in the day-by-day practice of modern medicine and dentistry. 9. Screening tests for early case-finding are an essential device in prevention. Used discriminately, these tests should be undertaken in physicians' offices, hospitals, industrial health services, schools, and health centers. Local health departments especially should foster efficient screening programs for large groups of the population. 10. The medical and dental professions should continue their col-

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laboration with insurance companies, voluntary prepayment plans, industrial health plans, union health plans, and appropriate tax-supported agencies to find the most satisfactory methods for financing screening and examinations. 11. The successful operation of programs for making screening tests available to large groups of the population cannot be accomplished until a number of problems are solved. Administrative research is needed to seek solutions to such questions as: the appropriate relationship of mass screening programs to the practice of medicine, the creation of a demand for services after screening which cannot be fulfilled with existing resources, and a standard of reasonable cost for screening. There are other similar questions stemming from present-day traditions and attitudes about which administrative research should be undertaken. 12. The Public Health Service is urged to use its leadership position and its resources to bring about the development and refinement of valid and feasible screening tests, to disseminate information about them, and to stimulate their prompt incorporation into general use. 13. Medical schools and other professional training resources should reorient their curricula so that graduates will have an appreciation of the potentialities of chronic disease prevention and will develop the skills to translate the available knowledge and techniques into everyday practice. 14. Associations which are directly concerned with curriculum improvement can be important instruments in reorienting professional education to bring to students modern concepts for prevention of chronic disease and long-term illness. We urge these organizations to continue and expand their efforts to be of assistance in bringing about the necessary changes. 15. General interest in prevention of all illness has been aroused. Vigorous and more effective public education is needed, however, if individuals are to take the initiative and responsibility necessary for the most rapid extension of this general interest. 16. There are serious shortages of trained, qualified personnel to staff existing official and voluntary programs for the prevention of chronic disease and disability. The expansion of preventive services recommended by the Commission cannot be accomplished unless and until training and recruitment programs are designed to alleviate current personnel shortages and to avoid even more serious future deficits. 17. Inasmuch as the basic approach to chronic disease must be preventive, and prevention and care are inseparable, it follows that pre-

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vention is inherent in adequate medical care. Practitioners, institutions, and programs, therefore, have an obligation to apply early diagnosis and prompt and comprehensive treatment of the whole patient to prevent or postpone deteriorations and complications which may produce or aggravate disability. 18. Coordination and integration of services and facilities are so valuable in promoting prevention that all concerned have an obligation to support and further arrangements to this end. 19. Planning and programs must be directed to the needs of all and not limited to those of any special economic, racial, cultural, or other segment of the population. Planning must, however, take into account the services now available to veterans, and to fraternal and other special groups. 20. N o one pattern for organizing preventive services is satisfactory for all communities. Programs of necessity must be adapted to local situations taking full account of what is good in existing resources for prevention. Planning should be based on facts—both local and regional — a s to needs, density of population, financial capacity, and types of illnesses and accidents likely to prevail. 21. Each state government should assign to its health department responsibility for developing and coordinating programs for the prevention of chronic disease. This responsibility should include the provision of consultation and financial assistance to local communities for initiating and expanding their own services in prevention. A guide for the development of chronic disease services in state and local health departments will be an important contribution to this effort as it was in the control of the acute communicable diseases. It is urged that the appropriate national official and voluntary health agencies do everything in their power to expedite the preparation and wide distribution of such a guide.

PART II

Summaries of Information on Prevention of Selected Chronic Diseases and Contributory Factors

Summary statements on the preventive aspects of major chronic diseases were first prepared for the National Conference on Preventive Aspects of Chronic Disease in 1951. Those statements have been brought up to date for this volume. Each statement was prepared and reviewed by the appropriate national voluntary organization and by the Public Health Service. Thirteen major chronic diseases are presented. In addition, five statements— Chronic Disease in Industry, Dental Health and Chronic Disease, Emotional Factors in Chronic Disease, Heredity as a Factor in Chronic Disease, and Malnutrition and Obesity as Factors in Chronic Disease— discussing common denominators in' chronic disease are included.

Chapter

9 Arthritis and Rheumatism1 RHEUMATOID ARTHRITIS

Etiology Three circumstances—heredity, sex, and age-—are known to influence the development of typical rheumatoid arthritis. Constitutional factors, in familial distribution, predispose to the disease; the risk to women is about three times as great as the risk to men; the incidence increases from adolescence to middle age. A pattern of precipitating events is discernible in about one-half of all cases. The more important precipitating factors are physical and/or emotional strains (including injuries and operations), infections, exposure to dampness and cold, and endocrine crises (including puberty, pregnancy, and menopause). Most of these "trigger mechanisms" are either too common or not sufficiently specific to be controllable. For instance, onset of the disease may occur following infections caused by a wide variety of bacterial or viral pathogens, or even following immunization to such organisms. A specific cause is not known. Particularly, proof of infectious, hypersensitive, endocrine, metabolic, or dietary etiology has not been obtained; nor has the feasibility of primary prevention been demonstrated. The study of the causes of rheumatoid arthritis has been hindered by (1) lack of an experimental model, (2) lack of a diagnostic standard, and (3) lack of research facilities. 1. Rheumatoid arthritis has not been induced in animals. Although nonspecific inflammatory reactions of connective tissue have been experimentally produced in several species, they elucidate the intermediary pathogenesis rather than the cause of rheumatoid disease in man. While adrenocortical steroids and other antiphlogistic drugs exert 1 Prepared by Hans Waine, M.D., for the Arthritis and Rheumatism Foundation; and reviewed by the National Institute of Arthritis and Metabolic Diseases, National Institutes of Health, Public Health Service.

Ill

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some effect on the clinical course of the natural illness, none terminate rheumatoid activity more reliably than do general supportive measures. 2. The clinical features of this syndrome need to be redefined in the light of recent findings. For example, rheumatoid arthritis has been recognized as a disorder of the connective tissue system commonly having manifestations in a number of organs; similarities and differences have been found between this syndrome and other obscure diseases of mesenchyme such as disseminated lupus, scleroderma, periarteritis nodosa, and dermatomyositis; variants of both greater and lesser intensity than characterize the conventional clinical concept have been identified with rheumatoid arthritis. For such reasons alone, present data on the epidemiology and ecology are unreliable. A committee of the American Rheumatism Association is now engaged in preparing a diagnostic standard for general, if tentative, acceptance as a prerequisite to much-needed biostatistical studies. 3. Planned research into the etiology of rheumatoid arthritis requires facilities for the following investigations: systematic and consecutive clinical observations on several hundred patients in various stages of the disease over a period exceeding five years and including the study of some patients hospitalized for 6 to 12 months; collaborative clinical work in various specialties, such as, internal medicine, dermatology, bacteriology, neuropsychiatry, roentgenology, ophthalmology, and surgery; laboratory work on fundamental problems in histology, physiology, biochemistry, immunology, pathology, and biophysics; and field studies in genetics and epidemiology. It may be neither practical nor necessary to endow any one institution with all these facilities if they can be effectively integrated in some other way. But today only a few medical centers in this country are equipped to handle all the various phases of such research. Specifically, more investigators are needed for both clinical and fundamental research; more specially equipped laboratories are needed, preferably in association with hospitals caring for the chronically ill. Pathogenesis Chronic inflammation of mesenchymal cells leads to deterioration of the ground substance of connective tissue, including its formed elements, and to new growth of fibrous tissue. These characteristics of rheumatoid lesions engender organic damage whose functional significance varies with the site, duration, and severity of involvement. The skin and its appendages, skeletal tissues, viscera, blood vessels, lymphatic system,

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endothelial and mucous membranes are frequently subject to inflammation, necrosis, deposition of fibrinoid material, and scarring. Conventionally, the crippling of joints thus incurred has been considered the chief liability of rheumatoid arthritis to public and individual health. However, there is suggestive evidence that the disease also detracts from normal expectancy of life in certain phases and at certain ages. Amyloidosis and heart disease are serious complications whose significance and extent have not been fully determined. Nonspecific iritis and uveitis occur in 3 to 5 per cent of patients with rheumatoid arthritis. Prevention

Because some adrenal steroids suppress rheumatoid inflammation, further clinical research may indicate to what degree these hormones, though they do not eradicate the disease, help to preserve the structural and functional integrity of connective tissue in various organs and especially in articulations. Short-term experiments have demonstrated that histological and biochemical abnormalities can be partially reversed by the influence of corticoids. Although some prolonged studies of the effect of steroid therapy have been made (some including randomly selected controls), the controversial results indicate a need for further clinical evaluation before definite conclusions can be drawn. Since recently synthesized analogues provide greater anti-rheumatic potency without enhanced electrolyte activity, one may reasonably hope for anti-inflammatory agents as effective as, for instance, prednisone, and as free of adverse results on long-term administration as salicylates. To date the most desirable method of avoiding complications in patients whose disease continues active over several months, is extended hospitalization for comprehensive supportive care. Thus may the coordinated techniques of medicine, surgery, psychiatry, and occupational therapy be applied in the concentrated manner necessary for the prevention of polyarticular ankyloses and deformities. But only a few American communities now can provide institutional space and the services of trained personnel at a cost within the financial reach of most rheumatoid patients. Equally necessary, but even less adequate, are means of applying similar categories of treatment to patients needing coordinated services and continuity of care at home. Subclinical

(Asymptomatic)

Stage

There is no evidence that rheumatoid disease has a subclinical stage. What used to be called prodromata—numbness, tingling, clamminess,

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and blanching of the extremities—are probably early systemic manifestations, but they do not occur with sufficient regularity to be useful as a screening device, and there are no tests for the presumptive identification of preclinical disease. In some cases, first assumed and later proved to be rheumatoid disease, the earliest histological lesions, from 2 to 4 weeks old, consisted of necrotizing angiitis. The erythrocyte sedimentation rate and the agglutination of streptococci are neither specific nor usually corroborative of incipient arthritis. The recently developed differential sheep cell agglutination test has shown a higher degree of accuracy than any other laboratory procedure heretofore applied. Extensive field trials over a period of several years will be necessary to determine which of various proposed modifications is the optimal technique. It is also important to establish the units of diagnostic specificity —especially during the first year of rheumatoid disease, when measures preventive of permanent damage may be most beneficially employed. Results of clinical trials (none of which included a control group) indicate that remission is most likely to occur and crippling most often avoided when treatment is instituted early in the course of the disease. Possible Areas of

Research

In addition to the investigational problems implied above, further research into the structure and reactions of connective tissue may identify the site and nature of primary involvement and pathogenic mechanisms. The role of hyperergy, especially to endogenous and exogenous mucoproteins, warrants broader investigation. The nature and significance of precipitating factors need to be more accurately defined, perhaps through forwardly-oriented continuous observation of population groups. It is not yet known whether epidemically- or seasonally-occurring stressful events (such as infections, frostbite, and exposure) can specifically initiate rheumatoid arthritis. The circumstances attending most spontaneous remissions are not known. The role of psychic trauma is not understood. The nature of the defervescence that is sometimes induced by jaundice and by pregnancy has not yet been explained. W e should know more of the biological differences between affected and healthy members of rheumatic families. The study of adventitious arthritis in humans such as sometimes occurs after hydralazine therapy, or of induced hypersensitivity of articular tissues in experimental animals may provide clues to the etiology of rheumatoid arthritis. W e need better definition and explanation of the concurrent familial incidence of rheumatoid arthritis and rheumatic fever and of the occasional clinicopath-

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ological overlap of psoriasis and of ulcerative colitis with arthritis and other collagen diseases. Another fruitful field for research is the determination of the chemical and immunological nature of the agglutinating factor present in rheumatoid serum and of the inhibitor present in normal serum. Such research may lead not only to a simpler, more reliable, more sensitive, and more specific diagnostic test, but may also afford some insight into the pathogenesis of rheumatoid arthritis. Summary Since we do not yet know any means of primary prevention, the most urgent need is for greatly intensified clinical and fundamental research. Important diagnostic or therapeutic measures may be rendered more practicable by providing institutions permitting treatment for 6 to 18 months; technicians and equipment to provide physical therapy, occupational therapy, and vocational retraining; home care programs; and professional education to foster early diagnosis and management. VARIANTS O F RHEUMATOID

ARTHRITIS

Still's disease, or juvenile rheumatoid arthritis, carries an unfavorable prognosis for functional capacity and life expectancy. One of its specific complications is stunting of skeletal development owing to the presence of rheumatoid lesions in the epiphyseal centers. Felty's syndrome is the eponymic designation for rheumatoid disease characterized by arthritis, hepatomegaly, splenomegaly, and leucopenia. In much higher percentage than would be expected of the general population, rheumatoid patients suffer from psoriasis. Certain patients, affected apparently by psoriasis only, develop destructive changes in peripheral joints. The relationship of these concurrences is not clear. Ankylosing spondylitis, or Marie-Strümpell arthritis of the spine, occurs about eight times as often in males as in females. However, one-fifth the number of spondylitis patients also have typical (peripheral) rheumatoid arthritis. The natural course of spondylitis differs in some respects from that of the classic rheumatoid syndrome, and its status as a variant or as a separate entity has not been decided. It carries relatively the best prognosis for functional capacity among the rheumatoid syndromes. OSTEOARTHRITIS

Clinical osteoarthritis is characterized by degeneration of articular cartilage. This occurs as a corollary to aging and is but part of a bodywide systemic process affecting the connective tissue of vertebrates.

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Degenerative and hypertrophic lesions of joints may be produced by numerous and diverse disturbances which reduce the integrity or maintenance of articular structures. Examples of such disturbances are injuries, strains, faulty body mechanics, malalignments and malformations of joints, chemical irritations (as by uric acid, melanin, hemosiderin), osteochondritis, aseptic necrosis of epiphyseal bone, rickets and scurvy, infectious or inflammatory joint disease, atrophy of disuse, lesions of the anterior horn cells of the spinal cord, Parkinson's disease, radiation, occlusive vascular disease, hyperthermia, and caisson disease. Such pathogenic stimuli do not explain the etiology of primary degenerative joint disease, but they may cause so-called secondary osteoarthritis. The specific etiology of degenerative changes in articular cartilage is not known. Genetic predisposition is a likely factor in man and has been demonstrated in certain strains of purebred mice. In some species, a deficiency of gonadal or thyroid hormones or an excess of anterior pituitary growth hormone increases the development and severity of characteristic lesions. Clinical osteoarthritis is associated with the menopause in a statistically significant number of women. It has not been proven that hyaline articular cartilage can be maintained in physiological condition throughout adult life. However, many, probably most, persons subject to degenerative joint disease pass without significant illness or functional impairment into a compensated state. When symptoms and disability do occur they can often be related clinically to various precipitating stresses. T o the extent to which these contributory factors can be obviated, one may assume clinical osteoarthritis to be controllable. It is difficult to prove the validity of this concept since osteoarthritis may appear only years after the onset of a pathogenic influence. Yet, the evidence obtained from animal experimentation and clinical experience indicates that efforts at correcting certain common disorders are warranted. The principal targets of such preventive measures in medical practice are: obesity, malposture, defective skeletal mechanics, faulty attitudes at work or sleep, and excessive or unusually intense use of joints in diversional or occupational activities. A s a positive measure of prevention regular and moderate exercising is necessary to sustain the vitality of the articular cartilage. Research on the structure, biochemical composition, and metabolism of connective tissue may yield a better understanding of degenerative joint disease. It may be possible to define the influence of various endocrine secretions on the physiological function of chondrocytes; to separate physical and chemical factors active in the differentiation of matrix;

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to control enzymes governing the destruction of hyaluronates; to induce neochondroplasia from relatively undifferentiated intra-articular mesenchyme. The most important complications of degenerative joint disease are malum coxae senilis and rupture or protrusion of intervertebral discs. It has been suggested that the correction of congenital dysplasia of the acetabulum or femoral head early in life will reduce the occurrence of malum coxae senilis. It has been proven that even physiological use of joints affected by symptomatic osteoarthritis tends to increase irreversible damage. During an acute attack, therefore, the involved articulation should be afforded the maximum of practicable relief from weight bearing and motion for a period of several days. Thereafter, guarded exercises should be instituted to promote repair. The subclinical stage of osteoarthritis is equivalent to asymptomatic degenerative joint disease. This may be expected to occur in persons during and after the third decade of life, the incidence progressing to about 80 per cent of the general population 55 years of age and older. The subclinical disorder cannot be demonstrated by any readily applicable test, and there is no conclusive evidence that management forestalls the progression to overt osteoarthritis. SPECIFIC GRANULOMATOUS DISEASES OF JOINTS

Specific granulomatous diseases of the joints may develop in the course of tuberculosis, syphilis, brucellosis, lymphogranuloma, and coccidioidomycosis. Prevention depends on the control of the primary infections. Success in controlling tuberculosis and syphilis has resulted in a significant decline of articular complications of these infections. REITER'S DISEASE

The association of synovitis with urethritis, conjunctivitis, and keratinizing dermatitis occurs in chronic form and possibly in epidemics. The cause of this uncommon syndrome has not been identified; preventive measures are unknown. GOUTY ARTHRITIS

Gouty arthritis is a complication of gouty hyperuricemia, a constitutional, hereditary, metabolic disorder which chiefly affects men. Gout is a fairly common disease, but chronic tophaceous rheumatism is a numerically minor cause of crippling. Recent metabolic studies suggest that in some patients, but not in all, the rate of urate synthesis is at

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times increased above normal. Factors other than metabolic abnormalities may be responsible for the increased urate mass often found in the tissues and serum of gouty patients, and for the precipitation of urate salts in articular tissues, such as frequently follows injuries, operations, and emotional stresses. A diet low in purines, which are urate precursors, is clinically indicated, but cannot obviate endogenous synthesis from the prime elements. Thus, while gout may not be preventable, the duration and recurrence of attacks can be effectively controlled by medicinal therapy with salicylates, colchicine, corticotropin, phenylbutazone, and probenecid. Indications for these drugs, individually or combined, depend on the stage of the attack, on the characteristics of individual patients, and on the phase of the disease. The latent stage of gout can be presumptively identified in many instances by serum uric acid determination and measurement of the miscible pool in total body tissues. Prophylactic administration of probenecid or other uricosuric drugs appear capable of preventing recurrences of gouty arthritis and of chronic tophaceous gout, but the duration and degree of their efficacy have not been determined. Under effective and persistent probenecid therapy, uric acid deposits often soften and shrink, and may even disappear. REFERENCES

Bauer, W., et al. Final Report by Committee for Survey of Research on Rheumatic Disease. Washington, D.C., National Research Council, Division of Medical Sciences, 1949. Bunim, J. J . (editor). Transactions of the First National Conference on Research and Education in Rheumatic Diseases. The Arthritis and Rheumatism Foundation in cooperation with the National Institute of Arthritis and Metabolic Diseases. Washington, D.C., McGregor and Werner, Inc., 1954. "Rheumatism and Arthritis" (tenth review). Edited by the American Rheumatism Association. Annals of Internal Medicine 39:497, 1953. American Rheumatism Association. Rheumatic Diseases (based on proceedings 7th International Congress on Rheumatic Diseases). Philadelphia, W. B. Saunders Company, 1952. American Foundation. Medical Research: A Midcentury Survey. Boston, Little, Brown and Company, 1955. 2 vols. "Primer on the Rheumatic Diseases." Prepared by a Committee of the American Rheumatism Association. Journal of the American Medical Association 152:323, 1953.

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Bunim, J. J. (editor). Bulletin on Rheumatic Diseases. New York, The Arthritis and Rheumatism Foundation, issued monthly (except June, July, and August). Collins, S. D., et al. Major Causes of Illness and of Death in Six Age Periods. Public Health Monograph No. 30. Department of Health, Education, and Welfare. Washington, D.C., Government Printing Office, 1955. Stecher, Robert, M.D. "Hereditary Factors in Arthritis." Medical Clinics of North America 39:9, March 1955.

Chapter

10 Blindness1 It is estimated that at least 334,000 persons in the United States are blind. An additional 1,300,000 are blind in one eye. At least 50 per cent of blindness can be prevented by avoidance of infections, by known methods of early diagnosis and treatment, and by safeguarding eyes against accidents in industry and at play. To discuss the principles of the prevention of blindness it is necessary to report separately on specific eye diseases. This is done for five leading causes of blindness: cataracts, optic nerve atrophy, glaucoma, corneal disease, and uveitis. Although retrolental fibroplasia is not one of the leading causes of blindness, it has been included in the statement. CATARACTS

Cataracts are responsible for 23 per cent of all blindness in the United States. Different kinds of cataracts are: congenital cataracts, cataracts of unknown etiology, cataracts due to trauma, and radiation cataracts. Congenital

Cataracts

Congenital cataracts are responsible for 15 per cent of all blindness in children. Conditions predisposing to congenital cataracts include interference with the development of the lens or surrounding structures, metabolic disturbances, intrauterine inflammation of the eye, German measles in the mother during pregnancy, and certain hereditary factors. Specific causes are unknown. Studies are needed to determine the etiology of congenital cataracts and the nature of the metabolic and hereditary factors involved. Complications that may accompany congenital cataracts are dislocated lens, secondary glaucoma, and other eye changes. 1 Prepared by the National Society for the Prevention of Blindness; and reviewed by the National Institute of Neurological Diseases and Blindness, National Institutes of Health, Public Health Service.

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Diagnostic procedures needed to confirm the presence of subclinical congenital cataracts include observation of light perception and pupillary reaction, dilation of pupil with atropine, and ophthalmoscopic and tonometric examination. Measures to prevent the occurrence of congenital cataracts include prevention of German measles in expectant mothers; examination of expectant mothers for such infections as syphilis and tuberculosis, with treatment when indicated; research into the causes of the disease; and dissemination of information about genetics. Cataracts of Unknown

Etiology

This type of cataract occurs mostly in people over 40 years of age, and is sometimes called senescent or senile cataract. There are many theories as to etiology but much more research on possible etiological factors is needed. A hereditary factor seems probable. Since etiology is not known, the disease cannot be prevented. However, since diabetes sometimes causes cataracts, it should be kept under control. Early opacities may be recognized by tests of the patient's reaction to light. Research should include studies to determine the etiology, the relationship of nutrition to development of cataract, and the possibility of nonsurgical treatment. The complications of senile cataracts include secondary glaucoma, hypermature lens, and uveitis. Blindness from senile cataracts can be prevented in individual patients by early diagnosis and surgery at the proper time. More broadly, educational programs about success and possibilities of treatment may encourage patients to take the necessary measures to prevent blindness. Cataracts Due to Trauma Eye injuries may produce cataracts. Prevention depends on preventing the injury. Radiation

Cataracts

Cataracts may be caused by exposure to infra-red rays, roentgen rays, radium, and possibly ultraviolet rays. Prevention depends on wearing special protective goggles and shielding from ionizing radiation.

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Optic nerve atrophy is responsible for 13 per cent of blindness in the United States. Some of the etiological factors are inflammation; degeneration; injuries; compression; syphilis; glaucoma; poisons such as wood alcohol, arsenic, and quinine; Leber's disease; and circulatory disturbances. Of these factors, injuries, syphilis, glaucoma, and poisons are controllable, and to this extent the disease is preventable. PRIMARY GLAUCOMA

Increased pressure within the eyeball is responsible for 13 per cent of blindness among adults. Over 200,000 persons are blind in one eye from this cause. It has been estimated that 1,000,000 persons have the disease but do not know it. Although primary glaucoma occurs at any age, it is much more common after 40 years. There is a predisposing hereditary factor. Emotional upsets often seem to precipitate attacks of acute congestive glaucoma and exacerbations of chronic simple glaucoma. However, the specific cause of primary glaucoma is not known. Since the cause is unknown, the disease cannot be prevented. However, other eye changes and blindness (which is the end result of glaucoma) can be prevented in a large percentage of cases if the disease is diagnosed in its earliest stages and treatment instituted. Screening with a tonometer will discover individuals with tensions of 25 mm. or higher who should then be referred to an eye clinic or private ophthalmologist for repeated tonometry, for the taking of central fields on a tangent screen, and for provocative tests. Such screening has revealed previously unrecognized early glaucoma in approximately twenty individuals per thousand over 35 years of age. Medical social service or public health nursing follow-up is then of great importance to be sure the patient remains under observation and treatment as long as he lives. Early detection is possible through mass screening surveys which include tonometry, tests of visual acuity and visual fields, ophthalmoscopy, and history-taking. For maximum efficiency, programs for the education of professional groups (general practitioners, nurses, social workers) and the general public should be undertaken. Research is needed to determine the cause of glaucoma and to develop better diagnostic methods. Further study of medical and surgical treatment is indicated as is study of related factors—heredity, nutrition, endocrine changes, blood system, and psychic state.

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Loss of vision can be prevented in a large percentage of cases if glaucoma is detected in the earliest stages. CORNEAL DISEASE

Corneal disease is responsible for 8 per cent of all blindness. Poor hygienic conditions predispose to corneal disease. Factors precipitating the disease are pathogenic organisms and trauma. Specific causes of certain types of corneal disease are changes in eyelids, deranged lacrimal secretion, disorders of the conjunctival glands, nutritional defects, metabolic disorders, loss or disturbance of nervous connections, heat, cold, and other physical disturbances, deleterious chemical substances, trauma, foreign bodies, and a wide variety of viral and bacterial pathogens. Ophthalmia neonatorum can be prevented through treatment of gonorrhea in the mother, required use of prophylactic eye drops at birth, and education of the public concerning the disease. Complications such as conjunctivitis and uveitis and, ultimately, blindness can be prevented by early diagnosis and prompt local treatment; improving the patient's general physical condition through adequate rest, nourishing diet, and cleanliness; and treatment of underlying cause (e.g., antisyphilitic treatment). Spread of trachoma can be prevented by education about personal cleanliness. Scarring can be prevented by early treatment with sulfonamides or aureomycin. Prevention of injury will prevent corneal disease caused by trauma. Corneal transplantation can often restore vision in blind persons. Study is needed to determine better methods of diagnosis and treatment and to improve prophylaxis against ophthalmia neonatorum. UVEITIS

Uveitis includes iridocyclitis, iritis, cyclitis, choroiditis, chorioretinitis and is responsible for 10 per cent of all blindness. Uveitis can be caused by tuberculosis, syphilis, gonorrhea, sarcoidosis, brucellosis, foci of infection, influenza, rheumatism, gout, toxoplasmosis, diabetes, arthritis, and perforating wounds of the eyeball. Primary prevention can be accomplished by avoiding the abovementioned causes. Secondary prevention of complications such as secondary glaucoma, vitreous opacities, retinitis, and optic neuritis, can be accomplished by early diagnosis and treatment. Research is needed to determine why uveitis occurs and to develop improved methods of treatment.

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FIBROPLASIA

Until 1954, several centers for premature babies reported blindness from retrolental fibroplasia among 7 per cent of all infants who weighed less than 1,500 grams at birth. Uncontrolled use of oxygen has been identified as the major cause of this condition. It is now recommended that oxygen not be administered routinely to premature babies and that it be given only when there is evident respiratory disease. In such instances, the concentration of oxygen within the incubator, rather than the flow rate, should be specified, and the oxygen concentration in the incubator should be measured frequently until it can be stabilized at the desired point, and thereafter at least once in eight hours. When indicated, oxygen should be administered for as short a period as necessary and in as low a concentration as possible, preferably below 40 per cent. Research is needed further to elucidate the pathogenesis of the condition and possible treatment. REFERENCES

Adler, Francis H. Gifford's Textbook of Ophthalmology (5th edition). Philadelphia, W. B. Saunders Company, 1953. Bellows, John G. Cataract and Anomalies of the Lens. St. Louis, C. V. Mosby Company, 1944. Berens, Conrad (editor). The Eye and Its Diseases (2nd edition). Philadelphia, W. B. Saunders Company, 1949. Carpenter, Evelyn M., Brav, Solomon S., and Seidel, Victor I. "Experiment in Glaucoma Case Finding—A Preliminary Report." American Journal of Ophthalmology 33:611-614, April 1950. Duke-Elder, Sir Stewart. Textbook of Ophthalmology. Vol. III. Diseases of the Inner Eye. St. Louis, C. V. Mosby Company, 1941. Foote, Franklin M., and Lancaster, Walter B. "The Battle against Blindness." Journal of the American Medical Association 145:26-30, January 6, 1951. Hathaway, Winifred. Education and Health of the Partially Seeing Child (3rd revised edition). New York, Columbia University Press, 1954. Hurlin, Ralph G., Saffian, Sadie, and Rice, Carl E. Causes of Blindness among Recipients of Aid to the Blind. Washington, D.C., Federal Security Agency, Social Security Administration, Bureau of Public Assistance, 1947. "Industrial Aspects of Ophthalmology." Proceedings of the 1944 Seminar. National Society for the Prevention of Blindness Publication No. 430. 1945. Kerby, C. Edith. "Causes and Prevention of Blindness in Children." Sight-Saving Review 20:67-80, Summer 1950.

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Knighton, Willis S. "Glaucoma and the Prevention of Blindness." SightSaving Review 15:75-79, Summer 1945. Kronfeld, Peter C., and McGarry, H. Isabell. "Five Year Follow-Up of Glaucomas." Journal of the American Medical Association 136:957965, April 10, 1948. Ryan, Ralph W., Hart, William M., et al. "Diagnosis and Treatment of Toxoplasmic Uveitis." Transactions, American Academy of Ophthalmology and Otolaryngology. November-December 1954. Tassman, I. S. The Eye Manifestations of Internal Diseases (3rd edition). St. Louis, C. V. Mosby Company, 1951.

Chapter 11

Cancer1 The primary prevention of cancer means the taking of any action by any individual or organized group which makes it possible for a person to avoid developing the disease. Prevention in this sense can rarely be accomplished except in the field of environmental and occupational cancer, where a relatively small number of specific agents have been shown to cause cancer in man. Numerous lesions or conditions have been labeled precancerous, but none can be said to lead invariably to cancer. In the final analysis, it becomes a matter of individual professional judgment as to whether corrective therapeutic measures can or should be carried out to prevent the development of cancer in a specific patient. To date, insufficient evidence has been accumulated to substantiate general statements about precancerous conditions beyond what is indicated in this statement. The secondary prevention of cancer means the prevention or retardation of progression of the disease from the early to the more advanced stages. Such an interpretation presupposes a program of cancer control to assure the cancer patient adequate care. The elements of a cancer control program which aims to decrease disability and mortality are: 1. An educational program to acquaint lay persons with facts about cancer so that, when necessary, they will seek medical advice in regard to cancer at the earliest possible opportunity. 2. Educational programs for medical and dental students, practicing physicians, public health workers, nurses, pharmacists, and other professional workers whose training and knowledge of cancer can promote the early diagnosis and treatment of the disease. 3. A postgraduate training program to provide physicians with the special training in diagnosis and treatment of cancer which will enable them to staff diagnostic and treatment services in general hospitals and cancer clinics. 1 Prepared by the National Cancer Institute, National Institutes of Health, Public Health Service; and reviewed by the American Cancer Society.

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4. A program directed toward encouraging the establishment and expansion of cancer clinics and hospitals, tissue services, nursing services, cytology services, registry services, and other services pertinent to the management of cancer. 5. A program to uncover the cancer hazards present in occupational and home environments. 6. A program of investigation directed toward both the evaluation of case-finding and diagnostic procedures and the development of new procedures and techniques. 7. A program designed to permit the application of new facts discovered in the laboratory to the human cancer problem on a pilot or special project basis. ETIOLOGY

The etiology of the great majority of human cancers is unknown. Factors such as heredity, congenital tissue malformations (nevi), nonspecific chronic irritation, and virus infections have been advanced as causes of cancer. However, experimentation has not elucidated the etiology of cancer in man, although some of these factors are evidently active in causing cancer in animals and may operate to some degree in humans. Predisposing Factors Heredity. Hereditary factors seem to provide a predisposition to the development of a few rare types of cancers (cancer of skin in xeroderma pigmentosum, cancer of intestine in familial intestinal polyposis, familial retinoblastoma, neurosarcoma in familial neurofibromatosis). The degree of skin pigmentation seems to be associated with the degree of susceptibility to cancer of the skin. Persons with minimal pigmentation are more susceptible not only to the carcinogenic action of solar radiation, but also to the carcinogenic products obtained by the distillation of coal and petroleum. Race. Epidemiological evidence indicates variation in the proportionate distribution of cancer of different sites among different ethnic groups. A classic example is the infrequency of cervical cancer in orthodox Jewesses. Other examples are the reported infrequency of breast cancer in Japanese women, the high frequency of liver cancer in the Bantus of South Africa, and the high frequency of gastric cancer in the Chinese. There is a great need for more extensive epidemiological investigation of these as well as other aspects of the human cancer problem to determine the significance of such observations.

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Sex. It is remarkable that although the total frequency of cancer in the two sexes is not greatly different, there is a considerable difference in the proportionate distribution by tissue site. About half of the cancers found in females occur in the special tissues associated with reproduction—mostly in the uterus and breast. However, only about 10 per cent of all cancers found in males occur in the genital organs. In sites common to both sexes—notably, stomach, lung, lip, and larynx—cancers occur much more frequently in males. Economic factors. Epidemiological evidence indicates that the proportionate distribution of cancer may be related to economic factors. Studies carried on in England suggest that lower economic groups have a higher incidence of cancer than higher economic groups. This appears to be true for all the important sites of cancer except the breast, where the reverse is true. American Negresses have more uterine cancer and less breast cancer than American white females—a difference which may be based on racial as well as economic factors. A recent study indicates that obesity is associated with a greater liability to cancer. These, as well as many other aspects of the human cancer problem, are in need of more extensive epidemiological study. Precipitating Factors Trauma. Acute physical or chemical trauma may precipitate the development of cancer in a tissue that has previously been irritated by the action of specific cancerigenic agents, such as tar or x-rays. Irritation. Although nonspecific chronic irritation does not itself invariably cause cancer, it may accelerate the development of cancer in tissue exposed to other cancerigenic influences. Specific Causes There exists a relatively small, but nevertheless impressive, number of specific environmental agents, mainly of occupational nature, that have been shown to cause cancer of various organs in man. Occupational carcinogens are the most important environmental cancer hazards in countries of the Western World. Known for about 175 years, they have attained real importance only during the last 50 years, and represent at present the only recognized and well-defined causes of human cancer. Exposure to occupational carcinogens through the pollution of air,

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soil, and water, and through use of certain industrial consumer goods, is hazardous not only for relatively large worker groups but also for large numbers of the general population. Occupational carcinogens include a wide spectrum of chemical and physical agents (aromatic amines, aliphatic hydrocarbons, polycyclic hydrocarbons, benzol, asbestos, various metals, ionizing and nonionizing radiations), although only a few members of these large groups possess specific carcinogenic properties. The organ or tissue in which cancers are produced by these agents varies with the nature of the chemical, the method of introduction into the body, and its route through the body (type of metabolism, excretion, or deposition). Occupational cancers may affect the skin, subcutaneous tissue, connective tissues, bones, blood-forming organs, vascular tissue, nasal cavity, nasal sinuses, larynx, lungs, liver, and urogenital organs. The minimal effective exposure time to such carcinogens varies with the type and potency of the agent and with the intensity of exposure. It may be a few seconds, as in the case of ionizing radiation; a few months, as in the case of beta-naphthylamine, benzidine, and 4-aminodiphenyl; or several years, as in the case of some petroleum oils. The percentage of individuals attacked by occupational cancers in a population at risk varies with the potency of the agent; the type, intensity, and duration of exposure; and the working habits and personal cleanliness of the worker. It ranges from 100 per cent of workers using aromatic amines to an occasional case among workers involved in the production of certain oils. Table 11:1 summarizes some of the salient facts concerning these agents. In addition to the agents known to be responsible for carcinogenesis in man, there are a number of compounds and elements known to have a carcinogenic effect on experimental animals. Although as yet no reactions have been observed in humans exposed to these chemicals, it is suspected that these materials are potentially carcinogenic to man. The materials, the animals used in experimentation, and the site of the resulting cancers are shown in Table 11:2. In addition to these more or less well-defined environmental agents of recognized or suspected carcinogenicity to which the industrially employed and, to a lesser extent, the general population are exposed, there are a number of contacts and conditions that display causal relations to certain human cancers. These conditions are listed in Table 11:3. A number of recently reported studies indicate the association between the use of tobacco (particularly cigarette smoking) and cancer of the lung. The increasing frequency of lung cancer and the fact that

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PREVENTION OF CHRONIC ILLNESS t a b l e 11:1.

Environmental agents of recognized carcinogenicity

Carcinogenic agent

Type of contact

Type of cancer

AROMATIC ORGANIC CHEMICALS

Benzene

Cutaneous Respiratory

Aromatic amines Beta-naphthylamine Benzidine Coal tar, pitch asphalt, soot bitumen, creosote oil, anthracene oil (3, 4-benzpyrene) Shale oil Lubricating oils Crude paraffin oils Lignite oils Lubricating oils Crude paraffin oils Tar oils Petroleum and petroleum products (high boiling fractions) Lubricating oils Crude paraffin oils Fuel oils

Cutaneous Respiratory Alimentary Cutaneous Respiratory (fumes)

Commercial soots

Leukemia Lymphosarcoma ? Myeloma ? Carcinoma of bladder, ureter, renal pelvis Carcinoma of skin Carcinoma of lung

Cutaneous

Carcinoma of skin

Cutaneous

Carcinoma of skin

Cutaneous

Carcinoma of skin

Respiratory (mist-dust)

Carcinoma of lung ?

ALIPHATIC ORGANIC CHEMICALS

Respiratory Isopropyl oil ?

Carcinoma of nasal sinuses and lung

INORGANIC CHEMICALS

Arsenicals Inorganic and organic ?

Cutaneous Respiratory Alimentary

Chromates Nickel

Respiratory Respiratory

Asbestos

Respiratory

Ionizing radiation of electromagnetic (gamma) and corpuscular types (alpha, beta) from radioactive chemicals

Cutaneous Respiratory Alimentary General body Parenteral

Ionizing radiation from x-ray tubes

Cutaneous

Carcinoma of skin Carcinoma of lung ? Carcinoma of alimentary tract ? Carcinoma of bladder ? Carcinoma of lung Carcinoma of nasal sinuses and lung Carcinoma of lung

PHYSICAL AGENTS

Ultraviolet radiation Solar radiation

General body

Carcinoma and sarcoma of skin Carcinoma of lung Carcinoma of nasal sinuses Sarcoma of bones Leukemia, lymphosarcoma Sarcoma of liver ? Carcinoma of skin Sarcoma of connective tissues and bones Leukemia, lymphosarcoma

Cutaneous

Carcinoma of skin

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131 TABLE

Carcinogenic agent

11:2. Potential environmental human carcinogens Experimental animal

Type of contact

Estrogens Natural Synthetic

Mouse Parenteral Rat Cutaneous Rabbit Oral Guinea Pig Oral Carbon tetrachloride Mouse

Chloroform

Mouse

Site of cancer Breast Lymph nodes Uterus Hypophysis Liver

Oral Liver Parenteral

Industrial solvent Degreasing agent Dry cleaning agent Fire extinguishing agent Manufacture Production of freon Grain fumigant Extractive of oils Manufacture Anesthetic Solvent and extractive of oils, resins, rubber, waxes, iodine, alkaloids Ingredient of lacquer, floor polish, cleaning fluid Production of artificial silk, plastics Manufacture Insecticide Food contaminant

DDT Rat (a, a-bis (pchlorophenyl)-l, 1, 1-trichloroethane) Tannic acid Rat

Oral

Thiourea and derivatives p-Phenetylurea (Dulcin) Diethylene glycol

Rat

Oral

Rat

Oral

Liver Thyroid Liver

Rat

Oral

Bladder

Methylated naphthalenes Coal oil, tars

Mouse

Cutaneous Skin

Mouse Rat

Cutaneous Skin Manufacture Parenteral Subcutaneous Fuel tissue Lubricants Plastic production Petrochemical Cutaneous Liver Manufacture Parenteral Fuel Lubricant Petrochemical Parenteral Subcutaneous Textile dyes tissue Food and cosmetic dyes (Table 11:2 continued on next page)

Coal oils, tars, waxes, greases

Mouse

Light green SF Brilliant blue FCF Fast green FCF

Rat

Liver

Type of human contact Manufacture Dietary additive Cosmetic ingredient

Parenteral Liver

Ingredient of foodstuffs (fruits, wine, coffee, and tea) Medicinal agent Tanning agent Citrus fruit preservative Medicinal agent Manufacture Sweetening agent Antifreeze Intermediate in explosive manufacture Softener of lacquer, inks, wood stains, glue, textile, humectant (tobacco) Insecticides

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PREVENTION OF CHRONIC ILLNESS TABLE 11:2 Potential environmental human carcinogens ( C o n t i n u e d ) Carcinogenic agent

Butter yellow Cellophane Polyethylene Polyamide Bakelite Polyvinyl chloride Polymethacrylate Beryllium

Experimental animal Mouse Rat Rat Mouse

Type of contact Oral Parenteral

Site of cancer

Type of human contact

Liver

Food dye (orient) Gasoline dye Subcutaneous Film, fiber, plastic—industrial manufacture and uses Wrapping material Medicinal agent

Rabbit Rat

Parenteral Bone Respiratory Lung

Metal alloy, x-ray tube, phosphor manufacture Refractory vessels Atomic energy production Liver Soil contaminant Thyroid Coloring matter of glass, ceramics, paint, rubber Metal alloy Rubber accelerator Photoelectric apparatus Decolorizer Fireproofing agent Medicinal agent Subcutaneous Alloy Plating Pigment Enamel Soap Medicinal agent

Selenium

Rat

Oral

Cobalt

Rat

Parenteral

TABLE 11:3. Ill-defined environmental carcinogenic agents Carcinogenic agent Parasites Schistosoma hematobium Schistosoma mansoni Schistosoma japonicum Indeterminate agents Kangri-Kairo-Kang (burns and soot) Thermic burns (carbonization of tissue) Chutta (inverted smoking of cigars) (tar, burns) Tobacco smoking (tar)

Phimosis-noncircumcised penis (disintegrated smegma) Vegetable-mineral mixtures Betel nut-tobacco-lime-buyo leaf quid Tobacco-lime (Khaini) quid

Type of contact

Site of cancer

Ingestion Skin penetration

Bladder Liver ? Intestine ?

Skin

Mouth Larynx Lip Mouth Larynx Lung Penis Mouth Lip Cheek Lower lip

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tobacco smoking is so extensively practiced make the continuation and extension of such studies of great importance. Observations made in various parts of the world indicate, moreover, that certain dietary imbalances occurring in some population groups are related to cancers of several organs. Areas where an iodine-deficient diet has caused endemic goiter exhibit an excessively high incidence of cancer of the thyroid developing in adenomatous goiters. Reports from Finland and northern Sweden suggest that the development of the Plummer-Vinson syndrome and cancer of the oropharynx is related to a diet deficient in vitamin Β complex. The high incidence of primary carcinoma of the liver among African Negroes and Javanese has been attributed by some observers to precancerous cirrhosis of the liver resulting from diets deficient in proteins and in vitamin Β complex. Control of Etiological Factors Heredity. The future occurrence of the relatively few cancers of recognized hereditary origin can be effectively reduced by cautioning individuals with such properties not to have children if definite hereditary tendencies can be demonstrated. Individual characteristics. Fair-complexioned persons should not be permitted to work in occupations where they become exposed to cancerigenic tars, pitches, asphalts, and other petroleum distillates and oils, or to intense solar radiation, without taking adequate protective measures. Such precautionary procedures can eliminate or greatly reduce the special liability of such individuals to develop skin cancer. Environmental and occupational factors. Occupational cancer hazards can in most instances be completely or almost completely removed by the institution of suitable preventive measures for all workers engaged in the primary production or handling of the various cancerigenic agents. At the present time, this goal cannot be achieved to the same degree for workers employed in the secondary or consuming industries, workshops, and professions, and is attainable to only a limited extent whenever industrial cancerigens reach the general population in the form of consumer goods or industrial wastes. Effective control of the environmental cancer hazards related to habits, diets, and infections is at present most difficult because of the important educational, sociological, economic, and political implications and complications that exist in countries and population groups where

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such hazards are prevalent. Nevertheless, since these hazards may constitute an important part of the entire field of environmental carcinogenesis, a determined attempt should be made to investigate them and to devise effective control measures. Likewise, the occurrence of cancers resulting from the medicinal use of ionizing radiation, arsenicals, tars, and benzol cannot entirely be suppressed since these agents are specifically indicated in the treatment of certain diseases and insufficient knowledge is available as to the amounts that may be cancerigenic for different individuals. PRIMARY

PREVENTION

Primary prevention of cancer depends upon knowledge of the various causes of cancer, of where and how cancerigenic agents are produced and distributed, and of the types and sites of their contact with the human organism. The limited information that exists concerning the causes of human cancer is not generally appreciated and utilized to prevent the disease. For this reason, the medical histories of cancer patients are usually completely devoid of any data as to the possible cause of the cancer. The following measures are recommended to provide effective application of existing knowledge: 1. An educational campaign describing the nature of known and suspected cancerigenic agents should be conducted among members of the medical profession, public health agencies, industrial hygiene agencies, labor and management organizations, and industrial insurance companies. 2. Cancer clinics and hospitals that are adequately staffed should be encouraged to include in their studies of cancer patients consideration of previous exposure to carcinogenic agents. This should include a complete occupational history as well as adequate data on hobbies, habits, diet (deficiencies, additives, and contaminants), endocrine imbalances, parasitic infections, prolonged use of certain medicinal chemicals (benzol, arsenic, tar, aromatic medicinals, estrogens, androgens), administration of x-ray or radium, residence in regions with natural or industrial pollution of air, water, or soil with cancerigenic agents. 3. Environmental cancer can be prevented by eliminating or greatly reducing contact with the known and suspected environmental cancerigens. At the primary (production) level, closed methods of production should be instituted. At the secondary (industrial and consumer) level, appropriate measures should be taken either to destroy the cancerigenic agents contained in industrial and consumer goods or to convert them into noncancerigenic substances. All cancerigenic wastes that might pollute the air, water, soil, or other elements of the human environment should be disposed of safely.

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4. Parasitic infections should be suppressed by suitable sanitary and therapeutic measures and dietary imbalances should be corrected by proper quantitative and qualitative adjustments. When instituted sufficiently early these methods are effective in combating parasitic cancers and dietary cancers, respectively. 5. Workers being considered for employment in cancerigenic industrial operations should have preplacement medical examinations and periodic check-ups. Workers whose occupational histories indicate previous exposure to cancerigenic agents should be excluded from further employment in such operations if further contact with cancerigenic agents would increase their liability to develop occupational cancer. Likewise, they should be studied for the presence of precancerous conditions of known or unknown origin that might be activated into cancerous development by occupational contact with cancerigenic agents. 6. Prophylactic therapeutic measures should be undertaken for a number of precancerous conditions of largely unknown origin, such as senile keratoses, cutaneous horns, leukoplakia of tongue and oral cavity, kraurosis vulvae, kraurosis penis, erythroplasia, Bowen's dyskeratosis, gastrointestinal polyps, undescended testis, and possibly chronic cervicitis and chronic cystic mastitis. The literature on clinical cancer contains many observations as to the precancerous nature of these lesions. On the whole, however, there is lacking good epidemiological data to indicate the prevalence of these lesions among the general population and the frequency with which malignant degeneration occurs in them. More extensive epidemiological study is needed to determine the degree to which cancer is more likely to develop in tissues where precancerous lesions exist, than in normal tissue. COMPLICATIONS AND SECONDARY

Causes

of

PREVENTION

Complications

Most of the primary complications of cancer are unavoidable results of the disease, and their control, therefore, is mainly a matter of proper therapeutic management. There exists, however, a small number of serious secondary complications that have been associated with the use of certain therapeutic procedures. The administration of x-rays or radium, for instance, has been followed, in some cases after a latent period of many years, by the development of cancers in the irradiated tissues (usually skin and bones, and possibly breast and uterus). Recent evidence suggesting that the prolonged use of large amounts of estrogenic substances in males with prostatic cancer has resulted, in a few cases, in the appearance of cancer of the breast. The therapeutic use of benzol, ionizing radiation (x-rays, radioactive substances, and isotopes), and urethane has caused occasionally fatal agranulocytosis and aplastic anemia.

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The serious effects that may result from the psychic shock and the physical disabilities connected with therapeutic facial disfigurements, amputations of breast and extremities, and similar mutilating operations furnish additional sources of important complications of cancer. Prevention of

Complications

Complications resulting from treatment. The very nature of the cancerous process often necessitates the use of therapeutic measures that carry a definite amount of calculated risk for the patient. Many of the secondary complications are therefore unavoidable even with the best and most competent treatment. Since such complications may be anticipated, patients should remain under close medical supervision for periods of time sufficient to cover the maximum range of latent period of the particular therapeutic complication. Complications resulting from no treatment, late treatment, or inadequate treatment. Since the chronic phase of illness due to cancer can be prevented in many instances by early and competent treatment, it may be said to be a complication of failure to achieve early diagnosis and/or apply definitive therapeutic measures. Obviously, a small cancer of the lip can be treated quickly, inexpensively, and without significant interruption of work routine—and a cure can be anticipated. The same lesion treated 6 months later may involve radical and costly surgical and/or radiation therapy, hospital care, substantial loss of earning capacity, prolonged invalidism—indeed, death—with all the associated social, economic, and psychological travail. Prevention of the Chronic Phase of Cancer Prevention of the chronic phase of cancer includes all efforts directed toward establishing the diagnosis at the earliest possible moment, and providing adequate treatment facilities. Early diagnosis. Education of the general public, education of professional workers, and periodic physical examinations are three methods of promoting the early diagnosis of cancer. EDUCATION OF PUBLIC. Efforts to inform all persons of the nature of cancer's early signs and symptoms (the "Danger Signals") and of the importance of immediate attention to them should be intensified.

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EDUCATION OF PRACTICING PHYSICIANS. Improved methods of surgical and radiation treatment make cancer more curable today than ever before. The time of treatment, therefore, is a most important factor and is subject to control. It is the doctor—the general practitioner—who sees the patient first and who controls the time of treatment. Therefore, efforts to make practicing physicians increasingly aware of cancer should be extended through such media as refresher courses, teaching days, films, and publications. EDUCATION OF PHYSICIANS IN TRAINING. Modern treatment of cancer demands unusual, if not special, professional skill and resourcefulness. Special fellowships or traineeships emphasizing cancer management should be encouraged in order that the supply of surgeons, radiologists, and pathologists able to provide the best professional service to cancer patients may be increased and properly distributed. EDUCATION OF MEDICAL STUDENTS. It is considered extremely important that new physicians should enter practice with a good clinical foundation regarding cancer as a disease. To this end emphasis is being placed on strengthening and improving undergraduate teaching about cancer. Federal funds have been made available on a grant basis to medical, dental, and osteopathic schools for the development of programs to improve cancer teaching. PERIODIC PHYSICAL EXAMINATIONS. Periodic physical examinations continue to be recommended for cancer case-finding in persons reaching the age where risk of cancer is increasing, although the feasibility and effectiveness of the general application of this recommendation has yet to be demonstrated.

Adequate treatment. It is generally felt that special cancer diagnostic facilities are highly desirable, if not essential. The diagnosis and treatment of cancer are best accomplished by the pooled skill and experience of the medical disciplines of surgery, radiology, pathology, and medicine. Since cancer is a lethal disease often difficult to diagnose and requiring sound judgment and skill in planning and executing the best treatment for the individual patient, clinics for the diagnosis and treatment of the disease would seem to be needed. According to the Bulletin of the American College of Surgeons (September-October 1956), there were 713 approved cancer programs in the United States, its Territories, Canada, and Cuba. These included cancer clinics, tumor clinics, diagnostic clinics, cytodiagnostic services, and hospitals caring for cancer patients. Despite the increasing number

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of cancer services, more clinics are needed, and the matter of their distribution presents many problems. Distribution by unit population, as the proposed one-clinic-per-100,000-population fails to provide for the rural areas. Distribution by distance, as the proposed 50-mile-radiusfor-each-clinic fails to allow for the vagaries of transportation. Pilot studies in Pennsylvania, Georgia, and New Jersey suggest that distribution by region, as outlined by individual states in conformity with the Hill-Burton Hospital Survey and Construction Act, may offer the best approach. In 1947, at the request of the American Cancer Society, the American College of Surgeons extended its inspection program to include cancer detection centers. This was discontinued in 1953 because cancer detection centers, as originally conceived, had not proved as effective as anticipated. The future of cancer detection centers at this time is most uncertain. Factors such as the excessive cost per case found, the small portion of the population served, and the long waiting lists indicate that detection could better be performed by private physicians and cancer diagnostic clinics. The problems of indigence and medical indigence complicate proper cancer care. Appropriate legislation by state or county governments providing for the care of cancer patients who are unable to pay for any part of their care is essential to a greater reduction of the chronicity of cancer. SUBCLINICAL

(ASYMPTOMATIC)

STAGE

Tests for Presumptive Identification of Subclinical Disease Screening tests to identify presumptively subclinical cancer involve ( 1 ) measurable changes in the host that portend the development of cancer before a recognizable lesion is formed; (2) measurable changes in the host that indicate the presence of a clinically recognizable (though asymptomatic) lesion; and ( 3 ) recognizable changes in clinical specimens from body areas being examined for the presence of cancer. Tests suitable for general application. Tests based on recognizable changes in clinical specimens from body areas being examined for possible cancer include a diversity of procedures. Cytology is the best established of these and vaginal cytology is the one technique which appears suitable for general application. The three-year voluntary screening project for the detection of uterine cancer conducted from 1952 to

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1955 by the National Cancer Institute in Memphis, Tennessee, indicated that this disease could be diagnosed in its early stages. The study produced a case-finding rate 40 times that observed in the community prior to establishment of the project. In addition to uncovering many unsuspected cancers, the study strongly suggested that carcinoma-in-situ lasts long enough—several years in fact—to permit effective curative treatment in practically 100 per cent of cases discovered at the yearly check-up. With additional funds made available by Congress in the fiscal year 1955, the National Cancer Institute widened its studies of the cytologic technique for early detection of uterine cancer by establishing field projects in eight different parts of the country in cooperation with local health and medical authorities. These projects will provide comparative data for the establishment of true incidence and prevalence rates, and more information on the natural history of carcinoma-in-situ. They will also help to determine the cost of detection procedures, the administrative techniques most suitable for general application, the relationship of carcinoma-in-situ to invasive cancer and the length of the usual period of latency (if this transformation is found to occur). The Public Health Service feels that these additional projects represent positive steps toward the ultimate goal of totally eliminating uterine cancer as a health problem. Tests requiring further evaluation. Tests based on measurements of host changes indicating the presence of a clinically recognizable (though asymptomatic) lesion have been described—blood protein and enzyme activity changes, immunological reactions, etc.—and are being evaluated.2 Evidence is accumulating that tests based on quantitative changes in major protein components of the blood will not be sufficiently sensitive or specific. However, tests based on qualitative changes of certain of the blood protein components show more promise. As yet, tests based on changes in the enzyme activity of blood appear to be insufficiently sensitive or specific for screening purposes. The field has not been extensively explored and may still hold possibilities for a test suitable for general application. Immunology in relation to cancer is receiving more and more emphasis and might furnish the basis for a screening test. The use of the cytologic method in detecting cancer in sites other than the uterus is largely limited to symptomatic individuals because of the difficulty in obtaining and processing specimens. Encouraging 2 Tests based on tumors retaining special functions of the tissue of origin are excluded because of their limited application to the general cancer field.

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results are being obtained, however, with the cytologic examination of repeated sputum specimens in bronchogenic carcinoma. In gastric cytology, more representative specimens have been obtained with recently developed techniques—the use of specific hormones and enzymes to obtain specimens of exfoliated cells in greater numbers; the mechanical abrasion of the gastric mucosa with a balloon studded with silk threads; and the use of lavage solutions containing an enzyme to accomplish mucolysis. An electronic device is being tested that will automatically search for and detect cancer cells in smears spread on microscopic slides by measuring the abnormally bright fluorescence shown by cancer cells under ultraviolet light. This instrument—the microfluorometric scanner —will make the cytologic technique more rapid and more efficient as a screening method for certain types of cancer. Still other techniques that are being evaluated include the use of gastro-photofluorography as a screening method for gastric cancer, the use of clinical findings such as anemia, achlorhydria, and family history of gastric cancer to select a potential gastric cancer group for x-ray study; the measurement of enzymes from exudates and transudates in cases where malignant lesions encroaching on serosal surfaces are suspected as the cause of the accumulation of fluid; and high voltage radiation for the detection of bronchogenic lesions. Diagnostic Procedures To Confirm Presence of Subclinical Disease Histopathological diagnosis of biopsy material is the only accepted method of confirmatory diagnosis. A few cytologists of broad experience feel competent to make final diagnoses of cancer as a basis of treatment when presented with certain cytologic complexes from certain tissue sites, but this diagnosis is not acceptable to most clinicians. Treatment of Subclinical Disease Complete excision or adequate radiation of the localized lesion is the only accepted method of treatment. It is generally believed that the earlier cancer can be treated, the better are the possibilities of cure. If preinvasive lesions (carcinomas-in-situ) are included in this consideration, there is a good logical basis for believing that excision or destruction would antedate any possibility of metastatic spread. In the case of cancer of the cervix, the clinical status of the preinvasive lesion and the efficiency of cytologic detection comprise the elements of effective control of cancer of this site.

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141 POSSIBLE AREAS OF RESEARCH

Obviously, "possible areas of research" in relation to the preventive aspects of cancer includes the entire spectrum of investigative effort (which today embraces virtually every scientific discipline) inasmuch as the ultimate goal of research—knowledge of cancer's causes—would be expected to result in the prevention of cancer. Therefore, for the purpose of this statement, it is assumed that the possible areas of laboratory inquiry into cancer and growth phenomena are recognized and require no detailed exposition. However, other areas of study holding promise of useful, perhaps essential, information are relatively unrecognized and neglected. 1. Systematic and extensive efforts should be made to investigate the epidemiology of human cancer and to enlarge thereby our knowledge of its etiology. 2. Since almost all known or suspected cancerigenic agents are of exogenous origin, it is probable that there exist other, so far undiscovered, environmental cancerigens and that the total number of cancers of environmental genesis is appreciably larger than the available data indicate. The existing differences, by social class and by sex, in the total cancer death rates and in the regional occurrence of cancers of various sites (skin, lung, stomach) indicate the need for a critical study of the possible causes of such variations and of the composition of the local environmental cancerigenic patterns that may be responsible for such differences.3 3. The rapidly growing industrialization of our country, associated with an increasingly widespread exposure of our population to physical and chemical agents of unknown biological (and possibly cancerigenic) properties, makes it imperative that more efficient and quicker methods be developed for screening large numbers of environmental agents for potentially cancerigenic properties. The progressive invasion of the human environment by new and artificial agents through a widening variety of channels (economic poisons; pesticides; weed killers; food additives, substitutes, preservatives, and coloring agents; dyes; textiles; plastics; resins; wrapping material for foodstuffs; medicines; and cosmetics) deserves serious attention. Research is needed to determine whether these agents resemble some of the known environmental cancerigens which are not particularly toxic and thus do not immediately produce any striking symptoms, although they have been found to cause cancers after an almost asymptomatic latent period ranging anywhere from 3 to over 40 years. 4. In view of the established fact that human cancers have resulted from an exposure to specific physical and chemical agents and consid3 See Registrar-General's Decennial Supplement, England and Wales, 1931, Part II a, Table 6A. London, H.M.S.O., 1938, p. 329.

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ering the distinct possibility that cancers as such may represent merely anatomic reactions as nonspecific as infectious and chemical granulomas, serious attempts should be made to develop etiology-specific diagnostic tests. Through the availability of such tests it might be possible to distinguish between specifically exposed and unexposed individuals and between effectively and ineffectively exposed individuals. Through the results of such tests a more reliable estimate of the malignant potentialities (reversibility and irreversibility) of precancerous lesions, including carcinoma-in-situ, might be possible. SUMMARY OF PREVENTIVE

MEASURES

1. Prevention of future contamination of the human environment by known or suspected physical and chemical cancerigenic agents, and institution of all possible preventive, protective, and prophylactic measures in all plants, workshops, laboratories, mines, and mills where carcinogenic agents are produced, handled, or used. It might be wise from a preventive point of view to consider all chemical agents which have elicited cancer in animals as being potentially cancerigenic to the human organism. 2. Education of members of the medical profession, public health officials, industrial hygienists, labor and industrial management leaders, industrial insurance carriers, and other interested parties in order to extend awareness of the existence and nature of environmental cancerigens and to increase alertness in the discovery and prevention of human cancers with known or suspected causation. 3. Expansion of systematic studies on cancer epidemiology and etiology on the basis of the entire country, individual states, regions, industries, and occupational groups. 4. Development of improved, rapid methods for screening exogenous and endogenous environmental agents for cancerigenic properties. 5. Development of etiology-specific diagnostic tests. REFERENCES

Aub, J. C. "Modern Cancer Research." Cancer—A Manual for Practitioners. Boston, American Cancer Society, Massachusetts Division, 1950. Dunn, J. E., and Greenhouse, S. W. Cancer Diagnostic Tests. PHS Publication No. 9. Washington, D.C., Government Printing Office, 1950. 23 pp. Evaluation of Cancer Diagnostic Tests. Public Health Monograph No. 12. PHS Publication No. 275. Washington, D.C., Government Printing Office, 1953. 49 pp.

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Heller, J. R. "Cancer—Α Public Health Problem." Journal of the International College of Surgeons 23:463-468, April 1955. Heller, J. R. "Chemical Carcinogens." Archives of Industrial Hygiene and Occupational Medicine 2:393, October 1950. Heller, J. R. "New Horizons in Cancer: Cytology in Research and Practice." Science 120:1085-1086, December 31, 1954. Heller, J. R. "Potentials of Chemotherapy in Cancer." Military Medicine 116:175-178, March 1955. Heller, J. R. "Recent Progress in Cancer Research." Public Health Reports 68.:309-316, March 1953. Hueper, W. C. A Quest into Environmental Causes of Cancer of the Lung. Public Health Monograph No. 36. PHS Publication No. 452. Washington, D.C., Government Printing Office, 1955. 54 pp. Hueper, W. C. "Considerations for the Selection of Chemicals for Carcinogenic Screening." ΑΜΑ Archives of Industrial Health 11:494504, June 1955. Hueper, W. C. "Medicolegal Aspects of Cancer." American Journal of Clinical Pathology 25:116-125, February 1955. Hueper, W. C. "Recent Developments in Environmental Cancer." ΑΜΑ Archives of Pathology 58:645-682, December 1954. Kaiser, R. F. "Cancer Control in the United States." Public Health Reports 67:877-882, September 1952. Kaiser, R. F. "Some Results of the Cancer Teaching Program." Journal of Medical Education 30:641-646, November 1955. Proceedings of the First Conference on Cancer Diagnostic Tests—1950. PHS Publication No. 96. Washington, D.C., Government Printing Office, 1951. 91 pp. Steiner, P. E. "An Evaluation of the Cancer Problem." Cancer Research 12:455-464, July 1952.

Chapter

12 Cardiovascular Diseases1 Any statement regarding the preventive aspects of cardiovascular disease should be prefaced with an affirmation of the transcending importance of research in the entire cardiovascular field. The causes of the most significant cardiovascular diseases—rheumatic fever, arteriosclerosis, and hypertension—are known only in part, and primary preventive measures can be only partially effective against diseases of unknown etiology. In the present state of our knowledge, then, prevention of cardiovascular disease is largely confined to prevention of complications, repetitive insults, and progressive advancement of the disease processes. However, in the field of secondary prevention we have many opportunities to apply existing knowledge through presently acceptable methods. We have also the challenge to improve these methods and discover new ones. The sine qua non of these efforts is adequate follow-up of all cases of cardiovascular disease however they may be discovered. An appropriate professional and public educational program is an essential corollary. This statement is intended to set forth clearly and concisely the knowledge and the methods presently available that will permit a successful preventive attack on the most significant cardiovascular diseases. CONGENITAL MALFORMATIONS

Etiology The specific causes of congenital malformations have not been established. Evidence has been presented that congenital malformations are associated with the presence during the first trimester of pregnancy of virus infections, vitamin deficiencies, and metabolic and endocrine dis1 Prepared by the American Heart Association; the Heart Disease Control Program, Division of Special Health Services, the Bureau of State Services; and the National Heart Institute, National Institutes of Health, Public Health Service.

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turbances. Excessive radiation during the first trimester of pregnancy is another possible cause. While there are good indications that heredity may account for some types of congenital malformations, the genetic factors have not been extensively investigated. It is probable that both hereditary and environmental factors produce the same kind of malformation. Primary

Prevention

Since the etiology is unknown there are no specific measures for prevention. However, on the basis of the implicated factors, the following preventive practices may be applied: Immunization against German measles (by exposure to infection of girls prior to puberty). Prophylactic use of gamma globulin in pregnant women exposed to German measles during the first trimester of pregnancy. Avoidance of virus infections during pregnancy. Maintenance of optimal nutrition. Proper management of metabolic and endocrine disturbances. Avoidance of excessive radiation during pregnancy. The application of these measures involves good prenatal care with special attention in the first trimester of pregnancy. Child-bearing by women with congenital malformation is not at present contraindicated on the basis of heredity. However, knowledge of the role of genetic factors is very limited. Complications and Secondary

Prevention

The most important complications that are likely to result from congenital malformations are subacute bacterial endocarditis, cerebral thrombosis, and unwarranted invalidism. The development of these complications can often be prevented by observing the following precautionary measures: Early precise diagnosis and correction of defects by surgery when indicated. This course should be taken only after study of the case by a specially trained team of physicians. Prophylactic use of penicillin or other antibiotics, as indicated, before and immediately following operative procedures, particularly those involving the oral cavity and the throat. This precaution is recommended for all persons with malformations of the heart in order to prevent subacute bacterial endocarditis. Prevention of dehydration for all cyanotic patients to lessen the danger of cerebral thrombosis. Daily fluid intakes should be 1,000 cc.

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for infants, 1,500 cc. for children, and 2,000 cc. for adults with persistent cyanosis and polycythemia. These patients should never be more than 12 hours without fluids. Efforts should be made to eradicate the feeling that patients with congenital malformations of the heart are necessarily chronic cardiac invalids. They should be allowed to lead as normal a life as is possible. Subclinical (Asymptomatic)

Stage

In some cases a careful physical examination will lead to the recognition of congenital malformations at birth or shortly after birth. In any event, most cases are identifiable during infancy. In many instances, patent ductus arteriosus undergoes spontaneous obliteration during the first 3 months of life. Special laboratory studies are not indicated in infants with malformations who are doing well and gaining weight. In certain types of malformations, surgery can correct the defect; in others, the disability caused by the abnormal circulation can be alleviated. Some cases do not require surgery. The indications for surgery depend on the type of malformation and the physical well being of the patient. All cases should be under continuing medical observation. Tests for presumptive identification of defects in subclinical stage. There are no specific tests for the presumptive identification of congenital malformations. Cardiovascular examination will single out those individuals requiring further observation. Diagnostic procedures to confirm presence of defects in subclinical stage. The diagnosis can be determined by means of a history and complete physical examination with one or more of the following procedures: fluoroscopy, x-ray, electrocardiography, determination of oxygen saturation of arterial blood, exercise tests, determination of circulation time, cardiac catheterization, and special x-ray techniques such as angiocardiography, performed only by physicians with special training. Treatment for defects in subclinical stage. All cases where the presence of a defect has been confirmed should be placed under medical supervision. Selective surgery is indicated in certain cases. The operation should be performed only by a specially trained team of physicians. Possible Areas of Research The determination of the etiology of congenital malformations requires a sound knowledge of embryology, the point at which departure from

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the normal occurs, and the causative agents which disturb the normal pattern of development. Investigation directed at finding answers to the following questions would serve to increase or strengthen the measures for prevention: At what period is the susceptibility to limitation of development of the embryo greatest? What is the role of heredity in the production of congenital lesions? What chemical, biological, and physical agents arrest development? What is the effect on the embryo of various infections in the mother? What is the effect on the embryo of poor implantation and/or site of implantation of the placenta? What is the relationship of the mother's nutritional and metabolic status to the development of the embryo? Do traumata such as falls, pressure, and continued jarring during pregnancy affect development? RHEUMATIC HEART DISEASE

Rheumatic heart disease is the most significant manifestation of rheumatic fever. The sequence of events in the development of rheumatic fever seems to be an initiating group A beta hemolytic streptococcal infection, a latent period of 1 to 3 weeks followed by a period of rheumatic activity which is extremely variable in intensity, type of involvement, and duration. The repetitive attacks and the persistent or protracted nature of rheumatic fever increase the possibility of lasting cardiac involvement. Etiology

While the cause of rheumatic fever is unknown, the disease is usually associated with recent prior group A hemolytic streptococcal infections. Genetic factors, poor housing, and nutritional status are predisposing factors. Primary

Prevention

Early administration (within 48 hours after the appearance of symptoms) of penicillin to persons with group A hemolytic streptococcal infections is recommended. Therapeutic blood levels should be maintained for 10 days thereafter. This is particularly important in persons who have previously had rheumatic fever and in 4- to 16-year-old children whose parents or siblings have a history of rheumatic fever. Whenever possible, drug prophylaxis should be instituted for persons in these groups (if they are not currently on a prophylactic regimen) whenever

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known or suspected exposure to hemolytic streptococcal infection occurs. The repetitive nature of rheumatic fever makes it important to institute programs for the prevention of hemolytic streptococcal infections in persons who have previously had rheumatic fever and in their families. Penicillin or sulfa drugs are effective prophylactically but their use requires close cooperation between the physician, the patient, and the family. The prevention and control of food-borne epidemics of hemolytic streptococcal origin would eliminate a source of infection. Rheumatic fever patients should not be cared for in open general hospital wards. They should receive drug prophylaxis during the period of hospitalization. Improvement of environmental conditions such as overcrowding and poor housing would lessen the danger of hemolytic streptococcal infection. Management of Rheumatic Fever and Rheumatic Heart Disease Patients with active rheumatic fever, as well as those with a history of rheumatic fever, should be under continuing medical supervision. The skills and knowledge of a variety of personnel are essential in a rheumatic fever program: physicians with experience in the care of patients with rheumatic fever and rheumatic heart disease, nurses, medical social workers, occupational therapists, school teachers, and cooperative parents. The organization and availability of professional services determine the facility to be used. The patient may need the type of care provided by one or more facilities, such as general and special hospitals, foster or convalescent homes, or care in the patient's own home. Special attention should be given to the protection of patients from exposure to group A hemolytic streptococcal infection. Antibiotics or sulfonamides are effective in prophylaxis. Evidence indicates that the antibiotics used therapeutically in group A hemolytic streptococcal infections prevent subsequent rheumatic fever in the majority of cases. Complications and Secondary

Prevention

The most important complications or unfavorable developments that are likely to result from rheumatic heart disease include: Subacute bacterial endocarditis superimposed on diseased heart valves. Emboli caused by thrombus formation over infected areas of the endocardium. Thrombi may also form in the auricles as the result of congestive heart failure. Congestive heart failure.

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Subacute bacterial endocarditis can often be prevented by the prophylactic use in patients with valvular heart disease of penicillin or other indicated antibiotics prior to and immediately following operative procedures, particularly in the oral cavity and the throat. Embolic phenomena can be prevented by the use of anticoagulants in some cases and by surgical procedures when indicated. Prevention of congestive heart failure depends on the prevention of active rheumatic fever. Subclinical (Asymptomatic) Tests for presumptive

Stage

identification

of subclinical

disease. There are

no tests to indicate the presence of rheumatic fever or rheumatic heart disease. History, physical examination, and in many instances laboratory procedures are usually required for even a presumptive identification. Alert parents and teachers may assist in early case-finding by noting mild symptoms in children. Diagnostic procedures to confirm presence of subclinical disease. N o specific diagnostic test is available. Diagnosis depends on the history, physical examination, laboratory procedures such as erythrocyte sedimentation rates, x-ray of the chest, electrocardiography, determination of antistreptolysin titer, and of C-reactive proteins. A t times cases present a difficult diagnostic problem. Clinical experience in the care and course of the disease is a valuable asset in making the diagnosis of mild and subclinical rheumatic fever and rheumatic heart disease. Possible Areas of Research Research in the field of rheumatic fever should be directed toward: Determination of the exact etiology of rheumatic fever and the mechanism of action. Development of an immunizing agent. Determination of the relationship of hemolytic streptococcal infection to rheumatic fever. Determination of the relationship of hormone balance to rheumatic fever. Studies of hereditary susceptibilities. Studies of metabolic and nutritional factors. Studies of environmental factors. Development of effective detection and screening methods. Development of a specific diagnostic test. Development of practical measures for the prevention, control, and early treatment of group A hemolytic streptococcal infections in the general population.

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SYPHILIS

Etiology Predisposing factors in cardiovascular syphilis are absence of treatment or inadequate therapy for syphilitic infection. Precipitating factors include the Jarisch-Herxheimer reaction and strenuous physical activity. The specific cause is the Treponena pallidum which invades the blood vessels, primarily those of the aorta, and produces an inflammatory reaction. The extent to which these known etiological factors are controllable depends on the proper use of effective therapeutic drugs and on maintenance of treatment schedules in syphilis. The incidence of cardiovascular syphilis in the United States has definitely declined in the last 10 years. Prevention The primary prevention of cardiovascular syphilis depends on prevention of syphilitic infection, or if syphilitic infection has already been contracted, on early and adequate therapy to prevent the development of late manifestations. The control of syphilitic infection can be promoted by case-finding and prevalence studies, by contact-tracing, and by worldwide use of penicillin in the treatment of syphilis. Secondary prevention after syphilitic infection has been contracted depends on early detection of cardiovascular syphilis and halting its progression by intensive treatment. Subclinical (Asymptomatic)

Stage

Tests for presumptive identification of subclinical disease. At present there is no test for the presumptive identification of subclinical syphilitic heart disease. Diagnostic procedures to confirm presence of subclinical disease. No specific test is available for the detection of cardiovascular syphilis. History-taking, physical examination, and appropriate laboratory procedures are required to establish the diagnosis. Fluoroscopic or other x-ray examinations are needed to confirm clinical impressions. Treatment for subclinical disease. The treatment needed for the subclinical stage of cardiovascular syphilis is penicillin therapy, the total dosage varying according to the preparation and the schedule of administration.

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Good treatment or management during the subclinical stage will prevent the progression of the disease. The preliminary reports on the effectiveness of penicillin therapy in cardiovascular syphilis are being confirmed in many clinics. The incidence of the disease and its many manifestations is markedly decreased. Possible

Areas

of

Research

Research is indicated to improve the chemotherapeutic and antibiotic preparations used in the treatment of syphilitic infection as well as to develop diagnostic tests of greater specificity and sensitivity. Research is also needed to determine methods of eradicating geographical foci of infection. HYPERTENSION

Primary (essential) hypertension, the most common type, is characterized by a persistent elevation of blood pressure in the absence of a known cause. Secondary hypertension, the less common type, is associated with a wide variety of other diseases. Cases of this type constitute less than 6 per cent of the hypertensive group. Etiology

The etiology of the increased peripheral arteriolar resistance which is present in essential hypertension is not known. It may well have various components: renal, endocrine, nervous, or cardiovascular disturbances, since hypertension of these various origins has been produced experimentally. A familial tendency seems established but whether this is due to genetic factors, rather than psychological ones, has not been determined. Hyperactive responses to the cold pressor test appear to be distributed in families as if dependent upon a dominant gene.2 The known causes of secondary hypertension may be classified as follows: Renal: Affections

Nephritis Pyelonephritis Hydronephrosis Polycystic disease Amyloidosis Infarcts Tumors 2

of

Parenchyma

Intercapillary glomerulosclerosis Hypernephroma Toxemia of pregnancy X-ray lesions Renal stones Congenital defects

See Chapter 25, "Heredity as a Factor in Chronic Disease."

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Renal: Affections of Perinephric Structures Perinephritis Neoplasia Hematoma Retroperitoneal and adjacent masses causing pressure on parenchyma Renal: Affections of Ureter Obstruction (pelvis, ureter, prostate, urethra) Pyelitis with involvement of kidney Renal: Affections of Vessels Arteriosclerosis Arteritis Periarteritis nodosa Visceral lupus erythematosus Scleroderma Vascular anomalies and obstructions (embolism, venous or arterial thrombosis, aneurysm, tumor) Primary

Cardiovascular Heart failure Arteriovenous fistula Coarctation of aorta Polycythemia Atheromatosis Endocrine Pheochromocytoma Adrenal carcinoma Adrenal cortical hyperplasia Adrenal-like ovarian tumor Cushing's syndrome Pituitary basophilism(?) Acromegaly Hyperthyroidism Arrhenoblastoma Desoxycorticosterone Nervous Increased intracranial pressure (trauma, tumor, inflammation) Diencephalic syndrome Anxiety states Lesions of brain stem (ascending paralysis, poliomyelitis) Acute porphyria

Prevention

The occurrence of essential hypertension cannot be prevented by any measure known at present. In those instances where it is possible to eliminate certain of the etiological factors prior to the onset of secondary hypertension, its occurrence can be prevented. Complications and Secondary

Prevention

The arteriolar and arterial sclerosis which often accompanies essential hypertension predisposes to cerebral hemorrhage and thrombosis, cardiac enlargement, myocardial infarction, congestive failure, and nephrosclerosis. All patients with hypertension, primary or secondary, should be under continuing medical supervision. Many methods of treatment for essential hypertension have become established on the basis of inadequate evidence. The variability of the course of the disease has added to the difficulty of determining the most beneficial regimen. In many instances, no therapy is indicated for asymptomatic essential hypertension.

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The complications resulting from secondary hypertension may be prevented by removing the primary disease when it is remediable. For cases of secondary hypertension the cause of which cannot be removed and also for selected cases" of essential hypertension, the use of hypotensive drugs and supportive therapy is recommended. General measures to produce adequate physical and mental rest are important in the management of hypertension. Prevention of obesity and reduction of body weight when it is excessive are desirable and usually are beneficial. The rice diet and other diets to assure low sodium, low protein, low cholesterol, or low caloric intake may be of benefit. Surgical procedures are used in some cases to reduce the increased peripheral arteriolar resistance. Subclinical (Asymptomatic)

Stage

Tests for presumptive identification of subclinical disease. A persistent elevation of blood pressure under basal conditions is presumptive evidence of hypertension. There is no test suitable for general application but the following opportunities for early case-finding exist: (1) routine examinations in the physician's office; (2) insurance examinations; (3) industrial examinations (preemployment and periodic check-ups); (4) preinduction and induction examinations for the Armed Forces; and (5) mass chest x-ray screening programs (to detect cardiac enlargement associated with hypertensive cardiovascular disease). Tests requiring further evaluation are: (1) single blood pressure determinations; (2) cold pressor tests; and (3) blood pressure determination, urinalysis, and electrocardiography as part of multiple screening programs. Diagnostic procedures to confirm presence of subclinical disease. Evidence of persistent elevation of blood pressure confirms the diagnosis of hypertension. Treatment for subclinical disease. When the primary disease is remediable, and is cured, the blood pressure returns to normal levels. Evidence is lacking that treatment of essential hypertension will retard progression of the disease. Until such time as proved methods of retarding progression become available, the measures outlined above should be applied. In many instances, these measures result in symptomatic improvement and may, therefore, contribute to the prevention of symptoms or retard their onset.

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Possible Areas of Research Special encouragement should be given to studies which give promise of elucidating the physiological and chemical aspects of circulation. Information is needed concerning the renal, endocrine, nervous, and psychological factors involved in the control of blood pressure as well as their effects on blood vessels. The relationship of obesity to the development and maintenance of hypertension needs clarification. In addition, studies in the epidemiology of this disease should be encouraged. ATHEROSCLEROSIS AND CORONARY ARTERY DISEASE

Etiology In over 97 per cent of cases, coronary artery disease is due to atherosclerosis and its sequelae. Other less common causes are syphilis of the aorta in which the coronary ostia are narrowed or occluded; periarteritis nodosa; rheumatic fever; and pressure on a coronary vessel from without, such as by a tumor or amyloid deposits in the heart muscle or by an intrapericardial aneurysm. Primary Prevention Atherosclerosis is not preventable at the present time. Early, adequate treatment of syphilitic infection and prevention of the occurrence and recurrence of rheumatic fever will contribute to the prevention of coronary artery disease resulting from these illnesses (see Rheumatic Heart Disease). Clinical Manifestations The most frequent clinical manifestations of coronary artery disease are the anginal syndrome, coronary occlusion with myocardial infarction, and congestive heart failure. Subclinical (Asymptomatic)

Stage

Tests for presumptive identification of subclinical disease. No tests suitable for general application are available at present. Exercise tests and the anoxemia test require further evaluation. Tests in the experimental stage include those for the determination of phospholipidcholesterol ratios and the Gofman lipoprotein fractions. Diagnostic procedures to confirm presence of subclinical disease. Diagnosis of coronary artery disease is extremely difficult, if not impossible, in the asymptomatic stage.

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155

A considerable degree of atherosclerosis of the coronary arteries may be present without having produced symptoms of disease if an adequate collateral circulation has been established. The patient's history of his symptoms may be the only available evidence, since physical examination, electrocardiography, and other diagnostic procedures may reveal no signs of the disease. In suspected cases, historytaking, physical examination, x-ray examination, electrocardiography, and repeated observations are needed to make a diagnosis. Treatment for subclinical disease. In suspected or diagnosed cases, continuous medical supervision is required with attention to medical, psychological, and social factors which may precipitate clinical manifestations. Vocational guidance may be needed. Weight reduction or prevention of obesity may be indicated. Certain drugs such as nitrites, anticoagulants, digitalis, quinidine, and mercurial diuretics are of value in the therapeutic regimen. Although there is no evidence that treatment will retard progression of the disease, better diagnosis and improved therapeutic procedures have lessened disability. Possible Areas of Research Investigation should be conducted along the following lines: Continued studies of sterols, esters, phospholipids, and lipoprotein fractions in the blood and the mechanism of deposit in the endothelium of blood vessels. Studies of endothelial permeability, subendothelial ground substances, and phagocytosis of lipids by the endothelial cells. Studies of localization of atherosclerotic lesions caused by variation in structure of blood vessel walls. Studies of the relationship of diet and obesity to atherosclerosis. Epidemiological studies. PERIPHERAL VASCULAR DISEASE

Peripheral vascular diseases include the following: arteriosclerosis, thrombophlebitis, phlebothrombosis, varicose veins, Raynaud's phenomenon, thromboangiitis obliterans, arteriovenous fistula, polyarteritis nodosa, lymphedema and lymphangitis, frostbite, trench foot, immersion foot and hand, and chilblain (pernio). Together these diseases cause a vast amount of disability, much of which could be prevented. The following list, which makes no attempt to be complete or specific, suggests various measures that could prevent some of the diseases, their complications, and resulting disabilities:

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Physician education that will stimulate an appreciation of the importance of this group of diseases as well as convey the knowledge necessary for their proper management. Early detection and adequate management of all diabetics. Educational programs for the public regarding the importance of good foot hygiene, early and adequate prenatal care, weight control, avoidance of constricting wearing apparel, and elimination of occupational equipment and work methods and habits that interfere with circulation. Provision of facilities and services that will permit physicians to apply present knowledge to the diagnosis and treatment of the peripheral vascular diseases. Study of etiology, epidemiology, and pathology of the peripheral vascular diseases. CEREBRAL VASCULAR DISEASES

Cerebral vascular diseases are usually complications of other forms of cardiovascular diseases such as arteriosclerosis, rheumatic heart disease, coronary occlusion with myocardial infarction, and hypertension. The most common form is cerebral thrombosis. Another form is cerebral embolism which may be caused by an embolus developing from a rheumatic heart with auricular fibrillation, subacute bacterial endocarditis, or from a mural thrombus occurring after a myocardial infarction. The third form, intracerebral hemorrhage, often causes death, so that thrombosis or embolism is usually the underlying factor in surviving hemiplegics. It is estimated that more than 1.8 million persons in the United States are disabled by these lesions. Both primary and secondary prevention of cerebral vascular diseases are therefore of great importance. The following outline, by no means complete, suggests measures which may be used: Long-term anticoagulant therapy in rheumatic heart disease patients with auricular fibrillation, and in certain cases of cerebral thrombosis. Preventive measures (outlined previously) for patients with hypertension and congenital heart disease. Good physiotherapy for restoration of function in unaffected muscles. Adequate speech therapy for cases in which aphasia results. General rehabilitative measures for prevention of unnecessary disability. REFERENCES

General Cardiovascular Disease—Data on Mortality, Prevalence, and Control Activities. PHS Publication No. 429. Washington, D.C., Government Printing Office, 1955. 68 pp.

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Collins, S. D. "Statistical Studies of Heart Disease. V. Illness from Heart and Other Cardiovascular-Renal Diseases Recorded in General Morbidity Surveys of Families." Public Health Reports 64:14391492, November 18, 1949. Diseases of the Heart and Blood Vessels—Facts and Figures (revised). New York, American Heart Association in cooperation with National Heart Institute, 1954. 16 pp. Proceedings of the First National Conference on Cardiovascular Diseases. New York, American Heart Association, 1950. 259 pp. Congenital Malformations Rutstein, D. D., Nickerson, R. J., and Heald, F. P. "Seasonal Incidence of Patent Ductus Arteriosus and Maternal Rubella." ΑΜΑ American Journal of Diseases of Children 84:199-213, August 1952. Warkany, J. "Etiology of Congenital Malformations." Advances in Pediatrics 2:1-63, 1947. White, P. D. Heart Disease (4th edition). New York, The Macmillan Company, 1951. 1015 pp. Rheumatic Heart Disease American Heart Association. "Jones Criteria (Modified) for Guidance in the Diagnosis of Rheumatic Fever." Modern Concepts of Cardiovascular Disease 24:291-293, September 1955. American Heart Association. "Prevention of Rheumatic Fever and Bacterial Endocarditis through Control of Streptococcal Infections." Circulation 11:317-320, February 1955. Denny, T. W., Wannamaker, L. W., Brink, W. R., Rammelkamp, C. H., and Custer, E. A. "Prevention of Rheumatic Fever." Journal of the American Medical Association 143:151-153, May 13, 1950. Stollerman, G. H. "The Prevention of Rheumatic Fever by the Use of Antibiotics." Bulletin of the New York Academy of Medicine 3:165— 180, March 1955. Thomas, L. (editor). Rheumatic Fever—A Symposium. Minneapolis, University of Minnesota Press, 1952. 349 pp. Cardiovascular Syphilis Abstract of Papers Presented at Symposium on the Latest Advances in the Study of Venereal Disease. Held under the auspices of National Institutes of Health in conjunction with Twelfth Annual Session of the American Venereal Disease Association. April 27-28, 1950. Washington, D.C. Processed. Stokes, J. H. Modern Clinical Syphilology; Diagnosis, Treatment, Case Study (3rd edition). Philadelphia, W. B. Saunders Company, 1944. 1332 pp. A Symposium on Current Progress in the Study of Venereal Diseases, April 7-8, 1949. Washington, D.C., Government Printing Office, 1949. 308 pp.

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Thomas, E. W. Syphilis: Its Course and Management. New York, The Macmillan Company, 1949. 317 pp. Hypertension Doyle, A. E., McQueen, E. G., and Smirk, F. H. "Treatment of Hypertension with Reserpine, with Reserpine in Combination with Pentapyrrolidinium, and with Reserpine in Combination with Veratrum Alkaloids." Circulation 11:170-181, February 1955. Master, A. M., Dublin, L. I., and Marks, Η. H. "The Normal Blood Pressure Range and Its Clinical Implications." Journal of the American Medical Association 143:1464-1470, August 26, 1950. Master, A. M., Goldstein, I., and Walters, Μ. B. "New and Old Definitions of Normal Blood Pressure." Bulletin of the New York Academy of Medicine 27:452-465, July 1951. Symposium. "Management of Patients with Primary (Essential) Hypertension." Journal of Chronic Diseases 1:471-574, May 1955. Atherosclerosis and Coronary Artery Disease Blumgart, Η. L. "Coronary Disease: Clinical Pathological Correlations and Physiology." Bulletin of the New York Academy of Medicine 27:693, December 1951. Enos, W. F., Holmes, R. H., and Beyer, J. C. "Coronary Disease among United States Soldiers Killed in Action in Korea." Journal of the American Medical Association 152:1090-1093, July 18, 1953. Gertler, Μ. M., White, P. D., et al. Coronary Heart Disease in Young Adults. Published for the Commonwealth Fund by Harvard University Press, Cambridge, Massachusetts, 1954. Symposium on Atherosclerosis. National Research Council Publication No. 338. Washington, D.C., National Academy of Sciences, 1955. 249 pp. Peripheral Vascular Disease Menendez, C. V., and Linton, R. R. "Peripheral Vascular Diseases." New England Journal of Medicine 251:382-393, 432-438, September 1954. Cerebral Vascular Diseases American Heart Association. Ε. H. Luckey (editor). Cerebral Vascular Diseases; Transactions of a Conference Held under the Auspices of the American Heart Association, Princeton, New Jersey, January 24-26, 1954. New York, Grune and Stratton, 1955. 167 pp.

Chapter

13 Cerebral Palsy1 Infantile cerebral palsy may be defined as a group of conditions characterized by paralysis, weakness, incoordination, or any other aberration of motor function caused by pathological involvement of the motor control centers of the brain. It should be differentiated from other types of palsy such as spinal palsy, peripheral nerve palsy, and palsy secondary to metabolic disturbances or to other conditions not primarily neurological. It should also be differentiated from those conditions in which organic cerebral involvement does not cause motor dysfunction. It excludes the adult form of cerebral palsy in which the brain lesion occurs after full growth and development have been attained. ETIOLOGY

Cerebral hemorrhage and anoxia, which often occur concurrently, are the two most important causes of cerebral palsy. The brain is highly sensitive to lack of oxygen and prolonged anoxia may cause irreparable damage. Fortunately, the infant brain is able to withstand anoxia for much longer periods than the adult brain. However, cerebral hemorrhage or vascular involvement, whether due to anoxia or other causes, is the most frequent cause of brain damage. Predisposing

Factors

Certain factors predispose to the occurrence of cerebral palsy. A history of pathology in previous pregnancies (toxemia, placenta praevia, or maternal infection) or abnormality in labor (high forceps delivery or malpresentation) is common. Cerebral palsy is more prevalent in premature than in full-term infants. It is also more prevalent in firstborn children, those of heavy birthweight, and those born to older women. In all of these instances dystocia or prolonged labor often 1 Prepared by M. A. Perlstein, M.D.; and reviewed by the National Institute of Neurological Diseases and Blindness, National Institutes of Health, Public Health Service.

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160

occurs. Cerebral palsy is also more common in male children who, on the average, weigh more than females at birth. Cerebral palsy seems to occur more frequently in white than in Negro children. This may be owing in part to the average smaller size of the newborn Negro infant, and in part to the lower incidence of Rh negativity among Negroes. A racial factor may also be present. The greater prevalence of cerebral palsy among twins and other multiples may be partly owing to the high incidence of prematurity in multiple births. Some types of cerebral palsy may be hereditarily transmitted. There are also certain distinct hereditary syndromes such as tuberous sclerosis, various forms of amaurotic familial idiocy, and phenylpyruvic amentia, which may have cerebral palsy as a complicating feature. Except for these factors, there seem to be no economic, social, or geographical predilections for cerebral palsy. Precipitating

Factors

Precipitating factors which produce cerebral palsy may be described as prenatal, natal, and postnatal. The prenatal factors, which account for about 30 per cent of cerebral palsy cases, may be roughly divided into hereditary or genetic conditions and those congenitally acquired in utero. Examples of hereditary conditions include aplasia of the pyramidal tracts, neurocutaneous syndromes such as tuberous sclerosis and Sturge-Weber's disease, Wilson's disease, and dystonia musculorum deformans. Congenitally acquired cerebral palsy results from the effect on the fetal brain of maternal or placental pathological conditions. These include gonadal irradiation; anoxia, due to compression of the umbilical cord, premature separation or infarcts of the placenta, or decreased maternal blood pressure; cerebral hemorrhage due to fetal anoxia, maternal toxemia of pregnancy, blood dyscrasia, or perforating wounds of the uterus; maternal infection causing fetal encephalitis (notably German measles and less frequently mumps, measles, chicken pox, herpes zoster, influenza, syphilis, toxoplasmosis); metabolic disturbances, chiefly diabetes; maternal nutritional and vitamin deficiencies; and erythroblastosis fetalis, caused by Rh or other blood incompatibilities. The natal factors, responsible for about 60 per cent of the total number of cases, are trauma and vascular damage, and anoxia. The traumatic and vascular causes of brain injury at birth are primarily physiological and constitute the greatest single group of etiological factors. Trauma traceable to obstetrical forceps, as distinguished from

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natural obstetrical trauma, may be responsible for less than 10 per cent of cases of cerebral palsy. The routine use of oxytocics to induce labor, as well as the "holding back" of a head may increase the tendency to brain hemorrhage. Sudden pressure changes, as in precipitate or Cesarean deliveries may cause diffuse petechial hemorrhages. Prematurity, with its increased fragility or friability of cerebral blood vessels and longer bleeding time, predisposes to massive hemorrhages. Debilitated, weak, or syphilitic infants commonly develop cerebral hemorrhages. Bleeding diathesis due to hemophilia or to lack of vitamin Κ is another factor. Anoxia, next in importance as a natal factor in cerebral palsy, may result from mechanical block of the infant's respiratory tract; fetal asphyxia due to narcotic or barbiturate depression; severe maternal anemia; maternal asphyxia due to obstetrical anesthesia or to decreased maternal blood pressure complicating spinal anesthesia; breech delivery; kinking of the cord during birth; or premature separation of the placenta. Postnatal factors, accounting for about 10 per cent of cases, include traumata caused by penetrating wounds and fractures of the skull; infections such as meningitis, encephalitis, brain abscess, parasitic or fungous infestation of the brain; neoplasms, both malignant and benign; drug poisoning, e.g., by lead, arsenic, barbiturates, or insulin; vascular lesions, e.g., ruptured cerebral aneurysm, hypertensive encephalopathy, cerebral embolism, or thrombosis from any cause; and anoxia, due to strangulation, carbon monoxide poisoning, or prolonged hypoglycemia. PRIMARY PREVENTION

It is difficult to estimate the efficacy of prophylactic measures. It is possible that cerebral palsy is the end result of increasing survivorship of infants who would have died without modern therapeutic measures. For example, the increasing survivorship of premature and erythroblastotic infants may be increasing the number of cases of cerebral palsy. That some success in prevention has been achieved is evident from the fact that the percentage of cases of cerebral palsy caused by Rh blood incompatibility has decreased from 10 per cent to about 1 per cent of the total cases. Public education and the use of exchange transfusions have been primarily responsible for this decrease. The prevention of cerebral palsy caused by hereditary factors is not a serious problem. In the first place, it accounts for not over 2 per cent of the cerebral palsy population, and the process of sexual selection keeps the number of such cases from increasing. Because of the asso-

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ciation of cerebral palsy with complications of pregnancy and other prenatal factors, it is quite possible that a more vigorous application of the various phases of the maternal health program, including better obstetrical care, may reap dividends. However, it is impossible to describe in quantitative terms the extent to which the various etiological factors may be controllable. SECONDARY

Associated

Defects

in Cerebral

PREVENTION

Palsy

Although prophylaxis is the ideal method of control, it becomes necessary at times to treat the disease from the viewpoint of minimizing the resultant disability. This can be done by the prevention of the secondary complicating aspects of the disease. As cerebral damage is not limited to a single area in the brain, defects in speech, vision, hearing, proprioception, intelligence, personality, physical development, and behavior may coexist with impairment of motor control. Prevention of these defects may be considered the prevention of the disease itself. Some secondary defects are not directly attributable to a brain lesion but are the result of a handicap which interferes with the proper social, emotional, and physical development of the child. Nutritional and dental problems are also common complications. The early diagnosis and institution of treatment may prevent many of the abnormalities, both physical and mental, that are so commonly associated with cerebral palsy. Early

Detection

of the

Disease

The diagnosis of cerebral palsy can be established by the experienced clinician in most cases within the first 6 months of life and in almost all cases within the first year. The diagnosis can be made more readily if the physician is aware of the following factors: (1) the relationship between etiology and clinical syndromes in cerebral palsy; (2) the developmental rates and patterns in normal and abnormal children; (3) the occurrence of associated defects and specific symptoms; (4) the specific techniques of the clinical examination; and (5) the differential diagnosis between cerebral palsy and other conditions. Early diagnosis is important because it permits early treatment, thus affording better therapeutic results. There are several techniques that might be utilized for case-finding. Since there is an association between cerebral palsy and various com-

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plications of pregnancy, labor, and the infant's condition immediately after birth, various health agencies might establish a case register of infants whose births weje associated with such complications. Intensive efforts could then be made to follow up this particularly vulnerable segment of the infant population. The experienced and alert physician will be aware of the possibility of cerebral palsy in certain children in whom strabismus, back-arching, or other such stigmata may occur. Treatment

and

Rehabilitation

Many mild cases of cerebral palsy do not require any treatment. In other cases, the defects are so severe that rehabilitation efforts are not feasible. In therapy and education the goals should be realistic and within the potential of the child. They should represent good, practical, functional attainments rather than ideals. The team approach necessitated by the wide range of defects presented implies utilization of the entire gamut of medical specialties, including pediatrics, orthopedics, neurology, physical medicine, psychiatry, ophthalmology, and otolaryngology, in addition to ancillary services in psychology, physical therapy, occupational therapy, speech therapy, social service, special education, and vocational rehabilitation. A knowledge of normal development is necessary for proper management of the cerebral palsied child, since he should not be expected to perform functions which the normal child cannot perform at the same age. Before specific treatment such as physical, occupational, or speech therapy, is undertaken the child should be emotionally and psychologically prepared. Nutrition and general health should be maintained; hearing and visual defects should be corrected where possible; and convulsive seizures should be controlled. Orthopedic surgery is important for the correction of deformities and muscle imbalance, and for stabilization of weak or deformed joints. Neurosurgery has been of benefit in some cases for the control of seizures, behavioral disturbances, and extraneous motions. Braces are used to prevent and to correct contractures, to support weak joints and muscle groups, and to eliminate extraneous motions. Many special types of equipment are used to implement training and positioning of the cerebral palsied child. Occasionally drugs are gainfully used in cerebral palsy cases. Facilities for special education are necessary. This special education should be integrated closely with a vocational program and should be directed toward economic usefulness rather than academic achievement. Since emotional problems may be the greatest deterrent to the eventual rehabilitation

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of the cerebral palsied patient, special attention should be paid to the psychiatric aspects of management, both from the preventive and therapeutic viewpoints. PROBLEMS AND IMPORTANT AREAS OF RESEARCH

It can be said that research in the prevention of cerebral palsy means research in the whole field of preventive medicine. Research on anoxia is of key importance because of the large number of cases of cerebral palsy which anoxia causes. Because rational treatment is based on diagnosis, research in diagnostic procedures is of utmost importance. Fundamental research in the metabolism, chemistry, and dynamics of the brain needs to be carried on, and the new techniques of electromyography and electroencephalography must be explored. There is need for reliable, factual data on the pathological changes in the brain associated with the various forms of cerebral palsy. Until more is known about the basic neurophysiology of the brain, it is not possible to embark upon a logical campaign for the primary eradication of cerebral palsy. From the basic scientific viewpoint, therefore, more research is necessary on the metabolic and electrochemical nature of the nerve cell, and on the transmission and integration of electrochemical impulses in the brain. This research should include neuroanatomical as well as physiological studies in both man and animals. From the clinical viewpoint, the necessary research involves more complete investigation of the natural history of the disease, as well as intense clinical study of the motor, sensory, psychological, and psychiatric patterns of abnormality. Such studies, integrated along a standardized plan of attack, would permit statistical evaluation of clinical material from various research centers. A study of the brains of cerebral palsied children, such as the project of the Brain Registry of the American Academy for Cerebral Palsy, would provide valuable information regarding correlations between etiological, pathological, and clinical syndromes. Research in therapeutic procedure is also essential in order to evaluate the relative efficacy of various methods of treatment. Naturally, before therapeutic values can be tested, standardized methods of measuring sensory ability, motor ability, and mentation must be developed. More research in the fields of drug therapy, bracing, neurosurgery, and orthopedic surgery is necessary. Educational techniques must be developed for children who are not only retarded, but who have perceptual and conceptual defects. Research on the sociological and economic implications of cerebral palsy is necessitated by the magnitude of the problem.

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Finally, instead of being reserved for postgraduate study, the subject of cerebral palsy should be incorporated into the basic curriculum of medical schools and schools for the training of ancillary personnel so that more of the people concerned with the the management of cerebral palsy will be aware of the problem and able to diagnose the disease and institute treatment early in life, before irreversible changes have occurred. REFERENCES

Cardwell, Viola E. Cerebral Palsy; Advances in Understanding and Care. New York, Association for the Aid of Crippled Children, 1956. Cruickshank, William M., and Raus, George M. (editors). Cerebral Palsy; Its Individual and Community Problems. Syracuse, Syracuse University Press, 1955. Diamond, Louis K. "Replacement Transfusion as a Treatment for Erythroblastosis Fetalis." Pediatrics 2:520-524, November 1948. Josephy, Herman. "The Brain in Cerebral Palsy. A Neuropathological Review." Nervous Child 8:152-169, 1949. Levin, Morton L., Brightman, I. Jay, and Burtt, Edith J. "The Problem of Cerebral Palsy." New York State Journal of Medicine 49:27932799, December 1, 1949. Penrose, L. S. "Birth Injury as a Cause of Mental Defect: The Statistical Problem." Journal of Mental Science 95:373-379, April 1949. Perlstein, Meyer A. "Infantile Cerebral Palsy." Reprinted from Levine, S. Z. (editor). Advances in Pediatrics, Vol. VII. Chicago, Year Book Publishers, 1955.

Chapter

14 Diabetes Mellitus1 From the practical standpoint, of greatest importance today is the actual substantiation of the theory that early treatment will lead to a lessening of the severity of the disease and retardation or prevention of late complications. Continued research is needed to determine whether primary prevention of diabetes is possible. For more practical, successful, and encouraging therapy of diabetes, particularly of long duration, more definitive study is indicated to determine just what degree of control will lead to the prevention of complications. Diabetes may have a long preclinical (i.e., biochemical) stage, up to two to three decades, so that a great opportunity exists for case-finding, even in early life.

ETIOLOGY

Predisposing Factors Heredity. The commonest predisposing factor may be heredity. There is strong evidence that diabetes may be inherited as a Mendelian recessive trait. Although the exact genetic mechanism is not clear, there is considerable agreement that there is an increase over normal expectation in both clinical diabetes and the occurrence of abnormal glucose tolerance curves among the relatives of diabetics. There is evidence of both an irregularly dominant and a recessive type of inherited diabetes. Obesity. Diabetes is particularly prone to occur in obese adults. Age. Four per cent of all known diabetics are under the age of 21. Seventy-five per cent are over the age of 50. 1 Prepared by the Chronic Disease Program, Division of Special Health Services, Bureau of State Services, Public Health Service; and reviewed by the American Diabetes Association, Inc.

166

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DIABETES MELLITUS

Precipitating

Factors

A variety of circumstances which subject a predisposed individual to stress may serve to precipitate diabetes. These include trauma, severe infection, surgical operation, pregnancy, and hyperthyroidism. Specific Causes Clinical diabetes mellitus results from a relative or absolute deficiency of insulin. The cause of this deficiency is in most cases unknown. Occasionally diabetes is associated with hyperfunctioning lesions of the anterior pituitary or the adrenal cortices. Obesity is the principal etiological factor which is controllable. While control of heredity is possible by avoidance of intermarriage of individuals with diabetes or with a family history of diabetes, this control is difficult to achieve. Increased case-finding and dissemination of knowledge regarding the role of genetics in diabetes will help in the prevention of the disease. PRIMARY PREVENTION

Education of the public in general and of the diabetic patient and his family in particular is the most important preventive measure. Emphasis should be placed on: (1) control of body weight, (2) avoidance of intermarriage of diabetics, (3) early case-finding (diabetes detection), and (4) recognition of early biochemical abnormalities, sometimes intermittent and variable. A number of problems, however, need to be overcome before the prevention of diabetes becomes a practical reality. Most of the known etiological factors (predisposing, precipitating, and specific) cannot practically be prevented or controlled at the present time. Early discovery and control of diabetes involve mass testing. There is need for improvement of methods. One neglected field in case-finding is the lack of a definitive diagnostic follow-up of every single case of glycosuria and/or hyperglycemia found in hospitals or clinics. Certainly post-prandial blood and urine tests and glucose tolerance tests should be easily available in these places. All aspects of methods for mass detection of diabetes should be evaluated. Evaluation of invalidism, absenteeism, morbidity, and cost of hospital care in diabetes is needed.

PREVENTION OF CHRONIC ILLNESS

168

COMPLICATIONS AND SECONDARY

PREVENTION

The important acute complications of diabetes include diabetic acidosis and coma. These result from poor control and are prevented by good control of the disease. Chronic complications of long-term diabetes are the more important today because of their high incidence, the mortality and morbidity which they induce, and the lack of a definitive solution. The chronic complications are closely related, and most of them are the result of generalized vascular damage which often develops prematurely in diabetics. These serious complications include: (1) diabetic retinopathy (often progressing to blindness), (2) intercapillary glomerulosclerosis, (3) coronary arteriosclerosis, (4) arteriosclerosis obliterans, (5) diabetic neuritis, (6) hypertension, and (7) floccular cataracts in relatively young people. The exact etiology of these complications has not been determined and remains a promising field for intensive study. To be more certainly fixed is the relationship between good control and the development of complications. What constitutes control good enough to prevent complications is still to be determined. Many of the complications of diabetes, particularly those associated with atherosclerosis and other types of vascular degeneration, appear to be disorders of metabolism, particularly of lipoproteins and cholesterol. The recent studies of these substances and other metabolites including the steroids provide a new field of investigation in diabetes. The etiology and possible preventive measures for diabetic retinitis and nephropathy are fields particularly in need of study. Acute complications are prevented by good control. Chronic complications of long-term diabetes present more of a problem. Since the etiology is not defined, preventive treatment is ill defined. Good control, attained through proper education of patient and physician, is the most important measure so far as is known. Low fat diets and lipotropic agents remain possible means of preventing some of the chronic complications. SUBCLINICAL

(ASYMPTOMATIC)

STAGE

Tests for Presumptive Identification of Subclinical Disease Tests considered suitable for general application. At present, two tests are considered suitable for general use in the presumptive identification of subclinical diabetes. These are tests for the presence of sugar in urine or an abnormal level of sugar in the blood.

D I A B E T E S MELLITUS

169

Tests requiring further evaluation. There is a need for better information and greater uniformity in preparation for, and interpretation of, glucose tolerance tests. Tests in experimental stages only. It has been shown that administration of cortisone or ACTH increases the severity of latent diabetes sufficiently to make it biochemically and sometimes clinically apparent. Through the use of cortisone as a provocative it is now possible to recognize the abnormal metabolic state of individuals who may have the potentiality for developing diabetes. This makes possible the study of various inciting factors before frank diabetes develops. Diagnostic Procedures To Confirm Presence of Subclinical Disease After a presumptive identification of the presence of diabetes, postprandial tests for sugar in blood and urine should be performed. Wherever indicated, glucose tolerance tests should also be performed. 2 Treatment for Subclinical Disease In the majority of such cases, restriction of carbohydrate intake will control the hyperglycemia. In others, the use of insulin, in addition to dietary restriction, may be necessary. It is important to give strict attention to adequate and prolonged observation and follow-up. Evidence is accumulating that treatment during the asymptomatic stage of the disease will retard progression or prevent its complications. More data are needed before valid conclusions can be drawn. The preponderance of opinion is that good management at the early or subclinical stage controls, to some degree at least, the progress of the disease. Current studies pertaining to the later development of diabetes in mothers of large babies and the correction, with insulin and diet, of transitory abnormal glucose tolerance tests during pregnancy may provide further information concerning the prevention of diabetes. POSSIBLE AREAS OF RESEARCH

Extensive research is needed in endocrinology and metabolism as related to diabetes. The action of insulin, the role of glucocorticoids, the significance of abnormal vascular patterns which can be photographed, and 2 For discussion of urine and blood tests see Diabetes Guide Book for Physicians (2nd edition). N e w York, American Diabetes Association, November 1956.

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PREVENTION OF CHRONIC ILLNESS

the relationship to diabetes and its vascular complications of such blood constituents as proteins, polysaccharides, sulfhydril compounds, and lipids need intensive study. SUMMARY OF PREVENTIVE

MEASURES

1. Treatment of obesity. 2. Patient education. 3. Treatment of the disease itself. 4. Discouraging intermarriage of diabetics. 5. Professional education. 6. Public education. 7. Early case-finding. Diabetes is no respecter of age, race, or sex. Anyone may become a diabetic, but the disease is found more often in the following categories of people: (a) people in whose family there are already known diabetics, (b) those over forty, (c) the overweight, ( d ) pregnant women, especially those predisposed through heredity. 8. Continued research directed toward clarification of etiology, prevention, and control. REFERENCES

Beaser, S. B. "Diagnosis of Diabetes." Postgraduate Medicine 1 8 : 4 4 5 450, November 1955. Becker, B. "Diabetic Retinopathy." Annals of Internal Medicine 37:273, August 1952. Berkman, J., Rifkin, H., and Ross, G. "The Serum Polysaccharides in Diabetic Patients with and without Degenerative Vascular Disease." Journal of Clinical Investigation 32:415, May 1953. Bornstein, J., and Trewhella, P. "Plasma Insulin Levels in Diabetes Mellitus in Man." Australian Journal of Experimental Biology and Medical Sciences 28:569-572, 1950. Colwell, A. R. Diabetes Mellitus in General Practice. Chicago, Year Book Publishers, 1947. Conn, J. W., Louis, L. H., and Johnson, M. W. "Studies upon Mechanisms Involved in the Induction with Adrenocorticotrophic Hormone of Temporary Diabetes Mellitus in Man." Proceedings of the American Diabetes Association 8:214—236, 1948. Ditzel, J., White, P., and Duckers, J. "Changes in the Pattern of the Smaller Blood Vessels in the Bulbar Conjunctiva in Children of Diabetic Mothers." Diabetes 3:99-106, March-April 1954. Duncan, G. G. Diabetes Mellitus—Principles and Treatment. Philadelphia, W. B. Saunders Company, 1951. Dunlop, D. M. "Are Diabetic Degenerative Complications Preventable?" British Medical Journal, No. 4884, pp. 383-385, August 14, 1954.

DIABETES MELLITUS

171

Fajans, S. S., and Conn, J. W. "An Approach to the Prediction of Diabetes Mellitus by Modification of the Glucose Tolerance Test with Cortisone." Diabetes 3:296-304, July-August 1954. Gofman, J. W., et al. "Blood Lipids and Human Atherosclerosis." Circulation 2:161-178, August 1950. Hoet, J. P. "Carbohydrate Metabolism during Pregnancy." Diabetes 3:1-12, January-February 1954. Houssay, B. A. "Action of Sulfur Compounds on Carbohydrate Metabolism and on Diabetes." American Journal of Medical Sciences 219:353-368, April 1950. Joslin, E. P., Root, H. F., White, P., and Marble, A. The Treatment of Diabetes Mellitus (9th edition). Philadelphia, Lea and Febiger, 1952. Keiding, N. R., Root, H. F., and Marble, A. "Importance of Control of Diabetes Mellitus in Prevention of Vascular Complications." Journal of the American Medical Association 150:964-969, November 8, 1952. LeCompte, P. M. "Vascular Lesions in Diabetes." Journal of Chronic Diseases 2:178, August 1955. Long, C. Ν. H. "The Endocrine Control of the Blood Sugar." Diabetes 1:3, January-February 1952. Progress in Diabetes. New York, Metropolitan Life Insurance Company, 1949. Rabinowitch, I. M. "Diabetes Mellitus." American Journal of Digestive Diseases 16:95-111, 1949. Root, H. F., Pote, W. H., and Frehner, H. "Triopathy of Diabetes." ΑΜΑ Archives of Internal Medicine 94:931, December 1954. Soskin, S., and Levine, R. Carbohydrate Metabolism: Correlation with Physiological, Biochemical, and Clinical Aspects (2nd edition). Chicago, University of Chicago Press, 1952. Styron, C. W. "Clinical Results and Early Detection and Treatment of Diabetes Mellitus." Southern Medical Journal 48:83-87, 1955. Warren, S., and LeCompte, P. M. The Pathology of Diabetes Mellitus. Philadelphia, Lea and Febiger, 1952. Wilder, R. M. "Reflections on the Causation of Diabetes Mellitus." Journal of the American Medical Association 144:1234-1239, December 9, 1950. Wilkerson, H. L. C., and Krall, L. P. "Diabetes in a New England Town." (A Study of 3,516 Persons in Oxford, Mass.) Journal of the American Medical Association 135:209-216, September 27, 1947. Wilson, J. L., Root, H. F., and Marble, A. "Prevention of Degenerative Vascular Lesions in Young Patients by Control of Diabetes." American Journal of Medical Sciences 221:479—598, May 1951. Wrenshall, G. Α., Bogoch, Α., and Ritchie, R. C. "Extractable Insulin of Pancreas: Correlation with Pathological and Clinical Findings in Diabetic and Nondiabetic Cases." Diabetes 1:87-107, March-April 1952. Young, F. G. "Experimental Observations in the Cause of Diabetes." Proceedings of the Royal Society of Medicine 42:321-323, May 1949.

Chapter

15 Epilepsy1 Persons in the United States subject to recurrent epileptic seizures number at least 800,000. This estimate is based on the draft figures of the first and second World Wars. In comparison with most chronic diseases, epilepsy presents certain points of difference. The onset of the disorder usually occurs in childhood. Contributing causes and symptoms are many and widely various. Present-day treatment, when skillfully applied, may give early relief. Prevention and treatment may be as difficult for sequelae as for the disease itself. Finally, and here the contrast is sharpened, the handicap may be as much social as physical, for epilepsy is commonly regarded as shameful and hence becomes a hidden disease, its importance too little recognized, and its victims inadequately aided. ETIOLOGY

Predisposing

Factors

As with many diseases, there is a predisposition toward seizures (a low seizure threshold) which may be inherited. The epilepsy of persons with a family history of the same disorder (or without evidence of an overriding precipitating cause) may be termed genetic (or essential). In terms of mechanism, such an epilepsy may be called metabolic, since some defect in the physico-chemical process of the discharging cell is at fault. Study of twins gives convincing evidence of a hereditary factor in epilepsy. Lennox and Jolly have studied 213 twin pairs affected by seizures (1). Among those without acquired brain lesion, concordance of epilepsy in the monozygotic group was 84.5 per cent and in the dizygotic group, 14.3 per cent. Corresponding values for schizophrenia as determined by Kallman were 86.2 and 14.5 per cent, and for tuberculosis 87.0 and 26.0 per cent (2). The electroencephalograms of monozygotic 1 Prepared by William G. Lennox, M.D., Chief of the Seizure Division, The Neurological Institute of The Children's Medical Center, Boston, Mass.; and reviewed by the National Institute of Neurological Diseases and Blindness, National Institutes of Health, Public Health Service.

172

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EPILEPSY

epileptic twins display similar abnormalities—96 per cent concordance for the 3-per-second spike and wave formation. Geneticists have been cautious in their speculations about the mode of inheritance for those cases in which heredity seems the predominant factor. Although Alström (3) minimizes the role of heredity, he favors "the hypothesis of a dominant main gene and modifying polygenes." Harvald (4) suggests for most cases "the additive action of several genes" but in a few cases "a single dominant or recessive factor." Data obtained by Metrakas (personal communication) favor a dominant of low penetrance (25 per cent) whereas twin data of Lennox and Jolly (7) are consistent with a simple recessive. Precipitating

Factors

Precipitating factors are many and are more likely to cause chronic epilepsy than is a predisposing condition. Almost always the precipitants alter the anatomy or structure of the brain. Abnormality that arises outside the brain, such as tetany, uremia, or hypoglycemia, is only rarely responsible for the onset of chronic seizures. Although congenital defects may, on occasion, be transmitted as hereditary traits, for the most part they arise from anoxia, toxemia, or injury to the brain of the developing embryo or fetus. In addition, birth accidents caused by trauma or anoxia, encephalitis associated with childhood infections, vascular lesions, tumors, traumata occurring in later life (brain damage from traffic accidents or war injuries), the many diseases of the nervous system (including the cerebral disorders of old age) may play a part in the causation of epilepsy. The injury and the initial seizure may be separated by years. Predisposing (genetic) and precipitating (acquired) factors are not mutually exclusive. Doubtless both are present in most cases. The relative influence of each may vary from person to person. Moreover, a cause cannot always be assigned. Among a group of 2,500 office and clinic patients a family history of epilepsy or migraine was obtained in 46 per cent and evidence of previous brain lesion in 27 per cent (5). In 38 per cent no cause could be found. The above figures total 111 per cent because 11 per cent of the patients gave both a positive family history and evidence of an acquired brain lesion. The percentage of cases in which the cause was unknown increased progressively with the age of the patients at the time seizures began: 29 per cent of cases in which the first seizure occurred during the first year of life compared with 49 per cent of cases in which the first seizure occurred after the

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PREVENTION OF CHRONIC ILLNESS

twentieth year. A decrease in the number of cases with family histories positive for epilepsy or migraine was mainly responsible. Control

of Etiological

Factors

As with other paroxysmal disorders, the cause for the initial and for subsequent seizures may differ. Thus, a first spontaneous convulsion may result in a cerebral vascular lesion. The focal convulsions that follow are then the sequelae of a primary, presumably genetic, epilepsy. Again, in the course of epilepsy, individual attacks may be precipitated by some apparently minor incident, such as fever, fright, or fatigue. Lennox's data on 2,500 patients suggest that a predisposing (genetic) condition is more likely to cause epilepsy than a condition that only precipitates. The successful control of these two factors and the means that must be employed to control them differ widely. Success that could be attained through the widespread practice of eugenics would require generations and be almost impossible to measure. On the other hand, the dramatic decrease in recent years of the exanthemata of childhood must immediately result in fewer cases of encephalitic epilepsy. PRIMARY PREVENTION

Logically, a predisposition to epileptic seizures can be remedied through the practice of eugenics. However, modifying factors must first be considered. The person who is a carrier of the tendency to seizures, whether he actually has them or not, may possess other valuable hereditary traits which far outweigh the tendency to seizures. Physical constitution is also a factor in most diseases, and probably plays a greater role in disorders such as rheumatoid arthritis, migraine, hypertension, schizophrenia, and tuberculosis than it plays in epilepsy (5). In order to gain evidence concerning the risk of epileptic progeny, 4,231 noninstitutionalized patients with epilepsy regardless of etiology were questioned about their parents, siblings, and children—of which there was a total of 20,000 (6). The frequency of epilepsy among all near relatives was 3.2 per cent. Among 15,690 near relatives of patients without acquired brain injury, 3.6 per cent had experienced one or more seizures. Only 1.8 per cent of the 4,310 relatives of patients with prior damage to the brain had experienced one or more seizures. The earlier the age at which epilepsy first occurs, the more important is the genetic factor. In the group of patients without damage to the brain, the percentage of one or more seizures in relatives varied with the age at onset of epilepsy in the patient. When the patient's epilepsy

EPILEPSY

175

started before one year of age, 6.4 per cent of relatives were affected; and only 1.5 per cent were affected when the patient's epilepsy began after the age of 30. Children with the usually innocuous febrile convulsions have an unusually large number of affected relatives. Here we have a prominent genetic factor linked with a transient epilepsy. The genetic factor is probably large also in the pure petit mal type of seizure, which is a relatively innocuous form. This finding explains the denial of a genetic influence by some doctors, when, as in the monograph by Alström (3), data were not analyzed ^o bring out any relationship between the age at onset of epilepsy in the patient and the occurrence of affected relatives. The ignorance of the past century has become embedded in the laws of 18 states which forbid epileptics to marry and in the federal statute which does not allow an epileptic to enter the country, even for medical advice. These laws are based on two assumptions: first, that inheritance is the outstanding cause of epilepsy, and second, that the condition is incurable and mentally deteriorating. These assumptions have been proven untrue. It has been estimated that the chance is only about 1 in 30 for a child with an epileptic parent to have a seizure and only 1 in 60 that he will have chronic epilepsy. Even this slim chance is reduced by modern therapy and, even without treatment, seizures tend to become less frequent with the years. Effective control of factors predisposing to epilepsy through the practice of eugenics would require that carriers of the predisposition (who far outnumber affected persons) remain childless. At best, such a procedure would require many generations. Laws regarding eugenics are both unjust and ineffective; the antimarriage law of Sweden dates from 1757 but has not sensibly reduced the marriage rates. Blanket laws that prohibit marriage cannot be condoned; however, the public and its health organizations should know the facts about the relationship between epilepsy and heredity and the need for further research—a matter discussed later. The physician armed with the facts ought to advise his patient as an individual and not as an arithmetical average. The epileptic whose family tree is laden with seizures or mental disorders or both should not have children. (However, two states, Connecticut and Massachusetts, do not permit doctors to give contraceptive information.) Other persons with valuable traits that should be preserved, and these are a majority, should marry. Barrow and Fabing (7) have coded the restrictive laws of all states including those regarding marriage and sterilization of epileptics and specify needed alterations.

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PREVENTION OF CHRONIC ILLNESS

As regards precipitating factors, methods of prevention vary from the selection of a spouse whose blood type is compatible to the avoidance of war. Preventive means are both public and individual. Public health measures include sanitation, control of contagious diseases, and the reduction of traffic and industrial accidents. Individual physicians can render important services at many points, from the first three months of pregnancy when the mother's illness is most likely to cause congenital defects in the embryo, throughout the life of the child, the adult, and the aged. Finally, the individfial citizen is responsible for habits and precautions that promote continued health and avoid brain injury. Epilepsy is peculiar because of the paroxysmal nature of its symptoms. Attacks may be separated by days, months, or years of seemingly perfect health. The chronic disorder is then a succession of widely separated, abrupt, brief illnesses. Therefore, prevention may include not just the initial attack, but some or all of those that might be expected to follow. Fortunately, if the patient receives the medical or surgical treatment appropriate for his individual case, most or all of his recurrent symptoms should cease. New surgical techniques (8) and a battery of medicines are now available. COMPLICATIONS AND SECONDARY

PREVENTION

There are four complications that may accompany epilepsy. They are physical injury, mental impairment, emotional disturbance, and social dislocation. Each of these complications has its own causative factors. Physical illness or injury is more unusual than might be expected. Prevention implies proper job placement in industry and common-sense precautions in ordinary living. Status epilepticus is a complication that may lead to pneumonia, or to exhaustion and death. Mortality in general and suicide in particular are not excessive. Postictal hemiplegia rarely occurs. Mental impairment, when it exists, may be a more serious handicap than seizure. Five possible causes may be named: heredity, either as part of the genetic process of epilepsy, or, more probably separate from it; the brain lesion which is also the cause of seizures; sequelae of seizures (uncomplicated seizures do not cause impairment); excessive sedation (causing only pseudo-impairment); or the social or educational handicaps imposed. The last two conditions should be preventable. The average I.Q. of a series of 600 office patients examined routinely was found to be slightly above the normal average of 106, and was 10 points

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EPILEPSY

lower in the group with precipitated (acquired) epilepsy than in the group with predisposed (genetic) epilepsy. Psychological and social handicaps may affect every epileptic in some degree since they do not result so much from the disease itself as from the attitude of the public. Prevention of these complications involves a change in the public attitude, which requires acquainting the public with present-day knowledge of seizures and their treatment. Personality disorders may be present, especially in persons who have suffered brain damage or who display seizures associated with electrical disorders of the temporal lobe. The most effective preventive measure for most of these complications is control of the seizures themselves by effective drug or surgical therapy. Thanks to the research of the past score of years, most patients can now be relieved of most of their seizures and, given public acceptance, can lead profitable lives. SUBCLINICAL (ASYMPTOMATIC)

STAGE

Tests for Presumptive Identification of Subclinical Disease The borders of epilepsy are not always clearly defined. Conditions such as syncope, hysteria, sensitive carotid sinus, hypoglycemia, dizziness, lapses of memory, or muscular jerks may be either premonitory symptoms or of no consequence. The one test which is suitable for general application is electroencephalography. The brain wave is, however, a phenomenon which alters with body conditions such as tension, sleep, overbreathing, and increasing age. The brain-wave pattern is a hereditary trait and monozygotic twins without acquired brain lesion almost invariably have the same pattern of dysrhythmia and the same type of clinical seizure ( 7 ) . Also, abnormality of rhythm, usually nonspecific, is unduly common among near relatives of the epileptic (4). The brain rhythm of the great majority of epileptics (75 to 80 per cent) is disturbed even in the interval when the person is free of seizures; an even larger majority of the so-called normal population have records with a normal rhythm. Hidden abnormalities may be brought to the surface by hyperpnea and by sleep. Nevertheless, electroencephalography does not always furnish conclusive evidence. Paroxysmal discharges of abnormal waves are significant, but simple variations in frequency may or may not be. The expense of the test and the time it requires preclude its use as a screening procedure. However, the test sometimes gives supporting evidence in the borderline conditions mentioned or in ques-

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tions about marriage and children, adoption, evaluation of damage from encephalitis or trauma, and suitability for hazardous employment such as the operation of an automobile or an airplane. Recordings from the surface or even from the depths of the brain provide hitherto secret information to the neurosurgeon and the neurophysiologist. Diagnostic Procedures To Confirm Presence of Subclinical Disease If epilepsy is suspected but the electroencephalogram is normal even during sleep, activating procedures may be employed. These include hydration by means of excessive fluid intake and injection of pitressin; or, more importantly, injection of a convulsant drug such as metrazol; or photic stimulation by use of rapidly repeated light flashes. One or both of these last two procedures may induce significant electrical discharges or a convulsion. The test provides an indication of the seizure threshold; but the height of the "normal" threshold has not been satisfactorily determined. The diagnostic procedure which takes precedence over even electroencephalography is the history of the patient's seizures. In order to judge borderline situations the physician must be familiar with the many phenomena of epilepsy. Convulsive seizures may vary from muscular outbursts of demoniacal intensity with the appearance of impending death, to a brief rigidity of muscles. Minor seizures, termed petit mal, may be a blank stare with unconsciousness persisting from 10 to 15 seconds, a single quick jerk of the extremities, or a collapse of body posture that resembles syncope. Psychomotor seizures may consist of some rigidity of muscles with turning of the head to one side, smacking or chewing motions, or periods of amnesia with automatic and perhaps even normal-appearing behavior. Abrupt and unprovoked violence or antisocial behavior may be epileptic. In children "out of the blue" tantrums, sleepwalking, or nocturnal periods of screaming may also be epileptic. Retention of awareness may accompany hallucinations of taste or smell, dream-like states, disorientation, or feelings of unreality. Seizures may also consist of autonomic symptoms such as flushing, alteration of pulse and blood pressure, pallor and sweating, headache or abdominal pain. Logically, migraine belongs in this division. Treatment for Subclinical Disease Because electroencephalography is not a routine laboratory procedure, asymptomatic cerebral dysrhythmia is encountered more or less acci-

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dentally in the course of examining a person with some of the questionable symptoms mentioned, or a person whose family history is strongly positive for epilepsy. If questionable symptoms are accompanied by definite abnormality of the electroencephalogram, medication suitable for the type of seizure experienced may be used as a therapeutic diagnostic test. If a definite abnormality is not accompanied by symptoms, treatment is not indicated. Gross and excessive, but asymptomatic, dysrhythmia may persist for years in a child with a brain injury. A possible exception to the statement just made is the case which, on repeated examinations, shows progressive worsening of the record—a condition which increases the likelihood of eventual seizures. Evidence of the preventive value of preictal treatment would require observation of treated and untreated groups of persons with asymptomatic dysrhythmia over a period of years. This has not been attempted. The difference in the mechanism of symptomatic and asymptomatic dysrhythmia is obscure. For example, the electroencephalographic tracings of one pair of identical twins were grossly dysrhythmic, A's more so than B's. Β had frequent petit mal seizures, whereas A had none except when required to breathe hard. POSSIBLE AREAS OF RESEARCH

Research is needed in most of the areas under discussion. Even the number of persons affected is not known. Such epidemiological aspects as age, sex, race, economic status, and geographical distribution need analysis. The secrecy which surrounds epilepsy must first be cleared away. The most far-reaching research would be efforts to protect the genes of human germ cells from noxious agents that cause mutations, since these generally are unfavorable. Mutations that alter the structure or function of the brain might increase the hazard of epilepsy. Muller (9) has estimated that each person contains an accumulation of about 8 detrimental mutant genes, which will persist for about 40 generations. Radiation of germ cells induces mutations proportional to the total amount of radiation received. The natural background radiation (about 0.1 roentgen per year) may cause about 5 per cent of the spontaneous mutations in man. Nuclear explosions of the past year doubled the background radiation even in regions remote from the explosions. Nevertheless, x-ray used in medical practice may offer a greater danger. The dose of roentgens per year to which generative organs are exposed

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in the course of medical treatment is perhaps twice the dose received throughout the United States from all the nuclear test explosions of the past four years. Furthermore, certain chemical agents (purines and more especially caffeine) have doubled the spontaneous mutation frequency in bacteria. The fact that the addition of ribose was found to counteract the mutagenic effect of the purines gives a glimmer of hope for future research. Knowledge of heredity and of the genetic mechanism involved for different groups of patients can be extended by wider studies of family trees and of twin pairs. The genetic relationship (if any) with other disorders of the brain and mind must be determined. Investigation of the physico-chemical process of the cerebral dysrhythmia which underlies seizures is as basic to prevention as it is to treatment. Correlated with this is the development of chemicals which are of specific value in the prevention or correction of the abnormality found. The demonstrated abnormality with respect to bound acetylcholine and glutamic acid deficiency in an epileptogenic area in the human brain is a case in point (10, 11). Social and psychological research that looks toward the prevention of complications in this area has hardly begun. What is public opinion about epilepsy? What is the source of fears and prejudice in the family and outside, and what is the remedy? How are federal and state laws that discriminate unfairly to be repealed? SUMMARY OF PREVENTIVE

MEASURES

Measures that may be of value in preventing epilepsy are listed below, in order of their practicality rather than their basic importance. 1. Prevention of disorders of brain structure or function throughout life, but with special attention to the early period of life. 2. Increase of public interest and understanding to prevent the psychological-social complications of epilepsy. 3. Continued research into the neurophysiology and treatment of seizures. 4. Intensified study of the genetics of epilepsy and dissemination of the information obtained. REFERENCES

1. Lennox, W. G., and Jolly, D. H. "Seizures, Brain Waves, and Intelligence Tests of Epileptic Twins." Proceedings of the Association for Research in Nervous and Mental Diseases. Baltimore, Williams and Wilkins Company, 1954, pp. 325-345.

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2. Kallman, F. J. Heredity in Health and Mental Disorder. New York, W. W. Norton and Company, 1952. 315 pp. 3. Alström, Ch. H. "A Study of Epilepsy in Its Clinical, Social, and Genetic Aspects." Acta Psychiatrica et Neurologica Scandinavica, Supplement 63, p. 284, 1950. 4. Harvald, B. Heredity in Epilepsy: An Electroencephalographic Study of Relatives of Epileptics. Copenhagen, Ejnar Munksgaard, 1954. 5. Lennox, W. G. Epilepsy and Related Disorders. Boston, Little, Brown and Company. (In press.) 6. Lennox, W. G. "The Heredity of Epilepsy as Told by Relatives and Twins." Journal of the American Medical Association 146:529— 536, June 9, 1951. 7. Barrow, R. L., and Fabing, H. D. Epilepsy and the Law. A Proposal for Legal Reform in the Light of Medical Progress. New York, Paul B. Hoeber, Inc., 1956. 177 pp. 8. Penfield, W., and Jasper, H. Epilepsy and the Functional Anatomy of the Human Brain. Boston, Little, Brown and Company, 1954. 9. Müller, Η. J. "Radiation and Human Mutation." Scientific American 193:58-68, November 1955. 10. Tower, D. B., and Elliott, K. A. C. "Activity of the Acetylcholine System in the Human Epileptogenic Focus." Journal of Applied Physiology 4:669-676, February 1952. 11. Tower, D. B. "The Nature and Extent of the Biochemical Lesion in Human Epileptogenic Cerebral Cortex." Neurology 5:113-130, February 1955.

Chapter

16 Impaired Hearing1 An average hearing loss of thirty or more decibels at 500, 1,000, and 2,000 cycles per second is considered significant, requiring assistance either in the form of medical therapy or rehabilitation. A loss of this magnitude causes difficulty in hearing speech under everyday conditions and must be considered as an important handicap to communication. Impaired hearing can be classified under three types: conductive, inner ear, and mixed. A conductive hearing loss results from faulty transmission of sound through the external and middle ear. An inner ear hearing loss is caused by pathology of the organ of hearing—the cochlea and/or the cochlear nerve neurons. The mixed type of hearing loss results from a combination of both conductive and inner ear impairments. ETIOLOGY

Impaired hearing may be either congenital or acquired. A suggested classification follows: Congenital 1. Biological a. Otosclerosis b. Organic malformations of the external, middle, and inner ear 2. Pathological a. Erythroblastosis fetalis b. Syphilis c. Virus diseases in the mother during pregnancy d. Toxic conditions in the mother during pregnancy e. Intrauterine accidents and birth injuries 1

Prepared by Aram Glorig, M.D., Director of Research, Research Center, Subcommittee on Noise in Industry, Committee on Conservation of Hearing, American Academy of Ophthalmology and Otolaryngology; and reviewed by the National Institute of Neurological Diseases and Blindness, National Institutes of Health, Public Health Service. 182

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Acquired 1. Primary a. Infections of the external, middle, and inner ear b. Physical agents c. Toxic agents 2. Secondary a. Brain pathology b. General infectious diseases c. Upper respiratory diseases Biological Congenital Hearing Loss Otosclerosis has long been accepted as a hereditary disease. When both parents are otosclerotic nearly all the female children will also be otosclerotic. However, only one-half to two-thirds of the male children will be otosclerotic. To date, nothing is known about the cause and prevention of otosclerosis. Malformations or organic dejects may be restricted to the ear or may be accompanied by malformations in other parts of the body, which show up in the ear as minute changes in the auditory response or as a complete absence of the external, middle, and inner ear, or any variation between these two extremes. Biological congenital hearing loss may produce variations of the auditory responses extending from a minimal loss at a single frequency to a total absence of response to any sound. Minimal losses at 4,000 cycles per second are commonly found by present-day audiometric methods. Total lack of response is rare, however. Consanguinity is important in congenital hearing loss cases. The incidence of impaired hearing in the offspring of marriages between nonrelated individuals with known familial hearing impairments is also high. Prevention is possible only by nonpropagation. Pathological Congenital Hearing Loss Erythroblastosis fetalis is a relatively rare cause of impaired hearing. Preventive measures depend on a thorough investigation of Rh factor compatibility. Syphilis as a cause of impaired hearing has been reduced by intensive control and improved techniques in the treatment of syphilitic infection. A continuation of these measures will, no doubt, continue this status. Virus diseases in the mother during pregnancy continues to be an important cause of congenital hearing loss. German measles in early

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pregnancy, although insignificant as a primary disease, has been placed among the first causes of congenital inner ear hearing loss. Toxic conditions in the mother during pregnancy are transferred to the fetus. Severe illness with prolonged high fever during pregnancy has produced inner ear hearing loss in the child. The toxicity of drugs— especially of quinine, and less so of salicylates and alcohol—is considered a significant factor in congenital hearing loss. Intrauterine accidents which produce undue mechanical strains or chemical changes such as anoxia are undoubtedly related to congenital hearing loss. Prenatal care and obstetrical management are the keynotes of prevention. Acquired Hearing Loss—Primary

Causes

Infections of the ear. Infections of the external ear commonly known as external otitis may cause a severe swelling of the skin of the external auditory canal and result in an obstructive type of hearing loss. Prevention is particularly important here because treatment is often ineffectual. Aural hygiene, prevention of injury by toothpicks or hair pins, and care while swimming are necessary precautions. Infections of the middle ear which result in purulent or serous exudates are particularly important. Few ears that have been chronically infected escape without a hearing loss. The loss may vary from mild to severe and may be a middle ear or a mixed type of loss. Infections of the inner ear are seldom, if ever, primary. Physical agents. A number of physical agents are related to acquired hearing loss. Impacted cerumen in the external canal is a frequent cause of hearing loss, particularly in older patients. Prevention is easy when yearly examinations are done and the wax is removed before it becomes impacted. Foreign bodies in the ear canal and sometimes in the middle ear may vary from insects to chewing gum. This is more of a problem in children than adults. If foreign bodies are not removed promptly, infection may follow with serious damage to the entire ear. Prevention is accomplished by education with resultant awareness. Injury to the ear may cause serious hearing losses by rupture and/or dislocation of the drumhead and ossicles. Even the inner ear may be damaged by injury to the stapes and round window or fracture of the

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temporal bone. In the cases with rupture of the drumhead only, aural hygiene is essential. Attempts to clean out the external auditory canal should be delayed unless, of course, the drumhead cannot be seen. In this event, intervention should be strictly aseptic and the ear should be kept as free from moisture as possible, to prevent severe middle ear infection with ensuing hearing loss. Intelligent neglect is the best preventive of hearing loss after the injury has occurred. Blows to the head may cause mild or severe losses in one or both ears. Total hearing loss in one or both ears may follow skull fractures, particularly of the basal type and/or fracture through the temporal bone. Hearing loss may also result from blows that are not severe enough to cause a fracture. It may immediately follow what appear to be minor blows, but unless the blow is severe enough to cause unconsciousness with symptoms of subdural hemorrhage, no severe, permanent hearing loss will occur. Naturally, all precautions to prevent accidents of this type should be taken. Noise-exposure and blast are serious causes of hearing loss. Excessive exposure to noise has been recognized for over a century as a cause of hearing loss. Its significance has increased many fold during the past twenty years, as industrial production has increased. Recent legislation regarding compensation for deafness acquired in this way has increased prevention since no treatment known today can restore hearing lost through excessive exposure to noise. Reduction of the volume of noise by the use of ear protectors (ear plugs or muffs) is the most practical preventive measure. Preplacement and follow-up tests to measure the hearing ability of industrial workers are additional precautions that should be taken. Barotrauma or middle ear damage due to rapid changes in altitude is not as common as it once was since pressurized cabins have been installed in modern planes. However, the increased amount of airplane travel makes barotrauma a condition still to be reckoned with. It usually follows an airplane flight made while the patient was suffering from an upper respiratory infection. Prevention involves postponing the flight until the "cold" has subsided. Excessive lymphoid tissue in the nasopharynx and pharynx must be considered an important cause of hearing loss in children. Early detection and surgical removal of the excess tissue is the best treatment. The use of radium or x-ray therapy to reduce the amount of lymphoid tissue is indicated in cases where surgical removal is difficult or impossible.

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Toxic agents. Toxic agents (usually in the form of drugs) may be responsible for acquired hearing loss. Quinine has been an important cause of inner ear hearing loss in the past. However, the use of newer drugs to replace it has reduced this hazard to a negligible problem. Nicotine (tobacco) and salicylates (aspirin) are still thought of as possible causes of hearing loss in hypersusceptible patients. Discontinuation of the agent as soon as auditory signs such as tinnitus are noticed, usually reverses the process. However, if the agent is continued over a longer period the hearing loss may be permanent. Streptomycin, dihydrostreptomycin, and neomycin have taken on considerable importance as causes of inner ear hearing loss because of their frequent use. None of these antibiotics should be used for longer than thirty days, in doses of one gram a day, without careful, periodic tests of hearing and labyrinthine function. Neomycin will produce hearing loss in a very few days and should be used only in cases where no other drug will produce the desired results. Miscellaneous. There are certain other disturbances that may result in acquired hearing loss. Meniere's disease—a disturbance of inner ear hydrodynamics whose etiology is still unknown—may cause both defective hearing and vestibular dysfunction. It can be treated with some success. Frequently, therapy directed toward reestablishing the fluid balance in the inner ear will result in a reduction of the auditory threshold if treatment is started early enough. Presbycusis (hearing loss due to aging) becomes evident, first in the high frequencies, and as age increases the hearing loss gradually involves the lower frequencies as well. The effects of presbycusis are usually first noticed in the early forties. Acquired Hearing Loss—Secondary

Causes

Brain pathology. Certain kinds of brain pathology may result in hearing loss. Meningitis of any type can cause hearing loss, usually by a direct extension of the infection into the inner ear. Early diagnosis and specific treatment of the primary disease will usually prevent the hearing loss. Tumors, hemorrhages, and vascular spasms may result in damage to the central auditory area, the auditory nuclei, or the eighth nerve and its end organ with resultant hearing loss. Although the loss is usually

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mild, it may be severe, as in the case of acoustic neuroma. Prevention of severe hearing loss may be accomplished through early diagnosis and appropriate medical and/or surgical treatment. General infectious diseases. All childhood diseases have been responsible for hearing loss in children. The effects may be directly on the middle and/or inner ear, or as a secondary infection on the middle ear. Such diseases as mumps, measles, chicken pox, and influenza may affect the inner ear either directly or through the middle ear. Scarlet fever and the common cold usually affect the middle ear with a resultant conductive type of hearing loss. If the middle ear is affected, proper therapeutic measures will usually reverse the process with no residual hearing loss. But if the infection is allowed to continue and suppuration begins, the result may be a permanent, mixed type of hearing loss of varying degrees of severity. Prevention of the primary disease is certainly the best prophylactic measure. The use of vaccines, serums, and antitoxins to immunize children has markedly reduced the incidence of hearing loss caused by infectious diseases. The incidence of hearing loss has been further reduced by the successful use of antibiotics to combat secondary infection. PREVENTION

Loss of hearing is insidious and gradual in most cases. The very nature of the symptoms makes it possible for considerable progression to occur before the patient is aware of difficulty. Even then he is prone to ignore it, for impaired hearing has no fatal complications and at first can be readily compensated for by asking the talker to raise his voice. There comes a time, however, when this does not help; but by this time, a significant loss has occurred which, in the majority of cases, is irreversible. Early detection and treatment of hearing loss, especially in children, may serve to reverse the process or, at least, prevent progression and problems of communication. Fortunately, there are exact and rapid tests available for early detection of hearing loss. A good example of this type of prevention is the screening test that in many states is given to school children at frequent intervals during their school years. This test serves to detect children with hearing difficulties; these children are then given more complete hearing examinations. Screening tests play a very important part in the prevention of hearing loss. Since hearing loss of any degree is unusually resistant to treat-

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ment, the earlier an impairment is discovered, the greater is the chance that treatment will be effective. Screening tests of all types are at last receiving more attention—a situation that bodes well for the prevention of impaired hearing. Screening tests for hearing may be divided into two general types: the individual sweep test and the group test. The sweep test uses an ordinary pure-tone audiometer with the intensity dial set at a fixed decibel level (such as 15 or 2 0 ) , depending upon the conditions in the testing room, and sweeps through several frequencies (for example, 500, 1,000, 2,000, 4 , 0 0 0 ) . With each frequency the patient signals to indicate he has heard the sound. If he hears each of the frequencies, he is considered to have hearing within the limits of the intensity setting. If he fails to hear any or all of the frequencies, he is then tested more specifically to determine the extent of his hearing loss. The object of this test is to separate individuals who hear normally from those who hear abnormally. The group test may be carried out in several ways. Usually, however, five or more individuals are fitted with earphones connected to a standard audiometer which produces a pulse tone at each of a number of frequencies set by the operator. Each frequency will deliver one or more pulses which are counted by the individuals being tested and then checked on an answer sheet. The consensus of the workers in the field is that screening with pure tones is more accurate than screening with speech, and the choice of the sweep method or the group method depends upon the individual situation. Many states are setting up compulsory, periodic hearing testing programs among school children. Although the most satisfactory testing methods have not yet been determined, these programs have already detected many early cases of hearing loss, and have referred them for treatment. This type of detection, extended to include preschool children and adults, would increase the chances of early detection of hearing loss. Adequate follow-up and rehabilitation of cases that have been detected are other important factors in the prevention of hearing loss. The present concept of a rehabilitation program for defective hearing includes instruction in the use of a hearing aid plus 3 to 4 weeks of training in speech reading (lip reading), speech conservation and/or speech correction, and auditory training. It is generally conceded that the effective use of a hearing aid depends on two factors—the type of hearing loss and whether or not the patient has received training. For example, a patient with a simple conductive hearing loss should have

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HEARING

very little difficulty in using a hearing aid; but a patient with inner ear hearing loss or a mixed type of hearing loss will have a great deal of difficulty accommodating himself to a hearing aid, and therefore, needs training. Regardless of the type of hearing loss, a patient will adjust himself to a hearing aid more rapidly and satisfactorily if he receives a training course at the time he is fitted with a hearing aid. Many industries have established preplacement and follow-up hearing test programs in many states. Such programs are useful in the prevention of noise-induced hearing loss as well as in classifying workers according to their hearing ability. Some industries have also gone one step further and established ear protection programs which, as they become widespread, will greatly reduce the number of cases of hearing loss caused by excessive exposure to noise. COMPLICATIONS

The most important complication of impaired hearing is its effect on communication. Impaired hearing may affect the production of speech or its reception. If the hearing loss occurs before the child has learned to talk, the effect on the development of speech is significant and varies with the degree and type of hearing loss. If the loss is great enough, it will prevent the development of speech or result in defective speech. Psychic complications frequently follow impaired hearing particularly when the loss is sudden and severe. It is generally thought, however, that severe psychoses are not a direct result of hearing loss, but that if latent psychoses are present, impaired hearing may precipitate overt manifestations. SUMMARY OF PREVENTIVE

MEASURES

1. Education of doctors, parents, teachers, management, and labor. 2. Control of hereditary defects, prenatal disease, infectious disease, obstructive pathology, and noise-exposure. 3. Early detection by adequate audiometry programs such as auditory screening tests on preschool and school children and on adults, preplacement and follow-up tests on all industrial workers. 4. Rehabilitation programs for persons with defective hearing. REFERENCES

Boies, L. R., Canfield, Norton, Carhart, Raymond, and Keaster, Jacqueline. "Hearing Loss in Pre-school Children: A Guide for Diagnosis and Treatment." Transactions, American Academy of Ophthalmology and Otolaryngology 56:835-846, September-October 1952.

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Coates, George, Schenck, Harry, and Miller, M. Valentine. Otolaryngology. Hagerstown, Maryland, W. F. Prior Company, 1952, Vol. 2, pp. 1-9. Downs, Marion P. "The Familiar Sounds Test and Other Techniques for Screening Hearing." Journal of School Health 26:77-87, March 1956. Glorig, Aram. "Military Audiology." Proceedings of the Fifth International Congress on Otorhinolaryngology. Assen, Netherlands, Van Gorcum, 1955, pp. 394-401. Glorig, Aram. "Noise in Industry." American Industrial Hygiene Association Quarterly 14:3, September 1953. Newhart, H., Reger, Scott N., et al. "Manual for a School Hearing Conservation Program." Supplement to Transactions of the American Academy of Ophthalmology and Otolaryngology, 1951. 23 pp.

Chapter

17 Mental Illness1,2 Mental illness constitutes a major segment of chronic disorders. The thousands of psychiatric patients who make up the more or less permanent population of public mental hospitals are monumental testimony to this fact. However, these patients do not make up the total of all persons who are emotionally disabled. Disability may range from mild to complete and its duration may be of indefinite length, depending upon diagnosis and treatment available. It is probable that some methods of dealing with emotionally ill persons contribute to chronicity and disability. The majority of patients released from public mental hospitals are discharged within one year after admission. The discharge rate drops sharply in the second year. After the third year a patient has a very slight chance of ever being discharged. Data are not complete on rate of readmission, but since a considerable number of the patients discharged are readmitted, the hospital's chronically ill population continues to grow, depleted only by death. Emotional disorders are so designated because they all show symptoms of an emotional nature, but the most prominent symptoms in any particular mental disorder may be of a physiological nature, may be in the form of social behavior, or may be in the sphere of the emotions. The first mentioned are represented by the psychosomatic disorders and some of the neuroses, the second by the behavior disorders of childhood and the character disorders which manifest themselves in adult delinquency, and the third by the majority of the psychoses and neuroses. If one were writing a volume, it would be appropriate to consider the emotional disorders as separate entities, but for this relatively brief discussion it is desirable to consider them as a unit. It must be kept in 1 Prepared by Community Services Branch, National Institute of Mental Health, National Institutes of Health, Public Health Service; and reviewed by American Psychiatric Association. ' See also Chapter 24, "Emotional Factors in Chronic Disease."

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mind, however, that disability from chronicity runs the gamut from slight incapacitation due to a mild neurotic disorder to the permanent disability of a malignant psychosis. Also it is well to remember that individuals of all races, sexes, and ages are susceptible and that the condition is prevalent wherever human beings are found. ETIOLOGY

A sound program of prevention of illness rests on knowledge of etiology and epidemiology. Such information with regard to emotional disorders is slowly being accumulated. In a few types of disorders specific etiological factors of an organic type have been identified and for some of these conditions specific programs for prevention and treatment have been devised. As more knowledge of etiology and epidemiology is developed, it will probably be possible to separate out other specific conditions from the mass. However, theoretical evidence at the present time seems to point to multiple causation of most emotional disorders. Hypotheses have been developed to explain the development of emotional disorders on a psychological and social basis. Genetic factors have been implicated in some, such as schizophrenia. Although our knowledge is insufficient to develop definitive preventive programs in the majority of mental illnesses, we do have a great deal of knowledge about the process of personality development and the environmental factors influencing it, upon which to base our present broad preventive programs. The personality of an individual at any time in life is the result of interaction between two influences: (1) constitutional hereditary factors and (2) experiences which he has gone through since the moment of conception. Hereditary factors are rarely all-determining (as in the psychosis of Huntington's chorea) but they do exert influence, for example, in slowing maturation of the mentally defective child, and probably in predisposing the personality to the development of schizophrenia. Environmental experiences contribute to healthy personality development if they can be integrated by the personality and used constructively. However, destructive experiences may contribute to faulty personality development. Personality is dynamic and able to change as a result of experience. It tends to heal and protect itself, developing resistances to stress. Sometimes the personality adjustments necessary to provide defenses against stress are so marked that they make the personality susceptible to later stress. They also may result in individual behavior so deviant from normal that it is categorized as mental illness. For example, brain injury occurring during the birth process may result

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in the appearance of behavior disorders when the child is subjected to the stress of everyday living, or deprivation of mother love in infancy may make it difficult for an individual to maintain adequate adult relationships. Using the stress hypothesis elaborated above as a basis, three lines of attack are indicated in the development of a preventive program against mental illness: Protection of the central nervous system from damage. The promotion of mental health (1) by facilitating the development of strong and mature personalities, (2) by providing help at critical periods, and (3) by alleviating stress. The prevention of chronicity through treatment and active rehabilitative measures. PRIMARY

PREVENTION

Protection of the Central Nervous System from Damage Stresses causing brain damage are usually in the form of traumata, infections, toxins, or malnutrition, and the damage may occur in the prenatal period, during the birth process, or at any time thereafter. Two outstanding examples of success in devising preventive programs are the marked reduction in incidence of general paresis through the treatment of syphilis, and of pellagrous psychosis through better nutrition. Research in the field of mental deficiency indicates that attention to accident prevention, good obstetrics, and good nutrition will result in a reduction of the number of cases. Injury to the brain at birth has been implicated as a cause of some behavior disorders among children. The role of encephalitis in intellectual defect and emotional disorders is well known. Contrasted with this is the almost complete disappearance of post-meningitis brain damage syndromes as a result of antibiotic treatment of that disease. Promotion of Mental Health by Facilitating of Strong and Mature Personalities

Development

A program designed to promote mental health cannot and need not be justified entirely on its effectiveness in preventing mental illness. Knowledge of etiology and epidemiology in the majority of the emotional disorders is scanty. However, there is a great deal of knowledge about the process of personality development and the effect of environmental stresses on that development. Emotional disorders are frequently precipitated by situations involving stress. There is also evidence that the way experiences are integrated when they occur is important in determining resistance to later stress.

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One aspect of programs for the promotion of mental health is concerned with the development of personalities with a high resistance to stress. In actual practice this program is carried on through educational programs for parents and for other persons who are in close relationships with children as a result of their occupation. The latter group is made up principally of physicians (particularly pediatricians), teachers, social workers, and nurses. It is important that these workers develop an awareness of the facts about normal personality development so that they can foster it through positive measures and avoid disturbing its normal course. These important people need to be ever aware of individual differences in children and also of cultural differences in the families involved, to avoid putting undue stress on the child by interpreting unfamiliar normal behavior as abnormal. A situation such as hospitalization of a child is at best productive of stress, and need not be made a situation fraught with childhood terror of parental desertion by imposing unrealistic and unnecessarily restrictive visiting regulations. The form which education of these key persons takes varies considerably. It is important that some knowledge of developmental factors and human behavior be integrated into the curriculum during the professional training period. After that time institutes, seminars, and the opportunity for consultation with professional people trained and experienced in mental health are useful. The importance of the parental, particularly the maternal, role in the development of adequate personalities is well known. However, there is some question as to how mental health personnel can help parents play their roles adequately. Much educational material seems to arouse anxiety which is disturbing to the relationship between mother and child. Here again it is important for the intervening person to be aware of cultural differences and individual differences and to avoid injecting his own biases into the situation. Fads in child care have swept the country from time to time and have seemed to confuse parents and to direct their attention to unnecessary and unimportant details of procedure rather than to meeting the emotional needs of their children according to their natural inclination. The role of mental health personnel is to help clarify this type of situation with parents, to help them arrive at appropriate judgments concerning what things are important in the lives of their children. Parental personalities have evolved by the same process as those of their children. Many of their attitudes result from poorly integrated experiences in their own lives which they tend to try to solve, or compensate for, in relationships with their children. These attitudes influence personality development of the child

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and—depending upon the reaction of the child—may be perpetuated or may arouse resistance and produce behavior problems. Promotion of a healthy personality in the child may then involve specific help of a psychiatric nature for the parents. Exhortation is of little value and may provoke an even more traumatic attitude on the part of the parent. Promotion of Mental Health by Providing Help at Critical Periods Certain periods in the life span of individuals are productive of more stress than others. These so-called "critical periods" include school enrollment, puberty, beginning a job, entering military service, marriage, the climacteric, and retirement. Emotional disorders are frequently precipitated by these stress situations. Ordinarily the periods can be anticipated, however, and the individual can be prepared to meet them by judicious counselling and guidance. Such services may be supplied by mental health clinics of various kinds, by social agencies, and by educational, vocational, and pastoral counsellors. Many industrial organizations and schools provide this service to their employees and students, respectively. Counselling usually involves helping the individual to look at the situation objectively and realistically and to assess his resources for dealing with it. The situation is often not so productive of extra stress in itself, but reawakens fears and anxieties from the past. Promotion of Mental Health by Alleviating

Stress

This facet of a mental health program is intimately involved with the preceding two. As stated above, it is sometimes necessary to treat parents in order to relieve stress on the child. In the periods of crisis it is often possible to alleviate stress by manipulating the environment in some way. A slow-learning child may be under great stress if he is operating to the limit of his ability and cannot keep up with his class or please his parents. This stress can be reduced by placing him in a class where he can compete with children who are also slow learners and by helping his parents to make a more realistic evaluation of the situation and bring their expectations into line with the possibilities. Similar situations occur in industry and in the military services. Soldiers who develop acute emotional disorders in battle may improve upon removal from the immediate stress situation. Patients in the old-age group sometimes improve markedly when environmental stresses are removed, and patients admitted to a hospital frequently improve solely because they are removed from the stressful situation outside the hospital.

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PREVENTION

Prevention of Chronicity through Treatment and Rehabilitation There is new interest in this country in the problem of mental illness. Because the overwhelming majority of our public mental hospitals are maintained and supported by state governments, it is here that we find the greatest interest. The cost to states of operating these hospitals is one-half billion dollars a year. The loss in productivity of the chronically ill individual and the cost in human misery are difficult to measure. The federal government is chiefly concerned by the tremendous and growing problem of providing care for the ever-increasing number of veterans in mental hospitals. The cost of this program in money alone, including pensions to veterans, is one-half billion dollars per year. The Council of State Governments has devoted a great deal of attention to the problem of the mentally ill. Regional interstate organizations have expended considerable energy in determining their needs in research and training, with the idea of developing interstate compacts to pool existing facilities and develop new facilities in the areas of training and research. Legislatures of individual states are appropriating increased amounts, not only for training and research, but also for providing better facilities and for increasing the number of personnel providing therapy. The federal government in 1955 appropriated $1,250,000 for a national survey of resources, methods, and practices utilized in care, treatment, and rehabilitation of the mentally ill. Treatment of emotional disorders is either empirical or based on hypothetical concepts of etiology and pathogenesis. Empirical treatment may consist of physical measures such as various kinds of shock therapy, insulin, lobotomy, and the so-called tranquilizing drugs, chlorpromazine and reserpine. Treatment based on theoretical concepts is either psychotherapy or sociotherapy. Most psychotherapy is based entirely on psychoanalytical theory or on some modification of that theory. Sociotherapy is based on the theory that mental disorders are modes of adjustment in reaction to environmental, social, and psychological stresses and that exposure to the same types of situations involving less psychological stress will assist in readjustment of the personality. The psychotherapeutic techniques have had their widest usage and greatest success in the field of the milder emotional disorders which can be treated in an outpatient clinic or in the office of a private psychiatrist. The physical treatments are confined for the most part to treatment of psychotic patients who are admitted to hospitals. Although we have

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not had enough experience to date to evaluate the tranquilizing drugs as therapeutic agents, trends are evident in hospitals where they are used extensively. For example, patients are being discharged from mental hospitals earlier and in larger numbers and many of them are continuing to receive the tranquilizing drugs after discharge. These patients need continued treatment as outpatients for two reasons: (1) the drug therapy must be supervised and (2) the patients' rehabilitation is not complete and it is essential that they be given further help if improvement is to be maintained and rehospitalization avoided. Coordination of all aspects of a mental health program is essential if maximum success is to be achieved. Promotion of mental health, outpatient treatment, and hospital treatment have too often been considered as completely separate activities and rehabilitation has been neglected. If best results are to be achieved, the rehabilitation of the patient must be the theme of all treatment programs. If this orientation is maintained, an active rehabilitation service will be part of any therapeutic program. Whereas cure of a disorder is a goal of all therapy and all efforts should be expended in that direction, we must often be satisfied with a lesser achievement. This should not result in apathy and neglect as is often the case in our mental hospitals. A good treatment and rehabilitation program is directed toward helping the patient to achieve the most adequate personal, social, and occupational adjustment of which he is capable. This requires continuous effort from the time the disorder first becomes apparent through the period when he is receiving active and specific treatment and for an indefinite period thereafter depending upon his needs. If the rehabilitative effort is not continuous the patient tends to regress and his disability becomes greater. This commonly occurs in the mental hospital. Many more patients can be discharged from mental hospitals, even though chronically ill, if efforts are made not only to rehabilitate the patient within the hospital but to provide the opportunity for him to make an adequate social and occupational adjustment outside the hospital. This requires some supervision of his activities and provision of outpatient treatment when necessary. Family care for mental patients has been used in Belgium and Holland for centuries and there is new interest in developing it in the United States in the form of foster home care. So-called "halfway houses" which exercise less supervision and care than hospitals and provide a bridge back to community living are being tried. Other experiments designed to provide the patient with treatment without removing him completely from community life and

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breaking family ties are the "day" hospitals and "night" hospitals. Here the patient spends roughly half of his time in the hospital and half with his family or on the job. One of the undesirable features of prolonged, full-time hospitalization is that it serves to break ties with family and community which, once broken, are not easily mended. One of the most extensive research projects in rehabilitation of mental patients is that being carried on at the Boston (Massachusetts) State Hospital. The Office of Vocational Rehabilitation of the Department of Health, Education, and Welfare is stimulating interest in the rehabilitation of mental patients through consultation and grants. One of the most pressing problems at the present time concerns the emotional disorders of older patients. Hospitalization of patients over 65 for emotional disorders has increased rapidly in the last few years out of proportion to the growth of this group in the population. Although we recognize that cerebral arteriosclerosis and senile changes cause emotional disorders, experience demonstrates that alleviation of environmental stresses will often result in marked improvement in the mental condition of these patients. Some of the stresses other than organic which appear to cause emotional disorders in older patients are: (1) loss of motivation for living because they no longer seem to be needed by family, community, or in the working world; (2) changes in living conditions making it more difficult to have old people in the family home; (3) changes in cultural values making it an ethical procedure to send parents to a mental hospital. A great deal of attention has been given to consideration of what might be done for people in the older age group to prevent personality disorganization. From a mental health point of view it might be well to consider what they can do for us. Many of them are haunted by feelings of uselessness. If we could find some place for them in our economy, the feeling of being useful would enhance their prestige and contribute to their mental health. Alternatives to hospitalization, such as family care, seem especially important in programs for our aged mentally ill. The programs discussed above in connection with rehabilitation are equally applicable here.

Chapter

18 Multiple Sclerosis1 ETIOLOGY

Predisposing

Factors

Various predisposing factors are believed to favor the development of the disease. These rest on reasonably good scientific evidence. Mortality and morbidity statistics show that multiple sclerosis is more prevalent away from the equator. Whether this prevalence is related to climatic factors is uncertain, but it is possible that cold weather may be especially favorable to the disease. There are many other factors, however, that may be related to latitude, and the importance of cold weather as a predisposing factor remains undecided ( 1 ) . The question of familial predisposition remains unsettled (2-4). A familial constitutional vulnerability to multiple sclerosis—possibly nonessential and nonspecific, subclinical and inadequate to produce the disease—may contribute to the etiology of the illness but a nonfamilial, exogenous cause may be required to evoke the disease. Age factors appear to be predisposing since the onset occurs in the majority of cases between 20 and 40. Certain personality types, early life experiences, and patterns of emotional reactivity appear to lay the groundwork for the development of the disease in many instances. Precipitating Factors Among long held beliefs concerning precipitating factors, documented largely by clinical experience, some are now rejected after thorough statistical study, or in the absence of such study are no longer generally accepted. Among these factors are pregnancy, physical trauma, and nonspecific infection. Exposure to acute chilling may initiate or exacerbate the disease. The same may be said for nonspecific infections, but 1 Prepared by Dr. George Schumacher for the National Multiple Sclerosis Society; and reviewed by the National Institute of Neurological Diseases and Blindness, National Institutes of Health, Public Health Service.

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both factors are absent in the majority of instances preceding onset or exacerbation. Physical or emotional stress, fatigue, and exhaustion often precede the first or renewed evidences of disease. Exposure to body heating (baths, sun) has been proved to produce transient worsening of neurological symptoms without, however, necessarily bringing on or worsening the disease process itself. Dietary fat, formerly thought to be lacking in patients with multiple sclerosis, now is considered a possible precipitating factor in the disease (5). The ingestion of foods to which the individual has shown a demonstrable allergic sensitivity is believed by a few to enhance exacerbation and progression (6). Specific

Causes

The specific cause of multiple sclerosis is unknown. Various hypotheses have been proposed and scientific evidence brought forth to support them, but no alleged cause has been conclusively proved. Some of the hypothesized causes or mechanisms involved in the pathogenesis are: allergic (hyperergic) tissue reactions in the central nervous system; localized or scattered vascular lesions due to vasoconstriction or venular thrombosis; viral, bacterial, or spirochetal infection; alteration in the enzymatic support of myelin metabolism; dietary deficiency (trace elements, vitamins); exogenous intoxication (lead); and specific emotional disturbances (6-11). Since there is as yet insufficient evidence to prove that any of the proposed specific factors cause multiple sclerosis, it would seem unwarranted to attempt control of the possible etiological factors. However, experimental application of promising control measures should be continued. PREVENTION

Since specific etiological factors are unknown, no measures are known that will specifically prevent the onset of multiple sclerosis. Among the generally accepted methods of preventing progression or exacerbation of the disease or its symptoms are the avoidance of the apparently precipitating factors mentioned above and the use of psychotherapy (5). The avoidance of dietary fat has not as yet become generally accepted as a preventive measure, though strongly advocated by one investigator on the basis of epidemiological, biochemical, hematological, and clinical data (5). Other methods strongly advocated by individual investigators on the basis of fundamental and clinical studies, but not generally accepted at present, are indefinitely prolonged anticoagulant therapy and long-term use of chemically induced vaso-

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dilatation (4, 7, 12). Whether changing to a warmer climate by individuals who already have the disease provides any future preventive effect on progress or exacerbations remains as yet undetermined. COMPLICATIONS

Complications of multiple sclerosis include bladder, skin, and lung infection, and musculoskeletal deformities. The prevention of these depends on good nursing care with appropriate medical attention including the use of chemotherapeutic and antibiotic agents, intensive physical therapy, and the kind of training for carrying out the daily acts of living provided by good rehabilitative programs. Additional complications are personality maladjustments, whose prevention requires morale building psychotherapy by the physician and social service worker, and specific (corrective) psychotherapy by the psychiatrist. SUBCLINICAL

(ASYMPTOMATIC)

STAGE

Tests for Presumptive Identification of Subclinical Disease Tests considered suitable for general application. Tests to presumptively identify subclinical (asymptomatic) multiple sclerosis are not available. However, patients who have had certain symptoms suspected of being caused by multiple sclerosis and who are in a quiescent state considered to be a remission, may be subjected to several tests, the results of which are of value in presumptive identification of the disease. These tests involve determination of the absolute and relative values of certain protein constituents in blood and cerebrospinal fluid, as measured by several techniques (i.e., immunochemical or biochemical methods), some of which are suitable for general application in hospital laboratories. However, these tests when positive are not pathognomonic of the disease. Their value lies chiefly in the high (over 80 per cent) incidence of positive findings in multiple sclerosis. The negativity of such tests militates against the diagnosis of multiple sclerosis, whereas positive findings only lend support to, rather than confirm, the diagnosis (14, 15, 18, 20, 23, 26). Tests requiring further evaluation. Biochemical tests of blood and spinal fluid, including protein, lipid, lipoprotein, and amino acid constituents, as well as the content and reactivity of formed elements such as platelets, platelet adhesiveness, tendency to sludge formation, suspension stability, fibrinogen and capillary fragility require further evaluation as tests of supportive value in diagnosis (14-27).

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Tests in experimental stage only. Specific complement fixation tests have been described but have received insufficient confirmation in this country (28-32). Additional work is at present in progress. If found valid, a serologic test would have easy and wide application in the diagnosis of the clinical condition and perhaps in the subclinical or asymptomatic state. This test must still be considered to be in the experimental stage. Diagnostic Procedures To Confirm Presence of Subclinical Disease Diagnostic procedures needed to confirm the presence of subclinical stages of the disease should ideally be related to the presence of specific substances in the blood or spinal fluid derived from the specific etiological factor itself or from the pathological process in the tissues. Treatment for Subclinical Disease There is no known treatment for the subclinical or asymptomatic stages. The evidence presented that prolonged anticoagulant therapy, avoidance of specific allergenic foods, removal to a warmer climate, or the avoidance of dietary fat will prevent exacerbations or retard progression has not been generally accepted to date. POSSIBLE AREAS OF RESEARCH

Possible areas of research in the field of etiology in multiple sclerosis are as wide as the field of medicine itself. Accumulating data are leading to new interpretations of pathological features (8, 13), and revealing pathophysiological states, abnormal biochemical patterns in blood and cerebrospinal fluid, possible metabolic abnormalities, serologic alterations, pathogenic factors in demyelination, details of basic structure and function of myelin, and the possible role of exogenous and psychiatric factors. The major problem is the separation of epiphenomena, associated factors, provocative factors, and links in the chain of pathogenesis, from basic etiological factors. Insufficiently explored has been the possible morbid anatomy of tissues other than the central nervous system in cases of multiple sclerosis. REFERENCES

1. Kurland, L. T., and Dodge, H. J. "Multiple Sclerosis: Its Frequency and Distribution." Neurology 3:557, 1953. 2. Muller, R. "Genetic Aspects of Multiple Sclerosis." ΑΜΑ Archives of Neurology and Psychiatry 70:741, 1953.

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3. McAlpine, D. "The Clinician and the Problem of Multiple Sclerosis." Lancet 268:1033-1038, May 21, 1955. 4. "Multiple Sclerosis and the Demyelinating Diseases." Proceedings of the Association for Research in Nervous and Mental Diseases (vol. 28 of series of research publications). Baltimore, Williams and Wilkins Company, 1950. 5. Swank, R. "Treatment of Multiple Sclerosis with Low Fat Diet. Results in Five and a Half Years Experience." ΑΜΑ Archives of Neurology and Psychiatry 73:631, 1955. 6. Ehrentheil, O. F., Schulman, Μ. H., and Alexander, L. "Role of Food Allergy in Multiple Sclerosis." Neurology 2:412, 1952. 7. Schumacher, G. A. "Multiple Sclerosis." Journal of the American Medical Association 143:1059-1065, July 22, 1950; 1146-1154, M y 29, 1950. Schumacher, G. A. "Treatment of Multiple Sclerosis." Journal of the American Medical Association 143:1241—1250, August 5, 1950. 8. "Symposium on Multiple Sclerosis and Demyelinating Diseases." American Journal of Medicine 12:499-595, May 1952. 9. Rosenow, E. C. "Bacteriological Studies of Multiple Sclerosis." Annals of Allergy 6:271, 1948. 10. Störtebecker, Τ. P. "Common Infections in Disseminated Sclerosis and Other Diseases of the Nervous System." Acta Medica Scandinavica 140:41, 1951. 11. Steiner, G. "Acute Plaques in Multiple Sclerosis, Their Pathogenetic Significance and the Role of Spirochetes as Etiological Factor." Journal of Neuropathology and Experimental Neurology 11:343372, October 1952. 12. Brickner, R. M. "Phenomenon of Relief by Flush in Multiple Sclerosis, Its Use as a Foundation for Therapy." ΑΜΑ Archives of Neurology and Psychiatry 73:232, 1955. 13. Lamsden, C. E. "Fundamental Problems in the Pathology of Multiple Sclerosis and Allied Demyelinating Diseases." British Medical Journal, No. 4714, pp. 1035-1043, May 12, 1951. 14. Von Storch, Τ., Harris, Α., and Lawyer, M. "Cerebrospinal Fluid Examination in Diagnosis of Multiple Sclerosis." New York State Journal of Medicine 49:145, 1949. 15. Kabat, Ε. Α., Freedman, D. Α., Murray, J. P., and Knaub, V. "A Study of the Crystallin Albumin, Gamma Globulin, and Total Protein in the Cerebrospinal Fluid of 100 Cases of Multiple Sclerosis and in Other Diseases." American Journal of the Medical Sciences 219:55, 1950. 16. Aird, R. B., Gofman, J. W., Jones, Η. B., Campbell, Μ. B., and Garoutte, B. "Ultracentifuge Studies of Lipoproteins in Multiple Sclerosis." Neurology 3:22, 1953. 17. Roizin, L., Abell, R. C., and Winn, J. "Preliminary Studies of Sludged Blood in Multiple Sclerosis." Neurology 3:250, 1953.

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18. Roboz, E., Hess, W. C., and Forster, F. Μ. "Quantitative Determination of Gamma Globulin in Cerebrospinal Fluid. Its Application in Multiple Sclerosis." Neurology 3:410, 1953. 19. Swank, R. L. "Blood Plasma in Multiple Sclerosis." ΑΜΑ Archives of Neurology and Psychiatry 69:281, 1953. 20. Roboz, E., Hess, W. C., Forster, F. Μ., and Temple, D. M. "Paper Electrophoretic Studies in Multiple Sclerosis." Neurology 4:4811, 1954. 21. Savitsky, J. P., and Werman, R. "Clot Retraction Time as a Diagnostic Aid in Neurology." ΑΜΑ Archives of Neurology and Psychiatry 71:496, 1954. 22. Roboz, E., Hess, W. C., Forster, F. Μ., and Temple, D. M. "Serum Lipid Studies in Multiple Sclerosis." ΑΜΑ Archives of Neurology and Psychiatry 72:154, 1954. 23. Volk, Β. W., Saifer, Α., Rabiner, A. N., and Oreskes, I. " 'Protein Profile' in Multiple Sclerosis." ΑΜΑ Archives of Neurology and Psychiatry 73:66, 1955. 24. Fog, T., Kristensen, I., and Helweg-Larsen, H. "Blood Platelets in Disseminated Sclerosis." ΑΜΑ Archives of Neurology and Psychiatry 73:267, 1955. 25. Persson, I. "Variations in the Plasma Fibrinogen During the Course of Multiple Sclerosis." ΑΜΑ Archives of Neurology and Psychiatry 74:17, 1955. 26. Ziegler, D. K., and Ross, G. "Cerebrospinal Fluid Gamma Globulin as a Diagnostic Test for Multiple Sclerosis." Neurology 5:573, 1955. 27. Logothetis, J. "A Study of Free Amino Acids in the Human Cerebrospinal Fluid." Neurology 5:767, 1955. 28. Sachs, H., and Steiner, G. "Serologic Investigations in Multiple Sclerosis." Klinische Wochenschrift 13:1714, 1934. 29. Steiner, G. "A Serologic Complement-Fixation Test for Multiple Sclerosis." ΑΜΑ Archives of Neurology and Psychiatry 34:466, 1935. 30. Ahringsmann, H. "Serological Findings in Multiple Sclerosis." Confinia Neurologica 10:70, 1950. 31. Frick, E. "Serologic Research in Multiple Sclerosis." Deutsche Zeitschrift für Nervenheilkunde 166:55, 1951. 32. Roemer, G. Β., Schräder, Α., and Schild, W. "Results of Serological Examinations in Multiple Sclerosis." Klinische Wochenschrift 31: 946, 1050, 1953.

Chapter

19 Poliomyelitis1 A distinction must be made between poliomyelitis infection and poliomyelitis as a disease entity. The infection is common, the disease entity rare. A further distinction must be drawn between paralytic and nonparalytic poliomyelitis. There are many "border-line" cases. In the United States the paralytic cases have recently averaged about 53 per cent of the total cases reported. Paralytic cases may be further classified as spinal, bulbar, and spinal-bulbar on the basis of clinical and postmortem evidence of the parts of the central nervous system invaded and damaged by poliovirus. Acute anterior poliomyelitis is the designation of poliomyelitis infection advanced to the point where it can be diagnosed, that is, has become a recognizable disease. The vast majority of infections, however, are subclinical and asymptomatic. The acute illness is of limited duration, although the effects of viral damage may remain. The immediate clinical diagnosis of nonparalytic poliomyelitis is difficult; it cannot be made for certain without subsequent laboratory (tissue culture) confirmation. The virus may be recovered and identified or an increase in antibody titer may be found during the course of the acute illness. The mere presence of antibody during the acute illness does not serve to identify the infecting agent, since the antibody may be present as the result of an earlier and undiagnosed infection. The diagnosis, and hence the statistical and epidemiological classification of paralytic as against nonparalytic poliomyelitis also offers problems. Muscle weakness or paralysis, if minimal, may not be detected unless careful and complete muscle evaluation is carried out. A simplified and standardized muscle-grading system was developed in connection with the follow-up studies of the 1954 Poliomyelitis Vaccine Field Trial sponsored by the National Foundation for Infantile Paralysis. 1 Prepared by Hart Van Riper, M.D., Medical Director, National Foundation for Infantile Paralysis; and reviewed by the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Public Health Service.

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Within these reservations of diagnosis it is estimated that the ratio of paralytic disease to poliomyelitis infection is of the order of 1 to several hundred. Fox (1955) estimated that in three study areas (1 million population) in Louisiana in 1954, the ratio was 1 paralytic case per 710 infections with poliomyelitis viruses of all types. In spite of these ratios the paralytic consequences of poliomyelitis infection are considerable, especially under conditions of epidemic attack rates. It is estimated that there are now living in the United States about 750,000 people who have from minimal to completely disabling muscle weakness or paralysis as the result of previous poliomyelitis. Of these, perhaps 35,000 would still benefit by having the advantage of presently available procedures and processes of rehabilitation or total medical care. Of those patients in whom paralytic poliomyelitis is diagnosed, approximately 50 per cent recover with no sequelae or residual muscle damage; approximately 30 per cent show a slight residual paralysis, but not enough to interfere with a normal way of life; approximately 15 per cent have marked residual paralysis for which clearly defined adjustments in their pattern of living must be made; and about 5 per cent die. Partly as a result of great strides in the early treatment and management of paralytic poliomyelitis (especially the bulbar and bulbar-spinal types with respiratory difficulties which account for the deaths), the case-fatality rate of poliomyelitis has been steadily reduced. In 1930 the case-fatality rate for poliomyelitis was 16.0 per cent; in 1940, 10.5 per cent; in 1954, 4.9 per cent. The result of life-saving treatment has been to increase significantly the number of patients living with marked residual paralysis, particularly those with breathing difficulties who require mechanical aids to respiration. On the other hand, the improved early treatment of acute poliomyelitis—preventive orthopedics—has reduced the incidence of crippling disabilities and deformities. Physical therapy in its broadest definition has been of inestimable value. ETIOLOGY

Predisposing

Factors

Susceptibility to polioviral infection is apparently universal. Man is the principal, if not the sole, source and reservoir of poliomyelitis infection. In 95 per cent of diagnosed cases poliovirus may be detected on the day of or the day before onset of the disease. It is found in the

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pharyngeal secretions, in the intestinal contents, or in both. The virus disappears fairly rapidly from the pharyngeal secretions; it persists for a long time in the feces—on the average 4 to 6 weeks but often longer. Rhodes and his coworkers found virus 188 days after onset of the disease. When the poliovirus appears in a community, or reaches a certain magnitude, the number of paralytic cases will to a great extent depend upon the ratio existing between the individuals who already possess a certain degree of immunity as a result of previous infection or artificially induced immunity (vaccination) and those who, devoid of immunity, are fresh hosts for the infection. In isolated populations, it has been shown (Paul and Riordan, Adamson et al, Clark and Rhodes) that the introduction of poliovirus produces a highly contagious disease affecting the whole community and sparing only those in the older age groups who have had previous contact with the infection and thus acquired some immunity. The disease entity, poliomyelitis, and epidemics of it are less common in undeveloped countries and underprivileged classes than in population groups that enjoy higher economic and hygienic standards. It is argued by Gear that early infection of the child, at a time (6 to 9 months after birth) when he still possesses antibodies received from his mother either via the placenta or possibly by breast feeding, creates an enduring naturally-acquired immunity which is a barrier against later epidemic infection. In the higher-standard groups, naturally-acquired immunity is gained at increasingly later ages. Many more "civilized" people, therefore, may reach adulthood without naturally-acquired immunity. This is borne out by the increasing incidence of paralytic poliomyelitis in older age groups in the United States. Approximately 22 per cent of the reported cases now occur in patients over 20; and the paralytic involvement is generally more severe than among younger patients. Extensive investigation has dismissed water, milk, food, and insects (flies) as significant factors, if factors at all, in the epidemicity of poliomyelitis. The seasonal character of poliomyelitis, a striking feature of the disease and one which has been much studied, still eludes satisfactory explanation. It seems more probable, however, that physiological and endocrine factors in the host, which may vary seasonally and help to determine individual resistance, play a larger role than climate or weather conditions.

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Hereditary predisposition to paralytic poliomyelitis probably occurs, as some evidence shows; but no preventive recommendations of any practical importance can be based on this possibility. Tonsillectomy at any age before the onset of paralytic poliomyelitis greatly increases the likelihood that the bulbar or spinal-bulbar form of the disease will occur (Anderson et al.). Precipitating Factors Stress on the host of poliovirus sums up what is known about the factors that sometimes precipitate the progress of virus infection to the stage of clinical disease. Among these stresses may be mentioned chilling, fatigue, overactivity, and pregnancy. Paralytic poliomyelitis is almost twice as frequent among pregnant women as among nonpregnant women of the same age group. Bulbar poliomyelitis is definitely associated with nose and throat operations performed in the poliomyelitis season. The injections of irritating substances into the muscles or under the skin during the poliomyelitis season, and particularly during a period of rising incidence, may localize paralytic consequence of current poliomyelitis infection in the injected limb. No satisfactory evidence has been presented to prove that injections provoke paralysis in human beings. We know only that if injections have been made within approximately 30 days before onset, paralysis, if it appears, is more likely to be localized in the limb that was injected. Specific Cause The specific cause of poliomyelitis infection is any one of three known immunological types of poliomyelitis virus (poliovirus type 1, 2, or 3). Hundreds of strains of poliovirus now have been typed, using tissue culture and (in earlier days) cultures grown in Rhesus monkeys, but no fourth type has yet been demonstrated. The virus has been purified to the extent that electron photomicrographs of virus crystals have been taken. A symptomatology somewhat like that of mild or subclinical poliomyelitis is known to be produced by other viruses, notably by the Coxsackie virus and probably by other members of the group called "orphan" and "echo" viruses. The sites of poliovirus multiplication or replication are numerous, but largely enteric. The old concept of the pathogenesis of the disease —that the virus of poliomyelitis traveled only along nerve pathways in the process of becoming fixed in the central nervous system—has had to be abandoned in the light of newer evidence. Tissue culture (Enders,

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POLIOMYELITIS

Weller, and Robbins) demonstrated that poliovirus was not solely neurotropic. A transient but definite state of viremia has also been shown to occur (Bodian, Horstmann)—at least in the prodromal stage of disease. Control

of Etiological

Factors

The predisposing factors in poliomyelitis infection cannot be controlled. Personal cleanliness and community sanitation may be urged, but their value is doubtful. The precipitating factors in clinical poliomyelitis can be controlled within limits. Children and adults can be warned against the risks of chilling and fatigue in the poliomyelitis season. Elective nose and throat surgery should be postponed. The risk of localizing poliomyelitis paralysis by injecting irritating substances must be weighed against the immediate therapeutic or prophylactic need and value for such injections. Since the risk is quite small, clinical judgment will generally favor the injection, certainly in vaccinated children. The effective control of paralytic poliomyelitis now rests upon typespecific immunization (vaccination) against the effects of its specific cause, the poliovirus. PRIMARY PREVENTION

The prevention of paralytic poliomyelitis is now a practical possibility through the widespread, if not almost universal, use of the Salk poliomyelitis vaccine. Although the stated precautions against the precipitating factors in paralytic poliomyelitis should continue, effort should be concentrated upon vaccination against the disease. It has been suggested, but not proved, that widespread vaccination will reduce the reservoir of poliovirus among human beings, thus possibly reducing the incidence of subclinical (asymptomatic) and nonparalytic poliomyelitis. That vaccination with presently available vaccines will materially reduce the risk of paralytic poliomyelitis is certain. The Salk vaccine now used in the United States (and with slight modifications in other countries) is a killed trivalent virus vaccine. To date its use has demonstrated both its safety and potency. The report of the 1954 field trials and those summarizing the 1955 experience concluded that the vaccine is safe and is 60 to 90 per cent effective in preventing paralytic poliomyelitis. In 1955, about 10 million United States school children received one or more injections of Salk vaccine. Reports from the states involved

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revealed that, under conditions of use in 1955, the vaccine was 75 to 80 per cent effective in preventing paralytic poliomyelitis. An even higher degree of effectiveness, statistically measured, may be anticipated when "full immunization" schedules of dosage have been carried out in a high percentage of children and young adults. The recommended dosage schedule for the present Salk vaccine is two 1 cc. intramuscular injections, spaced 2 to 6 weeks apart, with a booster injection at least 7 months later. The effectiveness of immunization can be measured by the antibody titer produced. This depends crucially on the mass of the antigen injected and the timing of the injections. Approximately 20 per cent of the persons inoculated do not respond measurably to the first injection of vaccine. For a high percentage of them, the second injection represents primary immunization. The booster effect, developing a high titer of antibodies—as high as, if not higher than, that resulting from naturallyacquired infection—depends upon the length of time after primary sensitization that the booster injection is given. Seven months delay is minimal for optimal booster effect. It has been calculated that the poliomyelitis vaccination programs of 1954 and 1955 dramatically reduced the incidence of paralytic poliomyelitis. This opens the vista of improved vaccines ultimately eliminating paralytic poliomyelitis. The situation in 1956 (and possibly 1957) will have to be viewed on the basis of a medical emergency and vigorous programs of vaccination must be undertaken to provide protection, first, to the entire population under age 20, and, later, to all those who so desire, up to about age 35, as well as to all pregnant women. If children up to age 20 and pregnant women are to be protected with "full immunization" schedules of dosage, approximately 175 million injections of vaccine will have to be given in the years 1956 and 1957. This is a mammoth undertaking for private medicine and public health. The significant problems of the immediate future in the prevention of paralytic poliomyelitis are those of obtaining an adequate supply of poliomyelitis vaccine and maintaining and encouraging its prompt and widespread use. This applies not only to initial vaccination but also to the administration of booster shots, when needed. The most important unanswered questions about the present poliomyelitis vaccine relate to the duration of the immunity it effects, and to the need for booster shots at intervals after the initial immunization. It will require years of observation and research to obtain a satisfactory

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answer to these questions, and to determine the extent to which the principles underlying the production of the present vaccine are those which will obtain for the ultimate product. COMPLICATIONS AND SECONDARY PREVENTION

Residual paralysis or weakness of any muscle or muscle group, and consequent muscle, bone, or joint deformity, may be considered the principal complications of paralytic poliomyelitis. The possibility of psychological damage should also always be considered. Respiratory paralysis may occur in the acute stage of the disease and endure for weeks, months, or years thereafter. Residual or respiratory paralysis results from damage to motor neurons of the central nervous system by poliovirus. The ultimate function of a voluntary muscle will depend in largest part upon the number of neurons that have been damaged by the virus. However, improper or inadequate early treatment of acute paralytic poliomyelitis may also be considered a possible etiological factor in residual paralysis. Correct and adequate immediate treatment of the patient with acute paralytic poliomyelitis will help to prevent complications insofar as they can be prevented. The practice of preventive orthopedics, properly prescribed physical therapy, and good nursing will do much to prevent subsequent crippling and muscle damage. A complete "medical team," representative of many medical specialties and staffed by properly trained ancillary personnel, usually gives treatment which assures the best eventual outcome of the specific acute case. In the management of respiratory paralysis it is additionally necessary to have the proper mechanical aids to respiration available in good working order on an emergency basis. Understanding of the indications for and adjustment of the mechanical apparatus on the part of the attending staff is equally requisite. Not only must patients' lives be saved by getting them into "iron lungs" in time; these lives must also be usefully prolonged by freeing them as soon as possible and as much as possible from dependence upon mechanical aids to respiration. SUBCLINICAL (ASYMPTOMATIC)

STAGE

The presence of subclinical (asymptomatic) poliomyelitis infection can be confirmed by laboratory (tissue culture) identification of poliovirus types 1, 2, or 3 in samples of feces or nasopharyngeal washings. Complement-fixation and skin tests are still in the experimental stage. If

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poliomyelitis is discovered in the asymptomatic stage, treatment consists in guarding the patient from the factors that are thought to precipitate paralytic involvement—fatigue, chilling, overexertion, elective nose and throat surgery, and irritating injections. Neutralization tests of serum antibodies from blood samples will reveal retrospectively whether or not a person has had subclinical poliomyelitis infection. Viremia might be detected in a person with a subclinical infection; but this would depend on the unpredictable time when a blood sample was taken and is quite impractical. POSSIBLE AREAS OF RESEARCH

The entire field of virology affords areas of research that will bear upon the production of poliomyelitis vaccines and methods of creating immunity to paralytic poliomyelitis or even poliomyelitis infection. The virus-host relationship is one of many such potential fields of study. So is the development of chemical agents for therapeutic or prophylactic effectiveness against poliovirus. Certain promising chemical compounds at present under laboratory study have not yet reached the stage of clinical trial. Investigation of live virus (attenuated virus) vaccines, with the possibility of producing an oral vaccine or one affording long-time if not life-long immunity, is currently being conducted. All research in the processes and techniques of rehabilitation will be of benefit to patients with paralytic poliomyelitis. Of particular importance are studies in respiratory physiology. SUMMARY OF PREVENTIVE

MEASURES

1. Vaccination against paralytic poliomyelitis with the presently available Salk vaccine. 2. Precautions against the factors that precipitate paralytic involvement in the presence of poliomyelitis infection (chilling, fatigue, overexertion, nose and throat surgery, irritating injections). 3. Proper early treatment of acute poliomyelitis to reduce residual paralysis. REFERENCES

Adamson, J. D., et al. "Poliomyelitis in Arctic." Canadian Medical Association Journal 61:339-348, October 1949. Affeldt, J. E. "Recent Advances in the Treatment of Poliomyelitis." Journal of the American Medical Association 156:12-15, September 4. 1954. Anderson, G. W., and Rondeau, J. L. "Absence of Tonsils as a Factor

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in the Development of Bulbar Poliomyelitis." Journal of the American Medical Association 155:1123-1130, July 24, 1954. Bodian, D. "Pathogenesis of Poliomyelitis." American Journal of Public Health 42:1388-1402, November 1952. Bodian, D., Francis, T., Jr., Larsen, C., Salk, J. E., Shope, R. E., Smadel, J. E., and Shannon, J. A. "Interim Report, Public Health Service Technical Committee on Poliomyelitis Vaccine." Journal of the American Medical Association 159:1444-1447, December 10, 1955. Clark, A. M., and Rhodes, A. J. "Poliomyelitis in Canadian Eskimos; Laboratory Studies. II." Canadian Journal of Medical Sciences 29: 216, 1951; "Lansing Antibody Levels in Baffin Land. Laboratory Studies. III." Canadian Journal of Medical Sciences 30:390, 1952. Committee on Typing of the National Foundation for Infantile Paralysis. "Immunologic Classification of Poliomyelitis Viruses. VII." Discussion of results and general summary of the co-operative program for the typing of 230 strains. American Journal of Hygiene 58:74-80, July 1953. Enders, J. F., Weller, Τ. Η., and Robbins, F. C. "Cultivation of Lansing Strain of Poliomyelitis Virus in Cultures of Various Human Embryonic Tissues." Science 109:85-87, January 29, 1949. Farrell, L. N., Wood, W., Franklin, A. E., Shimada, F. T., Macmorine, H. G., and Rhodes, A. J. "Cultivation of Poliomyelitis Virus in Tissue Culture. VI. Methods for the Quantity Production of Poliomyelitis Viruses in Cultures of Monkey Kidney." Canadian Journal of Public Health 44:273-280, August 1953. Farrell, L. N., Wood, W., Macmorine, H. G., Shimada, F. T., and Graham, D. G. "Preparation of Poliomyelitis Virus for Production of Vaccine for the 1954 Field Trial." Canadian Journal of Public Health 46:265-272, July 1955. Fox, J. P., et al. A Continuing Study of the Acquisition of Natural Immunity to Poliomyelitis in Representative Louisiana Households. Presented at the 83rd Annual Meeting of the American Public Health Association, Kansas City, Mo., November 15, 1955. Francis, T., Korns, R. F., Voight, R. B., Boisen, M., Hemphill, F. M., Napier, J. Α., and Tolchinsky, E. "An Evaluation of the 1954 Poliomyelitis Vaccine Trials. Summary Report." American Journal of Public Health 45: Part II, May 1955. 63 pp. Gear, J. H. S. "Distribution of Antibodies to Poliomyelitis Virus in the General Population." In Poliomyelitis (Papers and Discussions at the Third International Poliomyelitis Conference, Rome, 1954). Philadelphia, J. B. Lippincott Company, 1955. Gear, J. H. S., Measrouch, V., Bradley, J., and Faerber, G. I. "Poliomyelitis in South Africa—Studies in an Urban Native Township during a Non-Epidemic Year." South African Medical Journal 25:297-301, May 1951. Hammon, W. McD., Coriell, L. L., Ludwig, Ε. Η., McAllister, R. Μ., Greene, A. E., Sather, G. E., and Wehrle, P. F. "Evaluation of Red

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Cross Gamma Globulin as a Prophylactic Agent for Poliomyelitis. 5. Reanalysis of Results Based on Laboratory-Confirmed Cases." Journal of the American Medical Association 156:21-27, September 4, 1954. Horstmann, D. M. "Poliomyelitis Virus in Blood of Orally Infected Monkeys and Chimpanzees." Proceedings of the Society for Experimental Biology and Medicine 79:417—419, March 1952. Langmuir, Alexander D., Nathanson, Neal, and Hall, William Jackson. "The Surveillance of Poliomyelitis in the United States in 1955." American Journal of Public Health 46:75-88, January 1956. Lepine, P. "Epidemiology and Pathogenesis of Poliomyelitis: Present Status of the Problem." In Poliomyelitis (Papers and Discussions Presented at the Third International Poliomyelitis Conference, Rome, 1954). Philadelphia, J. B. Lippincott Company, 1955. Paul, J. R., and Riordan, J. R. "Observations on Serological Epidemiology; Antibodies to the Lansing Strain of Poliomyelitis Virus in Sera from Alaskan Eskimos." American Journal of Hygiene 52:202-212, September 1950. Poliomyelitis: Annual Statistical Review 1954. New York, National Foundation for Infantile Paralysis, 1954. Poliomyelitis (Papers and Discussions Presented at the Second International Poliomyelitis Conference, Copenhagen, 1951). Philadelphia, J. B. Lippincott Company, 1952. 555 pp. Poliomyelitis (Papers and Discussions Presented at the Third International Poliomyelitis Conference, Rome, 1954). Philadelphia, J. B. Lippincott Company, 1955. 567 pp. Poliomyelitis Vaccination. A Review of the Present Position at a Meeting of Experts Convened by the World Health Organization in Stockholm, Sweden, November 21-25, 1955. Mimeographed report issued by WHO, November 29, 1955. 55 pp. Pope, A. S., Feemster, Roy F., Rosengard, D. E., Hopkins, F. R. B., Vanadzin, B., and Pattison, E. W. "Evaluation of Poliomyelitis Vaccination in Massachusetts." New England Journal of Medicine 254: 110-117, January 19, 1956. Public Health Service Progress Report on the Poliomyelitis Vaccination Program. Department of Health, Education, and Welfare, Public Health Service. Washington, D.C., January 24, 1956. Processed. 35 pp. Rhodes, A. J., Clark, Ε. M., Knowles, D. S., Shimada, F., Goodfellow, A. M., Ritchie, R. C., and Donohue, W. L. "Poliomyelitis Virus in Urban Sewage; and Examination for its Presence over a Period of Twelve Months." Canadian Journal of Public Health 41:248-254, June 1950. Salk, J. E. "Immunization against Poliomyelitis." Symposium on Poliomyelitis in Pediatric Clinics of North America 1:49-51, 1953. Salk, J. E. "Poliomyelitis Vaccine in the Fall of 1955." American Journal of Public Health 46:1-14, January 1956.

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Salk, J. E. "Present Status of the Problem of Vaccination against Poliomyelitis." American Journal of Public Health 45:285-297, March 1955. Salk, J. E. "Vaccination against Paralytic Poliomyelitis. Performance and Prospects." American Journal of Public Health 45:575-596, May 1955. Salk, J. E., Krech, U., Youngner, J. S., Bennett, B. L., Lewis, L. J., and Bazeley, P. L. "Formaldehyde Treatment and Safety Testing of Experimental Poliomyelitis Vaccines." American Journal of Public Health 44:563-570, May 1954. Salk, J. E., Lewis, L. J., Bennett, B. L., Ward, Ε. N., Krech, U., Youngner, J. S., and Bazeley, P. L. "Antigenic Activity of Poliomyelitis Vaccines Undergoing Field Test." American Journal of Public Health 45:151-162, February 1955. Salk, J. E. (with the collaboration of Bazeley, P. L., Bennett, B. L., Krech, U., Lewis, L. J., Ward, Ε. N., and Youngner, J. S.). "Studies in Human Subjects on Active Immunization against Poliomyelitis. II. A Practical Means for Inducing and Maintaining Antibody Formation." American Journal of Public Health 44:994-1009, August 1954. Salk, J. E. (with the collaboration of Bennett, B. L., Lewis, L. J., Ward, Ε. N., and Youngner, J. S.). "Studies in Human Subjects on Active Immunization against Poliomyelitis. I. A Preliminary Report of Experiments in Progress." Journal of the American Medical Association 151:1081-1098, March 28, 1953. Schwerdt, C. E., and Schaffer, F. L. "Some Physical and Chemical Properties of Purified Poliomyelitis Virus Preparations." Annals of the New York Academy of Sciences 61, Art. 4:740-753, September 27, 1955. Spencer, W. A. Treatment of Acute Poliomyelitis (2nd edition). Springfield, Illinois, Charles C. Thomas Company, 1954. "Symposium on Poliomyelitis." Journal of the American Medical Association 158:1239-1281, August 6, 1955. Technical Report on Salk Poliomyelitis Vaccine. Department of Health, Education, and Welfare, Public Health Service. Washington, D.C., June 1955. Processed. 163 pp. Van Riper, Η. E. (editor). Information for Physicians on the Salk Poliomyelitis Vaccine. New York, National Foundation for Infantile Paralysis, July 1955. 36 pp. Van Riper, Η. E. (editor). New Information for Physicians on the Salk Poliomyelitis Vaccine. No. 2. New York, National Foundation for Infantile Paralysis, January 1956. For general review purposes the literature on poliomyelitis can be checked in the following sources: Fishbein, Morris, et al. (editors). A Bibliography of Infantile Paralysis, 1789-1949, with Selected Abstracts and Annotations. Philadelphia, J. B. Lippincott Company, 1951.

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Collected Reprints of Grantees of the National Foundation for Infantile Paralysis. Vol. I (1939-1940), and Vols. II (1941) through XVI (1955). Published annually by the National Foundation for Infantile Paralysis, New York. Index to Collected Reprints of the Grantees of the National Foundation for Infantile Paralysis, 1939-1951. New York, National Foundation for Infantile Paralysis, 1954. Poliomyelitis Current Literature. An annotated list of periodical articles compiled from material furnished by the editors of Excerpta Medica and the New York Academy of Medicine. Published monthly by the National Foundation for Infantile Paralysis, Division of Professional Education, Medical Department. (1956 is Volume 10.)

Chapter

20 Late Manifestations of Syphilis1 PRIMARY PREVENTION

Although studies of immunity in syphilis have been in progress for some time, the process is far from completely understood. No practical method of immunization by artificial means has been developed. The best way to avoid syphilitic infection is to avoid sexual contact with an infected person. This means that primary prevention is a facet of the larger problem of sexual conduct. As such it is susceptible of many approaches. However, there is agreement that educational counselling and social services are needed to promote sexual behavior that is consistent with epidemiological as well as social, moral, and religious concepts. As to the source of such services and the approach to the subject, individuals and interested groups can make their own choices. Social Hygiene Education This term encompasses advice and information to children, young persons, and adults on the subject of personal and family living, including sexual behavior and some reference to venereal disease. Such information and advice should include more than the physiological aspects of sexual behavior. Sex phenomena should be discussed as parts of the broad biological, psychological, sociological, and ethical patterns of life. Its basic importance to personal happiness and family stability should be emphasized. For children. Parents are the ideal sources of social hygiene training. Information supplied by parents should be accurate and commensurate with the child's ability to grasp facts and their ramifications. It should be recognized that information is only one aspect of social hygiene training. The success of this training depends upon the entire home 1 Prepared by the American Social Hygiene Association; and the Venereal Disease Program, Division of Special Health Services, Bureau of State Services, Public Health Service.

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environment and the guidance toward emotional and intellectual maturity provided in the family circle. Education for personal and family living may be incorporated into school courses on biology, hygiene, physiology, and family living. It may also be offered as a separate course of instruction. It should be remembered that school programs cannot serve as adequate substitutes for home training. For some children, information and guidance on sex and social hygiene provided in school will be the only source of enlightenment and the only opportunity for correcting misinformation and distorted concepts of the subject picked up by hearsay. Child guidance and advisory services provided through mental health clinics, social service departments and organizations, juvenile courts, church groups, etc. are other sources of social hygiene education. For adults. Social hygiene educational and counselling services are available for all interested adults, and are sponsored by local educational institutions, church and welfare organizations, professional societies, and local health departments. Premarital education classes, with opportunities for individual counselling, are useful to prepare adults for the relationships and responsibilities of marriage and family living. Classes, publications, and counselling services are available for parents, to assist them in providing social hygiene guidance to children in the home. The Armed Forces' character guidance and health education services are other sources of social hygiene information. For teachers. Instruction for teachers in the subject matter and methods of social hygiene education of children may be given not only in formal courses in pedagogy at the university level, but also through meetings, seminars, etc. Venereal Disease Education This term applies primarily to health department programs designed to inform the public about the nature, transmission, course, and consequences of the venereal diseases, and the importance of early diagnosis and treatment. Narrower in scope than social hygiene education, these programs have been employed chiefly as aids to case-finding of venereal disease. However, they are important in promoting primary prevention of syphilis in several ways: (1) accurate information about syphilis is

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publicized, misconceptions are dispelled; (2) public interest is generated in vigorous programs to promote treatment and control of syphilis; (3) to the extent that it stimulates persons with syphilis in an infectious stage to seek diagnosis and treatment, venereal disease education helps to reduce the number of persons who can transmit syphilis; (4) such information may prevent exposure to infection, or induce the use of prophylaxis against syphilis. Because venereal disease education should always be medically accurate, it should continue to be a function of health agencies and the health professions. However, the participation, cooperation, or support of social organizations is vital at both the planning and promotional stages. Law Enforcement Adoption and enforcement of laws (where either is lacking) will help to prevent and control venereal disease. Such laws include: (1) state laws (or board of health regulations) permitting health authorities to deal effectively with syphilis; (2) premarital and prenatal blood test requirements; ( 3 ) laws for the repression of prostitution. SECONDARY PREVENTION

The statement can be made unequivocally that adequate treatment of early syphilis will prevent any one of the late complications. The patient should receive a therapeutically effective dose of an antisyphilitic agent. For almost every manifestation of syphilis, penicillin alone administered in sufficiently large doses and over an adequate time interval has been found to be the drug of choice for treatment. Congenital syphilis can be prevented almost completely by adequate treatment of the mother before or during pregnancy. Therefore the responsibility for discovering and treating maternal infection rests with the attending physician or the responsible clinic or hospital. The congenitally syphilitic child ideally should be discovered by routine organized testing programs so that effective treatment may be given before development of complications. The crippling and serious lesions of syphilis usually develop following a long period of latency during which the only evidence of infection is a positive serologic test for syphilis. Through routine serologic testing, as in screening programs, such individuals can be discovered before serious damage is done, so that adequate treatment can begin. In a screening program the serologic test to be used must be capable

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of rapid application, highly specific, and not disproportionately expensive per unit test. Any of the tests listed in the Manual of Serologic Tests for Syphilis may be expected to give satisfactory results if properly performed and controlled by qualified technicians. As a rule biological false-positive reactions do not constitute a problem, though in population groups with a very low prevalence of syphilis such false-positive reactions may be troublesome. Tests employing treponemal antigens may be necessary to resolve some of the more difficult cases. CARDIOVASCULAR SYPHILIS2

Primary prevention of cardiovascular syphilis can be achieved (1) by prevention of syphilitic infection, and (2) by adequate treatment of early syphilis. Secondary prevention consists of the prevention by means of early treatment of vascular thrombosis or of cardiac decompensation. Cardiovascular syphilis may be discovered by means of serologic tests and subsequent examination of persons with positive serologic evidence of syphilis or through demonstration of cardiac enlargement in chest x-rays with subsequent serologic and other examinations. NEUROSYPHILIS

Primary prevention of neurosyphilis can be achieved (1) by prevention of the syphilitic infection, and (2) by adequate treatment of early syphilis. Complications such as paresis, tabes dorsalis, meningovascular syphilis, and syphilitic meningitis can be prevented by early treatment with penicillin. Examination of the cerebrospinal fluid in all cases of early syphilis within 6 to 12 months after treatment, and pretreatment examination of the cerebrospinal fluid in all cases of latent and late syphilis with subsequent physical examination of all patients with abnormal findings would discover virtually all cases of neurosyphilis. REFERENCES 3

Management of Venereal Disease. U.S. Department of Health, Education, and Welfare. PHS Publication No. 327. Washington, D.C., Government Printing Office, 1953. •See also Chapter 12, "Cardiovascular Diseases." "See also Chapter 12, "Cardiovascular Diseases."

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Manual of Serologic Tests for Syphilis. U.S. Department of Health, Education, and Welfare. PHS Publication No. 411. Washington, D.C., Government Printing Office, 1955. Moore, Joseph Earle. Diagnosis of Syphilis by the General Practitioner. U.S. Department of Health, Education, and Welfare. PHS Publication No. 426. Washington, D.C., Government Printing Office, 1949. Stokes, John H., Beerman, Herman, and Ingraham, Norman R., Jr. Modern Clinical Syphilology: Diagnosis, Treatment, Case Study (3rd edition). Philadelphia, W. B. Saunders Company, 1944. Thomas, Evan W. Syphilis: Its Course and Management. New York, Macmillan Company, 1949.

Chapter

21 Tuberculosis1 ETIOLOGY

Predisposing Factors The influence of nonspecific factors such as malnourishment, fatigue, overcrowding, low economic status, and poor personal hygiene seems well established. Tuberculosis morbidity and mortality rates are higher in certain racial groups and heredity may be a predisposing factor. Susceptibility appears to be highest in children under 3 years, and lowest from 3 to 12 years. Diabetes and silicosis increase susceptibility. Precipitating Factors Excessive and prolonged physical and emotional strain often seems to precipitate the onset of tuberculous disease. Specific Cause The human tubercle bacillus (Mycobacterium tuberculosis hominis) causes nearly all pulmonary tuberculosis. Infection occurs by inhalation of tubercle bacilli emitted from the respiratory tract of a person with "open," bacillary-positive tuberculosis. Direct and indirect contacts are important. Alimentary infection, as by contaminated eating and drinking utensils, is less frequent. Infection usually results from the continued and intimate exposure that characterizes household relationships, although some susceptible family contacts may avoid infection for long periods. The bovine strain (Mycobacterium tuberculosis bovis) causes a considerable share of extrapulmonary disease, the proportions varying according to exposure to infection. Bovine tuberculosis is transmitted by ingestion of unpasteurized milk or dairy products from tuberculous cows, by airborne infection in barns, and by handling contaminated animal products. 1 Prepared by the Tuberculosis Program, Division of Special Health Services, Bureau of State Services, Public Health Service; and reviewed by the National Tuberculosis Association.

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For practical purposes the real source of tuberculous infection is the active, sputum-positive human patient. The identification and proper isolation of all individuals with active tuberculosis would effect control of the disease. The control of bovine tuberculosis is being effected through elimination of infection in cattle and pasteurization of milk. PREVENTION

Prevention of tuberculosis can be accomplished by the following measures: 1. Education of the public about the danger of tuberculosis, the way it is spread, the methods used to control it. 2. Early case-finding by means of: (a) skin tests for sensitivity to tubercle bacilli and community-wide chest x-ray surveys (with dual reading of films), (b) segmental surveys of the population, such as low income groups, hospital admissions, and selected kinds of industrial workers, (c) admission chest x-rays for patients of general and mental hospitals, and periodic x-rays of long-term institutional populations, (d) examination of contacts of patients with known disease. All members of the household of a newly discovered case and all intimate extrahousehold contacts should have chest x-rays and tuberculin tests. In some areas, annual retesting of tuberculin-negative persons with intensive study of converters and their contacts has been effective in disclosing early lesions, and in finding previously unrecognized sources of infection. 3. Isolation and treatment of persons with active disease. This should include provision and utilization of adequate facilities; a period of hospital or sanatorium treatment which removes the focus of infection from the home, teaches the patient the hygienic essentials of prevention of spread of infection, and increases the chances of recovery; and antimicrobial therapy. At present a combination of two of the three most effective antimicrobial drugs (isoniazid, streptomycin, and para-amino-salicylic acid) is commonly employed. Isoniazid and para-amino-salicylic acid is now the combination of choice for beginning treatment, replaced later by other drugs in cases that fail to respond. Pneumothorax and phrenic nerve interruption are rarely employed now and even pneumoperitoneum is becoming infrequent. Thoracoplasty is occasionally and selectively indicated. Pulmonary resection is now frequently employed. In extrapulmonary tuberculosis, medical therapy as described above for pulmonary tuberculosis is combined with specific measures, including surgery, suited to the particular form and type of disease. 4. Adequate public health supervision before and after hospitalization. 5. Adequate rehabilitation and aftercare.

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6. Adequate economic assistance to the families of the tuberculous. 7. Elimination of tuberculosis in dairy cattle and the boiling of milk or pasteurization of milk and milk products. 8. Protection against inhalation of silica dust in dangerous quantities in industrial establishments and mines. 9. Betterment of living conditions among lower income groups. 10. B.C.G. vaccination is not recommended for general use. The complications of tuberculosis are an inherent aspect of the disease itself. Early diagnosis and prompt adequate therapy will prevent complications. PROBLEMS

Medical Problems Special techniques are necessary because tuberculosis is communicable. Susceptibility and resistance to tuberculosis do not follow a predictable pattern. The complicated clinical and laboratory processes necessary to a final diagnosis frequently delay isolation and treatment of patient. Determination of activity of disease is exceedingly difficult. Each patient with active tuberculosis requires an individual therapeutic regimen. Socioeconomic

Problems

For most patients a period of reduced physical activity under medical supervision is an advantage in producing arrest or healing of tuberculous lesions. The patient's diagnosis and treatment are frequently hampered by pressing emotional and psychological problems, family responsibilities, and economic stress. Many individuals fail to take advantage of diagnostic facilities even when these are available to them without charge; many refuse treatment when discovered to have tuberculosis; and many tuberculous patients leave hospitals against medical advice before the completion of treatment. Low economic status, which is usually accompanied by malnourishment, overcrowded living conditions, and poor personal hygiene, contributes to susceptibility to and development of the disease. Many popular misconceptions about tuberculosis (like the beliefs that only young, frail people contract it; that a warm, dry, or moun-

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tainous climate is necessary for its cure; that the disease itself is inherited) inhibit modern control activities. Facilities and Personnel Problems There are many areas in the United States where there is no properly equipped diagnostic center for tuberculosis. In some areas of the United States there is still an insufficient number of hospital beds for the isolation and treatment of active cases of tuberculosis. The number of trained professional persons—doctors, nurses, social workers, laboratory technicians, etc.—to care for tuberculous patients and to provide community tuberculosis control services is inadequate. Legal Problems Residence requirements in many state and local laws prevent persons without legal residence from obtaining necessary hospitalization. In many areas tuberculous persons are denied diagnosis and/or treatment because of unrealistic "means tests." SUBCLINICAL

(ASYMPTOMATIC)

STAGE

Tests for Presumptive Identification of Subclinical Disease Tests considered suitable for general application are the tuberculin skin test and chest x-ray. However, further refinement of both are indicated. Diagnostic Procedures To Confirm Presence of Subclinical Disease Presumptive identification of tuberculosis can be confirmed by the following procedures: (1) history and physical examination; (2) chest x-ray; (3) tuberculin test; (4) bacteriological examination of sputum or other body fluids; (5) special examinations, like bronchoscopy, when indicated. Treatment for Subclinical Disease The chosen method of treatment varies with each patient from close observation to extensive surgical therapy. Extensive evidence shows that early detection and proper therapy usually decrease the length of illness, diminish the degree of disability, and increase the length of life.

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For a better understanding of the medical aspects of tuberculosis, research needs to be carried out in the following areas: Further investigation of the tubercle bacillus itself—its metabolism, genetics, chemical composition, and the immunological properties of its various chemical components. Development of more reliable, specific, and rapid diagnostic tests. More precise methods for determining susceptibility and resistance according to age, sex, race, degree of exposure, nutritional status, and other factors. Basic research on description and classification of chest films. Evaluation of various methods of case-finding. Continued research on the use of known antibiotics and search for new therapeutic and prophylactic agents. Study of the relation of emotional factors to healing of tuberculous lesions. Comprehensive studies of the rehabilitation process. The following investigations are indicated to provide better understanding of the socioeconomic aspects of tuberculosis: Study of the effect of social and economic conditions on the incidence of tuberculosis. Studies to determine the true number of beds needed for the hospitalization of the tuberculous. Further study of the causes of hospital discharges against medical advice. Comprehensive studies of the extent and nature of the problems of tuberculosis among persons without legal residence. Studies of the implication of the "means test" to tuberculosis control. SUMMARY OF PREVENTIVE

MEASURES

The order of priority of preventive measures against tuberculosis is arbitrary because each is part of a total program. There is no one measure which could be taken effectively without the others. Preventive measures are: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Early case-finding. Isolation of persons with known active disease. Education of the public. Public health supervision of patients. Protection of workers against inhalation of silica dust. Economic assistance to the families of tuberculous patients. Betterment of living conditions among lower income groups. Facilities for rehabilitation and aftercare. Elimination of tuberculosis in dairy cattle.

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American Trudeau Society, Tuberculosis Hospital Administration. "Minimal Medical and Administrative Standards." American Review of Tuberculosis 72:699-709, November 1955. Anderson, R. J. "Methods of Finding Tuberculosis Cases and Reactors." American Review of Tuberculosis 71:406-418, March 1955. Anderson, R. J. "Outpatient Management and the New Drugs for Tuberculosis Control." Public Health Reports 70:294-296, March 1955. Anderson, R. J. "The Future of the Miniature Chest X-ray in Screening for Asymptomatic Disease." Journal of Chronic Diseases 2:418-426, October 1955. Anderson, R. J. "Tuberculosis Morbidity and Mortality—Facts and Trends." Public Health Reports 71:194-200, February 1956. Anderson, R. J., Enterline, P. E., and Turner, O. D. "Undetected Tuberculosis in Various Economic Groups." American Review of Tuberculosis 70:593-600, October 1954. Anderson, R. J., and Palmer, Carroll E. "BCG." Journal of the American Medical Association 143:1048-1051, July 22, 1950. Blackman, H., and Leahy, Kathleen M. "Nursing Service in a Tuberculosis Sanatorium." American Journal of Nursing 54:569-571, May 1954. Blomquist, Ε. T. "The Non-Hospitalized Tuberculosis Patient." American Journal of Public Health 46:149-155, February 1956. Coleman, Jules. "Attitudes of Professional Personnel in the Treatment of the Tuberculosis Patient." American Journal of Public Health 45: 849-854, July 1955. Comstock, George W. "Tuberculosis Studies in Muscogee County, Georgia. V. Tuberculosis Mortality during 7 Years After a Community-Wide Survey." American Review of Tuberculosis 73:157164, February 1956. Control of Communicable Diseases in Man. An Official Report of the American Public Health Association, New York, 1955. 219 pp. Mount, Frank W., and Ferebee, Shirley H. "Control Study of Comparative Efficacy of Isoniazid, Streptomycin-Isoniazid, and StreptomycinPara-Amino-Salicylic Acid in Pulmonary Tuberculosis Therapy." I. "Report on Twelve-Week Observations on 526 Patients." American Review of Tuberculosis 66:632-635, November 1952. II. "Report on Twenty-Week Observations on 390 Patients with StreptomycinSusceptible Infections." American Review of Tuberculosis 67:108113, January 1953. III. "Report on Twenty-Eight-Week Observations on 649 Patients with Streptomycin-Susceptible Infections." American Review of Tuberculosis 67:539-543, April 1953. IV. "Report on Forty-Week Observations on 583 Patients with Streptomycin-Susceptible Infections." American Review of Tuberculosis 68:1-6, August 1953. V. "Report on Thirty-Two-Week Observations on Combinations of Isoniazid, Streptomycin, and Para-Amino-Salicylic Acid." American Review of Tuberculosis 70:521—526, September 1954.

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National League for Nursing, Tuberculosis Nursing Advisory Service. Safer Ways in Nursing to Protect against Tuberculosis. New York, National Tuberculosis Association, 1955. National Tuberculosis Association. Diagnostic Standards and Classification of Tuberculosis. New York, National Tuberculosis Association, 1955. Oechsli, Waldo R., Kupka, Edward, and Bush, Chesley. "Classifying the Tuberculous for Isolation in California Mental Institutions." Public Health Reports 70:1194-1200, December 1955. Palmer, Carroll E., and Ferebee, Shirley H. "Prevention of Experimental Tuberculosis with Isoniazid." American Review of Tuberculosis 73: 1-17, January 1956. Palmer, Carroll E., and Shaw, Lawrence. "Present Status of BCG Studies." American Review of Tuberculosis 68:1-5, September 1953. Public Health Service, Division of Chronic Disease and Tuberculosis. Community-Wide Chest X-ray Survey. PHS Publication No. 222. Washington, D.C., Government Printing Office, 1952. 117 pp. Public Health Service, Tuberculosis Program. "A Point of View about Bacterial Resistance—USPHS Cooperative Clinical Investigation." American Review of Tuberculosis 70:739-742, October 1954. Public Health Service, Tuberculosis Program. "Experimental Studies of Vaccination, Allergy, and Immunity in Tuberculosis," Parts 1, 2, 3. Bulletin of World Health Organization 12:13-62, 1955. Public Health Service, Tuberculosis Program. "Experimental Studies of Vaccination, Allergy, and Immunity in Tuberculosis," Parts 4, 5, 6. American Journal of Hygiene 62:168-199, 270-282, September and November 1955. Public Health Service, Tuberculosis Program. "Routine Chest X-rays of All Patients Admitted to General Hospitals." Public Health Reports 69:569-570, June 1954. Roberts, Doris E. "The Positive Approach to a Tuberculosis Nursing Program." Public Health Reports 68:338-340, March 1953. Wittkower, E. D., Durost, Η. B., and Laing, W. A. R. "A Psychosomatic Study of the Course of Pulmonary Tuberculosis." American Review of Tuberculosis 71:201-219, February 1955.

Chapter

22 Chronic Disease in Industry1 This summary statement is concerned with the prevention of exposure to conditions of work which may lead to chronic disease, the proper placement of workers to avoid the aggravation of existing chronic diseases, and the provision of preventive health services in industry for early detection and diagnosis of all chronic diseases. OCCUPATIONAL CHRONIC DISEASES

A wide variety of chronic diseases have been found to be associated with specific occupational exposures. These include diseases of the respiratory tract (silicosis and silicotuberculosis, asbestosis, and bagassosis), cancer, 2 diseases of the cardiovascular system, and chronic metallic poisonings. Exposure to cancerigenic agents is found in diversified occupations. The processing of Chromates has been associated with a many-fold increase in the incidence of primary lung cancer. Ionizing radiation from radon and its decay products has been implicated in the extraordinarily high lung cancer rates among European uranium miners. Ionizing radiation may also be an etiological factor in leukemia and skin cancer; bone sarcoma has also been related to deposition of radium. Bladder cancers have been conclusively related to beta naphthylamine and to benzidine exposure. Arsenic and some of its compounds, as well as a variety of fractions of petroleum, coal, tar, and pitch, can cause skin cancers. Finally, cancer may complicate other occupational diseases, for example, lung cancer is suspected of being secondary to asbestosis. Diseases of the cardiovascular system directly traceable to the working environment are few. Thus, disabling cor pulmonale may accompany 1 Prepared by the Occupational Health Program, Division of Special Health Services, Bureau of State Services, Public Health Service; and reviewed by the Council on Industrial Health, American Medical Association. 2 See Chapter 11, "Cancer."

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severe pneumoconiosis and chronic beryllium disease. Also, damage to the peripheral vascular system may result from the prolonged use of vibrating tools and from exposure to low temperatures. Chronic effects are also associated with exposure to heavy metal poisons in industry. In this category, lead poisoning is the classic example. Although disabling chronic industrial lead poisoning is no longer a major disease problem, opportunities for exposure are widespread, temporary overexposure is frequent, and only by great vigilance can anemia, peripheral neuritis, and encephalopathy be prevented. Cirrhosis of the liver can result from carbon tetrachloride exposure, as well as from exposure to the chlorinated naphthalenes and diphenyls. Organic damage to the nervous system may result not only from lead exposure, but also from exposure to arsenic, carbon disulfide, and mercury and its compounds. Chronic anemia caused by exposure to benzol is well recognized. Chronic dermatosis can be caused by a variety of irritant or sensitizing agents encountered occupationally. Because of their frequency and duration, skin diseases are of special importance in industry. Often a worker who becomes sensitized to a particular substance, usually a chemical, may retain this sensitivity long after he has left a particular working environment. Excessive noise may lead to impairment of hearing. Lenticular cataracts have been associated with exposure to certain portions of the electromagnetic spectrum and have been experimentally induced by certain intensities of ultrasonic vibration. Certain chronic infectious diseases are at times of occupational origin. Among these are tuberculosis as it occurs in those caring for tuberculous patients, and brucellosis as it occurs in packing house workers, farmers, or veterinarians. While the foregoing examples illustrate chronic diseases whose occupational association is generally supported by strong evidence, certain types of chronic diseases fall into a gray area of possible occupational implication. For example, the relation between occupational stress and heart diseases is under study. Workers under constant tension would appear to be more susceptible to peptic ulcer and digestive and cardiovascular disturbances. Likewise, dust exposures have been implicated as a cause of emphysema, while miners and others who labor under humid conditions are suspected of having a greater incidence of arthritis. In addition, psychosomatic illnesses as well as other mental and emotional disorders may have their roots in work situations.

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NONOCCUPATIONAL CHRONIC DISEASES

The prevalence among the working population of chronic diseases generally considered to be nonoccupational in origin is not known. However, from the few experiences that have been reported, it would seem that the problem is fairly extensive. For example, the University of Michigan, in examining 500 business executives, found 52 per cent to have one or more defects requiring treatment. About 70 per cent of that number were not known to have defects prior to the examination. A substantial proportion of the defects were forerunners of chronic illnesses. The rapid development in middle-aged and younger persons of incipient chronic diseases and other conditions is illustrated by findings of subsequent periodic examinations of this same group. On reexamination, from 12 to 20 per cent of the men with defects were found to have developed new abnormalities requiring treatment. PREVENTION

Occupationally-associated chronic diseases are amenable to primary preventive measures embracing both medical and engineering activities. Medical activities are directed primarily at (1) preplacement medical examination for safe and effective placement of employees, and (2) early diagnosis of disease by the periodic medical examination. Engineering control measures employ such principles as change of process, substitution of safe for unsafe materials, enclosure or isolation of hazardous processes, wet methods, exhaust or dilution ventilation, proper housekeeping, and the use of personal protective equipment. Finally, educational activities are an integral part of a preventive program to assure that workers derive the full benefit of preventive measures. Nonoccupational diseases are subject only to secondary preventive measures, focusing chiefly on early case-finding. The most useful tools for early case-finding and prevention are the preplacement and periodic examinations, health education, and counselling. Health examinations in industry have repeatedly demonstrated their effectiveness in the early detection of incipient chronic diseases. It is the responsibility of the industrial medical department to assure that workers with such conditions obtain adequate care from private physicians and community facilities, and that they are placed in jobs which do not aggravate their condition or create hazards for their fellow workers. The industrial health service is in a position to provide to employees continuous health education directed toward improving personal health practices. Through health education and counselling the employee can

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be assisted to improve and maintain his health status. In this regard emphasis is placed on such health matters as the importance of adequate diet in maintaining health and efficiency, the advisability of seeking early treatment for illness, and the necessity for proper rest and recreation. Furthermore, counselling services contribute in helping the worker solve his health and personal problems. These services have a special part to play in the early detection of psychosomatic illnesses. In their early stages, such illnesses do not necessarily call for a trained psychiatrist, but rather for a physician or nurse with a knowledge of psychological and emotional reactions, who knows the temperament of the individual and his occupational situation, and who will give him sympathetic attention. Properly trained industrial health personnel frequently can recognize and assist the worker to solve problems relating to home, family, and financial worries, as well as emotional conflicts relating to the work situation. Through counselling, guidance, and appropriate referrals to community medical and social resources, employees can be assisted to recognize and overcome the more deep-seated problems. INDUSTRIAL HEALTH SERVICES

There is need for improvement and expansion of industrial health services, both medical and engineering. Also indicated is better coordination of these services at the operating levels. Expansion of Governmental Industrial Health Programs To render effective technical assistance, the industrial medical and engineering programs currently operating in health or labor departments in 42 states and territories must be materially strengthened in staff and budget. The services currently provided by these agencies within any one year can reach no more than 10 per cent of the country's labor force. Expansion of Health Programs in Industry Industrial health programs provide medical supervision of workers engaged in hazardous operations and preventive services for the improvement and maintenance of the general health of the worker. In-plant health services represent a concentrated point of attack on chronic diseases, offering the greatest potential presently available to the adult population for early case-finding and the secondary prevention of chronic illnesses. The full potential of these programs, however, can be realized

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only when they are expanded to include the 70 per cent of the total employed population working in small plants without the benefit of health maintenance services. There is also need to utilize more fully proper job placement which is one of the most important tools of an industrial health program in the prevention and control of chronic diseases. Although much has been done in the placement of the physically handicapped in industry, the placement of the medically handicapped is a relatively unexplored field. Consideration of chronic disease in job placement encounters a number of psychological barriers such as a worker trained in a special trade feeling that he is too old to develop a new skill and compete with the younger men; or, in the executive class, the tradition requiring that the job be carried on despite any medical handicap. Consequently, proper job placement of the medically impaired worker requires that psychological considerations be included in any medical evaluation of the worker's ability to perform a specific job. Once the worker has been properly placed, efforts should be made to help him understand his condition and how to live with it, and to motivate him to remain under continuous medical supervision. Community agencies concerned with the health and social aspects of chronic disease need to recognize more fully the role of the industrial health service in the medical supervision and rehabilitation of workers with chronic disease. The development of closer working relationships between community resources and industrial health services would facilitate early restoration of workers to maximum health and function. More

Widespread

Hygiene

Application

of

Industrial

Practices

The hazards inherent in various materials and processes are not universally recognized, and consequently a large segment of American workers is without the benefit of preventive engineering techniques. There is need, on the part of governmental industrial hygiene agencies, insurance carriers, and private industrial health specialists, to carry out more extensive educational programs and to direct greater efforts to the solution of occupational disease problems. Industrial hygiene controls not only prevent the occurrence of occupationally-associated chronic diseases but, by providing a more healthful working environment, also may prevent the aggravation of nonoccupational chronic diseases. Thus, the extension and application of industrial hygiene services to the mass of the employed population constitute a major line of defense against chronic disease.

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Research To keep pace with changes occurring in industrial materials and processes, research must be continued and expanded to determine the possible effects of the working environment on the development and progression of chronic diseases. Research is also needed to answer such questions as: What is the long-term effect of exposures below levels which produce recognizable disease? To what extent are certain prolonged exposures capable of hastening the onset of diseases regarded as having varied or obscure etiologies, the so-called degenerative diseases? To implement the required research, refinements and improvements are needed in clinical, chemical, and toxicological methodology necessary for the determination of toxic effects of new materials and for the systematic detection of chronic effects in significant occupational groups. Industrial health programs, serving large numbers of people, afford a unique opportunity for disclosing significant leads on the total ecology of the chronic diseases and the designing of research leading ultimately to improved techniques for the prevention of chronic illness. Since such programs are generally lacking in small plants, the expansion of industrial health services itself calls for intensive study. The extension of such programs to small plants calls for the development of practicable and effective methods and techniques for the provision of comprehensive preventive health services. Professional Education There is an extreme shortage of professional personnel who are prepared by education or experience to provide leadership in the development of occupational health services. Furthermore, many of the professional personnel currently providing health services in industry are unaware of the potential contribution of such services to the early diagnosis and control of chronic and other diseases. Much needs to be done, therefore, to orient these personnel in the constructive approach to positive health maintenance. Much also needs to be done to improve the knowledge of those in the health professions concerning occupational diseases—their causes, detection, and prevention. This means the integration of occupational health principles in the curricula of the basic professional schools of medicine, nursing, chemistry, and engineering. In the undergraduate education of physicians and nurses pertinent classroom instruction should be coupled with some training experience

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in industrial health services. More graduate instruction is also needed in the specialty of occupational health, which in addition to occupational diseases, emphasizes general health maintenance and the prevention of chronic diseases. In addition, there is need for refresher courses designed for physicians and nurses now employed in industry to assist them in doing a better job. Moreover, the potential contribution of industrial health services needs to be interpreted to health personnel outside industry to elicit their participation and full cooperation in promoting positive health among the gainfully employed. Public Education The proper utilization of preventive measures is dependent upon employee education, understanding, and acceptance. Protective clothing and equipment to safeguard the worker against hazardous exposures are effective only if he uses them. Preventive health services, in particular, are most effective when the employee has a sense of responsibility for maintaining his own health. Educational efforts, therefore, should be directed toward the building of constructive personal health and safety practices. Through the workplace, educational efforts can also be directed to the family. Such educational activity has special significance in the prevention and management of chronic disease. Finally, management needs to recognize the benefits inherent in maintaining employee health and be motivated to establish comprehensive employee health services.

Chapter

23 Dental Health and Chronic Disease1 Most dental diseases can be prevented, controlled, or corrected. However, they constitute in themselves a serious public health problem because of their widespread prevalence. They may also complicate and delay the full rehabilitation of patients with systemic illness. Adequate control of dental disease requires both individual and community action. Professional dental care, when obtained early and regularly, provides the individual with the means for prevention or the arrest and repair of damage from almost all dental diseases and conditions. The serious consequences of neglected dental disease in later life are thereby prevented. The fluoridation of community water supplies for the prevention of dental caries is a striking example of community action to improve oral health. Community groups also can do much to assist in the development of adequate dental services for persons with chronic illness. Hospital services should integrate dental care with the services of the other health professions. Programs that have demonstrated a highly developed interprofessional service include those designed to treat persons with cleft palates and with malignancies directly related to the oral cavity. They should serve as examples of the multidisciplinary approach to health service. Measures are available to prevent the occurrence or reduce the consequences of many of the dental diseases and conditions. These preventive measures are of two types: primary and secondary. Primary measures, if they are to be effective in reducing the prevalence of dental disease in the adult population, must be utilized during the early and formative years of tooth development and maturation. On the other hand, secondary preventive measures, utilized after the disease or condition is present, will be effective in reducing undesirable sequelae. 1 Prepared by the Division of Dental Public Health, Bureau of State Services, Public Health Service; and reviewed by the American Dental Association.

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237 PRIMARY

PREVENTION

Dental caries, periodontal disease, malocclusion, and fluorosis are all subject to control by primary preventive measures which either have been demonstrated to be effective in carefully controlled studies or which have been advocated on the basis of deductive reasoning. Dental

Caries

Dental caries is practically universal, affecting at least 95 per cent of the population at one time or another. If not cared for, dental caries practically always leads to pulp involvement, followed by either an acute periapical abscess or a chronic periapical granuloma, and eventually to the loss of the tooth. This loss may lead to further chronic conditions such as drifting of adjoining and opposing teeth and periodontal disturbances ( 7 ) . The use of fluorides, either through fluoridation of community water supplies or by topical application; carbohydrate restriction; good oral hygiene practice; and regular and frequent dental care will prevent dental caries or reduce the severity of the consequence of the disease. Water fluoridation represents the most significant recent advance in the prevention of tooth decay. It is possible to reduce dental caries 60 per cent by control of the fluoride concentration of water at an optimum concentration (1 part fluoride per 1 million parts water). In the 10-year studies made in Grand Rapids, Michigan, and Newburgh, New York, it has been demonstrated that fluoridation is effective in reducing dental caries and is a safe health practice. N o undesirable cosmetic effect was found (2, 5 ) . Other studies indicate that the benefits extend into adulthood (4). Decay also may be partially prevented by applying a fluoride solution to children's teeth soon after they erupt. This procedure is advocated for children residing in areas which do not have fluoridated community water supplies. The method, though simple, is exacting and must be performed by a dentist or a dental hygienist. The teeth should be treated once every three to four years until the children are 13 years old ( 5 ) . Dental caries also may be prevented through the control of the environment of the teeth, rather than through changes in the resistance of the tooth itself. The restriction of carbohydrates in the diet (a factor contributing to caries activity) is partially effective in preventing dental caries. This technique is effective in the control of rampant caries in individual cases, but has little practical value for general application because of the cultural pattern and food habits of the United States

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population (6). One of the ways in which caries may be prevented is through the restriction of frequent eating between meals to minimize the episodes of elevated mouth pH which occur each time food is ingested. Tooth brushing and other oral hygiene practices, long advocated empirically, appear to have limited effectiveness in preventing dental caries (6). The principal values of home care practices of this nature lie in their contribution to the tone and texture of supporting tissues, and to the general cleanliness of the oral cavity, tending to reduce the local factors predisposing to periodontal disease. Periodontal

Disease

Periodontal disease is an important cause of tooth loss in middle and later life. This disease, commonly called pyorrhea, often originates as gingivitis. As the inflammation spreads from the gingival to the periodontal tissues, the alveolar bone becomes resorbed so that the teeth may become loose and eventually lost unless prompt treatment is instituted. Good oral hygiene practices and removal of agents impinging on gingival tissues figure prominently in the primary prevention of this disease in its early stages. Early recognition and prompt treatment is essential in the control of periodontal disease. Control measures include removal of calculus and surgical eradication of pockets. Malocclusion

While there may be wide variation in normal occlusion, malocclusion is deviation to such an extent that interference is created with the normal functions of the teeth and their correlated structures, or with the usual dento-facial relationships. Marked malocclusion interferes with efficient mastication and normal speech, complicates oral hygiene problems, and predisposes to the development of dental caries and chronic gingivitis (7). Malocclusion, because of its detrimental cosmetic effect, frequently is an emotionally depressing condition and may contribute to behavior problems (7). Primary preventive measures for malocclusion include prevention of early loss of teeth and mechanical intervening devices such as space retainers and glide planes. Fluorosis

Fluorosis, commonly referred to as "mottled enamel," in its more severe manifestations is an unsightly condition resulting from ingestion of excessive amounts of fluoride. Consequently, in most areas, water supplies containing more than 1.5 ppm fluoride should not be used by children.

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Defluoridation of the water supply to approximately 1.0 ppm or changing the water supply is recommended. Because of the economic problems involved in defluoridating or changing entire community water supplies, parents living in communities with excessive fluoride in the water supply should obtain for their children other water containing only the optimum amount of fluoride. This is extremely important during the time the teeth are being formed—from birth through nine or ten years of age. SECONDARY

PREVENTION

The key factor in the control of dental disease is early detection of its presence and the immediate application of corrective measures. Many dental diseases are not self-limiting and progress to more serious stages. Functional, if not optimal, condition of the oral structure can be effected by early treatment in the great majority of cases. Secondary preventive measures are applicable to dental caries, periodontal disease, malocclusion, cleft lip and palate, and oral cancer. An estimated 10 per cent of cancer in men and 2 per cent in women occur in the oral cavity. Data show that 60 per cent of patients with oral cancer consulted the dentist first (1). Consequently, the responsibility of the dentist, especially in early detection of the disease is great. Cleft lip and palate, occurring in 1 out of every 700-800 live births (8) can be markedly improved by adequate surgical, orthodontic, and prosthetic intervention and treatment at the appropriate periods during the handicapped child's growth and development. Adequate and comprehensive treatment of the cleft lip and palate can assure the individual of a nearly normal physical dento-facial apparatus. While the provision of the aforementioned special services is requisite to the solution of the cleft lip and palate problem, basic dental health care also is an essential component in the rehabilitation of the affected individual. Orthodontic treatment can minimize and, in many instances, correct the disfigurements resulting from most malocclusions; early recognition and treatment of periodontal disease may prevent tooth loss; and carious teeth may be filled to interrupt the progression of that disease. All are obvious but important secondary preventive measures. SCREENING FOR DENTAL DISEASE

Screening for incipient or frank disease serves as a valuable component in chronic disease control programs. It may reveal many cases of previously unrecognized disease. The patient is then referred for diagnosis and treatment if necessary. Screening for selected dental diseases

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is also a recommended procedure and should be included in any multiple screening activity for adult groups. It is already known that nearly every individual has dental caries and should be seen by a dentist regularly. There is no need to screen specifically for this condition. Screening of adults for conditions other than dental caries is appropriate and desirable, and should be a part of any mass screening program. The dental x-ray may be used as a means for detecting cysts, abscesses, impactions, periodontosis, and other abnormal conditions. If the method employed utilizes personnel other than a dentist, it can be relatively inexpensive. A recent development appears to be of great potential importance in screening for dental conditions. The panographic x-ray can be used to take full mouth x-rays in 40 seconds as compared to the approximately 15 minutes now required for full mouth x-rays taken with conventional equipment. The device is simple to use and has the added advantage of exposing both patient and technician to less radiation than is required by techniques currently being used (9). Screening for overt manifestations of malocclusion is a relatively simple procedure and should be conducted routinely in school-age groups. No practical methods have been developed for screening for early oral cancer in the general population. THE DENTIST AS A DETECTOR OF NONDENTAL CHRONIC ILLNESS

The very fact that dental disease is so widespread, affecting almost every person sometime during his lifetime, brings some 60 to 80 million people to dental offices each year for treatment of these diseases. Many chronic illnesses have distinctive oral manifestations. For example, some of the earliest manifestations of the blood dyscrasias, such as anemia, leukemia, and the hemorrhagic diseases, appear in the mouth. The peculiar pigmentation of the oral mucosa is an early and common sign of Addison's disease. Severe, chronic gingivitis and periodontitis often accompany diabetes mellitus. Oral cancer and nutritional diseases also can be recognized in the earliest stages by the dentist. Many patients, unaware of their condition or aware only of their oral symptoms, seek dental care first. Consequently, the dentist has a potentially important contribution to make in the early detection of many chronic illnesses. In addition to his potential for detecting oral signs of chronic disease, the dentist, by observing the total individual may find signs of such chronic diseases as mental illness or tuberculosis.

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HEALTH

241

Without making a medical diagnostician out of the dentist, his "index of suspicion" can be raised for early detection of chronic disease in the large number of people he sees and for referral for treatment if necessary. Careful examination of oral lesions and alert observation of general changes in appearance, behavior, and function are all that is needed for referral of a really or potentially chronically ill person to a physician for definitive examination and diagnosis (10). DENTAL CARE FOR THE CHRONICALLY ILL

Curative and rehabilitative services for the chronically ill are incomplete unless dental care is provided along with medical and associated services. The removal of infection from the mouth and the restoration of the masticatory function so that patients can eat proper foods are vital elements in the treatment of the chronically ill patient. The recovery of a patient with a nonoral chronic illness will often be facilitated if complete dental treatment is provided. This applies not only to individuals with physical disorders such as tuberculosis, but also to those with mental illness. Regardless of the disease condition, oral, functional, and esthetic restoration is desirable for all patients. The majority of long-term patients are at a particular disadvantage in obtaining adequate dental care. Many institutions which care for long-term patients do not have dental facilities or do not have sufficient dental staff to provide the necessary services. Dental hygienists on the staffs of such institutions would contribute materially to the extension of available dental services and to the improvement and maintenance of the personal oral hygiene of the patient by providing dental prophylactic and related services and by instructing staff in bedside oral hygiene care for patients. A large number of chronically ill patients are cared for at home or in small nursing homes. At present there are no practical methods for bringing adequate dental services to these people. Except for emergency relief of pain and infection, dental patients are expected to come to the dental office or clinic for therapy. Since this is not practical for many of the chronically ill who are homebound or in nursing homes, they may be denied dental care when they may need it most. Methods are currently being investigated and developed which will enable the dental profession to provide adequate dental health service in places where there are no fixed dental facilities. These studies are concerned with the development of lightweight portable dental equipment for use in the home or at the bedside, new techniques for meeting special treatment needs of the chronically ill, and consideration of

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administrative problems inherent in providing dental services to the chronically ill patient unable to visit a dentist's office. It is essential that the dental profession be included in the planning stages as new programs for the chronically ill are developed. Unless the dentist participates actively, the program may be inadequate to improve the total health of the chronically ill. Every community-wide plan to provide adequate service to the chronically ill should include the dental profession in its planning group and dental care in its array of health services. The dentist has a very real contribution to make in improving their health and well being through the application of secondary preventive and corrective measures. REFERENCES

1. Council on Dental Health. "The Role of Dentistry in Chronic Illness." Journal of the American Dental Association 48:687-697, June 1954. 2. Arnold, Francis Α., Jr., Dean, H. Trendley, Jay, Philip, and Knutson, John W. "Effect of Fluoridated Public Water Supplies on Dental Caries Prevalence." Public Health Reports 71:652-658, July 1956. 3. Ast, David B., and Schlesinger, Edward R. "The Conclusion of a Ten-Year Study of Water Fluoridation." American Journal of Public Health 46:265-271, March 1956. 4. Russell, Albert L., and Elvove, E. "Domestic Water and Dental Caries. VII. A Study of Fluoride-Dental Caries Relationship in Adult Population." Public Health Reports 66:1389-1401, October 26, 1951. 5. Knutson, John W., and Scholz, Grace C. "The Effect of Topically Applied Fluorides on Dental Caries Experience. VII. Consolidated Findings for Four Study Groups." Public Health Reports 64:1403-1410, November 11, 1949. 6. Easlick, Kenneth A . (editor). Dental Caries—Mechanism and Present Control Technics as Evaluated at the University of Michigan Workshop. St. Louis, C. V. Mosby Company, 1948. 7. Mead, Sterling V. Diseases of the Mouth. St. Louis, C. V. Mosby Company, 1940. 8. Russell, Albert L. "Prevention and Control of Dental Caries," in Pelton, W. J., and Wisan, J. M. (editors). Dentistry in Public Health (2nd edition). Philadelphia, W. B. Saunders Company, 1955. 9. National Bureau of Standards Technical News Bulletin, Vol. 40, January 1956. 10. Galagan, Donald J. "What the Dental Profession Has to Offer in the Development of More Adequate Chronic Disease Programs." American Journal of Public Health 46:450-456, April 1956.

Chapter

24 Emotional Factors in Chronic Disease12 Emotions are the feelings of joy, anger, indifference, or sadness which inform us of our inner mental state. The emotions, which include feelings and their underlying attitudes, beliefs, values, goals, and concept of self, are by far the most important determinants of behavior. They may be contrasted with intelligence which takes into account relevant facts and plans, postponing decisions to act until the proper time. The emotions are the usual determinants of what we do and for the most part their operations are dimly perceived. Intelligence, on the other hand, is used sporadically and consciously. The emotions contribute to the cause of chronic illness and to its prolongation. Behavior based on the emotions may expose one to infection, increase the risk of accident, or cause one to pursue a course that undermines health, even though one "knows better." After illness is established, emotional factors may work against and nullify the needed remedial measures. Preventive efforts must be designed to take into account the emotions of the chronically ill individual, and at the same time they must strengthen his ability to apply intelligently the knowledge about living he has gained from his personal experience. Mental health and physical health must be the goal of prevention; they are inseparable. The contribution to mental health is more effective if it is made with the intelligent application of knowledge about the emotions of the chronically ill than if reliance is placed on common sense and good will alone. Mental health is likely to be poor among chronically ill patients because of the stresses—emotional, economic, and social—that prolonged illness places not only on the affected individual, but on his family as well. 1 Prepared by Community Services Branch, National Institute of Mental Health, National Institutes of Health, Public Health Service; and reviewed by the American Psychiatric Association. 2 See also Chapter 17, "Mental Illness."

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To understand the emotions of a chronically ill patient, the health worker must be able to put himself in the patient's shoes, perceive how the patient feels, and experience the same things the patient experiences. This is, of course, never completely possible. No one can possibly have exactly the same experiences as someone else. Everyone is really an island in this sense, known to others only through interpretations that others make about him, based on their own personal experiences. However, we can tell when we are close to understanding others. They usually give some indication of the closeness they feel—a nod, perhaps, or an appropriate word. When the other person responds in a way that tells us of this closeness, we say that we have rapport or that we are able to empathize with the other person. In a sense we have entered into the emotional life of the other in such a way that communications have meanings because each evokes feelings of experiences we recognize. Our own memories return to guide us in interpreting the patient's communications. Few health workers have had a serious chronic illness and so the world of the patient is unfamiliar to them. They may be familiar with his lungs, joints, blood pressure, or blood sugar concentration, but his outlook on life, likes and dislikes, private terrors, and feelings about his family can be as unfamiliar as the uncharted bottom of the sea. It takes a willingness on the part of the health worker to learn to reach out to the patient, and to imagine how he must feel, in order to understand the patient's emotions. Sometimes when communication is not good the patient, nevertheless, feels the effort of the health worker to understand. This little bit of communication can be extremely gratifying to patients who have helpful relations with few or no people. Schizophrenic patients, for example, are often sensitive to the efforts (or lack of them) of others to communicate, and they gain some sense of fellowship and security from the attempts even when they are unable to understand fully the meaning of the communication. Some health workers empathize easily with patients. They have developed an accepting attitude toward others, are inclined to disregard the unpleasantnesses and, in spite of resistance, continue to try to understand and be helpful. It is not easy to accept the hostility of patients without developing counterhostility. To do so requires considerable maturity and ability to understand. The hostility of the patient can take many forms. Much of it the patient is unaware of. He may reflect it in his indifference or inattentiveness. A sharp tone of voice,

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irritability, quarrelsomeness, or rejection of the health worker may be his way of resisting any interference with his way of life. The worker should remember that chronic illness is a way of life. Hostility is the mechanism patients use to drive people away or to control them. The patient may see friendliness as too risky. He may remember unpleasant experiences with people who said they wanted to help him. He may be afraid the health worker will find out something about him he wants to hide or will make demands requiring his cooperation. He does not know what to expect of the health worker until they get acquainted. This means that the major responsibility for building the bridge of understanding between the health worker and the patient rests on the worker. He must be careful and tender of feelings, but decisive and affirmative. Patients are made more anxious by too passive an approach. ANXIETY IN THE CHRONICALLY ILL

Anxiety is a state common to all mankind. It is recognized as a feeling of apprehension or dread. It is a kind of fear, but the thing feared is unknown or incompletely known. We usually reserve the word "fear" to indicate something definite and known that is anticipated as harmful. Even if the cause of the anxiety is recognized by others the anxious person has difficulty in seeing that it applies to him. Anxiety may come from such causes as the longing to be taken care of, the dread of rejection, fear of separation from others, the dread of dismemberment, and the fear of suffocation. Feelings of guilt are often associated with anxiety. Guilt is essentially self-disapproval. The patient tends to blame himself for what he has done or failed to do. He may imagine that his illness is a retribution for his supposed sins and irrationally resist efforts to take away his penance. The chronically ill are usually afflicted with more anxiety than are other people. These anxieties may reach such high levels that they interfere with rest and they usually prevent the patient from cooperating freely in the course of treatment. The illness often gets worse during periods of intense anxiety. When anxiety becomes intense, tuberculous lesions may spread, hyperacidity in ulcer patients increase, joint pains of arthritics become aggravated, hypertension increase, and insulin requirements of diabetics increase. The chronically ill patient may be acutely aware of the anxiety of others around him. The anxiety of others makes him feel insecure. He knows he cannot depend on someone who is as anxious as he. His own feeling of helplessness when his anxiety is intense makes him aware that others feel helpless too when they are anxious. To gain the con-

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fidence of chronically ill patients it is important for the health worker to recognize his own anxieties and to learn how they interfere with communications with patients. DEPENDENCY REACTIONS

The chronically ill patient may be forced by his illness to be dependent on others. Sometimes this state of affairs is welcomed by the patient. He may use the illness to get the attention he craves. He may be willing to pay the price of remaining ill rather than make the effort to get well and give up the advantages of illness. He may come to resent the health of others and make them pay for their health by forcing them to take care of him. Much of this illogical reasoning goes on outside the awareness of the patient or those about him. The overdependency reactions are sometimes extremely difficult to treat. Very seldom can the situation be faced squarely and the patient told outright to recognize what he is doing. He would deny it. To recognize it is too painful for him because his own feelings of guilt and the risk of losing his control of the environment are too great. The patient usually does not begin to give up his overdependency until he can substitute for it a healthier kind of relationship. The health worker who gains the patient's confidence and respect often is able to encourage him to be more independent. The encouragement is most effective when the health worker aligns himself with the patient's positive efforts to independence; criticism of dependency risks rupture of the rapport. The patient will become more independent when he feels that his minimum dependency needs will be met. For example, an arthritic patient said, "I will try to walk for you." In this patient the meaning was "I think it is safe for me to try to walk because I know that you will not leave me if I do." Overdependency may cause the opposite type of reaction. The patient being somewhat aware of his dependency and feeling guilty because of it may struggle to deny it. (The denial is sometimes provoked by telling the patient prematurely that he is overdependent.) He may say to himself, "I must show them that I can take care of myself." He then refuses to accept help from anyone. He becomes like a small child who refuses help to prove he doesn't need it. Sometimes this attitude is mistakenly called independence; actually it is a denial of dependency, an entirely different condition. Efforts to intervene may elicit hostility. In situations like this the health worker may have to act decisively and firmly in the patient's interest, just as a good parent does to protect his child. Hesitation may cause the patient to feel insecure; he does not

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know whether he can trust the worker to act wisely on his behalf if the worker is undecided. REGRESSION IN ILLNESS

Chronically ill patients will be seen in all stages of personality development. During our lifetime we each tend to grow toward greater maturity in our feelings and behavior. In growing emotionally we pass through recognizable stages: infancy, childhood, adolescence, adulthood, and old age. Some people mature emotionally much faster than others; some attain greater degrees of maturity than others. The characteristics of maturity are those of the well-developed adult. Such a person is self-directed, can accept responsibility for others, understands and accepts his limitations, is comfortable with himself and others, and can work cooperatively with others without sacrificing his independence or requiring others to sacrifice theirs. The immature person has the characteristics of an infant or a child. He must be protected to prevent him from harming himself or others; personal needs are so compelling that he cannot bear any delay in satisfying them; he is easily frustrated and reacts typically to stress by hostility or withdrawal. He cannot work cooperatively with others and at the same time maintain his independence. He tends to have behavior patterns of submission or dominance. He has poor judgment about his abilities, often overestimating or underestimating them. He has little confidence in himself. He is unable to relate to others on a give-and-take basis. During our lifetime we do not maintain at all times the highest level of maturity we attain; there is a tendency to fluctuate from time to time. When we are tired we feel less able to carry out our obligations and objectives, may become discouraged easily and lose some of our interest in others. In times of stress we may actually feel more comfortable functioning at a lower level of emotional adjustment: less is expected by others of us then and we expect less of ourselves. By renouncing the role of a more mature person we simultaneously renounce the responsibilities that go along with maturity. This renunciation of responsibilities and assumption of immature behavior are regression. Sometimes we use various devices to facilitate regression to levels where we feel more comfortable. Alcohol and sedatives are examples of such devices which are more or less acceptable means of invoking the regressive states. When they are used to excess, regression may be extreme and the individual may have to be taken care of like a baby. If this need for regression to infancy is persistent and alco-

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hol is used to induce it, we may be labelled by others as chronic alcoholics. Chronic alcoholism is a chronic illness in its own right. The same regressive process occurs in the other chronic illnesses, whatever their cause. It can be seen clearly in certain hemiplegic cases when the patients need the nursing care given to an infant, such as feeding, cleaning, and petting. The beginning of a good relationship with the patient is based on accepting and working with the patient at his current functional level. However, the greatest obstacle confronting the health worker is often not the problem of the patient but the feelings within the health worker himself, his resistance to offering care to a person who may be childlike in his demands and needs. SELF-UNDERSTANDING IN HEALTH WORKERS

Helping other health personnel become more aware of their feelings is the most important contribution mental health personnel can make to the care of chronically ill patients. It is through self-understanding that we discover the tendency to use patients to satisfy our personal needs instead of treating each patient as an end in himself. Each of us has some narcissistic tendencies; if we know about and control them they are less likely to intrude in decisions that affect the patients. Selection of people to go into health work should be given more consideration so that we begin with people already at a reasonable level of maturity. After selection, there should be continuing opportunities for the personnel to grow emotionally and professionally within their specialties. A part of the inservice training should be opportunities for the personnel to express feelings freely in group discussions and in private interviews. It is by the expressions of feelings in a climate of friendliness and mutual acceptance of shared experiences that we begin to understand ourselves and discover hidden needs. The better we understand ourselves, our drives and hidden desires, the better we are able to understand patients and to prevent our unrecognized purposes from controlling the patient and his situation in a harmful way. FAMILIES ARE IMPORTANT, TOO

Families see the chronically ill patient more often than the health worker; they live with him. It may be more important for the health worker to give psychologically supportive services to the family than to the patient. The exclusive preoccupation of the worker with the patient may have the effect of alienating the patient from his family, thus increasing his loneliness. Families are greatly helped by having

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someone to talk to who is not so involved as they in the patient's illness; the release of tensions, removal of fears, and clarification of their thoughts—achieved by talking to someone who can listen sympathetically and be objective—permit them to improve their attitudes and behavior toward the patient. There is always an interrelatedness in the family relationships of a chronically ill patient. A change in attitude or behavior in one set of relationships within the family of a chronically ill patient will usually have repercussions in all the others. Reality stress factors like housing problems, income, or the expense of treatment may have harmful effects on interpersonal relations within the family, making it difficult for them to be psychologically supportive. The health worker should be alert to these problems so as to get the maximum assistance available for the patient from private and public welfare agencies. Every emotional state of the patient is met with a distinctive pattern of interpersonal relations among the family members. If the patient is aggressive and hostile, the members of the family may have adopted a pattern of submissiveness or counteraggression in response to his aggressiveness. If he is very submissive and overly dependent, the family develops a modus vivendi appropriate to his submissiveness. In other words, when the health worker becomes sensitive to the dynamic interpersonal relations of the family he will begin to see the family unit as a whole and note how the changes in one set of relationships affect the others. By listening patiently and sympathetically to the family, the worker will get clues about their attitudes toward the patient which enable him to influence them. The health worker often is trusted by the family and is seen by them as a valuable resource person to whom they can turn in time of crisis. One elderly lady was explaining to a health worker that her arthritic husband had to stay in a room by himself because company made him nervous. His arthritic pains became worse and he became depressed. His wife was agitated and felt guilty about insisting that her husband stay in his room. As the health worker listened sympathetically the wife began to doubt her observations about her husband's nervousness in company. Actually, it was her husband's condition that made her nervous. After talking about it the wife was willing to permit her husband to join her in company and as a result his outlook on life was much improved. It is always a good idea to include the family in planning for the care of a chronically ill patient. When members of the family take some responsibility for the patient's care they accept it more readily

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and make a more positive effort to help him. It is quite human and understandable that the family would attempt to pass on to the health worker as much responsibility for the care of the patient as they can. Recognizing this the health worker should be alert for opportunities for the family to do things for the patient which they can and want to do. Sometimes the health worker will see families overattentive to the patient like the overattentive mother who "smothers the child with love." Most often this kind of behavior comes from a feeling of guilt about the illness. The family may, for example, have had some hostility toward the patient before the illness and now illogically blame themselves as if they had caused it. Here again, the health worker can be helpful by pointing out the true nature of the illness and how the patient can gradually become more independent. SUMMARY

Mental health is a prime objective of health workers for chronically ill patients. It is as important to provide mental health as physical health services to patient and family. Each health worker can contribute to the mental health of his patients. Understanding the chronically ill patient begins with self-understanding; it is by understanding ourselves that we learn how to understand others. The chronically ill usually have a high level of anxiety. Dependency reactions are to be expected. They may cause patients to seek more assistance than they need or to refuse assistance they need. Regression is movement backward in emotional adjustment to earlier levels. Chronically ill patients often regress to infantile or childlike stages of emotional adjustment. Families are important too. They sometimes require as much observation and support as the chronically ill patients themselves.

Chapter

25 Heredity as a Factor in Chronic Disease1 The geneticist envisions chronic disease as the end product of an interaction between intrinsic, largely genetic factors and extrinsic or environmental factors, with the relative importance of these two sets of influences varying widely from one disease to the next. Thus, in chronic disability secondary to trauma, genetic factors play little or no role, whereas certain types of blindness and deafness appear to be due to the action of a single gene, and no environmental factors now known can undo the effects of that gene. We may, for purposes of convenience, divide chronic diseases into three categories: those in which environmental factors are of primary etiological significance, those in which genetic factors bear the primary responsibility, and those where there is a complex interaction which, for the most part, has thus far defied exact analysis. An accurate estimate of the total contribution of heredity to the chronic diseases is rendered difficult by lack of precise knowledge of the role of genetic factors in the etiology of certain diseases, and by lack of prevalence figures for those diseases where the primary etiological significance of genetic factors is well established. ROLE OF HEREDITY IN CHRONIC DISEASE

Hereditary disease tends to be chronic disease. That the total contribution of heredity to the chronic disease problem is considerable is obvious from the fact that genetic factors are mentioned as of primary or secondary etiological importance in most of the statements concerning specific disease groups contained in this book. The various diseases under scrutiny in this volume may be arranged in the following approximate order as regards the role of heredity. 1 Prepared by James V. Neel, M.D., University of Michigan Medical School, Ann Arbor, Michigan; and reviewed by the National Cancer Institute, National Institutes of Health, Public Health Service.

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Blindness Hoist (1949), Sorsby (1950), and Foote (Chapter 10 of this volume) have presented figures as to the total frequency and types of blindness in Norway, England, and the United States, respectively. Hoist finds that of 3,181 blind individuals living in Norway in 1948, 1,585 (49.8 per cent) in all probability owed their loss of vision primarily to genetic factors. Although Sorsby and Foote have not analyzed their data in that fashion, their breakdown into types of blindness is sufficiently similar to the Norwegian experience to permit the assumption that heredity plays a similar role in England and in this country, being especially significant in primary degeneration of the retina, certain types of optic nerve atrophy, microphthalmos, and a significant fraction of cataract and glaucoma. Deafness Lindenov (1945) found that in Denmark 45.5 per cent of deaf-mutism was idiopathic, with the great majority of the idiopathic cases being caused by recessive heredity. The proportion of idiopathic cases will be even higher in the future owing to the increasing control of ear infections in infancy. Otosclerosis, the most common cause of impaired hearing in later life, appears to be due in most cases to the action of one or more dominant genes. Diabetes Mellitus Although the exact genetic mechanism is not clear, there is good agreement that there is an increase over normal expectation in both clinical diabetes and the occurrence of abnormal glucose tolerance curves among the relatives of diabetics (review in Gates, 1946; Neel, 1947). The genetic analysis is impeded by the possibility that clinical diabetes mellitus may be the end result of several different processes, each of which may be at least in part under independent genetic control (Himsworth and Kerr, 1939; Lawrence, 1951; Lister, Nash, and Ledingham, 1951). The literature contains a wide variety of suggestions concerning the precise pattern of inheritance exhibited by diabetes mellitus. Among more recent investigators, Harris (1950), after a careful review of the problem, feels that the question of the genetic heterogeneity of the disease and the type or types of heredity involved must be left open— a position with which the present writer concurs.

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Epilepsy The high incidence of abnormal electroencephalograms among the parents of idiopathic epileptics, the statistically significant increased occurrence of epilepsy among the relatives of epileptics, and the concordance of monozygotic twins have been interpreted as evidence that genetic factors play an important role in idiopathic epilepsy (Chapter 15 of this volume; Lennox, 1951; Kimball and Hersh, 1955). However, this point of view has been vigorously contested by Alström (1950), who believes that only a small fraction of epileptics owe their disease to heredity. Cardiovascular Diseases The principal types of heart disease are congenital, rheumatic, arteriosclerotic, hypertensive, and syphilitic. Hereditary factors are of demonstrated importance in each except the last-named of these types. Congenital heart disease. Several recent studies on the role of familial factors in the etiology of the various types of congenital heart disease suggest that following the birth to normal parents of a child with a cardiac malformation, the probability of a recurrence in subsequent pregnancies is approximately 1 in 50, roughly a 10- to 20-fold increase over normal expectation (McKeown, MacMahon, and Parsons, 1953; Anderson, 1954; Polani and Campbell, 1955). The degree to which this is a genetically determined phenomenon is not clear. Rheumatic heart disease. The tendency of rheumatic fever to affect multiple members of a given family is well known. To what extent this is due to a common environment and to what extent to a common genetic heritage has been and continues to be a highly controversial matter. The studies on the etiology of rheumatic fever illustrate the difficulties which may arise in untangling the relative contributions of heredity and environment to a disease entity. While the evidence for a genetic contribution to the tendency to develop rheumatic heart disease appears strong, no precise genetic mechanism can be specified at present (Stevenson and Cheeseman, 1953; Uchida, 1953). Arteriosclerotic cardiovascular disease. The genetic focus of interest here centers around the hereditary control of the ability to metabolize cholesterol and its esters. The dependence of primary essential hyper-

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cholesterolemia on a single dominant gene, and the susceptibility of persons with this condition to the early development of arteriosclerotic heart disease, is well documented (Fliegelman, Wilkinson, and Hand, 1949; Adlersberg, Parets, and Boas, 1949). While the extreme form of hypercholesterolemia with early and severe heart disease which usually forms the subject of case reports in the literature is probably rare, there is increasing evidence that lesser degrees of impaired cholesterol metabolism, which over a long period may conceivably be a factor in the development of arteriosclerotic heart disease, may be more common than is usually recognized and may also be at least in part genetically determined (Adlersberg, Parets, and Boas, 1949). To the extent that diabetes is determined by genetic factors, the arteriosclerosis to which diabetics are prone is also indirectly determined by an individual's hereditary constitution. Essential hypertension. That this disease has a familial basis seems clear. To what extent this familial basis is due to genetic factors, and to what extent to the creation of a psychological environment which favors the development of the condition at a later age, has not yet been established. However, the finding of Hines and Brown (1935) that a hyper-reactive response to the cold pressor test appears to be distributed in families as if dependent upon a dominant gene or genes is pertinent in this respect. Mental Disease Mental defect. Certain uncommon conditions often or invariably associated with mental defect are genetically determined (Huntington's chorea, epiloia, phenylketonuria, certain cases of microcephaly, certain cases of cerebral diplegia, gargoylism, infantile and juvenile amaurotic idiocy). There is good evidence that a very significant fraction of "undifferentiated mental defect" is also due to hereditary factors (Penrose, 1949). Psychosis. The relative importance of heredity and environment is particularly controversial in this field. The point of view seems to be gaining ground that in both schizophrenia and manic-depressive psychosis there are important genetic factors, in the former most often recessive in nature, in the latter most often dominant. Here again, the evidence derived from the study of identical and fraternal twins is especially provocative (Kallmann, 1946; Rudin, 1930).

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Psychoneurosis. Critical data are not yet available regarding any hereditary factors in the psychoneuroses. Chronic Arthritis Hypertrophic arthritis. The development of Heberden's nodes (and, by inference, possibly other manifestations of hypertrophic arthritis) appears to be conditioned by genetic factors. The hypothesis that the development of the nodes is caused by a single autosomal gene, sex influenced, dominant in females and recessive in males, provides a formal explanation for the observed facts (Stecher and Hersh, 1944). Gout. Hyperuricemia is due to a single dominant gene. About onetenth of the persons with genetically determined hyperuricemia develop clinical gout (Smyth, Cotterman, and Freyberg, 1948; but see Hauge and Harvald, 1955). Rheumatoid arthritis. Critical data are not yet available concerning the role of heredity in the etiology of rheumatoid arthritis. However, in the development of ankylosing spondylitis, which is usually regarded as closely related to rheumatoid arthritis, a genetic factor seems definitely implicated (Riecker, Neel, and Test, 1950; Hersh, Stecher, Solomon, Wolpaw, and Hauser, 1950). Cerebral Palsy An unknown fraction of cases of cerebral palsy is apparently due to recessive genetic factors (Penrose, 1949). Tuberculosis Twin studies suggest that there are genetically controlled differences in individual susceptibility as well as in the course of the disease (Kallmann and Reisner, 1943). Neoplasms The role of genetic factors varies widely according to the type of neoplasm under consideration. From the genetic standpoint, the following classification of tumors seems reasonable. 1. Rare types of neoplasms with a simple mode of inheritance. These include retinoblastoma (Weiler, 1941; Falls and Neel, 1951); multiple polyposis of the colon (Dukes, 1952; Reed and Neel, 1955); and multiple neurofibromatosis (Crowe, Schull, and Neel, 1956). The de-

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velopment of each of these types of neoplasms appears to be conditioned primarily by the presence of a single dominant gene. There are thus highly significant tendencies for these diseases to cluster in particular families. 2. More common types of neoplasms, with respect to which there are statistically significant tendencies to concentrate in particular families. The genetic significance of these familial concentrations is not yet clear. Under this heading should be included cancer of the breast (Penrose, Mackenzie, and Karn, 1948; Woolf, 1955); cancer of the uterus (Br0beck, 1949; Murphy, 1952); and cancer of the stomach (Videbaek and Mosbech, 1954; Woolf, 1955). In very round figures, with respect to these three types of malignancy there is observed among appropriately sexed near relatives (siblings, parents) of patients approximately three times the expected incidence. Although by analogy with the investigations into experimental cancer in mice it seems quite possible that the basis for these familial concentrations is a genetic predisposition, a conclusive demonstration of this fact is still lacking. 3. More common types of neoplasms, with little tendency to concentrate in families. Only one type of neoplasm appears at present to fall into this category. Despite earlier reports to the contrary (Videbaek, 1947), there appears to be no significant tendency for leukemia (at least that developing during childhood) to affect multiple members of a family (Steinberg, 1954). Poliomyelitis, Multiple Sclerosis, Late Manifestations of Syphilis Genetic data are either insufficient or conflicting, but in general genetic factors appear to be of secondary significance in the occurrence of these diseases. ROLE OF GENETICS IN PREVENTION OF CHRONIC DISEASE

With this as a background, we may turn to a consideration of the question of how a knowledge of genetics may be utilized in the prevention of chronic disease. Three general approaches to this problem will be discussed: Detection of the Genetic Carriers of Inherited Disease Two classes of individuals transmit inherited disease to their progeny: those who actually have the disease; and those who appear normal but whose genetic constitution includes determiners for the disease in question, which determiners for various reasons—environmental factors,

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dominance relations, etc.—fail to find expression. In the broad sense, "genetic carriers" are those individuals included in the latter group who may transmit an inherited disease to their progeny without themselves showing at the time the commonly expected findings of the disease. Genetic carriers may be roughly divided into two types: those who will never in their lifetime develop the disease which they transmit, and those who may at some date subsequent to the original examination be characterized by the typical signs and symptoms of the disorder in question. The first group includes, for example, persons heterozygous for a nominally recessive gene such as that responsible for albinism. The second group includes persons heterozygous for a dominant trait which is not usually apparent in youth or early adulthood, such as Huntington's chorea. Those diseases for which a recognizable carrier state exists have been discussed by Neel (1947, 1949); the diseases are listed in Table 25:1. The ability to detect either type of carrier places physicians in a position to make valid statements concerning the probability of transmission of various diseases. Furthermore, the development of methods of detecting the second type of genetic carrier discussed above is tantamount to the development of methods for the early detection of the disease in question. Such early detection raises the possibility of initiating treatment before irreversible pathological changes have occurred. Use of Genetic Knowledge for Prediction Purposes It is in many genetic situations possible to predict with a high degree of accuracy on the basis of the family history the probability that a given child will be affected with a particular disorder (Neel, 1951). Where simple dominant or recessive inheritance is concerned, these probabilities have an order of magnitude of .50 or .25. These statements may be used by parents as a basis for voluntary planning of family size. At the present time, most physicians who have first-hand contact with such patients are poorly informed concerning the facts of heredity. They do not have the background to analyze family histories and to arrive at valid conclusions concerning the type of heredity involved. Accordingly, it is not uncommon to see individuals who have been given widely varying statements by different physicians concerning the role of heredity in their disorders. The families of individuals who have a disease that is primarily genetic in origin have important genetic problems. A significant fraction of these families would voluntarily limit family size if they had accurate information at their disposal, and so

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HISTORY OF THE COMMISSION

309

of office space, furniture, and equipment by the American Medical Association from October 1949 to June 1952, and of office space by The Johns Hopkins University School of Hygiene and Public Health from June 1952 to June 1956. The important contributions of funds, services, and personnel by the Public Health Service are dealt with in a later section. Special Project

Financing

For the study of prevalence of chronic illness, financial support was requested from the Commonwealth Fund and that foundation agreed to provide the funds for the rural study in Hunterdon County and subsequently made a substantial grant toward the urban study in Baltimore. Major financial support for the Baltimore study was obtained from the Public Health Service in the form of research grants from the National Institutes of Health. Both of the national conferences were financed as projects separate from the basic operating cost of the Commission. In both instances, of course, there was inevitably a substantial investment of the funds contributed for general support of the Commission. However, the additional expenses entailed by the conferences were met through contributions obtained expressly for the purpose or through the contribution of personnel services by the cosponsors of the conference. This latter device especially characterized the contributions of the Public Health Service. The National Conference on Preventive Aspects of Chronic Disease was made possible by financial support from the National Health Council, a grant from the Public Health Service, and a generous allocation of personnel and other services by the Public Health Service. The Rockefeller Foundation contributed to the pre-Conference phases of the National Conference on Care of the Long-Term Patient. The meeting was financed jointly by the Equitable Life Assurance Society, the Liberty Mutual Insurance Company, the Metropolitan Life Insurance Company, and the New York Life Insurance Company. The cosponsoring agencies contributed to the financial support of the latter Conference by making personnel available and assuming the cost of the staff travel in connection with the Conference planning. The Role of the Public Health Service in Financial Support Participation of the Public Health Service in the organizing and operation of the Commission represented a substantial contribution in cash

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and services. A grant of $5,000 was made for the 1951 Conference on Preventive Aspects of Chronic Disease and a total of $182,144 was granted for the Baltimore study. In addition, services were provided for a variety of projects, principally by the Division of Public Health Methods and the National Heart Institute. For example, a sizable portion of the cost of the two conferences was assumed by the Public Health Service. Technical assistance was provided in the design and conduct of several phases of the Baltimore study. In addition, most of the National Institutes of Health and several divisions in the Bureau of State Services collaborated with the appropriate national voluntary health agencies in preparing (in 1951 and revising in 1956) the summary statements on what is known concerning prevention of the major chronic diseases. These summaries form Chapters 9 through 26 of this volume. The foregoing does not include the cost to the Public Health Service of its participation in joint projects such as the study of home care programs and the study of patients receiving nursing care in institutions. The cost of these joint projects is not considered by the federal agency as a contribution to the Commission, nor was it so regarded by the Commission. SUMMARY

The Commission was established for a temporary period to study a complex, nation-wide problem. At the time of the vote for dissolution, the Commission members expressed their belief that they "had carried forward a program designed to accomplish the objectives of its founders" and that "substantial progress toward the Commission's program objectives has been made." The Commission had been assured by the founding organizations that at the conclusion of the program the recommendations made would be vigorously pursued by the founding organizations and by other permanent agencies concerned with the various facets of a wide-ranging problem. The Commission's interests and activities reached into every aspect of our national life where the effect of prolonged illness was felt. Facts were collected, analyzed, and translated into conclusions and recommendations. Information was widely disseminated in an area where data had previously been sparse. Not the least of the Commission's accomplishments was the opportunity it provided for the working together of a group of national professional organizations and a number of the major national voluntary

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health agencies, each of the latter devoted to a specific chronic disease. The concern of the Commission was with the broad problems common to all chronic diseases and with which all the professions had to deal in connection with the long-term patient. The union of diverse interests in a single cause was one of the most significant successes of the Commission. A setting was provided where these heretofore largely independent and detached interests could, through working together, recognize the extent of their joint stake in a solution as well as the high promise of success inherent in a common approach. The demonstrated success of a joint approach, as embodied in the Commission, assured a much greater emphasis on unity in the future and, as such, was a major accomplishment in progress toward a practical solution to the mounting problem of chronic illness in the United States. So confident were the Commission members of the impetus which the Commission's program had provided to progress in chronic illness planning, that the Board of Directors when considering post-Commission plans decided against recommending reactivation of a joint committee such as had preceded the establishment of the Commission. The Board members preferred to put to a practical demonstration the forces for unity and progress which they believed had been set in motion by the Commission. The Board did recommend, however, that about 2 years after the Commission's dissolution the founding organizations appoint members to a joint committee which would—either as a committee or as a part of a larger conference body—review the progress since 1956 and decide what measures might be indicated to further the course of action charted by the Commission.

Appendix

Β Articles of Incorporation and Bylaws COMMISSION ON CHRONIC ILLNESS Articles of Incorporation Certificate Number 8304 STATE OF ILLINOIS Office of the Secretary of State TO ALL TO WHOM THESE PRESENTS SHALL COME GREETING: WHEREAS, Articles of Incorporation duly signed and verified of COMMISSION ON CHRONIC ILLNESS have been filed in the Office of the Secretary of State on the 16th day of June A.D. 1949, as provided by the "GENERAL NOT FOR PROFIT CORPORATION ACT" of Illinois approved July 17, 1943, in force January 1, A.D. 1944. Now Therefore, I, EDWARD J. BARRETT, Secretary of State of the State of Illinois, by virtue of the powers vested in me by law, do hereby issue this Certificate of Incorporation and attach thereto a copy of the Articles of Incorporation of the aforesaid corporation. IN TESTIMONY WHEREOF, I hereto set my hand and cause to be affixed the Great Seal of the State of (SEAL) Illinois. Done at the City of Springfield this 16th day of June A.D. 1949 and of the Independence of the United States the one hundred and 73rd. / s / Edward J. Barrett Secretary of State 312

313

ARTICLES OF INCORPORATION

COMMISSION ON CHRONIC ILLNESS Articles of Incorporation Under The General Not For Profit Corporation Act To EDWARD J. BARRETT, Secretary of State, Springfield, Illinois. We, the undersigned, (Not less than three) Address City State Name Number Street Hartford, Conn. James R. Miller 85 Jefferson St., Albert W. Snoke New Haven Community Hospital New Haven, Conn. Edward S. Rogers University of Calif., Berkeley, Calif. Andrew C. Ivy University of 111., Chicago, 111. Ellen C. Potter Dept. Comm. for Welfare, Trenton, N.J. being natural persons of the age of twenty-one years or more and citizens of the United States, for the purpose of forming a corporation under the "General Not For Profit Corporation Act" of the State of Illinois, do hereby adopt the following Articles of Incorporation: 1. The name of the corporation is: Commission on Chronic Illness 2. The period of duration of the corporation is: Seven years 3. The address of its initial Registered Office in the State of Illinois is: 535 N. Dearborn Street, in the City of Chicago (10), County of Cook and the name of its initial Registered Agent at said Address is: George W. Cooley 4. The first Board of Directors shall be 5 in number, their names and addresses being as follows: Name Leonard Mayo James R. Miller Thomas Parran Mrs. Jos. T. Ryerson J. Douglas Colman

Number Street Western Reserve Univ. 85 Jefferson Street Univ. of Pittsburgh 1406 N. Astor Street 15 E. Fayette Street

Address City State Cleveland, Ohio Hartford, Conn. Pittsburgh, Pa. Chicago, 111. Baltimore, Md.

5. The purpose or purposes for which the corporation is organized, are: A. To modify the attitude of society that chronic illness is hopeless; to substitute for the prevailing over-concentration on the provision of institutional care, a dynamic program designed as far as

314

APPENDIX Β

possible to prevent chronic illness, to minimize its disabling effects, and to restore its victims to a socially useful and economically productive place in the community. B. To define the problems arising from chronic illness among all age groups, with full realization of its social as well as its medical aspects. C. To coordinate separate programs for specific diseases with a general program designed to meet more effectively the needs which are common to all the chronically ill. D. To clarify the interrelationship of professional groups and agencies now working in the field. E. To stimulate in every state and locality a well-rounded plan for the prevention and control of chronic disease and for the care and rehabilitation of the chronically ill. 6. At least one member of the Board of Directors shall be a resident of the State of Illinois. Albert W. Snoke Ellen C. Potter / s / James Raglan Miller * Incorporators. Edward S. Rogers Andrew C. Ivy

ACKNOWLEDGMENT

I, J. E. Hartigan, a Notary Public do hereby certify that on the 3rd day of June, 1949, James R. Miller, Albert W. Snoke, Edward S. Rogers, Andrew C. Ivy, Ellen C. Potter personally appeared before me and being first duly sworn by me severally acknowledged that they signed the foregoing document in the respective capacities therein set forth and declared that the statements therein contained are true. IN WITNESS WHEREOF, I have hereunto set my hand and seal the day and year above written. (SEAL)

/ s / J. E. Hartigan Notary Public

ARTICLES OF INCORPORATION

315

COMMISSION ON CHRONIC ILLNESS BYLAWS Article I—Name Section 1—The name of this corporation shall be Commission on Chronic Illness. Article II—Objects Section 1—The objects and purposes of the Commission are: A. To modify the attitude of society that chronic illness is hopeless; to substitute for the prevailing over-concentration on the provision of institutional care, a dynamic program designed as far as possible to prevent chronic illness, to minimize its disabling effects, and to restore its victims to a socially useful and economically productive place in the community. B. To define the problems arising from chronic illness among all age groups, with full realization of its social as well as its medical aspects. C. To coordinate separate programs for specific diseases with a general program designed to meet more effectively the needs which are common to all the chronically ill. D. To clarify the interrelationship of professional groups and agencies now working in the field. E. To stimulate in every state and locality a well-rounded plan for the prevention and control of chronic disease and for the care and rehabilitation of the chronically ill.

Section 1

Section 2Section 3· Section 4-

Article III—Members -The members of the Commission shall consist of not more than 35 individuals who are interested in assisting the Commission to attain its objectives. -Members shall be selected by the Board of Directors with the approval of the existing members. -Members shall serve for the life of the Commission unless they die, resign, or are dropped prior to such date. -Members shall be automatically dropped if they miss three consecutive meetings of the Commission.

316

APPENDIX Β Article IV—Officers

Section 1—The officers of the Commission shall be a Chairman, Vice Chairman, Secretary, and Treasurer. Section 2—They shall be elected at the annual meeting, and the term of office shall be one year. Section 3—Their duties shall be those usually devolving upon such officers, and the Treasurer shall post a surety bond in the sum of $25,000 dollars. Article V—Board of Directors Section 1—The Board of Directors shall consist of the officers and six additional members of the Commission elected at the annual meeting for a term of one year. At least one member shall be a resident of the State of Illinois. Section 2—The Board of Directors shall be charged with the administration of the affairs of the Commission between annual meetings. It shall keep detailed minutes of its activities and shall fully report to the annual meeting and to any special meeting of the Commission as requested. Section 3—If the Board of Directors desires to obtain an official expression of opinion from the Commission at any time between Commission meetings, it may do so by submitting the question to each member of the Commission by registered mail at his last known postal address. At least fifteen votes must be returned and an affirmative vote of two-thirds of the members replying will constitute the opinion of the Commission. Article VI—Meetings Section 1—The Commission shall meet annually at a time and place to be determined by the Board of Directors. The Commission may also hold special or quarterly meetings at such times and places as the Board of Directors may determine. Section 2—Members shall be notified in writing of all meetings of the Commission at least fifteen days prior thereto. Section 3—The Board of Directors shall meet whenever and wherever necessary at the call of the Chairman. Article VII—Elections Section 1—Election of Officers and members of the Board of Directors shall be held at the annual meeting of the Commission.

317

ARTICLES OF INCORPORATION

Section 2—Nominations shall be made from the floor at such meeting. Section 3—Nominees receiving a two-thirds vote of the members present shall be declared elected, and each member present shall be entitled to only one vote. Section 4—Vacancies may be filled by the Board of Directors until the next annual meeting of the Commission. Article VIII—Quorum Section 1—Ten members shall constitute a quorum for the transaction of business at any meeting of the Commission. Section 2—Five members shall constitute a quorum for the transaction of business at any meeting of the Board of Directors. Article IX—Committees Section 1—The Board of Directors may appoint such committees as it may deem necessary for the proper conduct of the affairs of the Commission. Article X—Amendments Section 1—These Bylaws may be amended at any meeting of the Commission by a two-thirds vote of the members. Adopted: Amended:

May 29,1949 January 28,1952 and February 20,1953

Appendix

c List of Publications Care of the Long-Term Patient. Volume II of Chronic Illness in the United States. Published for the Commonwealth Fund by Harvard University Press, Cambridge, Massachusetts, 1956. 606 pp. Chronic Illness in a Large City (The Baltimore Study). Volume IV of Chronic Illness in the United States. (In press.) Chronic Illness in a Rural Area (The Hunterdon Study). Volume III of Chronic Illness in the United States. (In press.) Chronic Illness News Letter. Volumes 1-6. Baltimore, The Commission on Chronic Illness, 1950-1956. (Out of print.) Model Community Survey; Chronic Illness Facilities and Services, Scope and Schedules (Preliminary). Baltimore, The Commission on Chronic Illness. 1951. 81 pp. Mimeographed. (Out of print.) Prevention of Chronic Illness. Volume I of Chronic Illness in the United States. Published for the Commonwealth Fund by Harvard University Press, Cambridge, Massachusetts, 1957. 338 pp. Proceedings, Conference on Preventive Aspects of Chronic Disease. Raleigh (N.C.), Health Publications Institute, 1952. 311 pp. (Out of print.) Proceedings of First Meeting, May 20, 1949. Baltimore, The Commission on Chronic Illness, 1949. 73 pp. Processed. (Out of print.) Something Can Be Done about Chronic Illness by Herbert Yahraes. Public Affairs Pamphlet No. 176. New York, Public Affairs Committee, 1951. 32 pp. Steps toward the Prevention of Chronic Disease. Raleigh (N.C.), Health Publications Institute, 1952. 31 pp. (Out of print.) Welfare Council Activities in Chronic Illness Planning. Baltimore, The Commission on Chronic Illness, 1953. 48 pp. Mimeographed. (Out of print.) 318

LIST O F P U B L I C A T I O N S

319

WITH THE PUBLIC HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

A Study of Selected Home Care Programs. Public Health Monograph No. 35. PHS Publication No. 447. Washington, D.C., Government Printing Office, 1955. 127 pp. Nursing Homes, Their Patients and Their Care: A Study of Nursing Homes and Similar Long-Term Facilities in 13 States. Public Health Monograph No. 46. PHS Publication No. 503. Washington, D.C., Government Printing Office, 1957. 58 pp.

Appendix D Definitions

Chronic disease comprises all impairments or deviations from normal which have one or more of the following characteristics: Are permanent. Leave residual disability. Are caused by nonreversible pathological alteration. Require special training of the patient for rehabilitation. May be expected to require a long period of supervision, observation, or care. Prevention, in its narrowest sense, means averting the development of a pathological state; more broadly, it includes also all measures which halt progression of disease to disability or death. Under the broader definition, all definitive treatment of disease may be considered preventive, hence some discussion of treatment is pertinent to any consideration of prevention. Primary prevention means averting the occurrence of disease.1 Secondary prevention means halting the progression of a disease from its early unrecognized stage to a more severe one2 and preventing complications or sequelae of disease.3 Screening is the presumptive identification of unrecognized disease or defect by the application of tests, examinations, or other procedures which can be applied rapidly. Screening tests sort out apparently well persons who probably have a disease from those who probably do not. A screening test is not intended to be diagnostic. Persons with positive or suspicious findings must be referred to their physicians for diagnosis and necessary treatment. 1 Example: Preventing the occurrence of lung cancer by protecting individuals from exposure to Chromate dust. 2 Example: Preventing late pulmonary tuberculosis and its complications by detecting, diagnosing, and treating preclinical stages of pulmonary tuberculosis. 3 Example: Preventing subacute bacterial endocarditis in persons with rheumatic or congenital heart disease by prophylactic antibiotic therapy during periods of maximum risk.

320

DEFINITIONS

321

Detection is the identification of ordinarily unrecognized disease or defect by the application of screening tests, examinations, and diagnostic procedures. Case-finding is the active search for and pursuit of cases of chronic disease and disability in both asymptomatic and more advanced stages— in order to provide, for the patients concerned, available techniques of secondary prevention appropriate to the stage of the disease, and thus stop further progression of the disease or disability to a more severe, complicated, or disabling stage.

Appendix

Ε Largely Controllable, Partially Controllable, Largely Uncontrolled Chronic Illnesses (EXCERPTS FROM A SPEECH PRESENTED IN MARCH 1 9 5 1 BY DR. DAVID SEEGAL AT THE COMMISSION'S CONFERENCE ON PREVENTIVE ASPECTS OF CHRONIC DISEASE) 1

Table E - l lists 17 long-term diseases which may be largely controlled if proper preventive, diagnostic, and therapeutic measures are employed. TABLE E - l . Largely controllable chronic illnesses Beri-beri Scurvy Rickets Hookworm infestation Malaria Amebiasis Thrombocytopenic purpura Familial hemolytic jaundice

Diabetes mellitus Pernicious anemia Syphilis Hyperthyroidism Myxedema Hyperparathyroidism Sprue "Alcoholic" neuritis Pellagra

Table E - 2 contains a list of 27 chronic illnesses which are partially controllable.

TABLE

£_2 Partially controllable chronic illnesses

Congenital heart disease Addison's disease Cretinism Diabetes insipidus Acromegaly Coeliac disease Hemophilia Erythremia Tuberculosis Actinomycosis Osteomyelitis Rheumatic fever Rheumatoid arthritis Gout

Disseminated lupus erythematosus Bacterial endocarditis Lung abscess Bronchiectasis Trypanosomiasis Hay fever Asthma Myasthenia gravis Myotonia congenita Familial periodic paralysis General paresis Epilepsy Certain neuroses and psychoses

1 In the intervening years, there have been additional advances in diagnosis and management of certain of the diseases cited. F o r example, rheumatic fever and patent ductus arteriosus would now be classed as largely controllable. Other diseases not mentioned in 1951 such as poliomyelitis and retrolental fibroplasia would be added to the list.

322

APPENDIX Ε

323

Table E-3 presents a list of the more common, largely uncontrolled chronic illnesses. TABLE

E-3. Largely uncontrolled chronic illnesses Certain congenital defects Certain neurological diseases Certain psychoses Certain neoplasms Chronic glomerular nephritis Hypertension Arteriosclerosis

INDEX

Index Accident prevention, 14, 22-23, 104 Addison's disease, 4, 240, 322 Aged components of periodic health examinations, 37 health promotion, 11, 13 housing requirements, 14 life expectancy and nutrition, 12 recreational facilities, 11 Air pollution as cause of respiratory disease, 22, 25 need for control, 22-23 role of government in controlling, 23, 104 Akron, Ohio, multiple screening program, 52, 91 Albinism, hereditary factors, 257 Alcoholism, 18, 247-248, 273 Allergies, hazards from air pollution, 22 Amebiasis, controllability, 5, 322 American Academy for Cerebral Palsy, 164 American Academy of General Practice, 78 American Academy of Ophthalmology and Otolaryngology, 182 American Academy of Pediatrics, 9, 78, 291 American Cancer Society, xi, 126, 138, 307-308 American College of Surgeons, 137-138 American Dental Association, xi, 236, 297, 308 American Diabetes Association, 166, 169 American Heart Association, xi, 144, 307-308 American Hospital Association, xi, 3, 58, 86, 98, 287-288, 290-293, 297, 302, 308 American Medical Association, xi, 3, 29, 33, 51, 287-288, 290-293, 297, 299300, 307-309 Study of Multiple Screening, 51-52, 61-63, 303 American Nurses Association, 297 American Psychiatric Association, xi, 191, 243, 308 American Public Health Association, xi, 3, 88-89, 93, 98, 103, 287-288, 290, 292293, 297, 303, 308 American Public Welfare Association, xi, 3, 93, 287-290, 292, 297 327

American Red Cross, sponsorship of screening program, 61 American Rheumatism Association, 112 American Social Hygiene Association, 91, 217 America's Health, 291, 298 Anemia iron deficiency, 268 pernicious, controllability, 4-5, 322 screening examinations, 47 Ankylosing spondylitis, 115, 225 Arteriosclerosis, 4-5, 18, 155, 253-254, 322 Arthritis, 111-118 hypertrophic, hereditary factors, 255 nutritional factors, 273 references, 118-119 rheumatoid. See Rheumatoid arthritis Arthritis and Rheumatism Foundation, xi, 111, 308 Assistance recipients case-finding, 59, 94 preventive medical service, 59, 93 Association for Aid of Crippled Children, 292 Association of State and Territorial Health Officers, 101, 290 Atherosclerosis, 20, 154-155, 272 references, 158 Atlanta, Ga., multiple screening program, 52 Auditory screening tests, 187-189 See also Hearing impairment Baker, J. P., 38 Ballou, H. C„ 38 Baltimore, Md., multiple screening program and survey of chronic illness, xi, 42-43, 48, 52, 60, 301, 309-310, 318 Baney, Anna Mae, 303 Barotrauma, 185 Beland, Irene L., xviii Belloc, Nedra B„ 64 Bergsma, Daniel, 92 Beri-beri, controllability, 5, 322 Bierman, Pearl, 93-95, 102 Bigelow, George H., 285 Blindness, 120-124 prevention, primary, 18-19, 121-124 references, 124-125

328 Blindness (cont.) See also Cataracts; Corneal disease; Glaucoma; Optic nerve atrophy; Retrolental fibroplasia; Uveitis Blood tests in periodic health examinations, 36-37, 39^10 in screening examinations, 52-53, 56, 64 See also Tests for detection and diagnosis, under specific diseases Boston, Mass. Children's Medical Center, 172 coordinating role of welfare council, 96-97 multiple screening program, 52 poison control center, 23 State Hospital, rehabilitation of mental patients, 198 Bowen's dyskeratosis, 135 Bradley Mining Company, 30-31 Breslow, Lester, xviii, xix, 12, 64, 66, 296 Brightman, I. Jay, 12 Brodman, K.., 54 Building America's Health; America's Health Status, Needs and Resources, 10, 87 Burney, L. E., 46 Cancer, 126-142 control program, elements of, 126-127 controllability, 4—5, 323 economic factors, 128 education and training needed for control, 126, 134, 136-137 etiology, 20-21,127-135, 229 facilities for detection, diagnosis, and treatment, regional distribution of, 138 gastric, screening relatives of persons affected, 262 hereditary factors, 127, 133, 255-256 nutritional factors, 133, 272 prevention, primary, 18, 20-21, 133-135 prevention, secondary, 135-142 programs for diagnosis and treatment, approved, 137-138 references, 142-143 research needs, 67, 141-142 site variations, by sex, 128 tests for detection and diagnosis, 31-32, 36, 47-48, 56-57, 67, 138-140, 262 treatment, 135-138, 140 vaginal cytology, 36, 53, 57, 138-140 Cancer of liver, 272 Cancer of lung (pulmonary) association with smoking, 20-21, 68, 129, 133 prevention, 16, 22

INDEX Carcinogenic agents, substances, sources, and sites affected, table of, 130-132 Carcinoma. See Cancer Cardiac malformations, congenital. See Cardiovascular malformations, congenital Cardiovascular diseases, 144-156 etiology, occupational agents, 229-230 health examinations, 36-37, 39 references, 156-158 screening, 47, 57-58, 67 See also Atherosclerosis; Cardiovascular malformations, congenital; Cerebral vascular diseases; Coronary artery disease; Hypertension; Peripheral vascular disease; Rheumatic heart disease; Syphilis, cardiovascular Cardiovascular malformations, congenital, 4, 18, 144-147, 253-254, 322 references, 157 Cardiovascular syphilis. See Syphilis, cardiovascular Care of the Long-Term Patient, xi, 26-27, 69, 71, 73-74, 77, 85-87, 90, 102, 296297, 299, 306, 318 Care of the Long-Term Patient, National Conference on, 296, 299, 305-306, 309 Caries, dental. See Dental caries Carrier states for chronic diseases of genetic origin, 256-261 Carroll, Benjamin E., 66 Case-finding definition, 28, 321 locale, 29 purpose, 28-29 register of complications of birth to locate cases of cerebral palsy, 162-163 role of medical and dental professions, 29, 105, 240-241 through periodic health examinations, 28-44 Cataracts, 19, 120-121 Cerebral palsy, 159-165 references, 165 Cerebral vascular diseases, 156 references, 158 Cervical cytology test. See Cancer, vaginal cytology Chapman, A. L„ 50, 92 Cherkasky, Martin, xviii Chicago, 111. coordinating role of welfare council, 9 6 97 poison control center, 23 Child Health Services and Pediatric cation, Supplement, 9, 78

Edu-

INDEX Children, preventive dental care for, 93-94, 237-240 Children's Medical Center, Boston, Mass., 172 Cholera, prevention, 16 Chope, Harold D., 12 Chronic disease common denominators, 25, 78-86 definition, 4, 320 epidemiological principles, 72-73 natural history, research in common factors, 24-27 scope of problem, xv Chronic Disease Program, United States Public Health Service, 166 Chronic Illness, Digests of Selected References, 305 Chronic Illness in a Large City (Baltimore, Md.), xi, 43, 48, 52, 60, 301, 309-310, 318 Chronic Illness in a Rural Area (Hunterdon County, N.J.), xi, 43, 48, 52, 60, 300, 309, 318 Chronic Illness News Letter, 303-304, 318 Cincinnati, Ohio coordinating role of welfare council, 9 6 97 poison control center, 23 Public Welfare Federation, 302 Cirrhosis of liver controllability, 4 etiology, occupational, 230 nutritional factors, 274 Clark, E. Gurney, 11 Clark, Katharine G., 70-72 Cleveland, Ohio, coordinating role of welfare council, 96-97 Clinitron, 56, 99 Commission on Chronic Illness Articles of Incorporation, 312-317 conclusions and recommendations, 104107 definitions, 320-321 financial support, 306-310 history, 285-311 Interim Commission, xii, 291-292, 295298, 307 organization, 294-300 program activities, 300-306 publications, list, 318-319 purposes, 294-295, 313-315 Commission on Hospital Care, 291-292 Commonwealth Fund, xi, xiii, 300, 308-309 Community Chests and Councils of America, 97, 301-302 Community planning for preventive services, 88-103

329 Community responsibilities for health promotion and preventive services, 10, 13, 88 Community welfare and civic agencies, sponsorship of screening examinations, 61 Community welfare councils, programs and plans for chronically ill, 301-302 Conferences Care of the Long-Term Patient, 296, 299, 305-306, 309 Preventive Aspects of Chronic Disease, xvi-xix, 4-5, 16, 18-19, 47^t8, 296297, 303, 306, 309-310 Preventive Medicine in Medical Schools, Report of Colorado Springs Conference, 69-70 Consolidated Edison Company of New York, 39 Control of Communicable Diseases in Man, 103 Controllable diseases, 322-323 Cooley, George W., 292 Coordination and integration of preventive services community planning, 88-103 hospitals and health departments, 97-98 recommendations adopted by Commission on Chronic Illness, 88, 90, 95, 107 Corneal disease, 123 Cornell Medical Index, 54 Coronary artery disease, 154-155 references, 158 Council of State Governments, 11, 196 Council on Foods and Nutrition, American Medical Association, 267 Council on Industrial Health, American Medical Association, 229 Council on Medical Service, American Medical Association, 51-52, 61-63, 292, 303-304 Council on Rheumatic Fever, 99 Coxsackie virus, 208 Crocker, Lucy H., xvii Cronin, John W., 98 Cunningham, Margery R., 299 Cushing's syndrome, 152 Custodial facilities, overemphasis on, 90

Danstedt, Rudolph T„ 97 Darley, Ward, xviii Deaf-mutism, hereditary factors, 252 Deafness. See Hearing impairment Degenerative joint disease, 18, 116-117 Dental care for children, coordination of community resources, 93-94

330 Dental caries nutritional factors, 271 prevention, primary, 18, 21-22, 237 recommendation adopted by Commission on Chronic Illness, 22, 24, 104 Dental disorders, 236-242 references, 242, 278 Dental health, references, 242, 278 Dentists education and training for prevention, 73-74 recommendation adopted by Commission on Chronic Illness, 24, 105 role in care of chronically ill, 241-242 Dependency reactions of the chronically ill, 246-247 Dermatosis of occupational origin, 230 Detection of chronic disorder, definition, 321 Diabetes Guide Book jor Physicians, 169 Diabetes mellitus, 166-170 cataracts, association with, 121 controllability, 4-5, 18, 166-168, 322 cortisone provocative test, 67, 169, 262 hereditary factors, 34, 166-167, 252, 254, 262 prevention, primary, 167 prevention, secondary, 168 references, 170-171 research needs, 67, 168-169 screening, 47, 56, 68 tests for detection and diagnosis, 168— 169, 262 Diagnostic confirmation, health examination findings, 30-31, 38-44 Diagnostic services, availability for periodic health examinations, 43 Dietary habits, correction of, 9, 12-13, 267-281 Directory of Full-Time Local Health Units, 86 Directory of National and International Unions in the United States, 59 Division of Chronic Disease and Tuberculosis, United States Public Health Service, 304 Division of Dental Public Health, United States Public Health Service, 236

Economic security, relation to health promotion, 9-10, 15 Education and training need for, in cancer control, 126, 134, 136-137 need for, in cerebral palsy, 165

INDEX Education for prevention professional, 69-77, 234-235 public, 77-86, 106, 235 Educational institutions, case-finding among students and teachers, 59 Elyria, Ohio, 32 Emotional factors in chronic disease, 243250 Employer groups, sponsorship of screening examinations, 62 Enterline, Philip E., 49 Environmental sanitation examples of primary prevention, 16-17, 20, 24-25 role of government, 23-24, 104 Epidemiological principles in chronic illness, 72-73 Epilepsy, 172-180 controllability, 322 etiology, 172-174 hereditary factors, 18, 34, 172-177, 179180, 253 prevalence, 172 prevention, primary, 174-176 prevention, secondary, 176-177 references, 180-181 research needs, 179-180 tests for detection and diagnosis, 177-179 Equitable Life Assurance Society, xi, 308309 Erdmann, A. J., Jr., 54 Erickson, Cyrus C., 57 Eye tests, screening examinations, 52

Familial factors in chronic disease. See Hereditary factors in chronic disease Families of chronic invalids, emotional problems, 248-250 Family history, importance in case-finding, 34-35 Felty's syndrome, 115 Ferree, John W-, xviii Fluoridation of water supplies effectiveness in reducing dental caries, 21-22, 24, 89, 271 recommendation of Commission on Chronic Illness, 22, 24, 104 role of government, 24, 104 significance as public health measure, 236-237 time lag in application, 89 Fluoride, topical application, 21, 237 Fluorosis, primary prevention, 238-239 Foster home care for mental illness, 197198 Franco, S. Charles, 31-32, 3 7 ^ 0

INDEX Gallbladder function tests in periodic health examinations, 36-37 Gastrointestinal disturbances, nutritional factors, 274 Gastrointestinal tests in periodic health examinations, 36-39 Gastrointestinal ulcers, case-finding in periodic health examinations, 30 Gastro-photofluorography as screening method for cancer, 140 Genetic carriers of chronic disease, 256-263 Genetic effects of radiation, 179-180 Genetics, role in prevention of chronic disease, 256-263 Georgia, integrated health and welfare services, 95 Gerl, A. J., 31-32, 37-40 German measles (Rubella), hazards in pregnancy, 19, 21, 120-121, 145, 160, 183-184 Geschickter, Charles F., 53-54 Glaucoma hereditary factors, 252 prevalence, 46, 122 prevention of blindness from, 18-19, 46 screening equipment needing validation, 68

tests for detection and diagnosis, 55, 68, 122 Glorig, Aram, 182 Goiter, endemic, 268-269 Goldstine, Dora, xviii Gouty arthritis, 117-118, 255, 273, 322 Governmental agencies, sponsorship of screening examinations, 62 Governmental roles in chronic illness control, 23-24, 100, 107 Grand Rapids, Mich., fluoridation studies, 237 Group health programs, case-finding among membership, 59-60 Group practice settings for periodic health examinations, 40

"Halfway houses," 197 Hall, W. Thomas, 38 Health, definition, 8 Health and welfare departments' cooperation in provision of health services, 93-95 Health centers, role in coordinating health activities, 98-100 Health councils, role in coordinating health services, 97 Health counselling opportunities for, in periodic health examinations, 38-44, 231-232

331 Health counselling (cont.) value in occupational health services, 231-232 Health departments, coordination with hospitals, 97-98 Health education dietary and nutritional instruction, 13 reorientation toward prevention, 76-86 roles of physicians and dentists, 9, 24, 105 Health educators, education and training for roles in prevention, 76-77 Health examinations, periodic, 28-44 abnormalities revealed, 30-32 accuracy of findings, 43 availability, 29 components, 34-41, 53-54 counselling opportunities, 38-44 diagnostic confirmation of findings, 30-31 equipment needed, 36 findings among supposedly healthy persons, 30-32 frequency for various age groups, 29, 33 group practice settings, 40 industrial settings, 24, 37, 39-40 limitations, 32, 41-45 locale, 29 occupational and geographic variations in scope, 33-34 physician's manual, 29 preventive aspects, 28-44 public acceptance, 42-43 recommendation adopted by Commission on Chronic Illness, 29, 105 responsibility of medical and dental profession, 29, 105 scope, 32-39 Health examinations, special purpose, 4041 Health inventory. See Health examinations, periodic Health maintenance. See Health promotion Health motivations, 26, 82-86 Health organizations, role in primary prevention, 24 Health promotion, 8-15 components, 9-15 definition, 8 individual's responsibility for, 6, 10, 104 recommendation adopted by Commission on Chronic Illness, 6, 9, 104 relation to prevention, 8-9, 17 role of medical and dental profession, 24, 104 See also Health counselling; Health education Health Resources Advisory Committee, Office of Defense Mobilization, 87

332 Hearing impairment, 182-189 etiology, 182-187 hereditary factors, 183, 252 prevention, 18, 21, 187-189 references, 189-190 tests for detection and diagnosis, 53, 55, 182, 187-189 Heart disease, congenital. See Cardiovascular malformations, congenital Heart Disease Control Program, United States Public Health Service, 144 Heart tests in periodic health examinations, 36-40 Heberden's nodes, 255 Hereditary factors in chronic disease, 251263 arteriosclerosis, 253-254 arthritis, hypertrophic, 255 blindness, 252 cancer, 127, 133, 255-256 cardiovascular malformations, congenital, 253-254 cataracts, 252 cerebral palsy, 255 diabetes mellitis, 34, 166-167, 252, 254, 262 epilepsy, 18, 34, 172-177, 179-180, 253 glaucoma, 252 gouty arthritis, 255 hearing, 183, 252 hypercholesterolemia, 253-254 hypertension, 34, 254 psychosis, 254-255 references, 263-266 rheumatic heart disease, 34, 253 rheumatoid arthritis, 255 schizophrenia, 192, 254 tuberculosis, 255 Highway safety, 23, 104 Hill, Elizabeth H„ 49 Hill-Burton Hospital Survey and Construction Act, 98, 138 Home care study, 301, 310, 319 Hookworm infestation, 5, 322 Hospital facilities for care of long-term patients, study of, 302 Hospital patients, screening procedures for, 58 Hospital Survey and Construction Program (Hill-Burton), 98, 138 Hospitals, coordination with health departments, 97-98 Housing, importance in health promotion, 9, 14 Housing for the Aged, 14 Housing programs, need for cooperation of health agencies in planning and administration, 93

INDEX Hubbard, Ruth, 296 Hunterdon County (N.J.) Heart Association, 99 Medical Society, 99 morbidity survey, xi, 43, 48, 52, 60, 300, 309, 318 Hunterdon Medical Center, xi, 98-100, 300 Huntington's chorea, 192, 254, 257 Hygiene, personal, role in health promotion, 6, 9, 104 Hygiene Laboratory, United States Public Health Service, 287 Hypercholesterolemia, hereditary factors, 253-254 Hyperparathyroidism, 5, 322 Hypertension, 151-154 case-finding in periodic health examination, 30 controllability, 323 etiology, 34, 151-152, 254 hereditary factors, 34, 254 nutritional factors, 272 prevention, primary, 4 - 5 , 1 8 , 152 prevention, secondary, 152-153 references, 158 research needs, 154 tests for detection and diagnosis, 30, 153 Hyperthyroidism, 5, 322 Hyperuricemia, hereditary factors, 255 Illinois, integrated health and welfare services, 93 Immunization examples of primary prevention, 16, 1920 role of physicians, 24, 105 Impaired hearing. See Hearing impairment Indianapolis, Ind., multiple screening program, 52 Industrial health services. See Occupational health services Industrial hygiene. See Occupational health services Industrial medicine, role in prevention, 24, 229-235 Industrial settings, periodic health examinations, 37, 39-40 Industrial workers, case-finding among, 58-59 Industry, chronic disease in, 229-235 occupational diseases, 229-230 prevention, 231-232 Infantile paralysis. See Poliomyelitis Interim Commission on Chronic Illness, xii, 291-292, 295-298, 307 Intestinal disorders, parasitic, health examinations for, 33-34

INDEX Iodine deficiency, 268-269 Ionizing radiation, potential health hazards, 21-22, 121, 179-180 Iritis, 113 Jarisch-Herxheimer reaction, 150 Jarrett, Mary C., 285 Jaundice, familial hemolytic, 5, 322 Job placement of physically and medically handicapped, 233 Johns Hopkins University, xi School of Hygiene and Public Health, 300, 309 Joint American Public Health AssociationAmerican Public Welfare Association Committee on Medical Care, 93 Joint Committee on Chronic Disease, 3, 287-295, 298 Jones, T. Duckett, xviii Kennedy, Robert Woods, 14 Kidney tests in periodic health examinations, 36-37, 39-40 Kountz, William B„ 37 Kovar, Edward B„ xix, 101, 303 Krueger, Dean E., 298, 301-302, 305 Kurlander, Arnold B., xix, 49, 66 Kurtz, Russell H., 97 Kwashiorkor, and incidence of liver cancer, 272 Labor groups, sponsorship of screening examinations, 58-59, 62 Laboratory tests importance in diagnosis, 29-31, 36-37 in periodic health examinations, 36-38, 40 needs of geriatric patients, 36-37 Larimore, Granville W., xviii Lead poisoning, chronic diseases resulting from, 22, 230 Leavell, HughR., 11 Leber's disease, 122 Lemon, Willis E., 38 Lennox, William G., 172 Leukemia, hereditary factors, 256 Levin, Morton L., xiii, 79, 296, 298, 304 Liberty Mutual Insurance Company, xi, 308-309 Lilly, Eli, and Company, xi, 308 Liver disease cancer, 272 cirrhosis, 4, 230, 274 nutritional factors, 273-274 Liver function tests in periodic health examinations, 36 Lombard, Herbert L., 285 Lorain County (Ohio) Medical Society, 32

333 Lorge, I., 54 Los Angeles, Calif, coordinating role of welfare council, 9697 multiple screening program, 52 Lull, George F., 291 Lung cancer. See Cancer of lung Lung tests in periodic health examinations, 36-37, 40

Malaria, controllability, 5, 322 Malnutrition. See Nutritional factors Malocclusion, primary prevention, 238 Manic-depressive psychosis, hereditary factors, 254 Marie-Strümpell arthritis of spine, 115 Maryland Association of Registered Nursing Homes, 301 State Department of Health, 298, 301 State Planning Commission, 300 Mass screening, definition, 47 See also Screening Massachusetts chronic disease control program, 285 Maternal health program, potentialities in prevention of cerebral palsy, 162 Mayo, Leonard W., xiii, 292, 299 Medical history, 31, 34-35 Medical profession recommendation adopted by Commission on Chronic Illness, 24, 105 Medical-service organizations, sponsorship of screening examinations, 62 Meek, Peter G„ xiii, 298 Memphis, Tenn., cancer screening program, 138-139 Meniere's disease, 186 Mental defect, hereditary factors, 254 Mental health programs health promotion value, 9, 13-14, 193— 195 role of state health departments, 101 Mental Hospital Administrators and Statisticians, Proceedings of the Second Conference, 302 Mental illness, 191-198 etiology, 192-193 health promotion as preventive measure, 193-195 prevention, primary, 193-195 prevention, secondary, 196-198 rehabilitation, 196-198 susceptible age periods, 13-14 treatment outside hospitals, 197-198 Metropolitan Life Insurance Company, xii, 308-309

334 Microfluorometric scanner, use as screening device, 140 Microphthalmia, 252 Miller, James R., xii, 87, 290-293, 307 Milmore, Benno Κ., 64 Minneapolis, Minn., coordinating role of welfare council, 96-97 Model Community Survey, 297, 318 Morbidity rates, association with housing deficiency, 14 Morhous, Eugene J., 38 Morris, J. N„ 26, 72-73 Mortality rates, relation to nutrition, 12 Mortensen, J. D., 29-30 Mulholland, Henry B., xix, 296 Muller, Jonas N., 93-95, 101-102, 303 Multiple sclerosis, 199-202 references, 202-204 Multiple screening. See Screening, multiple Multiple Screening, Study of (American Medical Association), 51-52, 61-63, 303 Murdock, Thomas, 307 Muscular Dystrophy Associations of America, xii, 308 Mydriatics, hazards of use for older persons, 24, 105 Myxedema, controllability, 5, 322 Nasopharyngeal lymphoid tissue as cause of impaired hearing, 21,185 National Cancer Institute, 57, 126, 139, 251, 287 National Foundation for Infantile Paralysis, xii, 205, 307-308 National Health Assembly, 290-291, 294, 298 National Health Council, xii, xvii, 308-309 National Health Survey, 1935-1936, 14, 285, 292 National Heart Institute, 144, 287, 310 National Institute of Allergy and Infectious Diseases, 22, 205 National Institute of Arthritis and Metabolic Diseases, 111, 267, 287 National Institute of Dental Research, 287 National Institute of Mental Health, 191, 243, 287, 302 National Institute of Neurological Diseases and Blindness, 120, 159,172, 182, 199, 287 National League for Nursing, 297, 302 National Microbiological Institute, 22, 287 National Multiple Sclerosis Society, xii, 199, 308 National Organization for Public Health Nursing, 302 National Society for Crippled Children and Adults, xii, 307-308

INDEX National Society for the Prevention of Blindness, 120 National Tuberculosis Association, xii, 222, 308 Neel, James V., 251 Neoplasms. See Cancer Nephritis, chronic glomerular, 5, 323 Neuritis, "alcoholic," controllability, 5, 322 Neurological diseases, controllability, 5, 322-323 Neurosyphilis, 220 New Jersey Department of Institutions and Agencies, 285 State Health Department, 92, 99, 300 New York City coordinating role of welfare council, 9697 poison control center, 23 welfare council, 285 New York Foundation, xii, 307-308 New York Life Insurance Company, xii, 308-309 New York State Department of Health, 298 Health Preparedness Commission, 298 integrated health and welfare services, 93 Newburgh, N.Y., fluoridation studies, 237 Norby, Maurice, 292 Nurses, education and training for prevention, 74 Nursing home study, 301, 303, 305, 310 Nursing homes, inclusion of patients in xray screening programs, 94 Nursing Homes, Their Patients and Their Care, 301, 319 Nutritional factors, 267-275 as cause of chronic illness, 267-275 disease prevention, 12-13 health promotion, 9, 12-13 references, 275-281 Nutritional requirements, individual variations, 271 Obesity association with mortality from cardiovascular disease, 12 screening, 47 See also Nutritional factors Occupational diseases. See Industry, chronic disease in Occupational factors cancer, 128-135 importance as clues to illness, 33-34 silicosis, 33 tuberculosis, 33 Occupational Health Program, United States Public Health Service, 229

INDEX Occupational health services need for expansion, 232-233 personnel shortages, 234 prevention and treatment of chronic illness, 17, 20-21, 229-235 research needs, 234 Office of Defense Mobilization, Health Resources Advisory Committee, 87 Office of Vocational Rehabilitation, 198 Ophthalmia neonatorum, 18-19, 123 Optic nerve atrophy, 122, 252 Oregon, inclusion of indigent patients in nursing homes in tuberculosis control program, 94 Osteoarthritis, 115-117 Otosclerosis, 183, 252 Oxygen, hazards of use for premature infants, 18-19, 24, 101, 105, 124 Papanicolaou smear test. See Cancer, vaginal cytology Paralysis, infantile. See Poliomyelitis Parasitic infections, examinations for, 33-34 Parkinson's disease, 116 Pearse, Innes H., xvii Peckham experiment, xvi-xvii Pediatricians, preventive services and health promotion, 9, 78 Pellagra, controllability, 5, 322 Peptic ulcer, nutritional factors in prevention, 12 Periodic health examination. See Health examination, periodic Periodic Health Examination: A Manual for Physicians, 29 Periodontal disease, primary prevention, 238 Peripheral vascular disease, 155-156 references, 158 Perlstein, Meyer Α., 159 Personnel shortages, 41-42, 45, 69, 86-87, 106, 234 Phoenix, Ariz., poison control center, 23 Physical examination components, 35-38 equipment needed, 36 importance in diagnosis, 31 scope and content in periodic health examinations, 29-41, 52-54 Physicians, education and training for preventive medicine, 73-75, 234-235 Planning for the Chronically III, 3, 288-289 Plummer-Vinson syndrome, 133 Poison control programs, 23 Poliomyelitis, 205-212 case-fatality rate, 206 controllability, 322 etiology, 206-209

335 Poliomyelitis (cont.) prevalence of disability from, 206 prevention, primary, 18, 20, 209-211 prevention, secondary, 211 references, 212-216 research needs, 212 Salk vaccine, field trials, 205, 209-211 Pollen control, 22-23, 104 Potter, Ellen C., 292 Presbycusis, 186 President's Commission on the Health Needs of the Nation, Report, 10, 87 Prevalence of chronic illness, xv See also under specific diseases Prevention common denominator approach, 7, 25, 78-87, 285-321 definition, 4, 320 individual's role in, recommendation adopted by Commission on Chronic Illness, 6, 104 methods for achievement, 6 Prevention, primary, 16-27 definition, 8, 16, 320 examples, 18-23 recommendations adopted by Commission on Chronic Illness, 18, 22-25 recommendations of state chronic disease program directors, 100 relation to health promotion, 8, 17 relation to secondary prevention, 17 research needs, 24-27, 105 responsibilities for, 17-18, 101-102 role of government, 23-24, 100-104 roles of physicians and dentists, 24, 105 See also under specific diseases Prevention, secondary, 28-68 definition, 16, 28, 320 examples, 28 recommendations adopted by Commission on Chronic Illness, 29, 45-46, 68, 105-106 recommendations of state chronic disease program directors, 102 relation to primary prevention, 17 role of government, 46, 68, 102, 106 value of periodic health examinations, 28—44 See also under specific diseases Preventive Aspects of Chronic Disease, National Conference on, xvi-xix, 4-5, 16, 18-19, 47-48, 296-297, 303, 306, 309-310 Preventive Aspects of Chronic Disease, Proceedings of Conference on, xvi-xvii, 4, 45, 48, 79-80, 318 Preventive medicine concepts, 71-73

336 Preventive medicine (cont.) reorientation needed in education of health personnel, 69-77 Preventive Medicine in Medical Schools, Report of Colorado Springs Conference, 69-70 Preventive services community planning, recommendation adopted by Commission on Chronic Illness, 88, 90, 95, 107 inseparability f r o m treatment, 90 obstacles to public use of, 83 time lag in application of existing knowledge, 89 Price, Julian P., 23 Primary prevention. See Prevention, primary Professional education and training needs, 69-77, 234-235 Professional organizations, sponsorship of screening examinations, 62 Psychoses, controllability, 5, 322-323 Psychosis, hereditary factors, 254—255 Public Affairs Committee, 304 Public assistance recipients case-finding, 59, 94 preventive medical service, 59, 93 Public education and information groups to be reached, 83-84 occupational health, 235 purposes and limitations of screening examinations, 81-82 recommendation adopted by Commission on Chronic Illness, 77, 106 research needed on attitudes and motivations toward use of health services, 84-85 Public employees, case-finding among, 60 Public health departments guide for development of chronic disease services in, recommendation adopted by Commission on Chronic Illness, 100, 107 local, chronic disease activities, 100-101 Pyorrhea, 238

Racial factors cancer, 127-128 cerebral palsy, 160 Radiant energy, hazards from increasing use, 21-22, 121, 179-180 Radiation cataracts, 121 genetic effects, 179-180 overexposure, 21, 55, 68, 121, 128, 134, 151, 179-180, 229 Ragweed control, 22-23, 104

INDEX Randall, Ollie, 296 Recommendations, Commission on Chronic Illness, 104-107 community organization, 88, 90, 95, 107 education of public for health promotion, 77, 106 fluoridation of water supplies, 22, 24, 104 health promotion, 6, 9, 104 periodic health examinations, 29, 105 personnel shortages, 86, 106 prevention, primary, 18, 22-25, 104-105 prevention, secondary, 29, 45-46, 68, 105-106 professional education for health promotion, 71, 106 screening examinations, 45-46, 68, 105106 state governments' responsibilities, 100, 107 Recreation, relation to health promotion, 9, 11 Registrar-General's Decennial Supplement, 141 Rehabilitation services in hospitals, study of, 302 Reiter's disease, 117 Research, needs for expansion allocation and distribution of funds, 2 6 27 etiology of chronic illness, 5, 24-27 role of government, 24, 105 social sciences, 26-27 See also under specific diseases Retrolental fibroplasia, 18-19, 24, 101, 105, 124, 322 Rheumatic fever cardiac involvement. See Rheumatic heart disease control program, Hunterdon County, N.J., 99-100 controllability, 322 coordination and integration of community services, 98-100 role of state health departments, 101 Rheumatic heart disease, 18, 20, 147-149 references, 157 Rheumatism. See Arthritis Rheumatoid arthritis, 111-115 controllability, 322 prevention, 4, 18, 113 tests for detection and diagnosis, 67, 114 Richmond, Va., multiple screening program, 52 Rickets, controllability, 5, 322 Ring, Martha D., xix Roberts, Beryl J., xviii Roberts, Dean W., xiii, xx, 296, 298, 301, 305

INDEX Rockefeller Foundation, xii, 308-309 Rogers, Edward S„ 293 Rosenau, Milton Joseph, 56 Rubella (German Measles), 19, 21, 120121, 145, 160, 183-184 Rutstein, David D., xviii, 48 Salk Vaccine. See Poliomyelitis San Francisco, Calif, coordinating role of welfare council, 9 6 97 multiple screening program, 52, 64-65 San Mateo, Calif., integrated health and welfare services, 94-95 Scheele, Leonard Α., xv, 3, 5, 78 Schizophrenia, hereditary factors, 192, 254 School teachers, education and training for roles in promotion of health, 75-76 Schumacher, George Α., 199 Screening, individual, definition, 47 Screening, mass, definition, 47 Screening, multiple coordination of community programs, 91-92, 94 definition, 47 program of Hunterdon Medical Center, 98-100 Screening examinations, 45-68 acceptability, 51 case-finding in industry, 58-59 coordination of community resources for, 91 costs, 50-51, 63 criteria for evaluating, 47-51 definition, 45, 47, 320 diagnostic confirmation, 49 financing, 46 follow-up services, 49, 51-52, 63-64 improvements needed, 67-68 limitations, 66 personnel, 51, 62-63 population groups appropriate for, 5860, 98 procedures, 52-58, 62, 64 productivity, 49-50 public information on purposes and limitations, 81-82 recommendations adopted by Commission on Chronic Illness, 45-46, 68, 105-106 recommendations of state chronic disease program directors, 102 reliability, 48-49 reproducibility of results, 48 research needs, 67-68 sponsorship, 46, 61-62 validity, scientific, 49 yield, 49-50

337 Screening examinations (cont.) See also Tests for detection and diagnosis under specific diseases Scurvy, controllability, 5, 322 Secondary prevention. See Prevention, secondary Seegal, David, xviii, 4, 322 Self-screener, screening examinations, 53-54 Services for Handicapped Children, 89 Shelby County, Tenn., 57 Sheps, Cecil G„ 26 Shillito, Frederick, 38-39 Siddall, A. C., 32 Silicosis case-finding in periodic health examinations, 30-31 prevention, 17 Smillie, W. G„ 66 Smith, Lucille M„ xiii, xix, 290-291, 296, 307 Smog. See Air pollution Snoke, Albert W„ 293 Snow, John, 16 Social hygiene education, 217-218 Social responsibilities for health promotion, 10, 88-103 Social science research, increase needed, 26-27 Social security. See Economic security Social Security Act, 286 Social welfare workers case-finding among, 60 education and training for prevention, 74-75 Socioeconomic factors identification in medical history, 33-35 importance as clues to illness, 32-35 Solon, Jerry, 303, 305 Something Can Be Done About Chronic Illness, 304, 318 Source Book on Size and Characteristics of the Problem of Care of the LongTerm Patient, 305 Spondylitis, ankylosing, 115, 255 Sprue, controllability, 5, 322 Stafford, Frank, xviii State and Territorial Health Officers Association, 101, 290 State Chronic Disease Program Directors, Proceedings of First Meeting, 101 State governments, responsibilities for coordination and planning, recommendation adopted by Commission on Chronic Illness, 100, 107 State health departments role in developing and coordinating programs for prevention, 100-103, 107 study of activities for chronically ill, 301

338 State medical societies, study of activities in care of chronically ill, 301 States and Their Older Citizens, The, 11 Statistical Abstract of the United States, 60 Steps toward the Prevention of Chronic Disease, 318 Steroids, use in rheumatoid arthritis, 111113 Stibnite, Idaho, 30 Stieglitz, Edward J., xviii Still's disease, 115 Stool examination in screening, 53 Stress, as cause of mental illness, 195 Study of Selected Home Care Programs, 301,319 Sturge-Weber's disease, 160 Summit County (Ohio) Tuberculosis and Health Association, 91 Syphilis controllability, 5, 18, 20, 322 prevention through health education and law enforcement, 217-219 screening, 47, 55 Syphilis, cardiovascular, 150-151, 220 references, 157 Syphilis, late manifestations, 18, 20, 217220 references, 220-221 Syphilis, Manual of Serological Tests for, 55 Taylor, Eugene E., 26 Tennessee Valley Authority, 62 Terris, Milton, 292 Thrombocytopenic purpura, controllability, 5, 322 Tonometer, 36, 46, 52, 55, 68, 121-122 Traffic accidents, prevention, 22 Treatment of illness, related to secondary prevention, 28 Truman, President Harry, 290 Trussell, Ray E., 99-100 Tuberculosis, 222-226 case-finding, 31, 47, 55, 223 control, 94-95, 322 hereditary factors, 255 references, 227-228 socioeconomic problems, 33, 224-225 Tuberculosis Program, United States Public Health Service, 222 Turner, Violet B., 305 Underweight, 269 United Community Funds and Councils of America, 97

INDEX United States Children's Bureau, 62 United States Public Health Service collaboration with Commission on Chronic Illness, xii, xvii, 99, 301, 303, 305, 308-310, 319 multiple screening programs, 61-62 See also entries for components of National Institutes of Health and titles of control programs University of California School of Public Health, 293 Urine tests in screening examinations, 53 Uveitis, 113, 123 Van Riper, Hart, 205 Venereal disease, prevention, 217-219 Venereal Disease Program, United States Public Health Service, 217 Visiting nurse associations, services to chronically ill, 302 Vital Statistics of the United States (1953), 58 Vitamin deficiency prevention, 267 Voluntary health agencies, sponsorship of screening examinations, 61 Waine, Hans, 111 Washington, D.C. multiple screening program, 52 poison control center, 23 Waterhouse, Alice M., xix Waybur, Anne, 64 Weight control. See Nutritional factors; Obesity Weinerman, E. Richard, 35, 64 Welfare Council Activities on Chronic Illness Planning, 318 Welfare councils, roles in coordinating preventive services, 96-97 Welfare programs, need for cooperation of health agencies in planning and administration, 93-95 White, Benjamin V., 53-54 Wilkerson-Heftmann test, 56 Williams, Roger J., 12 Wilson's disease, 160 Wisconsin, integrated health and welfare services, 94 Wisconsin State Board of Health, 94 Wolff, H. G., 54 World Health Organization, 8 Yahraes, Herbert, 304, 318 Young Men's Christian Association, 61