Medical revolution; a plea for national preservation of health based upon the natural interpretation of disease

Preface

Even in such a short and imperfect sketch of medical reform as this is, many details must be introduced that may well seem at first sight somewhat bewildering to the layman. The adjustment of details will occupy much time, and this adjustment belongs exclusively to the profession; but the question whether reform is needed or no, turns on a broad and simple issue that is as comprehensible to the laymen as to the professional man.

When Darwin had finished his marvellous scientific work, he affirmed the natural origin of species ; we accept this conclusion without possessing any knowledge of natural history whatever, and why? Because once our eyes are opened we can see for ourselves that his interpretation is in accordance with facts.

The natural interpretation of disease is a corollary of Darwinism; no one denies that occurrences of tuberculosis, plague, scurvy, heat-stroke, are natural processes, that they arise in accordance with the unvarying sequence of cause and effect. The fundamental question at issue between the medical authorities and myself is, whether there is any longer any justification for interpreting some of the' processes of disease on an artificial system, now that the natural method based on causation has been recognised. All that has been written here is intended simply to illustrate this central dispute, and to show how prac-

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tical results in medicine follow inevitably the theoretical views that dictate them.

There are two reasons, generally quite sufficient, why the regular practitioner should not address the public on professional matters. In the first place, it may lead consciously or unconsciously to advertising; in the second place, it may lure the layman on to morbid self-examination. The first reason does not apply to the retired practitioner. As regards the second, nothing could be further from my intention than to give the layman any encouragement, or even excuse, to enter the slough of despond that belongs to the quack and the self doctor er; I have a firm and conscientious belief that the desertion of the regular profession leads always and inevitably in the wrong direction.

I have felt bound, nevertheless, severely to criticise some of the scientific and practical methods of the regular profession, and to suggest drastic changes. These criticisms and suggestions have been put as shortly and pointedly as possible, so that any one of average intelligence, inside or outside the profession, may follow and judge for himself. Whatever technical matter is introduced is only intended by way of necessary illustration; it is hoped it may prove sufficient, and yet not copious nor obscure enough to bewilder the layman.

It is now nearly forty years since observation from without convinced me that medicine had lagged behind the other sciences in the advance of the Darwinian epoch, and stood therefore in urgent need of revision. So definite was this impression that it was formulated, in speaking to a friend, by saying that the time had come for a physician to put medicine in

PREFACE IX

order as Darwin had revised natural history. More than thirty-five years of observation and reflection from within have given this impression definite shape. It is now quite clear to me that medicine is hampered with a false interpretation of the processes of disease, just as natural history was confused, before Darwin's time, by a false interpretation of the origin of species ; our undefined diseases seem to me to offer a strict parallel to the specially created species of pre- Darwinian natural history. l But there is a difference between medicine and natural history that I was not then in a position to realise : natural history belongs entirely to pure science; the end and object of medicine is practical. Darwin studied for the sake of pure knowledge, however usefully this may be applied by others; the physician's business, although primarily scientific, is to take charge of patients.

When Darwin had overcome professional and theological prejudices, the science books were put in order, and there the matter ended; the mass of humanity remained unconcerned and passive, because Darwinianism did not touch their life directly. Medicine contains a huge personal element that makes the physician's task utterly different. One man put natural history in order in the course of a few years; the work of one man, or of a whole generation of men, will not do so much for medicine; the individual physician can indeed do no more than set up a fingerpost to guide those who come after him.

My object, therefore, is to lay bare a false interpretation of Nature that still vitiates the scientific method of medicine; and, further, to show how the adoption of the natural interpretation of disease

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would introduce order and uniformity into all our methods, both scientific and practical.

My thanks, in connection with the production of this book, are due first and foremost to my brother Herbert. But for his comprehension, sympathy, and help — extending over many years — it would probably never have been written. Mr. G. Montagu Harris has also, for several years, given most valuable aid. He has read my work, and has pointed out, as only one of clear and cultivated intelligence could, the difficulties of the layman in face of medical matters. Mr. and Mrs. Sidney Webb have taken a most friendly and active interest in the production of the book. Their help, owing to their unique position in the field of social reform, has been invaluable. When the time came for the final reading of manuscript, and other essential steps towards production, Mr. F. James Matheson, representing Messrs. P. S. King & Son, brought both capacity and enthusiasm to my help. His suggestion, tending towards better English and greater clarity, are scattered all through the book.

Contents

PAGE

Preface vii

I. Introductory i

II The Evolution Of Medicine

At the very outset, the reader must be reminded that medicine consists of two wholly distinct parts; it includes a pure science and an applied science, or scientific art. The fact that the physician * is scientist and practitioner in one has led to much confusion, even inside the profession; it is well, therefore, to draw a parallel. Navigation is an art, a scientific art; it is founded on pure science, on astronomy. The sailor who guides his ship to the Antipodes uses astronomical knowledge in just the same way as the physician uses pure science when he vaccinates against smallpox or typhoid fever. Science has been well described as organised knowledge of Nature, and of this great whole, medical science is a branch ; it is our organised knowledge of human disease. One of the leaders of English medicine has described my work as, " a bold attempt to make of medicine an exact science," and has condemned it accordingly ; because medical science is not supposed to have any claim to rank among the exact sciences.

With all due deference, I must protest that this statement represents a certain confusion of mind, a tendency to confound natural phenomena with our attempts to interpret and record them. There is, ac-

1 As a distinguished physician has said : " It is time to discard that mongrel word ' doctor ' and to restore the good old English word ' physician.' "

cording to the theory on which I work, no more inexactness or uncertainty in the occurrence of the processes of disease than there is in the genesis of those other processes that go to make up the province of the astronomer, the chemist, or the engineer. But our observation and records of any of these processes can never be free from inexactness; medical science, a record of natural processes, is just as exact as we can make it, so is the science of astronomy or of chemistry.

The territory of Nature has been more or less arbitrarily divided into provinces, and each province has been allotted to a body of scientists for special study; the processes, of disease form one of these; the same limitations hold for the physician as for his brother scientists, but he is not separated from them by any natural division ; we all reach broad truths, but the details of astronomy and of chemistry are no more exact than are the details of medical science. Not unless Nature became her own recorder should we reach exact science, and then it would be comprehensive as well as exact.

The question whether the supernatural enters into the causation of disease is not for argument; it is part of the greater question that was, for scientific purposes, settled in the last century. When Darwin affirmed the natural origin of species and the evolutionary descent of man, he said that the truth or falsehood of his theory could not be settled by argument, that the decision must rest on observation of Nature. The natural origin of disease processes is the axiom on which rests all that is here to be said, and this is claimed as a plain corollary of the Darwinian theory. If man is subject as to his origin and condition to

THE EVOLUTION OF MEDICINE 9

the same- invariable sequence of cause and effect as rules elsewhere in Nature, then so also are all those phenomena that go to make up human disease. There is no room for argument on the subject, nor for compromise; some minds postulate supernatural interference, some do not; I proceed on the theory that the processes of human disease occur in accordance with the natural, invariable sequence of cause and effect.

Its two component parts must thus be borne separately in mind while glancing at the evolution of medicine. It is at once evident that the art is much the older of the two ; the beginning of the art of medicine, indeed, takes us back far beyond the origin of the human race; for there is no difficulty in discovering attempt amongst the lower animals to escape the pains and penalties of disease. And amongst primitive men, medicine is represented by efforts to escape disease that are almost unreasoning. Pure science, organised knowledge of disease, cannot be said to exist as a foundation of primitive medicine. Just as there is no line to be drawn between the nebular state of our system and the highly differentiated condition of matter as we now know it, so is there no difference, but one of degree, between the nest-building art of the earthworm and our highly elaborated art of medicine; " art is but a part of Nature." The worm knows, when the autumn comes and the leaves fall, that he must build his nest at a certain depth and in a certain way to escape the winter cold; he also knows that he must grasp the leaf by a certain part in order that it may be easily pulled into the earth. There is much knowledge at the back of this art of building; it is not organised, it is not science, but such are the

IO MEDICAL REVOLUTION

beginnings from which our wonderful science has been evolved.

As the higher reason that belongs to man developed, his primitive medical art was gradually fortified by observation; these observations were slowly systematised, and then recorded ; our organised knowledge of human disease began to grow; the pure science of medicine was born of the older art. The evolution of medicine has not advanced with an even front, as the tide mounts the level beach, far from it; and so, in some backwaters we can still see for ourselves to-day what the medicine must have been like that antedated the science and art of Hippocrates, in the direct line, by ages. Any one wishing to read the history of medicine nowadays must begin with the lucid accounts that have recently appeared of its practice amongst the Australian aborigines, in Tibet, and elsewhere.

Those who, like myself, have listened to the Australian describing, with palpable sincerity, the descent of his deity, more than half -demon, to snatch up to a giddy height in mid-air the candidate who is to be admitted D.D. and M.D. in one, cannot fail to realise the meaning of primitive medicine. Its science is a branch of theology; its art consists, essentially, in attempts to control the cause of disease through propitiation of the deity. All the essentials of both our science and our art are there represented. The ultimate desire of all men is the preservation of health, the prevention of disease ; the only possible way to accomplish this is by controlling the cause; the aboriginal ascribes disease, just as he ascribes drought, hurricane, eclipse and flood, to the interference of a supernatural power which he seeks to propitiate, because in his ignorance he cannot hope to control it.

THE EVOLUTION OF MEDICINE II

Man has been eloquently described as " Nature comprehending herself"; the medical man, at least, has had to pass through a stage when he could be only truthfully described as Nature misunderstanding herself.

The only great epoch in the history of medicine occurred when it was clearly asserted that the processes of disease were of natural, and not of supernatural, origin; it is connected with the name of Hippocrates ; it marks the beginning of the end of the domination of the theological school in medicine. When Hippocrates said that the physician is but the servant of Nature, he looked, as only men of genius can, from the mountain top, he discerned an ultimate truth. We are taught in this masterly phrase that only in the light of a full knowledge of their causation can we hope to guide and control the processes of disease, and for the reason that they are natural processes. Thus was the natural interpretation of disease established once for all as the true ideal of medical science, as the true foundation of all medicine.

How far the science and art of Hippocrates fell short of this ideal we do not know; for although the fantastic Humoral Pathology, that served so long as the orthodox science of medicine, is ascribed to him, there can be no doubt that it gathered many incrustations for which he was never responsible. Whatever the intervening details may be, the fact remains that Hippocrates spoke from the inspiration of genius ; but the common mind will not, cannot accept the dictates of genius ; common belief must rest on common experience ; and so, the profession has been toiling ever since through the flat of detailed observation, until at last we are face to face with facts, now fully substantiated, that Hippocrates realised nearly two thousand five hundred years ago.

Medicine reached very nearly its high-water mark for the period of the older civilisation in ancient Greece; and then, with the destruction of order and stability, came the great gap of the Dark Ages. When security began to reappear in Western Europe, and men could turn their thoughts again to science, the Humoral Pathology was adopted in medicine and kept the field, at least nominally, until nearly the middle of the last century. W r hen the time was ripe for its destruction, the task was undertaken and completely accomplished by the great German anatomist Virchow. When Virchow had destroyed the Humoral Pathology, he set up his Cellular Pathology in its place and described it as the true science of medicine. This brings us down to our own time, for " Pathology " is still authoritatively held to be the scientific basis of medicine.

What it is intended to impress on the reader by this reference to the evolution of medicine is this': the art of medicine has its origin in Nature, even before the appearance of man on the earth, in the instinctive, unreasoning efforts of the lower animals to escape the inconveniences of disease. With the evolution of the higher reason that belongs to man, and the consequent development of the habit of intelligent observation, the science of medicine was grafted upon, sprang from this primeval art. At a much later date came the dawn of our own time, when disease was ascribed to natural causes, and when the study of Nature was pointed out as the only basis on which the art of medicine could be securely founded. The greatest scientific advance of all time occurred in the

THE EVOLUTION OF MEDICINE 13

last century, when Darwin threw natural history into the crucible ; but medicine was then still too completely under the domination of an artificial system to share in the purification that followed. As far as Virchow and his " Pathology " are concerned, Darwin might as well have been silent; medicine was not then truly recognised as a branch of natural history.

Ill

THE PURE SCIENCE OF MEDICINE

The structure that we call medicine consists of two parts; the foundation is, a branch of pure science, part of our organised knowledge of Nature; the superstructure is a scientific art. For the moment, we are concerned only with pure science. It is essential to grasp clearly at the outset how the word " disease " is used in medical science. This word is used in two wholly different senses, and much confusion arises from a very general failure to understand this.

When we say: Disease is a calamity; the first use of the word is illustrated. Here " disease " stands simply for the negation of health; when health is deficient disease arises. Health may be taken to mean the condition associated with a normal, or wholly desirable state of existence. Our conception of " disease " in this general, negative sense, corresponds precisely with our conception of cold as the negation of heat. Health and heat are positive conceptions, disease and cold are their negations.

When, on the other hand, we say: The disease from which these people are suffering is microbic in origin, the particular, positive use of the word is exemplified. When an immense number of cases have been investigated, and it has been found that a certain microbe is actively parasitic in every case, these patients are said to be all suffering from the same

THE PURE SCIENCE OF MEDICINE 1 5

" disease." From a number of cases in which we observe a series of symptom-groups of determinate and similar causation, we are enabled to draw a mental conception that stands for " a disease."

A caution must be given here. When it is said, for instance, that a patient is suffering from typhoid fever, it is meant, literally, that he is suffering from an attack of typhoid fever. There is a great tendency, even inside the profession, to overlook the obvious distinction between the actual attack and the mental conception — " the disease " — that is derived from the observation of a series of attacks. It must also be pointed out that when the specific cause of the symptoms present has been determined, the whole problem of causation is not thereby solved.

When, for instance, it was discovered that the symptoms called malarial were caused by the parasitism of a certain protozoon, it became possible for the first time to define accurately " the disease malaria." But the observers recognised at once that until they had discovered all the conditions immediately antecedent and leading to each particular attack, their scientific task was not completed. This rule applies universally; no symptom-group has been fully interpreted until both the specific cause and the conditions leading to the attack have been laid bare. But, be it noted, in framing our conception of the specific disease, account is taken only of the specific cause; the conditions leading to the attack are neglected. These two factors in causation are the " exciting and predisposing causes " of medical writers. This misuse of the word " cause " still leads to much misunderstanding.

The specific causes that lie at the basis of the scientific — the natural — definition and classification of diseases fall into two primary divisions; those of one division arise in the environment of the patient, those of the other originate in his constitution. The causes of extrinsic origin fall again into three main groups, under the headings of parasitism, poisoning, and traumatism. Typhoid fever, lead-poisoning, and heat-stroke are respectively examples from each of these groups. The diseases of extrinsic causation are so universally recognised that they need not be more particularly referred to.

But the diseases of intrinsic causation, in attacks of which the cause arises in the patient's constitution, are not officially recognised and must be described. The individual begins his separate existence with a number of inherited characters, and these characters carry with them certain tendencies. Both characters and tendencies become modified through contact with environment. It is, therefore, evident that we have to deal with a variable quantity. But the constitution may be roughly described as the intrinsic tendencies of the individual at the time of observation.

The diseases of intrinsic causation fall into five main groups, thus —

I. Certain children are born in whom the develops ment of the heart is incomplete; the observation of a long series of such cases clearly leads to the conception of " a disease.'' We have a series of cases presenting symptom-groups of determinate and similar causation. But the cause is not to be found in the child's environment, therefore it must be sought in the constitution; it is intrinsic in origin. The cause in all these cases is, in fact, incomplete development.

As in the case of diseases of extrinsic causation, so

THE PURE SCIENCE OF MEDICINE 17

here, it must be recognised that the determination of the cause of the symptom-group does not complete the solution of the whole problem of causation. The conditions leading to the individual attack clearly go back beyond the child's separate existence; they must be sought in heredity. Heredity is the channel through which this cause of disease has reached the child, and our study of the child, and of its disease, is not complete until we understand its family history.

II. Other children are born, apparently, quite healthy, but despite the best possible hygienic surroundings, they sicken and die, perhaps at at the age of three, with symptoms called diabetic. Again, the cause of these symptoms does not arise in the environment, it is intrinsic in origin, it is a constitutional defeet; received again through the channel of heredity. There are many other diseases of a similar nature.

III. What is and what is not overwork must ultimately be decided in accordance with an arbitrary standard, and the standard will vary for different individuals. But it is quite clear that overwork is a prolific cause of disease. It is also true that the symptoms are definitely recognisable, they are susceptible of systematic record. This is all that it is necessary to insist on here.

'IV. On the other hand, health cannot be maintained in idleness; in other words, deficient work is a cause of disease. Again, of course, the amount of work, and the proportion of mental and bodily work, that conduces to health must be fixed arbitrarily for each individual. But the urgent necessity of ascribing the symptoms that arise in idle people to deficient work, and the duty of systematising our knowledge of the subject, are obvious and need not be insisted on further.

V. Finally, a man may enjoy good health for many years, and although continuing to live under ideal conditions, there will come a time when simple wear and tear bring his life to a close. We may hesitate to call the natural degenerations of old age symptoms of disease, but the fact remains that arteries grow hard, muscles waste, even bones, sight and hearing fail, health disappears, and its negation is disease. All that I wish to insist on now is that the symptoms of wear and tear must be systematised and set down for the guidance of the profession.

There is, in fact, no generic difference between attacks of disease due to intrinsic and those due to extrinsic causes ; in both cases we find series of cases that exhibit symptom-groups of determinate and similar causation ; therefore, the conception of " a disease " of intrinsic causation is no whit less definite and useful than the conception of " a disease " of extrinsic causation. Before the causation of an attack clue to an intrinsic cause can be said to be fully elucidated, it is essential that the conditions leading to the attack be cleared up ; the determination of the specific causes is not sufficient.

This is not the place, nor am I competent, to discuss the relation that heredity bears to the constitution, but it is nothing less than a scandal that the student passes through his whole course without ever having his attention specially drawn to the part played by heredity in the causation of disease. The medical profession has no right to stand idly by and to accept theories, and even dogmas, from students of heredity; we are concerned with the effects of heredity as they

THE PURE SCIENCE OF MEDICINE IQ

are presented to us clinically, that is, at the bedside, in practice ; no one, statistician, biometrician, nor Mendelian, can solve our problems for us.

It must be pointed out that, not only do the causes of a vast number of attacks of disease originate in the constitution, but it profoundly modifies in each patient the character of attacks of which the cause is extrinsic. It is no exaggeration to say that the recognition of the constitution as a factor in the causation of disease will necessitate an entire rearrangement of our science, the rewriting of medical text-books.

The reader cannot yet fully appreciate the significance of the statement, but it must be emphasised here that, while the intrinsic causes of disease remain unrecognised more than half of the pure science of medi* cine must remain unsystematised. The layman can hardly realise, but he may surmise how far-reaching is the paralysing effect of this lack of scientific method. But I would beg him to bear the point in mind while reading subsequent chapters.

My only object at present is to give the reader, especially the layman, a definite idea of what is aimed at by those who cultivate the pure science of medicine, and of the methods they use; probably this end has now been attained. What has been written may be very briefly summed up. " Disease " — lack of health — arises in consequence of the occurrence of certain natural processes; to observe and record these processes is the scientific duty of the physician. Experience has shown that this vast array of natural processes falls into divisions, groups, and sub-groups, until we reach ultimate sub-divisions in each of which all the processes are of determinate and similar causation. From each of these ultimate subdivisions — representing a series of attacks — we draw a mental conception and call it " a disease." This bird's-eye view of the results obtained in the pure science of medicine maybe put diagrammatically in the form of a chart.

The definition of the meaning of " a disease " given above, although implied in the recognition of, for instance, typhoid fever as a true disease, has never, so far as I know, been previously formulated. And the recognition of the causes of disease of intrinsic origin — with the consequent recognition of diseases of intrinsic causation — is a new departure. These are the two points on which the validity of both my constructive work and my destructive criticism ultimately depend. I shall, therefore, state and answer the only criticism to which these ideas have been subjected in the profession.

I have often been told, more especially by teachers of medicine, that the demand for the defining of the meaning of " a disease " represents an unpractical fad. Again, I am told that to determine, in any particular case, that the cause of symptoms arises in the constitution is of no practical value. I shall illustrate the fallacy of these two orthodox contentions by referring to a problem that is much in the public eye at present, the cancer problem.

In the first place, it is quite evident to the onlooker that those who are investigating this problem have not any clear idea of what they are seeking. They have set out to track down " the disease " cancer, without first attaching a definite meaning to " the disease." They do not realise that " the disease " is not lurking in every case, but that it is a clear mental conception that can be framed only when a series of symptom-

THE PURE SCIENCE OF MEDICINE 21

groups of determinate and similar causation has been observed.

In the second place, using the word " cancer " in its proper, comprehensive sense, all cases' have one fundamental character in common ; that is, certain cells take on an abnormal manner of multiplication, leading to overgrowth, recurrence, malignancy. This abnormal activity can only be accounted for by the action of some intrinsic cause, some dislocation, temporary or permanent, of the normal tendencies of the patient. Various antecedent conditions may lead up to the constitutional dislocation, as for instance, chronic irritation ; but the " cause " of the abnormal cell-growth must be sought in the constitution. Cancer, being of intrinsic causation, will prove ultimately to be " a disease " that is not sharply or definitely bounded ; it will be indefinitely and arbitrarily divided from other conceptions.

I venture, therefore, to state dogmatically that until two essential conditions are complied with, the cancer problem cannot be finally solved. These two conditions are, the defining of the meaning of " the disease," and the recognition of the reality of constitutional causes of disease. I would only add that — in medicine at least — we cannot be practical, usefully, until we have first been truly scientific.