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America’s Public Health Scene at the time at the turn of the century

Before 1880 we knew nothing; after 1890, we knew it all; it was a glorious ten years. (William T Sedgwick)

Of course progress did not stop in 1890; William Thompson Sedgwick (1855-1921), himself, continued contributing to the revolution. Furthermore, as the first president of the Society of American Bacteriologists, which was established in 1899, he witnessed first-hand many of the exciting developments that took place after the turn of the century.

New findings followed in such rapidity that it proved difficult for health researchers and practitioners to keep up with what was going on. It did not help that countries were in active competition with one another and nationalistically-inclined scientists did not readily share early results for fear that others would exploit them for gain and fame. This state of affairs contributed to false beliefs lingering beyond their natural life span. By 1900, however, there was no turning back. The world of microbes had won the battle, even if skirmishes continued to be fought here and there, in some instances for several more decades.

During these critical two decades discoveries of one disease-causing microbe followed another. There were first the observations of the typhoid bacillus and the malaria parasite in 1880. Diphtheria (1884) followed those of tuberculosis (1882) and cholera (1883). In 1894, the plague bacterium was isolated. The role of the mosquito in the transmission of malaria and yellow fever was discovered in 1898 (bird malaria), 1899 (human malaria) and 1900 (yellow fever). The discovery of the vectors of plague and typhus soon followed. The viral nature of influenza was not unraveled until the early 1930s.

These new findings allowed public health authorities to target their actions, and in the process eliminate those that served no immediate purpose. It naturally followed that disease-oriented actions took precedence over less-well defined ones. Many of the latter, however, served the public good and for social minded public health officials deserved attention even though their impact could not be scientifically proved. What emerged slowly was a division that effectively split the public health world into two, a division that still exists today.

Tuberculosis led the list followed by diphtheria, and typhoid. These diseases affected the whole of America. In the Southern states, however, malaria and yellow fever were of far greater importance given their epidemic nature. Hookworm, as well, was recognized as a terribly debilitating disease, one that sapped the energies of all those infected.

One of the first medical officers to address the problem of tuberculosis was Arthur Newsholme (1857-1943), the first full-time Medical Officer of Health (MOH) in Brighton, England. As he played an important role in the promotion of public health in America later in his career, his early work deserves attention.

As opposed to the United States where no national legislation obliged local communities to develop administrative machinery for public health, England’s Public Health Act of 1872 required communities to have a sanitary or health authority which was responsible for appointing a Medical Officer of Health (MOH). The 1875 Public Health Act gave local authorities the power, under certain conditions, to build sewers, establish a public water supply and to construct an isolation hospital. As well, street cleaning, rubbish collection, and disinfection services, along with other services, were to be carried out to protect the health of the public.

To reduce the person-to-person spread of tuberculosis it was necessary that each case first be recognized. Newsholme proposed that tuberculosis be added to the list of notifiable diseases allowed under the legislation of 1889. Failing to gain support for this idea from his fellow MOHs he turned to the use of voluntary notification. Brighton was the first town in England to initiate such a system. In 1897 the new municipal laboratory began offering free sputum examinations for medical practitioners; results were made available to the practitioner, but no official action followed a positive examination.

The reporting of positive cases led to more home visits to encourage the infected individuals to practice better personal habits. Disposable tissues and pocket spittoons were freely made available to poor patients. As well, a campaign against public spitting was started.

Brighton adopted the Notification Act in 1891, but by then Newsholme had already initiated a surveillance system using the household as the basic reporting unit. Once the reporting of certain diseases became mandatory, the home of each case was visited and the opportunity used to gather information on each member in the household as well as on past cases of disease. While using such studies to obtain a better understanding of the causes of epidemics, Newsholme also used household inspections to force owners to connect their houses to the sewer system and to fill in their cesspools. Within 10 years, all old cesspools had been destroyed and toilets were in everyone’s home. Inspections were also used to improve the drainage system, with particular attention given to preventing any sewer gases from entering the house, with the erroneous idea that such gases caused diphtheria, sore throat, and other serious diseases.

When he had first arrived in Brighton there was no clear strategy for dealing with tuberculosis. Koch’s discovery had little effect since the disease appeared too complicated to be explained by the mere presence of the bacillus. Tuberculosis’ high prevalence in the slum areas of the town led Newsholme at first to adopt an environmental approach with the hope that tuberculosis would decline as his slum clearance program advanced.

In the meantime he called for the use of disinfection (with the agreement of the family doctor) in the sickroom of patients to reduce exposure of other family members. Following any deaths he had his Sanitary Inspectors encourage families to wash the floor, ceiling and durable articles from the sickroom and strip and burn the wallpaper, and made chemical disinfectant free of charge for these purposes.

Newsholme’s successful career in Brighton led him to become a strong believer in government involvement in medicine (so-called state medicine), a belief that he promoted for the rest of his life. It is due to his work in the field of tuberculosis that Newsholme mostly owed his subsequent (1908) promotion to chief Medical Officer of the Local Government Board.

Newsholme’s counterpart in America was Hermann Biggs (1859-1923). Shortly after obtaining his medical degree from Bellevue Medical College Biggs became responsible for the Carnegie Laboratory at Bellevue, a laboratory built with a gift of $50,000 from Andrew Carnegie. Biggs used this laboratory to gain first-hand knowledge of common diseases in the New York area and to lay the basis for an important expansion of laboratory facilities.

Following the outbreak of typhus fever in the summer of 1892, the City’s Board of Health decided to create a new administrative division of Pathology, Bacteriology and Disinfection, with Biggs in charge. Biggs’ laboratory was the first health department laboratory in the world applying the new science of bacteriology to the routine diagnosis of disease. Charles Chapin, responsible health officer for Providence, Rhode Island, judged Bigg’s appointment as “perhaps, the most important step in modernizing public health practice in the United States.” Particularly important were the use of diagnostic testing in the control of diphtheria and tuberculosis.

Late in 1893, Biggs decided to take action against tuberculosis – “the most common and fatal disease… Over 30,000 deaths were reported to the New York City Department of Health as having been caused by the tubercular diseases during the five years ending January 1, 1893”. And this number did not include all those cases suppressed by physicians who wrote in some other cause of death in order for the patient’s surviving family to receive an insurance payment, since many insurance companies issued policies that did not pay any death premiums if death was due to tuberculosis.

Biggs program called for – (a) the laboratory examination of sputum to confirm the presence of the tubercle bacilli, (b) compulsory reporting and registration of cases, (c) official supervision of patients kept in isolation, (d) terminal disinfection of any premise where evidence of tuberculosis infection exists, (e) provision of hospital facilities, and (f) instruction to the public concerning the care of the disease. The London Lancet in 1894 called it “a bold experiment in sanitary regulation.” The medical profession, on the other hand, actively opposed it, especially the compulsory registration of consumptives. It was judged “offensively dictatorial and defiantly compulsory in character.” It would be “adding hardship to the lives of these unfortunates, stamping them as the outcasts of society.” It was simply “an extra bid for public applause (while) unduly magnifying the importance of (the) bacteriological department”.

The medical profession also strongly resented the notion that a simple bacteriological test could replace a diagnosis arrived at clinically. Biggs persisted, adding new directives as time went on, for example, making spitting in a public place a penal offense and destroying cattle found to be infected with tuberculosis.

Biggs recognized that complete success, i.e. elimination of tuberculosis, was not possible. But rather than accepting this as an excuse to do nothing to prevent it, he argued that:

If one-quarter of one-third can be eradicated there will be a proportionate gain, which will be increased each succeeding year. To individualize still more, it is certain that if an advanced case of pulmonary tuberculosis is taken away from the family in a tenement house, or is taught to carefully destroy his sputum, the chances of the infection of the members of his family or of the inmates of the house will be diminished, and with each source of infection thus removed a definite gain will surely follow.

The declining number of TB cases in New York seemed to confirm Biggs’ control philosophy. And not only did TB decline during those early years of his leadership. By 1900 the death rates of New York had reached new low levels leading him to claim in November 1895 “with certain limitations… the inhabitants of any city have it largely within their power to determine what degree of healthfulness their city shall have,” an idea that subsequently took the form, “Public Health is Purchasable».

Chapin, in Providence, chose not to move as strongly against tuberculosis as Biggs had. He feared that the opposition of private practitioners would jeopardize any such program. He did, however, support the examination and destruction of tuberculous cattle. Furthermore, he followed the course of tuberculosis in New York and other cities and from his observations was able to note in 1906:

The reduction of consumption in New York City is instanced as a brilliant example (of success). But in Providence, where very little has been done in the way of prevention, consumption has decreased nearly as rapidly and is less prevalent than in New York.

Following the discovery of the cause of diphtheria and the development of an antitoxin for treating cases of diphtheria, Chapin launched a campaign in the 1890s to eliminate diphtheria in Providence. Bacteriologically tested victims and carriers were isolated. Antitoxin treatment was made compulsory, and a comprehensive programme of disinfecting victim’s dwellings was carried out. This approach to disease prevention soon became the model for public health training and practice in the United States.

In America, William H. Park (1863-1939) definitively established the concept of the healthy carrier of diphtheria. Biggs was so impressed with the work of Park that he offered him the job of being responsible for diphtheria diagnosis for the city, a job that Park accepted in 1893. In families where diphtheria was present and where isolation was not practiced, Park found half of the children to be carriers (40% of whom later came down with the disease). Where isolation was practiced, this number was reduced to 10%. At the end of 1893 Park concluded, “Virulent diphtheria bacilli are present probably in about 1 per cent of the healthy throats in New York City”.

Like Hermann Biggs and William Park, Chapin asked for the reporting of all diphtheria cases, even handing out fines to delinquent doctors. He bought diphtheria antitoxin from New York and from the Pasteur Institute and made it available for free to Providence patients who could not afford to pay for it. He adopted Park’s diagnostic methods, making negative cultures a prerequisite before patients could be released from hospitals. In 1896 he went even further; all family members where there was a case of diphtheria had to show negative cultures before removing the placard announcing the presence of disease in their home.

However, as the presence of large numbers of healthy carriers made it more and more obvious that no system of isolation could hope to stamp out the disease totally, Chapin stopped using cultures to isolate cases and stopped trying to control healthy carriers other than among schoolchildren.

In 1901, during one the meetings of his Committee on Diphtheria Bacilli in Well Persons, which included public health specialists from a number of states, Theobald Smith, then Director of the Massachusetts State Board of Health Antitoxin Laboratory, observed that perhaps it was still worthwhile to reduce transmission among children. Chapin liked this idea, and asked the Committee to come up with specific suggestions for schools to take up, which led to:

  • Do not spit if you can help it. Never spit on a slate, floor or sidewalk.
  • Do not pick the nose or wipe the nose on the hand or sleeve.
  • Do not put the finger in the mouth when turning the leaves of books.
  • Do not swap apple cores, candy, chewing gum, half-eaten food, whistles or bean blowers, or anything that is put into the mouth.
  • Never cough or sneeze in a person’s face. Turn your face to one side.

Confounded with many other fevers, typhoid only gained an independent identification in the early part of the 19th century. Typhoid outbreaks at military camps led to intensive investigations to on cover its origin. Researchers were able to show in some instances that the affected camp had had arrivals of soldiers from an area in which typhoid fever was prevalent. Its spread could easily be imagined in the appalling sanitary conditions present in each camp – fecal-stained soil, clouds of flies, hardly any screening of mess halls and kitchens, and unprotected food was the common picture they found.

The most important factor in the spread of typhoid was personal contact between a well soldier and a sick soldier, either by his person, his clothing, his excreta, or articles that he had handled. Contaminated food and water played a role as well. A new finding was that the common housefly might serve as an agent to transmit typhoid bacilli from feces to food.

As a result of this research latrines were better constructed and better protected, and their contents were covered periodically with disinfecting lime; careless disposal of human excreta was forbidden; water supplies were protected from contamination by sewage; mess halls were screened, and food was protected from flies; and clothing and other articles that had been in contact with typhoid patients were either burned or disinfected.

The need to filter river water used to supply cities with drinking water was well established in Europe by the 1870s. With the discovery of microbes, however, it began to be obvious that the physical and chemical analysis of water needed to be complemented with a bacteriological one as well. Although most of the laboratory science emerged in Europe, it was America that took the lead in applying that science to the problem of purifying drinking water supplies.

The work of Sedgwick in Massachusetts led to important changes in the methods used to treat the growing volumes of wastewater produced by cities and towns. Intent on a career in medicine, Sedgwick entered the Yale School of Medicine in 1877 where he quickly came to the conclusion that that there was nothing to be learned there! This led him to shift to the field of biology, obtaining his PhD from Johns Hopkins in 1881. In 1883 he accepted an offer from an old teacher and friend to take the chair of biology at MIT. In 1888 he was named Consulting Biologist to the Massachusetts State Board of Health in 1888, a position that made him responsible for all of the early bacteriological and biological work at the Lawrence Experimental Station, which had been founded the year before.

Sedgwick and his students developed and applied techniques for the identification and quantitative analysis of the microorganisms in water and sewage, techniques that were then incorporated in the routine examinations conducted by the State Board of Health. Standards were established in 1890 that were adopted by health boards of other states. Sedgwick concentrated much of his attention on the study of typhoid fever. Its laboratories were largely involved between 1890 and 1893 in determining the means by which typhoid fever was transmitted. In their annual report for 1891 it was indicated that “typhoid fever is one of the diseases now generally attributed to one of the bacteria known as the typhoid bacillus”.

Sedgwick was asked in December 1890 to investigate a typhoid epidemic in the cities of Lowell and Lawrence. This provided him the first opportunity to apply the methods of the laboratory to the practical work of a field study. He visited every typhoid patient to determine the exact date of the onset of symptoms. Believing it to be primarily a water-or-milk-borne disease, he examined water from all five systems that provided Lowell with its drinking water. Although he was not able to isolate the typhoid bacillus from any of these supplies, this did not alter his idea concerning the mode of its transmission. Knowing that fecal bacteria were abundant in the water supplies, he concentrated on discovering where the typhoid bacillus might have been introduced into that system. He finally traced the source of infection to an outbreak of typhoid in Lowell’s neighboring village of North Chelmsford, while systematically eliminating all other possibilities.

He concluded:

We shall look in vain for any adequate explanation of the constant excess of typhoid fever in Lowell and still more in Lawrence except to the fact that both these cities have constantly distributed to their citizens water, unpurified, drawn from a stream originally pure but now grossly polluted with the crude sewage of several large cities and towns.

Other studies were conducted during the years that followed. In each Sedgwick was able to determine with some precision the means whereby water systems had become contaminated. All confirmed his original hypothesis. An outbreak of typhoid fever, in time, was regarded as “a reproach to the sanitation and civilization of the community in which it occurs”. As a consequence of Sedgwick’s report, Lowell abandoned the river and introduced a ground water supply, while at Lawrence a filtration plant was constructed which materially reduced the amount of typhoid fever in that city.

Another major step was the development of a vaccine against typhoid fever made from heat-killed cultures of the typhoid bacillus. Almoth Wright (1861-1947), a British bacteriologist and physician, was a strong advocate of using this vaccine to protect soldiers. He injected 4000 British soldiers in India in 1898-99 and, with William Leishman (1865-1926), a Scottish army doctor, about 100,000 British soldiers in the Boer War (1899-1902). Owing to a dispute concerning its efficacy, only those soldiers who volunteered for the experiment received the vaccine. Many chose not to be vaccinated, leading to loss to typhoid of some 13,000 men as against 8000 battle deaths during this war.

The American Army followed these studies and sent Captain Frederick  Russell (1870-1960) to Europe in 1906 to investigate the question further. He judged the vaccination to be “both useful and harmless». In 1909 Russell began an experiment of vaccinating the whole US Army against typhoid fever. By 1915 the incidence of typhoid in the Army was reduced to 3.24 cases per 100,000 troops. Such a low rate was not achieved in the civilian population until 1935. After a favorable review by a special commission in 1913 the British Army introduced it during World War I, with comparable dramatic results. Whereas the Boer War typhoid incidence was around 10% with a mortality of 14.6 per 1000, in the Great War incidence was down to 2%, with a minuscule death rate.

The control of typhoid in heavily populated urban centers proved far more problematic, especially as it too was a disease that could be carried by apparently healthy individuals; the history of Typhoid Mary bore witness to that fact.

Under the leadership of the previous Superintendent, Edwin M Snow, who had served for 28 years, Providence was one of the first cities in America to record births and deaths and to carry out demographic analyses, including the impact of immigration on the city’s growth. More importantly Snow had established a permanent public health department, one largely directed against ‘dirt’.

Providence’s water supply was a good one; its streets were relatively clean, and its homes were in good condition as well. Not all homes, however, were connected to the public sewage system and a majority of them had badly defective plumbing. This, plus hundreds of stables, polluted streams and unburied animals, joined to make Providence foul smelling and, if you were a believer in pre-microbial theories of diseases, an obviously unhealthy place in which to live.

Having come to the realization that odors, per se, were not public health dangers, Chapin had to overthrow centuries of belief to get the public to accept the program of his agency. As he described it later (1921):

The garbage pail, the manure pile, the cesspool, the privy vault, decaying leaves and rubbish, an odorous slaughter house, a public dump, a dead cat or a heap of oyster shells are still, in the minds of the public, a “source of sickness,” and it is still believed that it is the first duty of the health officials to cause their abatement.

Chapin used statistical methods that would become common place later, when the discipline of epidemiology took hold, to help him determine which conditions were associated with what diseases. By 1891 he was in a position to announce that there was “no causative relation between unsanitary conditions, as ordinarily understood, and scarlet fever, diphtheria and typhoid fever». He reached this conclusion by comparing the findings of six years of sanitary inspections of houses with the occurrence of these diseases. There were no significant differences, in terms of disease prevalence, between ‘clean’ houses and those whose plumbing was defective or whose yards were covered with garbage or whose cesspools were ‘filthy’. These findings were further supported by laboratory analyses that showed that germs were not easily given off from moist surfaces and rarely multiplied outside the body, a finding that strongly contrasted with what was being taught in Rhode Island as recently as 1878:

These germs, by their exceeding lightness … separating immediately in the sick chamber from the breath, perspiration, scaling off, or other discharge from the body, may rise and, floating about in the room, infect some unwary caller, to find lodgment in some nook or crevice, or on some shelf, moulding, sash, ornaments, curtain, drapery, or other clothing, to be again dislodged from their resting places, weeks, months, or years afterwards, to affect some casual visitor or new occupant, or be carried away in articles of furniture, ornaments, or wearing apparel, to spread infection and carry dismay to other persons and in other localities.

However, this did not prevent Chapin from using his authority to pressure for better living conditions. Periodically, he led campaigns to compel landlords to improve the homes and buildings they owned and let, saying, “I am not one of those who believe that the lowest classes of society can be raised to a high level by any one agency, be it sewers, Sunday schools or prohibition, but I know that clean and healthy homes will help do it». On the other hand, as he gathered evidence to separate out real public health work from those activities that pertained to the general improvement of the quality of life of Providence, he moved forcefully to off-load the latter to other branches of local government.

Commissioned by the American Medical Association (AMA) to report on State Public Health Work, Chapin then went on to develop a scoring system to rate each of the 48 states. It included 11 categories – Supervision of Local Health Officers (100 points); Communicable Diseases (160 points); Tuberculosis (140 points); Diagnostic Laboratory (80 points); Distribution of Sera and Vaccines (50 points); Vital Statistics (100 points); Child Hygiene (70 points); Education (100 points); Food (60 points); General Sanitation (40 points); and Control of Water and Sewage (100 points).

The highest-ranking state, Massachusetts, scored 745 points, with New York immediately behind it with 730 points. Several years later Chapin judged New York to be “the best health department in the Union,” and Biggs to be “the leading health officer of the country».

Chapin first admitted that his review caused a “feeling of discouragement… there is so much to be done and so little to do it with.” Nevertheless, he believed that progress was accelerating. The greatest hindrance was the “terrible incubus of politics.” It seemed incredible to him that “the citizens of an otherwise progressive state are content to see their health officers elected with no regard for fitness or training ….

Hibbert Hill, a physician who worked for the Minnesota Board of Health, was inspired by Chapin’s book to write a series of monthly articles in 1912. In 1916 these were brought together, expanded and revised into a book entitled The New Public Health. How, in America at least, did the ‘new’ differ from the ‘old’ public health. Following Chapin’s lead, Hill explained how when the Sanitary Movement had been launched in Europe during the first half of the 19th century it was believed that infectious diseases were generated in the “foul, ill-smelling, unventilated, sunless hovels of the slums». By living in such conditions the poor invoked the coming of smallpox, scarlet fever, typhoid fever, diphtheria and a host of other common diseases. For the well-to-do to fall ill, the explanation was sought elsewhere:

a pinhole leak in some plumbing fixture accounted amply for diphtheria; rotten potatoes, forgotten in a dark corner of the cellar, for typhoid fever; scarlet fever was traced to a letter bearing “scales” from a friend who had the disease months before; small pox to unpacking books used by a patient a quarter of a century previously; manure piles gave rise to cholera; and dampness to malaria, which was not recognized as transmissible at all.

Sanitary laws were passed that called for a general cleaning up of the environment in order to eliminate its disease-generating qualities. Knowing nothing of bacteria and viruses, the old public health was largely ignorant of the routes of transmission that each disease followed. Dirty cloths, bad smells, damp cellars, leaky plumbing, dust, foul air, rank vegetation, swamps, stagnant pools, certain soils, smoke, garbage, manure, dead animals … “in fact everything physically objectionable, were lumped together as ‘unsanitary’ without much distinction of source or route”.

The New Public Health, on the other hand, sought the sources of infection “and finds them” among “those infective persons (or animals) whose excreta or other constituents or body contents enter the bodies of other persons».

The essential change is this:

The old public health was concerned with the environment; the new is concerned with the individual. The old sought the sources of infectious disease in the surroundings of man; the new finds them in man himself.

Little was known, argued Hill, because the individual had been neglected and “excessive, misguided, attention” had instead been given to his surroundings. A focus on infected individuals promised to be more efficient. Hill used the example of tuberculosis to make this point.

Handling tuberculosis in a “general” manner would mean bringing the environment of a hundred million Americans up to some standard-level designed to maintain each individual in his or her alleged “highest state of health». Alternatively:

If, however, the infectiveness of the disease be the great factor, only 200,000 people (the actively infective cases) need this supervision in the United States, and they need it, not for the improvement of their “general environment,” but merely to prevent them from infecting others. This problem, even numerically, is but one five-hundredth the magnitude of the other. Consider the utterly impossible expense and difficulty of the attempt to insure only the four quoted factors,- good food, proper temperatures, temperance, and repose, – to one hundred million people (to say nothing of the other “factors of safety” called for by those who lay chief emphasis on control of environment, i.e. abolition of foul air, smoke, dust, damp cellars, bad smells, dirty back yards, etc.), and contrast with this the expense of supervision of two hundred thousand people merely to the extent of confining their infective discharges to themselves.

Hill resorted to this parable to clarify his approach to public health:

General Pershing was authorized, equipped, and sent to Europe for the one purpose of combating the Germans and defeating them. Suppose that, instead of his doing this, he had decided that the relief and reconstruction of the devastated areas were more popular, would get him more public sympathy, greater prestige, etc.

Good food, proper temperatures, temperance, repose and clean air constitute acts of relief and reconstruction; implicit in this parable is the clear message that health officers should refrain themselves from such activities and concentrate their efforts on freeing infected individuals from their infection and preventing them from infecting others.

No-one disputed that the battle against infectious diseases was the sine qua non of public health, but not all wished to ignore what today are called the socio-economic determinants of health. For example, Rosenau, who was Professor of Preventive Medicine at the Harvard Medical School and was one of the original founders (along with Sedgwick) of the Tech School for Health Officers, in his 1100 page book Preventive Medicine and Hygiene, referred frequently to the importance of these factors, e.g.

Poverty with all of its attendant hardships, such as poor food, bad housing, overwork, and worry, diminishes resistance to the infection [tuberculosis]; while prosperity, which buys good food, rest, change of air and scene, choice of occupation, and diversion, increases our resistance to the infection.

Carrying this to its logical conclusion led Rosenau and other social medicine advocates to call for the improvement of housing conditions, which not only diminished the spread of tuberculosis, but raised the standard of living, afforded better air and more sunshine, and tended generally to the well-being and uplift of mankind. Municipalities were called upon to “enact and enforce stringent laws regulating the construction of houses, offices, stores, and workshops.”

Less clear, however, was the implications of incorporating such factors into the undergraduate medical curriculum at the time. A curriculum committee organized by the Association of American Medical Colleges in 1923 called special attention to the increased requirement in hygiene and sanitation, noting that such a course “should deal with the fundamentals of the subject and lay the basis for a sound grasp of the problems of public health”. Preventive medicine, on the other hand, could not be taught as part of hygiene and sanitation because it “must of necessity deal more or less with the individual”, and in particular to the “prevention of disease”. If the physicians of the future “are in fact to be important agents in preventing disease they must have a sounder knowledge of the standards of health than has been the case in the past”.

It is not obvious at what point in his career Gunn began to pay attention to what was being taught in medical schools, but as time went on, he became more and more concerned as will become clear in later chapters.