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[OCT. 2, 1943ORIGINAL ARTICLES

MEDICINE AND THE COMMUNITYTHE TASK OF STATESMANSHIP

A SPEECH TO THE BRITISH MEDICAL ASSOCIATION

LORD DAWSON OF PENN, F R C P

PRESIDENT OF THE ASSOCIATION

MEDICINE does not stand alone, it stands in relationto the whole social organism. An upheaval at once so vastand universal as this war must change the texture ofcivilisation, ’and the changes will for the most part bethose already in seed or in bud, waiting for someimpetus to bring them to fruition. Land tenure, plan-ning for town and country homes, industry, socialsecurity, health and education afford examples and thereseems to be a common line of thought running throughthese projects-that the community must, in varyingdegrees, form a partnership with individual effort so asto give direction and equality of opportunity withoutblunting the enterprise and zest of individual man tothink and strive for the benefit of himself and his kindand thus preserve to personality freedom and scope.If in that.partnership the scales are weighted too muchin favour of community direction, the result will be regi-mentation and a deadening uniformity, and if weightedtoo much in favour of individualism the result will behaphazard and uncoordinated service ; thus the task ofstatesmanship is to find the mean.The.progressive quickening of the social conscience, an

outstanding feature of this century, has found expression.in the humanising of industry and in a body of socialefforts without precedent, and a body of legislation toimprove the health and welfare of the people. But ifwe pause to inquire whether the achievements of socialreform between the last war and this, as judged by theremoval of social inequalities and the establishment ofsocial justice, were effective, our answer would have tobe No. I need but instance housing, social security,medical services and education ; there has been andthere still is a sense of frustration in the community.To focus on our own special concern, is it not a reproach,

in view of the way medical knowledge has marchedahead, that a corresponding comprehensive health andmedical service has not been made available to allcitizens long ere this ? In this connexion the pioneerefforts of the medical profession stand forth to its credit,and I am going to stress that historical truth. From1920 onward it has, through various agencies, successivelyand consistently advocated a comprehensive medicalservice and cooperation between local authorities andvoluntary hospitals and agencies, and the latest of theseefforts is the Medical Planning Commission-a widelyrepresentative body. In contrast, the Ministry of Healthfrom the death of Sir Robert Morant in 1920 to nearlythe outbreak of this war, has cold-shouldered or opposedany such suggestions. It is only fair, however, to addthat those many years of obscurantism have given placeat the Ministry for two or three years past to enlightenedcooperation, and, let me say further, that the presentMinister, who is greatly interested in this reconstruction,has repeatedly stated that this comprehensive serviceshould be a partnership between the local authorities andvoluntary hospitals and that in the administration ofsuch a service doctors would play an important part.

Since the Interim Report of the Planning Commissionsaw the light of day the Beveridge report on SocialInsurance has come into the picture. Most of us wouldsay that greater security against want is socially just, butthe social-security scheme postulates Assumption B,which is concerned, with a nation-wide comprehensiveservice ; the inference is that the foundation of such aservice is an accepted policy, and incidentally it has wideand strong popular support.

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In recent weeks there has been public misunder-standing because discussion about the form of theservice has been interpreted as opposition to its founda-

. tion, and this has led to a considerable amount of criti-cism of the profession which shows at present little signof abatement. An illustration has arisen from themotion passed at yesterday’s meeting, when by a largemajority " a whole-time, salaried state medical service "was rejected. No less than 3 intelligent people said to

me last evening that they were surprised to see thatthe Representative Body had, after all, voted against a" state medical service," which is quite a different pro-position, for it is impossible to carry out Assumption Bwithout the state having a general direction.

Needless to add, in the shaping and organisation of theservice doctors must have a big say ; after all, they haveto work it, they know the complexities of medical practice,and they, with the public good in the forefront of theirminds and subject to the authority of Parliament,must carry a leading responsibility. Be it rememberedthat the changes in medical practice to be wrought aredeep and fundamental and will affect all members of theprofession, and no other nation, comparably placed, hasundertaken so big an endeavour. Is it not obvious,therefore, that this service must be built up in stages,in accord with the Prime Minister’s Five Year Plan,foundations first ? I will now consider one of these

, foundations. ’

Any service needs administrative direction. TheBritish Medical Association is an ’example. If properlydesigned that direction will not interfere with our freedomand the Minister has promised that the profession shallhave a large share in such administration. What, then,is the best form of local administrative body for thisservice, for that, after all, is the prerequisite to anyaction of any kind, and has to be settled first. Shouldthat local administrative body be the major local authori-ties ; or a joint board enbracing several major localauthorities with vocational advisory bodies attached(and that last is an essential condition) ; or should therebe large areas specially delineated for health purposes,each administered by a widely representative HealthCouncil ?The last idea is, to my mind, the most far-sighted and

attractive proposition; both for the public and thedoctors it offers the best prospect of future development.I hope the Government will give it favourable considera-.tion, but we must remember this, that the Minister ofHealth is between the upper and nether stone. On theone hand he has to pay attention to the medical pro-fession and wishes to do so ; on the other he has to carryalong with him the local authorities. Local authoritiesmight not be too eager to agree to the larger plans whichI personally would favour-health provinces adminis-tered by a representative health council.

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In the light of Assumption B, the Beveridge reportleaves to the medical profession and the community thedevisal of the comprehensive service. The social-securitypayment for sickness is only a maintenance payment,and the Beveridge report favours voluntary insurance tobe " jam " for the " bread." Here contributory schemeswould provide amenities according to the taste of thepatient. Supposing a grocer who by his industry hasbecome a successful man wants to provide his sick wifewith the comforts of a room in a pay block, is he to bedenied that privilege ? The service of medicine needs to beinfinitely flexible. Man sick is individualistic, and letus beware of the doctrinaires who think in terms oftyrannical uniformity, one of the faults of the Nazi creed.We want the same essential service for all-namely, thebest, but no dull uniformity with it. A comprehensiveservice free to all citizens does not necessarily involvea whole-time salaried service for all doctors, nor is itincompatible necessarily-I am not saying desirably-with private practice and pay blocks. Though, in mybelief, more earnings in the future will be derived fromsalary and less from fees, I am far from convincedthat any uniform system of service or payment willmeet conditions so multifarious as those attaching tomedical practice, and any emergence of official andnon-official groups of doctors would, in my opinion, bedisastrous.We must recall that one of the evil consequences of

the Ministry of Health not accepting the advice of theleaders of the profession in 1929 was that they therebyinstituted in any one town, two sets of hospitals andtwo groups of doctors. If they had then acceptedadvice and instituted machinery for progressivecoördination of local government and voluntary serviceswe should be much nearer our goal today than we are.Fortunately we now have at the Ministry a differentorder, anxious to work with the profession.

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Payment by salary, by fee, by capitation grant,separately or in combination, these admittedly thornyquestions can only find their solution in the light ofexperience. Any satisfactory scheme for a compre-hensive medical service can only be built up in stages-foundations first and soon, superstructure later andgradually in the light of accrued experience. Suchexperience could be obtained by different" try-outs"in different regions during an experimental period, andthat applies, for instance, to health centres. Customs,.habits and feelings, many of them centuries old, mustnot be suddenly uprooted, rather must the new order be ,gradually grafted on to medicines historic past. Suchis our English way. So following it, not otherwise, whenits re-orientation reaches completion medicine will havebecome greater in its comprehension and will offer toits disciples a life of fullness and content, and to thepeople a steadily enlarging prospect of health and welfare.

PATHOLOGY OF ACUTE HEPATITISASPIRATION BIOPSY STUDIES OF EPIDEMIC,ARSENOTHERAPY AND SERUM JAUNDICE

J. H. DIBLE, M B GLASG, F R C PPROFESSOR OF PATHOLOGY IN THE UNIVERSITY OF LONDON

JOHN McMICHAELM D EDIN, F R C P EREADER IN MEDICINE

S. P. V. SHERLOCKM B EDIN, M R C P *

RESEARCH ASSISTANT

DEPARTMENTS OF PATHOLOGY AND MEDICINE, BRITISH POST-GRADUATE MEDICAL SCHOOL

THE problem of jaundice in war-time is of such magni-tude that we decided to amplify and extend the biopsystudies of its pathology started in Denmark by Iversenand Roholm (199). Our main morbid histologicalfindings are presented in this paper with some preliminaryclinical associations. More detailed analyses of thetechnique and its applicability, and of biochemicalcorrelations, will be published later.

, TECHNIQUE AND RISKS

The technique is essentially that of Iversen and Roholm(1939). A small cylinder of liver tissue is aspirated intoa 2 mm. bore cannula passed transpleurally through ananaesthetised track into the right lobe of the liver. Thetissue is fixed in absolute alcohol, sectioned and stainedhistologically by standard methods, including glycogenstaining by Best’s technique.Though liver puncture for diagnostic and research purposes

has long been used in the tropics, it has not gained anypopularity in western countries on account of its undoubtedrisks. Yet it is probably safer than spleen puncture and ofmuch greater value. A survey of 613 published cases with6 deaths (Bingel 1923, Olivet 1926, Huard, May and Joyeux1935, Baron 1939, Iversen and Roholm 1939, Tripoli andFader 1941) shows a mortality of about 1%, mainly in severeanaemias (2 cases with haemoglobin under 15%), and in severeobstructive jaundice. We felt, however, that this risk couldbe considerably reduced by a careful selection of cases,precautionary measures such as are usual when - operatingon a jaundiced patient, and a close watch for, and prompt

transfusion in, haemorrhage. Moreover Iversen and Roholmhad claimed 160 punctures with no fatalities. No immediate

bleeding was recognised in any of our cases, but 3 out of 126punctures were followed by signs of haemorrhage within 24hours. Two were promptly transfused and gave no furtheranxiety. In the third, a severe case, the patient died and atautopsy acute liver necrosis was found. A fourth case,

already moribund from subacute liver necrosis with ascites,general paralysis of the insane and rectal carcinoma, de-

veloped signs of haemorrhage 48 hours after the punctureand considerable blood-staining of the ascitic fluid was

present at autopsy. The risks are thus maximal in themost severe cases. -

The technique, therefore, cannot be recommended as aroutine procedure. Applied with full knowledge of the risks,and under conditions permitting a close watch on the patients,it yields results of considerable-value, justifying its applicationto the research study of obscure cases of jaundice. No deathshave occurred in non-jaundiced cases in which there 7jnaybe an even wider field of application.

* Working on behalf of the Medical Research Council.

MATERIAL

Adult cases of epidemic hepatitis- admitted to thishospital during the year 1941-42 have been studied.The Army authorities cooperated in the investigation byputting at our disposal cases of jaundice developingduring arsenotherapy for syphilis. The American RedCross Harvard Unit also invited us to apply the methodin cases of hepatitis following the inoculation of mumpsconvalescent serum. To this group we add 2 cases ofjaundice which followed serum transfusions in thishospital (for burns and hypoproteinsemic oedema). Thecases can be tabulated as follows :

Cases Biopsies

Epidemic hepatitis .... 14156

18Arsenotherapy jaundice .. 35 56 3561Serum jaundice 7 8

Although there may be different aetiological factors ineach of the above groups, we have not found any r-ecog-nisable histological criteria for their differentiation. Ahepatic inflammation of varying intensity and distri-bution is common to them all, and therefore for purposesof pathological description we may disregard thissetiological grouping and consider the findings as a

whole.PATHOLOGY

The changes in the liver are related to the severityand duration of the disease. For purposes of com-parison we have dated the condition from the onset of

jaundice, although there is always a variable period ofdiverse prodromal symptoms.Broadly sneaking, the picture is one of hepatic cellnecrosis and autolysis, associated with leucocytic andhistiocytic reaction and infiltration. The centres of thelobules show the first of these changes most markedly,. .and the portal tracts the greatest cellular infiltration.In certain cases, which, seem to be either those which aremild from the beginning or in which the lesion is retro-gressing, the periportal cell accumulations predominatein the picture (fig. 6), in contradistinction to the moresevere cases in which hepatic cell degeneration is møre

pronounced and the histiocytic and leucocytic infiltrationmore widespread (figs. 1 and 4). For descriptive pur-poses we call the first of these the " zonal" and thesecond the " diffuse " type of change, but it must be,understood that there are no good reasons for regardingthese differences as fundamental, and that an inter-mediate picture occurs which we have denominated a" mixed" lesion (fig. 5). Finally, there are those casesin which the lesion is well on in the phase of retro-gression, or is progressing to a stage of necrosis, nodularhyperplasia or cirrhosis.

FREQUENCY WITH WHICH THE DIFFERENT PATHOLOGICAL

LESIONS WERE FOUND IN RELATION TO DURATION 03’

DISEASE AND INTENSITY OF THE JAUNDICE

* Duration 7-26 weeks ; only 2 slightly jaundiced.

In the table it will be noted that diffuse lesions areseldom encountered after the second week, and thatzonal inflammation tends to fall into two groups, one ofshort and the other of long duration. These correspondrespectively to early and mild lesions, and late resid7nallesions in cases which at an earlier stage presumablyshowed more extensive hepatic change.

HISTOLOGICAL EXAMPLES

We may illustrate the different degrees of intensity ofthe liver damage by reference to typical cases.

1. Severe, acute hepatitis, with a diffuse lesion affectingthe whole liver lobule.