TEXTBOOK OF PREVENTIVE AND SOCIAL MEDICIN: (A Treatise on Community Health BY J.E, PARK, BA,MD,DPH,FIPHA Professor of Preventive and Social Medieme MEDICAL COLLEGE, JABALPUR Second EditionPublished by Siar BaNaRsipaS BHANOT, MA 1268, NarieR Town JABALPUR, M P (INDIA) © ALL RIGHTS AND RIGHT OF TRANSLATION RESERVED ‘THIS BOOK 13 PROTECTED BY CoPpyRIGHT. NO PART OF IT SHOULD BE DUPLICATED ‘OR REPRODUCED IN ANY MANNER OR FORM WITHOUT THE WRITTEN PERMISSION FROM THE PUBLISHERS, Price Rs 35Preface to the Second Edition The reception of the First Edition of Textbook of Preventive and Social Meheme has been most favourable As the demand exceeded our expectations, the need to bring out a revised new edition became urgent In preparing this revision, no change has been made in the chapter arrangement, but every page of the book has been scrutinised to bring the book up to date. An attempt has been made to imcorporate new material, and remove that which 1s outdated Subyects such as medical geography and immunoglobulins are discussed for the first time. The chapters on Nutrition, Epidemiology, Family Planning and Concepts m Community Health have undergone extensive revision, The 1971 census data of India that has been published so far has been incorporated Several new illustrations have been added A much larger list of current references has been appended to each chapter to increase the usefulness of the book Although the temptation has been irresistable simply to add what 1s new, care has been taken to keep the book within bounds and the new material added does not exceed 90 pages. It is hoped that this edition will prove even more useful to students and teachers of preventive and socal medicine than the previous edition, I take this opportunity to express once again my gratitude to Mr. Banarsidas Bhanot who strove so energetically for mamtaming the general excellence of the publication. My thanks are due to Professor B G Prasad, Head of the Department of Social and Preventive Medicine, K. G Medical College, Lucknow for the constant encouragement and help I have had from him im the preparation of this book In conclusion, I wish to express My appreciation to Mr. Amnt Lal Parwar, and staff of Messrs Singha Printing Press for the gare they foal ae panting thir bok November 1, 1971 J. E PARK Menicat. Coitncn JABALPURPreface to the First Edition A textbook on Preventive and Social Medicine (Community Health or Community Medteme, as 15 being redesignated by the Indian Medical Council) has long been a_want. As a new discipline, textbooks on Preventive and Social Medicine or Community Health, have been few and students have been appearing for exammation in the subject without a textbook, or relymg heavily on books on Hygrene and Public Health which do not present the subject im its modern concept As a teacher of over a decade, the author felt the necessity Of bringing out a textbook which reflects the great changes made im recent years im the approach to the subject Spetialization 1s a hallmark of modern times, and Preventive and Social Medicine 1s no exception Each chapter (eg, genetics, sociology, nutmtton, epidemofogy) is in fact the domain of a specialist, there are even single diseases (eg, tuberculosts, malaria, leprosy} which enjoy considerable specialization Considering the diversity and vast scope of the subject, covering as it does from “womb to tomb’, it has been quite a difficult task to synthesize the available information and to bring the book up-to date Preventive and Social Medicine differs from non clinical and clinical subjects m the respect that the brand‘ of PSM or community health vanes from country to country because of divergent geographic, environmental, social, demographic, economuc, cultural and health characteristics — nay, there are variations even within the same country An attempt has been made to Present the subject matter from an Indian standpoint, but the book may be just as useful in all countries where the subject 1s taught All contnbutions on the subject have been freely consulted and m this connection special mention must be made of the publications of the World Health Orgamzation, reports of the Government of Indra and books on related subjects, Indian and Foreign At the end of each chapter, a hist of references 1s given which does not however represent a com plete bibliography on the subject Acknowledgements are made under references at appro priate plates throughout the text, any omission of acknowledgement of phraseology of Others which ts inevitable in a book of this kind has not been wilful and the author craves indulgence of such lapses ‘The author wishes to render his thanks to his father, Dr S D Park for makmg thts publication financially possible, to Mrs Dorothy L Bradley, American Peace Corps Volunteer attached to this department, for helpful assistance with the manuscnmpt, Dr K. K Kaul, Head of the Department of Paediatrics, Medical College, Jabalpur for valued help in proof readmg Dr Y G Rao, Reader im Anatomy, Medical College, Jabalpur for bis con- stant encouragement, and Dr Kumud Bhanot for undertaking the arduous tash of compiling the mdex The author owes a debt of gratttude to Mr Banarsidas Bhanot who spared no pains in bringing out this publication In addition, the author wishes to express hts thanks to many authors and publishers, meluding the World Health Organization for permussion to reproduce iMlustrations from their pubhcations acknowledgements are given im the legends of the figures ‘The author expresses his grateful thanks to Professor B G Prasad, Head of the Department of Social and Preventive Medicine, K G Medical College, Lucknow and Professor Rameshwar Sharma, Head of the Department of Preventive and Social! Medicine, SMS Medical College, Jarpur for kindly consenting to write the foreword Lastly, Special appreciation ts extended to Mr A. L. Parwar and staff of Messrs Singhai Printing Press, Jabalpur for the great care they bestowed in printing the book july 1, 1970 ARK Mieke Courcr IEP JABALPURForeword to the First Edition When we were asked by Professor J E Park to write a foreword to his book ‘Textbook of Preventive and Social Medicine {A Treatise on Community Health) we wondered how a single author could produce a textbook on such a subject which covers not only diverse fields but has grown im concept and approach rapidly during the past two decades, This was before we had seen the manuscript After having had the privilege of seeing and studying it we realise our fears were completely unfounded Dr Park was silently working on this monumental work. to meet the long felt need of a comprehensive textbook containmg not only the newer concepts and up to date information, but also data relevant to India This is probably the first textbook im India on Preventive and Social Medicine (Community Health) which has opened up new homzons im giving a clear concept of the Subject to students Some of the outstanding features of this book are tts comprehensiveness, organization of chapters and ther contents along with a bibliography Its clanty and the beautiful format and clear print on good paper makes the book a joy to read This book, 1t 1s hoped will meet the pressing need of teachers and students im preventive and social medicine (community health) not only in India but also abroad and in particular developing countries The author and publisher are both to be congratulated on the production of a medical book which probably is the best textbook on the subject published in India Rearnnclaw Lows BG Read ————— (RAMESHWAR SHARMA ) (BG PRASAD) MD MPH Harvard) MD DPH DTM FAMS Profe sot afd Head of the Professor and Head of the Deparument of Preven ve and Socal Med re Depa tment of Soc al and Preventive Med ¢ ne SMS Med cal College Ja pur RUG Medcal College Lucknow March 30 1970Contents Chapter +l Primitive Mepicine To ComMUNITY HEALTH + 2 Conceprs mv COMMUNITY HEALTH V4 Genetics anp Heaurit \ A Sociology AND Heatmt~ . AC wemetion AND Hemme Ni 6 ENVIRONMENT AND HEALTIV 7 EPIDEMIoLocy ¥ u—8-* FAMILY, PLANNING Xs RREVENTIVE MEDICINE JN ORSTETBICS, Paep! ICS_AND_ GERIATRICS ATR eee 10 Occupanional Heath +” Dy Mental Heautir 12. Mepicar Statistics 134 Epucation For Heautiy” oe eit } ADMINISTRATION FoR HEALTH 15 INTERNATIONAL HEALTH INDEX Page i 45 58 92 168 233 — 561) 595 624 628 67 685 745 187Jead and copper salts were all used by the Egyphan physicians The Egyptians wor- stupped many gods Imhotep was their god of medicme, to whose name temples were erected The Egyptian physicians were tramed in those temples Specialisation prevailed in Egyptian times There were eye doctors, head doctors, tooth doctors, etc All these doctors were officials paid by the State Homer, speaking of the doctors of the ancient world, considered the Egyptians to be “the best of all’? In the realm of public health also, the Egyptians showed much progress They built planned crtres, public baths and underground drainage systems which even the modems might envy They had also some knowledge of inoculation against smallpox, the value of mosquito nets and the association of plague with rats Their god of health was Horus Egyptian medieme occupied a dominant place im the ancient world for about 2500 years, when it was replaced by Greek medicine Indian Medicine The medical systems that are truly Indian am ongin and development are the Ayurveda and Siddha systems Ayurveda 1s practised throughout India but the Siddha system 1s practised mamly in the Tamil speaking areas of South India. These systems differ very Little both in theory and practice? Ayurveda by definition imphes the “science of life , not a science of disease Its ongin 1s traced far back to the Vedic times, about 5000 B C. According to some authorities, the medical knowledge im the Atharvaveda (one of the four Vedas) gradually developed anto the scence of Ayurveda The develop ment of Ayurveda was slow until we come to the penod of Atreya (about 800 BC) Atreya 1s acknowledged the first great Indian physician and teacher He lived in the ancient university of Taxila, about 20 mules west of modern Rawalpind:* Aynrveda wit 2 nessed tremendous growth and development during the Buddiust times King Ashoka (226 BC) and the other Buddhist kings patro- mised Ayurveda as state medicine and estab- lished schools of medicine and public hos pitals Charaka (200 AD), the famous ancient Indian physician, was a court physt- cian to the Buddhist king, Kaniska Based on the teachings of Atreya, Charaka com piled Ins famous treatise on medicine, the ‘Charaka Samhita’, which ts the first docu- ment of Indian medteine Similarly, Susruta of Benares compiled the vast knowledge handed down from generation to generation in his classic, the ‘Susruta Samluta" It 1s beheved that this document was compiled between 800 BC and 400 AD Susruta Samhita deals at length with the surgreal aspect of early Indian medicine The early Indians set fractures, performed amputations, excised tumours, repaired hernias and did couching for cataract* It is sad that dur- ing the Buddhist times, Indian surgery suffer- ed a set back because of the doctrne of ahmsa or non yrolence Of significance in Ayurveda 1s the tridosa theory of disease The dosas are three+ they are vayu, pitta and Kapha. When they are in their normal state they are beneficial to the body, when they become disordered, they afflict the body with diseases of diverse kinds* This theory 1s similar to the theory of four humours im Greek medicine Medical historians admit there was free interchange of thought and expenence between the Hindu, Arab, Persian, Greek and Jewish scholars Hygiene also played a very impor- tant part m Indian medicine The laws of Manu are a code of personal hygiene Dhanwantri (1500 BC.) 1s said to have prac- trsed inoculation agatnst smallpox TI golden age of Indian medicine was betwee 800 BC. and 600 AD Durmg the Mogh period and subsequent years, Ayurvec declined due to lack of state supportMention must be made of Homoeopathy Although not of Indian origin, Homoeopathy ts farrly widely practised im India Its orig nator, Samuel Hahnemann (1755-1843) was a German Homoeopathy may be described as a method of drug therapeutics in which the remedy 1s selected on the ground, of its power to produce im the healthy a disturbance of health stmiar to the disease condition of the patient That 1s, any drug or agent which 1s capable of producing symptoms similar to the symptoms of a disease will cure the same symptoms in disease provided the said medi- cine 1s administered in smaller quantities than the quantity required to produce symptoms Thus Hahnemann put forward a new concep- tron in disease treatment Samba Srmiltbus Curantur, 1¢, let likes be treated by likes The Indian systems of medicine are very much alive in India even today There are about 9,000 Ayurvedic dispensaries in this country maintained by the State Governments, Local Bodies and Voluntary Organtzations An autonomous Central Councrl of Research in Indian Medicine and Homoeopathy had been constituted by the Government of India for encouraging scientific research into vari- ous aspects of these systems The Govern- ment of India have also introduced a Bill in Parlament to establish a Central Council for Indian Medicine and Homoeopathy with a view to regulate practice and also to maintain a uniform standard of education in these systems 7 Chinese Medicine The Chinese medicine goes back into the distant past — about 2700 BC. Surgery was rudimentary Medicine was based on two principles the yang and the yin The balance of these two opposing principles (the yang was imagined to be an active masculine principle of vital warmth, the yin a negative feminine principle) meant good health The Chinese has a vast armoury of medicines to relieve various illnesses Some of their remedies were — rhubarb, oprum, mercury and arsente, which are sull in use The Chmese were early pioneers of um- munization They practised vanolation to Prevent smallpox Hygiene, dietetics, hydro- therapy, massage and drugs were all used by the Chinese physicians To a Chinese, “the great doctor 1s the one who treats not some one who 1s already ill but someone who 1s not yet sll’ Even today, the proportion of traditional ta European style doctors shows the Chinese fidelity to their ancestors, one modern doctor to three traditional ones* Greek Medicine The Greeks earned the reputation — the avilsers of the ancient world They taught men to think in terms of “why” and ‘ how” They looked upon disease, as a natural pro- cess, not a visitation from a god of immola- tion They placed greater relance on rest, diet, graduated exercise and baths in treat- ing diseases than on undue medication An early leader in Greek medicine was Aescu- lapius (1200 BC) whose daughter Hygiea was worshipped as the goddess of health By far the greatest Greek physician was Hippo- crates (460-370 BC) who is often described as the “father of medicine” He stressed the importance of preventive medicine as distinct from curative medicine. He studied such things as chmate, race, water supply, housing, clothing, halts of eating and drnkmg and the effect they had in producing 1I1 health and disease His book, Atrs, Water end Places was indeed a treatise on social medi- cine for he stressed the importance of the environment on the health of the community Hippocrates also studied the rise and fall of emdemic diseases * Hippocrates was also a shrewd climeian He studied and classified diseases in a scientific way and left us a nich store of his observations in his collection of papers, the 3‘Corpus Hippocraticum". His famous oath, the Hippocratic Oath, 1s the hasts of medical ethics even today The Greeks were great behevers in the theory of humours — blood, phlegm, yellow bile and black bile When these were in balance there was a state of health This theory 1s stmilar to the tr:dosa theory in Ayurveda We owe an enormous debt ta the Greeks for separatng medicine from magic and raising it to the status of a science They had a scientific method, although not scientific knowledge. The glory of Greece faded away, but not their contri- bution to arts and science Roman Medtcine: ‘When the great days of the Greeks ended, the centre of civihzation shifted to Rome The Romans borrowed their medicme largely from the Greeks whom they conquered, but added hittle to Greek medicine The Romans were a more practical minded people than the Greeks Their main contribution was in the field of pubbe health and sanitary engi ucenng They made fine roads throughout their empire They brought pure water to all ther cities through aqueducts, They drained marshes to combat malana and built sewage systems, fine market places and bath houses, They made strict laws and compelled people to obey them They even established hospitals to care for the sick The medical men of note in Roman times were Celsus (25 BC — 50 AD) who gave us the cardinal signs of imflammation, and Galen 31 — 200 A.D) who laid the foundation of expenmental physiology Galen observed that disease was due to three factors — predisposing factors, exciting factors and environmental factors, 2 truly modem 1dea An author of some 500 treatises on medical subjects, Galen was literally a “medical dictator” aim Ins time His wntngs were accepted as standard medical textbooks in medicme for centunes after is death With 4 the fall of the Roman empire, the science of medicine also fell away Middle Ages The mediaeval period (600 — 1400 A.D) 38 called the “The Dark Ages” of medieme. Dissection of the human body was probubit- ed, and there was no progress :n anatomy and phystology The history of Europa m those days was the history of typhus and plague, of rats, hee and men In 1348, the Black Death devastated Europe and England The Jack of scientific knowledge promoted super- stihon m medicine Saints were invoked for the cunng of diseases — St. Sebastian for plague, St. Clare for sore eyes, St Appoloua for tooth ache, etc” However, the Arabs stole a march over the rest of ervilization They translated the works of Hippocrates and Galen and pre served much of the Greeco Roman wisdom. They founded schools of medicine and hospitals in Baghdad, Damascus, Caro and other Muslim capitals ‘The Arabs it a brilliant torch from Greecian lamps’ says Osler Two Arab physicians are outstanding namely Rhazes (860 — 932 A.D) who was the first to differentiate between smallpox and measles, and Avicenna (980 — 1037 AD) who was the first to describe the guinea worm They both have many contnbutions to their credit. The greatest contnbution of Arabs in general was in the field of pharmacology They mtroduced many drugs— benzoin, camphor, saffron, myrrh, musk, senna etc The words drug, alcohol, syrup, sugar are all Arabian'® The golden age of Arabian medicme falls between 800 — 1300 AD When the muslims invaded India in the 12th century, they brought with them ther Greeco Arabian system of medrcime, which is popularly Known as the Unam system of medicine By the 13th century, the Unant system of medicme was firmly entrenched in certam places notably Lahore,Lucknow, Hyderabad, Ahgarh and Delhi By the time of Mohammad bin-Tughlaq (1325—- 1352 A.D) there were almost 70 hospitals in Delhi region itself‘ There are many Unant schools of medicme im India today where this system of midicine 1s taught Revival of Medicine Medicine which was long in the bondage of superstition and speculation began to emerg* aS 2 true science as new discoveries were made and human knowledge advanced Fracastorius (1484 — 1553) enunciated the “theory of contagion’ and explained the cause of epidemics He became the founder of epidemiolagy He alsa predicted the existence of the “seeds of disease” which multiply and propagate Medicine was revived by Paracelsus (1490 —~ 1541) who publicly burnt the works of Galen and attacked superstition and dogma in medicine. Vasahus (1514 — 1564) did a lot of dissec- tions on the human body and founded ana- tomy Ambroise Pare (1517 — 1590) revived surgery and became the father of modern surgery In 1540, “The United Company of Barb r Surgeons” was established in England which became Jater the Royal College of Surgeons The 17th century wis full of even more exciting discoveries in medicine = Wilham Harvey (1578 — 1657) discovered the circu: lation of blood tn 1613 and made modern physiology possible Leewenhock (1632 — 1723), a Dutch merchant made his own mucroscope and discovered the existence of microbes Thomas Sydenham (1624 — 1689), an English phystcan turned the minds of people from speculation to the bed side study of mediane John Graunt (1620—'74), a contemporary of Sydenham studied the Bills of Mortality im England and Jad the foundation of vital statistics Further adyances were made during the 18th century John Hunter (1728 ~— 1798) laid the foundation of surgical pathology The discoveries of James Lind of the pre- vention of Scurvy in 1753, and of Edward Jenner of the prevention of smallpox in 1796 revolutionised the concept of preventrve medicine. A new cra was born, an era of sp*cific dissase prevention Ramazzm, early m the 18th century inaugurated the study of occupational diseases and became the father of occupational medicine Mendel fonnded the science of genetics in 1866, and Francis Galton founded the scrence of eugenics in 1883 Medicine thrived on these advances The Rise of Public Health The birth of public health occurred m England around 1840 The evils of the industrial revolution on one hand, and the visitations of cholera on the other, led to the rapid growth and development of public health in the western world The industrial revolution of the 18th century brought in its wake new problems to society — creation of slums, accumulation of refuse and human excreti, overcrowding, women and child health and social problems, industrial and crowd diseases. Cholera, which 1s often called the ‘father of public health” hut the western world in the first quatter of the 19th century Johanna Peter Frank (1745 — 1821), a hberat health philosopher of his trme, con- ceived public health as good health Jaws enforced by the police, and enunciated the principle that the State 1s responsible for the health of the people The great cholera epidemic of 1832 led Edwin Chadwick (1800 — 1890), a lawyer in England to in- vestigate the health of the inhabitants of the large towns with a view to improving the condittons under which they lived" Chadwick’s report on “The Sanitary Condi- trons of the Labourmg Population” (1842) focussed the attention of the people and government on the urgent need to improve 5public health Filth was retognised as man’s greatest enemy, and with this began an anti- filth crusade This great movement, often described as the “great samtary awakening” led to the Public Health Act of 1848 mm England, and acceptance of the principle that the State 1s responsible for the health of the people, Cholera continued to occur time and again m the western world dunng the 19th century In 1854, John Snow in London, by tireless epidemiological inveshgations pro- duced evidence that cholera 1s a water borne disease. In 1856, Wilham Budd, another pioneer produced similar evidence about typhoid fever These two discoveries pin- pointed polluted water as the clef culpnt m the spread of cholera and typhoid fever ‘Then came the demand from people for clean water A comprehensive piece of legislation was brought into force in England, the Pubhe Health Act of 1875 for the control of the physical environment and public health The torch had already been ht by Chadwick but the man who was responstble more than any other for samtary reforms m England was Ste John Simon (1816 — 1904) He built up a system of public health which became the admuration of the rest of the world* The development of the public health movement in America follows closely the Enghsh pattern In 1850, Shattuck, a book- seller and publisher, publishea hus report on the health conditions in Massachusetts Like Chadwick's report, it stirred the conscience of the pzople to the :mprovement of public health, France, Spain, Austra, Germany, ttaly, Belgium and the Scandinavian countries all developed their public health, By the begmaing of the 20th century, the broad foundations of public health — clean water, clean surroundings, wholesome condition of houses, control of offensive trades, etc. were laid in all the countnes of the civiksed world After the First World War, there were three 6 particular new comers to the public health scene — Yugoslavia, Turkey and Russia These three countries in 1920 presented the typical picture of the under-developed world Today, they are quite advanced in public health India entered late into the public health scene, in 1920s after the Govt of India Act (1919) had transferred health admumstration to the provinces. The public health mm India 18 mperfectly developed, and we have yet to witness the “sanitary awaken- mg’ among the people After the Second World War many new countries have jomed the public health movement, under the im- fluence of the World Health Organization Changing Concepts in Public Health: Public health during the 19th century was largely a matter of samtary legislanon aimed at the control of the physical environment. But good health cannot be legislated. There- fore, a new public health concept began its development at the beginning of the 20th century, the concept that the community has a direct responsibility for the health of the individual It was imthated as mother and child health services. School health services were developed concurrently Child health cluics and maternity chmics were established by the health departments. Public health nursing was a direct outgrowth of this con- cept. Initially these services were planned for the poor, and not for the community at large? Gradually the idea grew that every well individual m the community 1s a com- munity asset and a sick person 1s a com- munity habiity People began to estimate the “money value" of man Thus there developed the concept that a healthy people as a nations greatest resource The em- phasis in public health shifted to conservation of individual health, not only of the poor but of every citizen Then came the mdust- nal health services, accident prevention and mental health services within the purview ofpublic health Aga, during the past fwo or three decades, public health in the affluent societies began te assume new responsibilities sn the field of chrome diseases and rehabilitation Heart diseases, arthmitis, cancer, diabetes, hypertension, glaucoma all came into sharp focus a8 community health problems largely because of an ageing population Public health 1s now engaged in this broad field of effort ** A further development in public health was proposed by the sociologists, that the community should assume responsi- bihty for development and support of ail necessary facilities for protection and pro- motion of health*’ This imphes adequate medical care for all, the provision by the community of faciltres for comprehensive preventive and curative medical services for all citizens With these developments, the term public health 1s being replaced by the term community health m many places Com- munity health or modern public health 1s quite different from public health of a gene- ration ago Jt encompasses ail those actt vities which individually and collectively contribute to the maintammg protecting and improving the health of the people While public health has made rapid stndes m the developed countries the post tion ts quite different in the uaderdeveloped countries such as India where the mam public health problems are those faced by the western world 100 years ago — environ mental sanitation problems, communicable disease problems, sutmtional problems and certan medico social problems such as illsteracy, sgnorance, preyudicial social cus toms and behets, low standards of Irving and to top it all, the more recent population explosion The winds of change have reached the underdeveloped countries and they are making frantic efforts to catch up with the more fortunate countries in every sphere of endeavour The goal of modern public health has been set by the World Health Organization (1948) — ‘ the attainment by all pronle of the highest possible level of health’ Like any other ideal, it may be difficult to attain, but it does set the standard for the basic philosophy of modern public health The Growth of Preventive Medicine The science of preventive medicine really dates from the 18th century James Lind, a naval surgeon advocated the intake of fresh frmt and vegetables for the prevention of scurvy in 1753 Edward Jenner of England discovered vaccination against smallpox in 1796 These two discoveries matked the beginning of a new era, the era of diszase prevention by specific measures Spectacular advances in preventive medi cme occurred only after the discovery of the causative agents of disease The discoveries of Lows Pasteur (1822 — 1895) and Robert Koch (1843 ~~ 1910) fad the founda tion of preventive medicine Pasteur s work Jed Lister (1827 —- 1912) to bus great dis- covery of antisepsis During the latter part of the 19th century and early 20th century, disease agents were discovered one after another, in rapid succession — matanal parasite (1878) anthrax (1881), tubercle bacillus (1882), diphtheria bacillus (1883), cholera vibrio (1884), typhotd bacillus {1885} and seyeral others The “germ theory" of disase was firmly established Medtcine finally shed the rags of superstition and sp culation and put on the shining robes of scientific knowledge In the wake of these discoveries, the concept of disease preven- tion by specific measures gained momentum. Pasteurs discovery of ant:rabtes vaccine led others to undertake research in ammuno+ logy ‘Von Behring (1854 — 1917) discover- ed the prinerples of serum treatment Anti- diphtheria and anti-tetanus sera were soon perfected Almoth Wright (1861—1947) in Engiand did pioneer work on immunisation q