3. Serum disease: This occurs usually 7-14 days following administration of the serum and may consist of fever, urticarial or erythemal skin rashes, arthralgia, generalized adenopathy. These conditions may occur singly or in any combination, and may be mild or quite distressing. or quite distressing. Fortunately these symptoms are transitory, leave no permanent ill effect, and require only symptomatic treatment. WATCHWORDS OF CONTROL Here then are the means which science has placed at the disposal of health officers, within our times, for the control of pneumonia: certain knowledge of 32 types of pneumococci which produce the disease; a speedy way of determining the type of infecting organism; specific serum therapy for at least those types that result in a high percentage of the deaths; and new means of producing effective sera at a lowered cost that should make specific treatment available to many more patients. There is a brighter outlook for the control of pneumonia. Its watchwords are: Early diagnosis, early typing and early serum treatment. the majority of patients, this means early recovery. For REFERENCES Osler: The Principles and Practice of Medicine, 8th ed. (1912) p. 98 1. 2. 3. 4. 5. 6. 7. 8. 9. U. S. Mortality Statistics, 1932. U. S. Dept. of Commerce, Bureau of the Census "Acute Lobar Pneumonia", Monograph No. 7, Rockefeller Institute for Medical Research. Abernethy: Concentrated Antipneumococcic Serum in Type I Pneumonia. New York State Journal of Medicine, 36: 627 (April 15, 1936). Cecil: Pneumococcus Type III Pneumonia. American Journal of Medical Science, 191: 305-319 March 1936) Cooper, G., et al. Separation of Types among pneumococci hitherto called Group IV and development of therapeutic antiserums for these types. Jour. Experimental Medicine, 49: 461-474 (March 1929). Cooper, G. et al. Further separation of types among pneumococci hitherto included in Group IV and development of therapeutic antisera for these types. Jour. Experimental Medicine, 55: 531 (April 1932). Bullowa: Treatment of Type XIV pneumonia with specific serum. Jour. of Clinical Investigations, 14; 373-383 (July 1935). Cecil: Early Serum Treatment of Type I Pneumonia. Jour. Amer. Med. Assn., 108:9, 689-692 (Feb. 27, 1937). 10. Hamilton: Treatment of Pneumonia. Medical Record, (Sept. 19, 1934). 11. Sabin: Jour. Amer. Med. Assn., 100:20, 1584 (May 20, 1933) 12. Horsfall, Goodner, MacLeod, Harris: Antipneumococcus Rabbit Serum as a Therapeutic Agent in Lobar Pneumonia. Jour. Amer. Med. Assn., 108:18, 1483-1490 (May 1, 1937) 13. Goodner and Horsfall: The Protective Action of Type I Antipneumococcus Serum in Mice. erimental Medicine, 62: 359, (1935) Jour. Bxp PUBLIC HEALTH AND PREVENTION IN "AMERICAN MEDICINE" ESTHER EVERETT LAPE The American Foundation Studies in Government Positive health rather than negative health--illness--can be said without equivocation to be the dominant concern of the American Foundation's two-volume report on its inquiry to medical men, "American Medicine Expert Testimony Out of Court." Omnipresent in the report is emphasis upon the steadily increasing recognition of a changing goal in the organization of public health services and of medical care. "What is needed", the report very early sets forth, "is a quite definite change of outlook for all of us, by which the health of the race is conclusively substituted for the cure of disease as the major objective of medical care." Throughout the report there is a fairly general implication that only medical men that live in the past can, or would wish to, evade realization of the increasing impossibility of separating what is preventive and what is curative in a program looking toward the general objective of better health for the citizenship as a whole. More than a few of the doctors contributing to the American Foundation's report show increasing distrust of a conception that places the cure of illness above the maintenance of health. They would like to see the resources of medical science used more largely for preventing disease. They would like, frankly, to devote their own time and energies more largely to the same objective. Many a keen scientist is increasingly alive to the discrepancy between the direction of his education and his equipment and the purposes for which these things are daily used. Scientifically he is absorbingly interested in the possibilities of preventing disease or controlling it in early stages; yet his actual practice consists in very large degree not in "controlling" disease and certainly not in preventing it, but rather in standing by and helplessly observing the relentless progress of disease that has passed the stage of control. By and large, it is not the vital and productive and well-endowed part of the population that the doctor is aiding; he is rather--as one contributor to "American Medicine" puts it-"working on the drag." "How", he asks, "can the powers of science be directed more adequately toward positive health; how can medical care be 'organized' so that it nets a definite return in the health and happiness of the individual, in his employability, in his usefulness to society, in his contribution to his fellow men, in his realization of competent living?" The communications that constitute the two volumes "American Medicine" convey with force the scientists' strike against a false limita "American Medicine: Expert Testimony out of Court is published by The American Foundation, 565 Fifth Av tion upon the use of science, the conservers' protest against waste. They convey also a clear belief that the problem of "organizing medical care" cannot be narrowed or diverted to the problem of discovering ways and means by which medical care can be distributed to more people, and by which the underprivileged can pay for it. These are problems of sharp social and economic importance, but attempts to solve them must not condition the larger program of so organizing me lical care that it ministers quite as directly to conserving the health of the worker as to curing him when he is ill. For the realization of this broader objective the kind of planning that is needed calls for, it is recognizel, an approach not from the angle of the poor laws or of the economic dependence of the low income group, but from the broader angle of the health of the whole population and, in general, of the prevention even more than the cure of disease. THE PRESENT STATUS OF "PREVENTION" IN MEDICAL EDUCATION The American Foundation's report clearly recognizes that prevention is still a stepchild in medical education. There is probably not a medical school in the country in which, in a subtle and pervasive way, the influence of preventive medicine is not increasingly felt in the whole point of view of the institution. The formal expression of this understanding is still lacking, however. and public health have still in many institutions not achieved the status of many another "specialty." By the testimony of students, courses in preventive medicine are still uninspired and incomplete. They connote, as some of the younger doctors testify, trips to sewage outlets and to milk plants. They do not form the basis of a new conception of the uses of medical science generally. A former president of the Association of American Physicians expresses the point of view of a number of contributors to "American Medicine" when he says: "I am convinced that medical education is challenged to prepare doctors that understand the underlying principles of medical service and to train them to maintain high standards of health rather than to gain a livelihood from man's misfortunes by competitive methods of special practice." One dean says, a bit wryly, that he is now used to having all ills in medical practice laid at the door of the medical schools. The medical schools are not wholly responsible, certainly, for what is unsatisfacoory in the present status of preventive medicine; they are not, for instance, responsible for the public's low degree of interest in prevention. But the schools cannot evade responsibility for the medical graduates' failure to conceive the necessary integration of curative and preventive medicine and the cooperative approach essential on both sides. The point is well put, in the report, by a member of the staff of the Harvard Medical School: "There is, I believe, an unfortunate tendency among us to try is said, should be restricted to state and national agen- "As a matter of fact, it is difficult to separate definite- "Obviously, there are overlapping areas in the application of preventive and curative measures that do not permit hard and fast boundaries to be drawn." CRITICAL NEED OF CHANGE IN POINT OF VIEW OF THE PUBLIC If preventive medicine is ever to be commonly practiced in doctors' offices (and if prevention is ever to be a major field in public education) a change in public attitudes, little short of revolutionary, will have to have taken place. Contributors to "American Medicine" point out repeatedly how little the vision of prevention has captured the imagination of the public. They reflect upon how much easier it is to interest the public in cures of any nature for diseases they think they might have; or in schemes to provide for hospital care of in insurance with its emphasis upon "accommodations for more illness", than it is to interest them in the most hopeful means of prevention. Adequate medical care, as contributors to this report repeatedly stress, assumes a public that understands it, wants it and is capable of receiving it. It assumes a public that understands that it is more important to make prevention a part of the policy of their individual lives and to prize, and to pay for, whatever assistance the government and the medical profession give them in the realization of their objective. Rather despairingly the medical men point out that the same man who will willingly pay three dollars to have a boil lanced would most unwillingly pay a fee for the information or advice or medical care that would prevent the boil entirely. What is needed amounts to a revolution in social consciousness and in public values. It will not be lightly brought about by sporadic "campaigns", health weeks and community drives to emphasize social responsibility. It must become a part of the very fabric of individual education. There are dramatic values of the first quality in prevention, but they have not been conveyed to the public. Quite the contrary: to the average citizen prevention still means, as the report points out, "a dull kind of community teaching, a collection of wise but boresome procedures and precepts, about the right loca tions for the outhouse and the well." Few individuals indeed have any creative realization of what preventive medicine means to their own chance of life, productivity, success, happiness. As one of the surgeons contributing to the report puts it: "Despite the fact that preventive medicine has been preached Among all the surveys and studies that have been made there has been, so far as our knowledge goes, no competent study of the degree to which both personal happiness and industrial or professional productivity are related to degrees of health. Before we have finished surveying the citizenship with a view to "planning" for its greater happiness and its greater effectiveness, we shall certainly need to study not only the degree to which the population is smitten with dangerous diseases but also the degree to which its happiness is nullified and its productivity liminished by the presence of disease as yet undeclared--but in a stage where control or "cure" is still possible. The real quarrel which some philosophers have with certain medico-economic schemes, notably insurance, is the tendency of these programs to set the public to pondering on what it will do when it is sick, how it will pay for medical attention, for hospital care, etc. All this kind of planning, they assert, induces a negative attitude toward health. The sharper need, they believe, is to concentrate public thinking upon the possibility--and the joys--of positive health. The understanding of the consumers' group has not been adequately developed. If, says one of the correspondents, the public could be made to see that prevention is possible and that cure is speculative, they would not look to the doctors for magic but would themselves more patiently and systematically attack the real problem which, after all, is not the "cost of medical care" or the "distribution" of it but rather the development of an increased health consciousness in the population generally. DEVELOPMENT OF THE PUBLIC HEALTH SERVICES Two chapters of the report deal with this subject, Chapter VII, Public Health Organization, and Chapter XI entitled Limited State Medicine (as distinguished from State Medicine discussed in another chapter). A distinct group of writers believe that present problems will best be met by an evolutionary development of governmental functioning and tax support in directions already established. The increase in government functioning would not be confined to extension of the present public health services, which, is, however, advocated; it would include the extension of government authority and government funds to other important aspects of medical care. The most important recommendations, aside from the extension of the public |