THE DAWN OF THE ^rS^^^^^^^^S^^^^ 4i45'<' -iK';g'/^y^^«?®Mft&-4S¥ *- 1lM! T^y ', Co. At the BHlIantyne Press, Edinburgh PREFACE This book is intended to demonstrate, on clear, broad lines, the necessity for entirely remodel- ling the present system of medical service in the interests of the whole community. It shows that hundreds of thousands of lives and millions of money can be saved every year if disease is attacked on scientific principles, instead of being dallied with as at present. It proves that such a course is best both for the millionaire and the pauper, because there is but one set of disease agents in the whole world, which attack rich and poor alike, and are trans- mitted from the one to the other. There is not one word of party politics in the book from cover to cover, and readers and re- viewers are requested to attach no labels to it, but to judge it honestly on its own merits. In the interests of our common humanity, and to aid in the evolution of a fitter and healthier race, it is addressed equally to con- servative and liberal, to humanitarian and economist, to capitalist and labourist, to indi- vidualist and socialist. All the great political parties in our State are vi PKEFACE committed by public utterances of their leaders, and by the tide of public opinion, to social reform, and the hygienic aspect of social reform is the most dominant of all, commanding the whole situation. Poverty and destitution simply cannot exist amongst a fit, virile, healthy nation. Banish acute and chronic infectious diseases, teach temperate and normal habits of eating, drink- ing, and living, making the reverse a crime, and poverty and suffering in corresponding measure must decrease. The passion for drugging and doctoring the individual with specific cures and quack nostrums is one of the prepotent curses of our time ; while the health and well-being of the species, and all things making for fitness of the race, are neglected. We allow diseases to invade and enfeeble us, then ruin our systems with drugs in attempting to exorcise the demon of disease, and when we fail we turn to the claptrap of faith-healing or homoeopathy, imbued with all the spirit of the superstition and idolatry of the Middle Ages. Take up any daily paper or monthly maga- zine and look at the columns and pages of costly advertisements devoted to quack medi- cines and remedies of all kinds, reflect on the thousands of pounds spent by poor human gulls in supporting these frauds and the authors of them, and then ask yourself, is it not nearly time that we had some rational system of dealing PREFACE vii with disease and protecting people from their own ignorance 1 It is only a strong public feeling, demanding a rationally constituted public medical service armed with powers to fight disease, which can bring reform in these matters. BENJAMIN MOORE. Shrewsbury Boas, Birkenhead, Oct. 1910. THE DAWN OF THE HEALTH AGE CHAPTEE I HOW WE TINKER WITH DISEASE INSTEAD OP STOPPING IT At the present moment we possess sufficient knowledge of medical science to enable us to save at least three hundred thousand lives every year in this country alone, and the saving of these three hundred thousand valuable lives could all be effected without costing the nation a single penny, but rather at the same time many million pounds a year might be saved which under pre- sent conditions are absolutely wasted. In the face of all this spendthrift extrava- gance in lives and money, we eagerly call for more scientific research to enable us to cope with disease, utterly ignoring the rich harvest which medical science has already yielded ready to be garnered all around us. It is true that we are still ignorant of the causes and modes of propagation of certain diseases, and attempts to discover these are in A 2 DAWN OF THE HEALTH AGE themselves most laudable ; but it is equally trae, and much more important, that we do know perfectly weU how to combat some of the direst and most common diseases, and that we move neither hand nor foot to do so, but stand benumbed and useless, as if we were a race of savages without any polity or system of govern- ment or capacity for any concerted plan of action for the national welfare. The problems of disease, from which radi- cally spring all the most important problems of social reform, require now to be tackled by statesmen, and not by doctors and scientists. The exponents of medical science have accomplished their aims in many important directions and have laid their results before the public; they can proceed no further without concerted statesmanlike action, and it is for the public now to awaken statesmen into activity. While a statesman can to a certain extent give definiteness and objective to reform, he alone cannot move unless the public are ready for the forward movement. There are signs present even now of awaken- ing interest of the public in health problems, as shown by the general approval of foreshadowed legislation dealing with some of the great problems of social reform, commencing with invalidity insurance and reform of the Poor Law, especially on the medical aspect which furnishes the key to the whole situation. HOW WE TINKEE WITH DISEASE 3 It is method more than money that we want in order to combat and conquer in our battles with disease; we must fight in the future by means of a disciplined army instead of, as at present, with an undisciplined mob, each member doing what is right in his own eyes and working at cross purposes to his neighbour. It is not the slightest exaggeration to say that our present methods of attacking disease are mediaeval in their antiquity and their ignorance. The scheme which is here to be laid down is most benevolent and most charitable, both to those now afflicted with disease and those of all ranks of society which it proposes to save from the clutches of disease and untimely death ; but attention is asked for it not primarily on bene- volent or charitable grounds, but mainly as an economic scheme that will save millions of pounds annually to the nation. All misdirected labour is labour wasted, and the labour of the thirty-two thousand medical men at present practising in this country is almost wasted as far as the health of the community which they serve is concerned. Anything more futile, less scientific, more hopelessly absurd than the present method of dealing with disease can scarcely be conceived. Constant associa- tion has blinded us to this topsy-tiurvy want of aU system and all method in tackling dis- ease problems which has slumbered on in our midst from generation to generation in despite 4 DAWN OF THE HEALTH AGE of all our advance in knowledge of medical science. With a self-satisfied air we make survey of what we term the modern advances in medicine and surgery, as applied to tinkering the diseased individual, diudi complacently the credulous public swallows the glorification, while we slumber over the thousand-fold greater achievements possible to organised effort in the wholesale eradication of disease from the commonwealth. Meanwhile hundreds of thousands of the fittest of our citi- zens die yearly without one effort being made to save them. Naturally our organised army of doctors would have to be paid, and this would cost the nation eight to ten millions a year; but this money is all paid now, and more than paid. All that is necessary is to pay it through different channels, and the advantage gained is that we shall possess, as aforesaid, an army instead of a mob. Needless to say, no disrespect is meant to the medical profession by designating it as a mob. That term is only intended to signify that it is entirely lacking in the first elements of organisa- tion so far as dealing with the diseases of the nation is concerned, and preserving the nation in a fit state of health. There is no more noble profession than that of medicine ; it is one which is only too sacri- ficing of its own interests ; there is no pro- fession which does so much for charity without HOW WE TINKEE WITH DISEASE 5 recompense sought or obtained. Charitable work is the bane and curse of the medical profession, as it is of the nation at large, and the constant exploitation of doctors by hospitals and Poor Law municipal agencies is a disgrace to our times. But speaking of the medical profession as a whole, it is developed upon wrong and anti- quated lines of tinkering the individual for fees after he has fallen into ill-health, and it is impossible for it from within to organise itself into an army of health and public safety against disease, which shall seek disease at its source and commence to deal with this large problem of eradication in a modern and scientific way. Even if it set about reorganising itself on new lines, the profession lacks those effective com- pulsory powers of dealing with disease which will be elaborated in subsequent chapters, and these only can be given to it by legislation. The problem of saving these hundreds of thousands of lives and millions of pounds of money annually is accordingly one for the public itself, led by those publicists who take an interest in medico-social problems. It cannot be too strongly reiterated in this introductory chapter that what is required for the successful solution of this gigantic problem is method, method, and once again method. In the first place, we must form our highly organised and equipped Army of Health ; and, in the second place, we must give that army 6 DAWN OF THE HEALTH AGE plenary powers by legislation to deal with disease on the lines which scientific research has disclosed for us in the past generation. This plenary power to fight disease will not in the slightest degree prejudice the rights of the individual sufferer from disease, but, on the contrary, will give him double the chance of recovery, while at the same time it will protect the healthy from the danger of infection. Under the new regime, medical treatment will be as free to every one as is the school and education to-day, and every one must accept medical treatment in his own interest and that of the community, just as he must to-day accept education for his child, whether he wants to or not. After ten years of such a system, nine-tenths of the disease and almost an equal proportion of the destitution will be found no longer amidst our population, and the benefit will be felt not only amongst the working classes, but from palace to hovel — if indeed hovels still exist. The Briton, in the opinion of some superficial critics, wiU become a slave under such com- pulsory conditions when his home — his castle of dirt, ignorance, and disease — is visited by the health officer, and so he is advised to fight to the last gasp against such inspection. But there is, fortunately, also a clean Briton, an edu- cated Briton, a hard-working Briton ; he exists already by the hundred thousand amongst the working classes, and he is rapidly becoming HOW WE TINKER WITH DISEASE 7 a power in the land. This type of Briton is acquiring new and strange ideas of liberty ; strange to say, he believes in education, and has no objection to his indolent and ignorant neigh- bour being punished for neglecting to send his children to school. The school officer is not to his mind a tool of the Holy Inquisition ; and, similarly, he has only to realise that he and his wife and children stand in danger, in real mortal danger, of being infected and destroyed by the disease harboured by the filth and igno- rance next door, in order to let the health officer attack and remove that filth and dis- ease. When thoroughly awakened by the new preachers of health, the virile, healthy type of Briton may be depended upon to be so anxious for the health of body of himself and those near and dear to him that no power on earth will long prevent the necessary legislation, and reform will come with the ever-growing velo- city of an avalanche. Our new health army may be an inquisition, but what an inquisition it is — one of knowledge against ignorance, of health against disease, of life against death, of salvation against damnation. Who would not welcome such an inquisition ? If this be slavery, let us welcome our chains, and be bondsmen in a cause such as the world has never seen. Here is a crusade worth join- ing, a fight worth waging, a fight that can be won — nay, a fight that must be won. For more rapid success we must, however, 8 DAWN OF THE HEALTH AGE ' win to our cause the cautious and stolid econo- mist, and so, in concluding this introduction, let us show what vast stores of gold, which being transmuted means energy and work done, can be saved and accumulated every year through the operations of this Army of Health ; let us point out the spoils of this bloodless warfare. It has been stated above that we already pay for the health army, but not in such a manner that we can either organise it or set it to fight. These payments that we already make, and which collectively give the doctors their none too magnificent livings, are now so exacted in fees, varying according to our incomes, the rich man paying a bigger and the poor man a smaller fee, that there would be but little variation if the sum were raised by taxation ; and so this taxation would mean no additional drain on the nation, for we would not then have to pay the doctors their fees privately and directly, but would have full and free treatment when we needed it. Of course, disease would in a few years become so abated that the treatment aspect would be at a minimum ; we should, fortunately for us, rarely need treatment, and nearly aU the work would be work of inspec- tion, instruction on how to live healthily, and prevention of the incidence of disease by pounc- ing on every infectious case and isolating it at once. Still, as far as disease did still exist, the State Health Army doctor would attend to it. Accordingly, apart from some initial expense HOW WE TINKER WITH DISEASE 9 for hospitals and sanatoria — necessary until the army of consumptives, for example, had been reduced from its present figure of about one hundred and fifty thousand of unfortunate sufferers travelling to a certain death, to less, say, than five hundred throughout the whole country — apart from this initial expense, no fresh money is required for the scheme, but only a new organisation, and a payment of our doctors' fees as a tax to Government, instead of directly to the private doctor. Now, let us look at the other side of the balance-sheet, and leaving out all question of lives saved and the happiness that accompanies better health, let us pay attention to pounds sterling alone. The magnitude of the Annual Disease Bud- get which iU-health, consequent loss of em- ployment, destitution of widows and children consequent upon illness, and later the dpath of fathers from preventable disease, costs the nation is undoubtedly colossal, but difficult of accurate estimation. It can be stated with considerable probability to be located somewhere about one hundred million pounds annually. This is a truly colossal sum ; one poor half-year of it, if it could be raised in any way and applied to clear away the causes of disease, would be more than sufficient to stop the whole hideous panorama of disease and destitution ; but, alas ! we are in the grip of a vicious circle. One has only to spend a few minutes in 10 DAWN OF THE HEALTH AGE reflecting upon how disease does its work of destruction, to see how the millions mount up. If we take that biggest scourge of all diseases, viz. tuberculosis, as an example, we have in Great Britain and Ireland about 150,000 affected individuals at one time. We may take it that the disease runs an average course of two years before the curtain is drawn, and as it is a disease occurring at all ages, it is probable that of the 150,000 sufferers, two-thirds, or 100,000, are adults capable of employment. As a result of the disease, not only the sufferers, but their families and dependents if they have any, are thrown on the support of others. All the time, it must be remembered, these 150,000 are in- fecting others, while we do nothing to prevent the process, so that the horrible tale is made perpetual, and the economic loss goes on year after year. Since consumption is considerably commoner nowadays amongst men than amongst women, we may take it that of the 150,000 of the army of tuberculosis at least 60,000 are adult males ; and if these be taken at the low average wage of one pound sterling a week, the annual loss of wages alone is a sum of £3,000,000, to which we may certainly add another £1,000,000 for lost female labour, making £4,000,000 for wages alone. Of the 150,000 sufferers, about 75,000 die every year, and the melancholy item of funeral expenses must cost a sum worth saving. At least one- third of these poor unfortunates die in Poor Law HOW WE TINKER WITH DISEASE 11 or other public institutions ; ^ but wherever they die, the expense falls ultimately on the nation, for any expense broadly enough distributed amongst some hundreds of thousands of people becomes indistinguishable from a national ex- pense. Each individual upon whom it falls, sink- ing down, pulls upon others all around him to help him in his calamity, and ultimately the burden of phthisis, just as it is propagated and carried to us all, rich or poor, by the same common microbe, falls to be borne as to its finance in the same common way by the whole community. In nine-tenths of the cases, sooner or later it comes on the rates, just as do insanity, alco- holism, and all other forms of long-continued or chronic disease. But the actual wages lost in the period of illness of the phthisical patient, considerable as we have just seen it to be, is insignificant compared to the burden of destitution left as its aftermath, first upon the family survivors and later on the community. The widows and orphans fall nearly always to the State or community to maintain, and, alas ! history will have a sad tale to tell as to how we have, up till now, been looking after these * The cost of tubercular patients to the Poor Law Institutions is at least one and a half millions a year ; those belonging to Friendly Societies and in Sick Benefit cost their Societies over one million a year ; and Voluntary Charities and Sanatoria for the Consumptive cost almost half a million. In addition we have over 100,000 cripples with decreased earning powers, and about eighty per cent, of these owe their lameness to tubercular disease. 12 DAWN OF THE HEALTH AGE unfortunate orphans and turning them into un- desirables in the General Mixed Workhouses, or in immoral and dissolute homes.^ We are, however, just now dealing with economics, and so may attempt to get at some idea of how much the widows and orphans of deceased phthisical fathers cost the nation. The estimate is most difficult. In some cases the adult dying from phthisis happily leaves no children behind ; in other cases three or four are left to be brought up by the parish for periods varying from ten years downwards ; but if it be taken that it averages out at one child to be maintained, schooled, clothed, and fed for ten years, this, at a cost of only four shillings a week, works out at £10 a year, or £100 for the ten years. If we take the modest estimate that there are 30,000 deaths a year in the United Kingdom necessitating such provision, the sum of £3,000,000 a year is obtained. If we add this orphans' maintenance to wages loss, we have a sum of at least seven million pounds. We have as yet by no means exhausted the financial drain on the nation due to tuberculosis, for economically this is the most expensive of all diseases upon the community. This arises from the fact that, on account of its modes of propagation, pulmonary phthisis takes oj0f most of its victims between the ages of twenty-five and forty-five years, just when economically they are of the highest value to the community, in the '■ See Reports of Royal Commission on Poor Law. HOW WE TINKEE WITH DISEASE 13 midst of their best working and wage-earning power. Not only do we lose the wages of each phthisical workman during the later part of his period of illness, when, on an average, as statistics show, he takes more than a full year's sick benefit out of his society ; and not only have we to support in our poorhouses his orphan children after he has gone ; in addition, the community as a whole suffers from the loss of many years of the services and work done by the workman which would have accrued had consumption not cut him off in his prime. The average age has been shown to be only forty years at which phthisical workmen are removed, whereas in the absence of phthisis, and with their expectations of life at the age at which phthisis fell upon them, they would have lived and worked on the average to fifty-five years. It follows that while we only gain economically by the death to the extent of the food, cloth- ing, and other wants actually consumed by the workman himself, and spared by his death, we lose economically the fifteen years' labour, re- presented by fifteen years' wages, which the workman would have turned out had phthisis not seized him. On an average this loss may be set down at least at £20 a year — probably it would be more — and this multiplied by fifteen, for the fifteen years, gives the national value of each of these workmen cut off at forty, instead of fifty-five, at £300. If, on this basis, we take 14 DAWN OF THE HEALTH AGE it that of the 75,000 deaths annually in the United Kingdom from tuberculosis only 30,000 are adult workmen — although 40,000 would probably be nearer the mark — we obtain an- other nine million pounds lost every year to the nation. This added to the other two items makes up sixteen million pounds a year lost by tuberculosis ; and there are many other sources of loss, in lameness, in recoveries after long illness and inability in cases which do not die, in tuberculous animals slaughtered, in necessary inspection, and so on, which need not here be enumerated and calculated out. Another method of getting at the total loss is that tuberculosis, as has been calculated by actuaries, reduces the expectation of life of every inhabitant of the country by two and a half years, when the diminution of life duration is distributed all round. Now, taking man, woman, and child, the average income of the wage-earning classes is about £23 a year per individual, and in our total 44 to 45 millions of population there are about 38 millions consisting of wage-earners. Multiplying 38 millions by 23 and again by 2^, we obtain 2185 million pounds as the wages earned; and if we take about two -thirds of this as the sum necessary to adequately support the 38 millions for the two and a half years, we obtain at least 700 million pounds as the capital value to the nation of total eradication of consumption, which, at 3 per cent, interest, means an annual HOW WE TINKEE WITH DISEASE 15 saving of 21 million pounds. This eradication, as we shall see, can be guaranteed for an ex- penditure of less than ten million pounds a year, for ten years, further expenditure almost stopping at the end of that period, A calculation by Dr. Hermann Bigg,^ Medical OflScer of Health of New York City, made in 1903, estimates the annual loss to that city due to tuberculosis at 23,000,000 dollars, or £4,600,000, a year. The estimated total annual number of deaths in the whole United States is 150,000 people, representing an annual financial loss, calculated on the same basis as for New York City,of330,000,000dollars, or £66,000,000. On the same basis, the 75,000 deaths from aU forms of tuberculosis in the United Kingdom in 1908, the last year for which we have figures, would cost exactly half the bill of the United States, or £33,000,000. Another enormous national biU which would be almost entirely wiped away by a National Health Army is that which might be grimly described as the bill for the slaughter of the innocents. One person out of every five persons bom dies before the fifth birthday is reached, and under proper conditions of sanitation and healthy living at least eighty per cent, of these deaths could be avoided. Latin names figure in the returns of the Eegistrar-General as the * Quoted from Latham and Qarlandj " Conquest of Consump- ion" (Fisher Unwin, 1910), p. 1^1. 16 DAWN OF THE HEALTH AGE cause of death, but in plain English the children die from dirt, ignorance, carelessness, and starvation. Also, sad to relate, there has not been the slightest improvement in this respect vi^ithin the past forty years. Neither is it possible to hug the fond delusion that these are weak, enfeebled children, to preserve whom would deteriorate and enfeeble the race. These children who die are born healthy, and placed in similar circumstances any other children would succumb just as fast as these. The diseases of infancy fall upon the fit and the unfit ; and epidemic diarrhoea, or bronchitis caused by neglect after measles, kill the fit just as much as the unfit. Just as in the case of the adults, infection with tubercle bacilli kills the fittest as well as the feeblest. The healthy have not been seized by tuberculosis because they have not been sufficiently exposed to infection, and the infection of tuberculosis comes up from the slums and slum-life, where it is cultivated and propagated by our present system of neglect. Filth and filth infection causes nine-tenths of the preventable deaths occurring before the age of sixty-five, and if we join in this crusade for a National Health Army to help the poor, we help ourselves at the same time. Time was when that filth disease, smallpox, claimed in the palace as its victim a French king, and at another the consort of a British monarch; as it was then with smallpox so is HOW WE TINKER WITH DISEASE 17 it now with phthisis, and it is our duty to see that as it now is with smallpox so shall it be within the next ten years with phthisis. So much for the doctrine of survival of the unfittest as a result of the stamping out of disease in general, and infantile slaughter in particular; let us now look at the economic effect of allowing a state of affairs to persist under which one life in five is destroyed before five years of life have run. In the first place, there is the cost of pro- duction of these children, the drain on the mother's strength and energy, the extra food, the nursing, the doctors' bills, and all wasted in sorrow and bitterness of heart. But of more importance to the nation is the wrongful age distribution caused by this infant slaughter as between workers and non-workers of the com- munity. This inordinate infantile death-rate, about ten times as great as the rest of the population, leaves us with a much dispropor- tionate number of non-earning children to be supported by the workers. Just at the period hardest for family maintenance, on account of this enormous death-rate, there are too many small mouths to fill, and too few growing up to earning ages to help the toil-worn father with his task of keeping a home together. A certain order of social economist talks of the necessity of keeping up the birth-rate, but as long as present social conditions persist this is but adding fuel to a consuming fire. B 18 DAWN OF THE HEALTH AGE We could have a happier, healthier, and wealthier people of equal population with little more than half the present birth-rate, if we looked after the death-rate with an eflScient National Health Army. Let us look after the death-rate and the birth-rate will take care of itself. There are even now nearly twice as many births as deaths in our country, and the wonder is where to find, at any rate under present social condi- tions, employment and maintenance for our ever-increasing population. Improve social conditions by attending to health, and aU this vicious circle of over-pro- duction and slaughtering of children will dis- appear automatically by the operation of a fundamental biological law ; the natural law will assert itself that as you improve the con- dition of the people they will reproduce less rapidly, but we shall get a more virile race, with a less proportion of children to adults. Birth- rate and death-rate will both go down together, which is the best economic and social result which could possibly exist. Meanwhile the slaughter of the children goes on unchecked, and as a strange result, most paradoxical but most true, we have to maintain at least one-third more children between the age of infancy and five years than we ought to have ; these luckless infants have to be maintained by the productive work of the nation, and the cost estimated in money is HOW WE TINKEE WITH DISEASE 19 certainly .not less than £1,000,000 sterling every year. At least 100,000 children lose their lives every year from preventable causes, which we do nothing to make impossible. Did we ask the fond mothers of some of these lost children their value, we might be told they were " worth their weight in gold " ; but if, on the economic basis of what they have cost, and leaving out of account their future productive value to the nation, we set them -down as equivalent to £10 each, we obtain the sum of £1,000,000 a year. These two instances of tuberculosis and in- fantile mortality have been selected to show what disease costs in money every year ; dozens of other diseases, less heavy in their incidence but mounting up in their totality, might be put forward along similar lines. The two that have been quoted, together cost us more than double the price of an eflfective national service for their prevention ; and hence, provided it can be shown that prevention would be effectual, a clear case has been made out on the basis of economics alone for taking action in this matter. CHAPTEK II THE FOLLIES OF OUE PEESENT PUBLIC HEALTH SEKVICE The reader of the previous chapter has pro- bably come to the conclusion that the object of the writer is to convert all, or the great majority of, medical men into medical officers of health on the system now in vogue on a smaller scale under our municipalities and county authorities. To this the reply of the writer is, " Heaven forbid ; " his object is the prevention of disease, and any system less likely to achieve this object than our present wretched Public Health System, or rather lack of all system, he cannot well imagine. Such a system of how-not-to-do-it far surpasses the Circumlocu- tion Office in its wild and ludicrous absurdity. No attack whatever is intended upon the personnel of the Medical Officers of Health of the Country, but a new National Medical Service must be formed, and the present hetero- geneous collection of absurdity and impotence removed, if any true progress is to be made in safeguarding the National Health. The difficulty is to know where to make a start in attacking this colossal Castle of 20 FOLLIES OF PEESENT SERVICE 21 Humbug that we caU our Public Health Service. Let us commence with a particular example. Quite in recent times, a Corporation of over 300,000 citizens required what is called an M.O.H., that is to say, a Medical Officer of Health. They wanted, it will be noted, one medical officer of health to prevent disease ravaging these 300,000 people, a task which, if undertaken with any approach to seriousness, would require at least 150 to 200 medical men. But in this, strange to say, they were in nowise peculiar, for that is the custom all over the country, so let us pass over this ludicrous aspect as too common to excite our risible faculties. The next point is that the Corpora- tion in question offered the magnificent salary of £600 for this Medical Officer ; for, of course, he would have a good deal to do in preserving the health of 300,000 people. Now, in spite of the arduous duties, the Corporation might have had the services of men well trained in exactly the type of work required ; they might have picked and chosen from amongst many men who had for years executed such duties in other large Corporations ; but the Corporation, acting through its City Council, thought it might be better to have a local man with some knowledge perhaps of the individual constitutions peculiar to the 300,000 odd people who inhabited this city, so they chose a worthy gentleman who, in addition to being up till then a private general medical practitioner, had recently been 22 DAWN OF THE HEALTH AGE a City Father, or, in other words, a City Coun- cillor. The City Councillors knew him well, and knew they could work harmoniously with him, and he with them ; besides, his predecessor had likewise been chosen from the ranks of the City Fathers, with eminent success. The result has clearly demonstrated the wis- dom of the choice ; the health of that city is excellent — it is by no means the highest in its death-rate amongst our great cities, and there has been no observable increase in death-rate during the few years that have elapsed since the appointment. What is the moral ? The moral might be that no prolonged ex- perience as Medical Officer of Health is neces- sary in appointing to such an important post, provided you can obtain a man who has ac- quired experience and tact by service on the City Council; but it might also be that the experience and ability of the Medical Officer of Health matter very little under present conditions as far as the Health of the City is concerned. There is both humour and pathos in this plain true tale ; the humour is that it did not matter, the pathos that it should not matter. Yet the position of Medical Officer of Health of a large city is no sinecure ; his duties are most multifarious, and although a great many are carried out by deputies, the situation re- FOLLIES OF PRESENT SERVICE 23 quires great tact and a good deal of knowledge for successful treatment. But, as a matter of fact, by far the greater part of the work requires little or no medical knowledge, and could be done as well by an astute solicitor's clerk as by a medical man. As far as his official duties at present are concerned, the Medical Officer of Health simply is an administrator of an ill-assorted collection of Laws, some good and others bad and in- complete, supposed to be all that is necessary for the due maintenance of Public Health and prevention of disease. Meanwhile, if we may personify Disease, we can truly say that it laughs and jeers at us and our Public Health Acts and Medical Officers of Health and their Sanitary Inspectors, not merely in our slums, but in all our public places, and carries off to premature deaths every year at least 300,000 persons, whom an organised State Public Health Service could preserve as sound and healthy lives. It is true that there are, here and there. Medical Officers of Health who exceed their Commission, because they are keen on their work and introduce reforms as far as they can get backing from their local authorities; but it is not in the Bill, and voluntary ejffort can do little or nothing towards tackling the larger problems of disease prevention. The fundamental condition of reform is that the whole aspect and outlook of (1) Govern- 24 DAWN OF THE HEALTH AGE ment, (2) Public, (3) Private Medical Practi- tioner, and (4) Public Health Officer must be radically and completely changed. We do not require an extension and amplifi- cation of the present systems or any branches of them, but a new system, including in organic co-ordination the Private Practitioners ; the Hospitals, Voluntary and Poor Law, and their Staffs; the Infectious Diseases and Municipal Hospitals and their Staffs ; the Dispensaries, Public and Provident ; the District Medical Offi- cers and Relieving Officers; and the present so-called Public Health Service. We require a Cosmos evolved out of this Chaos. Order cannot be evolved out of chaos until this heterogeneous mass of machinery is set in gear, and driven by one motive-power managed by one overseeing intelligence. Till this has been achieved, waste of money and human energy, and impotence to handle and prevent disease, must coexist side by side, as every sociologist who has studied the subject admits they do at the present moment. The National Medical Service, to be at all co- ordinated and effective, must be truly National, and not merely a congeries of Municipal Ser- vices out of touch with one another. There must be provision at each local centre for the direction of local affairs, and every particle of useful voluntary service on City Councils and Hospitals can be, and ought to be, utilised FOLLIES OF PRESENT SERVICE 25 as at present, or, rather, much more than at present ; but the medical men must be part of a service as truly National in its scope as any of our present great civil or military National Services. A young medical officer entering this service should have the opportunity of seeing service in all parts of the country, and being called by a local authority from any one part to any other ; and after the Service has once been established there must be no irregular admis- sions. The National Medical Service should bp made one of the finest in the country, for none in the country would be more fundamental or essential, and the honours and emoluments should be such as to attract the finest brain- power of the youth of the nation. The main objects of the National Medical Service should be twofold — (1) To give instruc- tion in the laws of hygiene and healthy living, sowing this knowledge broadcast in both school and workshop ; and (2) to take effective steps to stamp out infectious diseases, armed with compulsory powers for this purpose. Nearly all disease is due either to unhealthy habits of life, or to infection from other in- dividuals pursuing unhealthy habits or living under unhealthy conditions. Wipe out these two fundamental causes, and the number of diseased individuals left to be " doctored " would shrink to such dimensions that our hospitals would be well-nigh empty, and our National 26 DAWN OF THE HEALTH AGE Chest correspondingly fuller of treasure for other good work. Let us look for a moment at the question of how these two fundamental objects of a national health service are carried out now by all the disunited branches of the medical pro- fession, both private and public. By long odds, the more important of the two functions is the educative one, for if the mass of the people could be taught in a real practical way the elementary laws of healthy living and what made for good health and what for disease, there would be no delay in introducing reforms for prevention of infection. The Government that refused to take adequate action, once the people saw what was required, would soon be swept out of existence, and re- placed by one that would carry out reform. Now, what attempts are at present being made to give the people this education ; what is the medical profession doing in public health service or in private practice, and what is being dpne by educated laymen ? The answer is simple : there is no concerted action whatever, nothing in the way of a national effort. A few posters on the walls of our slums about temperance, and feeding babies ; notices not to spit in our public conveyances; occasional and sporadic attempts at " Health Lectures " ; tuberculosis crusades with limelight views, and lectures. Very good, aU of it, and much to be commended ; but as an attempt at a national effort to educate FOLLIES OF PEESENT SERVICE 27 the people in the laws of health — well, one can only repeat some of the responses to the Litany over it, in great sorrow of spirit. Let us wake up and be truly ashamed of ourselves, and start to teach some practical hygiene in our schools as a compulsory and important subject. Let us teach our school teachers first some of the principles of how health is preserved, so that they know more about the little bodies they have to look after physically as well as mentally, and so do not treat them as disembodied minds. Let us start our newly appointed School Medical Officers as teachers as well as inspectors, and see if they can prevent some children falling ill, in addition to writing reports on those already afflicted. This is no sneer at work well begun, but rather to say let us do more of it. Next let us take most of our 32,000 qualified medical practitioners and turn them loose on the slums as missionaries of health, as a change and relaxation from pottering in vain at disease so far advanced as to be beyond their skill. It is a peculiar irony of fate that the very name of "doctor" means a teacher, and yet he never, or very rarely, teaches nowadays, but earns his living chiefly by pouring medicines into people who would in most cases be better without them. The average poor person, as also many who are not poor save in intelligence, goes to the " doctor " for " medicine," and the doctor panders 28 DAWN OF THE HEALTH AGE to the prejudice and gives " medicine." He can scarcely help himself; if he gave no " medicine " he would soon have but little practice. Advice thrown in gratis may be good, and after all you need not take it if you do not want it ; but it is certainly the " medicine " that is going to make you well, that is what costs the doctor something, and that is what you pay your fee for, and expect to have. Yet the doctors themselves complain of quackery and the undoubted frauds of patent- medicine vending and advertising. Why, the people are only bettering their instruction, for the doctors, by their actions if not their words, lay such stress on the "bottle" that it becomes the essential thing to the patient's mind. He sees a well-written piece of quackery in a news- paper advertisement, a widely-cast net which includes his symptoms, and he imagines the others he has not got ; this represents to him the doctor's palaver. Is it any wonder that he sends for the essential thing from his point of view, to wit, the " medicine " ? After aU, will it do him much more harm, or good, than the rapidly thrown together "bottle" supplied at the dispensary of the private practitioner who sees forty patients in an hour at a shilling a head ? Truly, the medical profession has itself to blame for many of the evils which have come upon it. The medical profession requires sadly to have some dignity put back into it by being made a FOLLIES OF PEESENT SEKVICE 29 truly teaching profession, as the popular name of its exponents indicates. Many medicines are most valuable, and need not be taken in homoeopathic doses when their use is really indicated. There is only one greater medical fraud than homoeopathy, and that is faith-healing. But, at the same time, if doctors could see their way to give one-tenth the present amount of drugging and ten times the amount of teaching, it would be better both for the world at large and the self-respect of the medical profession. Turning to the second fundamental purpose of a National Medical Service, viz. the preven- tion of infection, how do we find that provided for at the present time ? Here we do find legis- lation existent which attempts to place the Medical Officer of Health in some co-ordina- tion with the Medical Practitioner. The best possible attempt, it may be, which can be made under present conditions ; but the most elemen- tary examination of its mode of operation and restraining effect upon the spread of disease is sufficient to convince any one with an open mind that it is but a miserable pis oiler, that would not be tolerated for a moment did we possess a real National Medical Service armed with powers to proceed on the offensive against infectious diseases. The present mechanism is that any medical practitioner who has seen a case which he has diagnosed as an attack of one of certain types 30 DAWN OF THE HEALTH AGE of infectious diseases is compelled to notify the same to the Public Health Authority; and unless he can certify that- the case can be properly isolated and attended at home, the Public Health Authority has power to remove it to a Public Infectious Diseases Hospital. Usually in the case of poor people the case is so removed, if there is room, at the time being, in the Hospital. To the lay mind this may sound perfectly all right, but there is little doubt that it costs lives by the ten thousand annually, and is one of the most puerile ways of dealing with a most serious problem which can well be ima- gined. Especially in the case of children's diseases does this hold good, and it is a con- servative estimate to say that in infectious diseases peculiar to childhood this nefarious system costs the country fifty thousand lives annually. Observe, in the first place, that here, where the safety of the community is at stake and the spread of infection is to be prevented, the machinery is first set in action by some ignorant lay person, living in all probability in a dirty slum, and entirely uneducated in matters of health and disease. Neither the medical practitioner nor the public health ofiicer has any commission to go forth and find the disease, not even when an epidemic is on ; no — the disease must come to the doctor. The enemy must walk past FOLLIES OF PRESENT SERVICE 31 our outposts and into our camp, and ask to be attacked and arrested, before we stir hand or foot. Is not the whole thing too ludicrous for the serious consideration of any one but the witch-doctor or medicine-man of a savage tribe ? It is reminiscent of the days of burn- ing for witchcraft or healing by incantations and charms. If we reaUy believe in this as a modern method of combating infectious disease, let us at least show some charity to those just a shade less advanced in intelligence than ourselves, who cultivate the pious art of faith-healing and swallow the miracles of Lourdes. The patient reports to the doctor, and the doctor reports to the medical officer of health, and the medical officer of health reports to the infectious diseases hospital,^ and then, if there is room, the ambulance is sent for the patient. Meanwhile, the disease germs have not been reporting at all, but have been going on with their business, and next day there is another case to be removed from the same house or the house next door, after " the tale of the house that Jack built " has been run through again. Is it any wonder that we have epidemics of acute infectious diseases? It is to be remembered that nine-tenths of the disease is situated in the low-class, closely crowded property of slum-land, where • "And the parson told the sexton, and the sexton tolled the bell." 32 DAWN OF THE HEALTH AGE the people are poor, ignorant, and perhaps sometimes careless of what to do, and that bad cases have often run a good deal of their in- fectious course, and had contact with a good many susceptible persons, before ever a doctor has seen them at all. The poor hard-working wife of the labourer, with all her family and housework to attend to, may be forgiven if she fails to understand even for two or three days that what she thinks is a cold or sore throat in one of her children is the beginning of a serious infectious disease, and there is no one going round inquiring for sick children in the houses, even when it is known that a severe epidemic is in progress. No; the free- born Briton must be allowed to infect his neighbours in peace, and undisturbed by any domiciliary visits of a Health Authority. He is not permitted to neglect the mind of his child, but he can practically neglect the body, and its care and requirements, to his heart's content. The infectious ailments of the middle and upper classes practically aU originate in this way in the lower classes, and are carried up by casual contacts in a hundred ways : by contacts made on the street; in public build- ings, in public conveyances ; through food and clothing which has been in contact in the slums, and so on. In nothing so much as in infectious disease is it really true that we are our brother's keeper, and that "no man liveth to himself, FOLLIES OF PEESENT SERVICE 33 and no man dieth to himself"; there is but one set in all Nature of infective organisms, which produce the same results in the bodies of rich and poor alike, and we cannot be healthy as long as our poor brother in the slum is afflicted. Both common humanity and self- interest call out loudly to us to help him, and we have just seen how we have been doing it. The better-circumstanced classes suffer less severely from infectious disease, not because they are immune, but because they are brought less in contact with it, in the first place ; and, secondly, because they are better nursed and cared for when it falls upon them. For ex- ample, fatality from measles is very rare in middle or better class practice, but it is one of the most dangerous and fatal of diseases in slum-land, because of the want of care. By far the greater number of cases are never seen by a doctor at all ; the children are allowed to infect any other susceptible children about them in a wholesale fashion ; there is scarcely any attempt at isolation, proper feeding, nursing, or after-attention, and a doctor is only called in when the child is choking in bronchitis, or past help almost from some other sequel arising from the want of care. Is it any wonder, then, that 20,000 children die every year of measles alone ; nearly as many more of whooping cough, and twice as many of epidemic diarrhoea? Until we have our properly organised National Medical Service, 34 DAWN OF THE HEALTH AGE this hideous sacrifice of at least 90,000 children every year is going on, and bound to continue. When we get our service it can be stopped. In the second place, the present Public Health Service is defective and incomplete. in that cer- tain infectious diseases, and these often most dangerous, are not even compulsorily notifi- able at all. For example, infantile or epidemic diarrhoea, the most dangerous disease of infants in the summer months, and with a frightfully high mortality, is not notifiable, and most of the poor little sufferers only reach hospital when they are utterly collapsed and there is absolutely no chance of saving them. More remarkable still, that disease which in oiir country slays double the number of any other, viz. tuberculosis, has until recently not been a notifiable disease. Even now it is per- missible to the Local Authority to say whether it is to be notifiable or not ; and even when it is made notifiable the whole object of notification is stultified by the fact that no action follows on notification. The Local Health Authority has no power to isolate without the full consent of the patient, who has carte blanche to go on infecting new sacrifices for the microbe of this dread disease all around him. Nor would it be of much value for any one Local Authority to attempt to deal properly with tuberculosis, if it was being infected by invasion from the areas of other Local Authorities all round, producing an effect like the thistle-down from the lazy man's FOLLIES OF PEESENT SEEVICE 35 farm alongside falling upon the ground of the thrifty. This question is one for the Nation, not for local authorities, either Poor Law or Municipal or County. But tuberculosis, with its annual national tribute of seventy-five thousand lives, and the way it can be conquered, is worthy of a chapter to itself, so we shall only point it out here as one amongst the many diseases against which no effectual steps are at present being taken by our present Public Health Service. From all that has been said, it will be seen that we possess no Public Health Service worthy of the name, even we Anglo-Saxons who pos- sess the reputation of leading the World in matters of Hygiene. As well might we send forth the privateers and letters-of-marque of Queen Elizabeth's time to fight the modern navy of our most powerful rival, as go on with our present equipment for ofiensive action against disease, and hope or pray for a victory. AH honour to the wooden walls of England and to the memory of the brave men who fought within them, but their day is over; and all honour to our Municipalities and medical oflScers of health, and the private donors who have supported our Voluntary Hospitals like the old privateers, and fought the good fight against disease in the face of long odds. But the day of these things is passing away. Science has shown us a better and more excellent way ; our 36 DAWN OF THE HEALTH AGE pioneers have found out how to win the long- contested battle if we only possess the grit to organise and send forward a disciplined army. Let us once more lead forward the whole world on the glorious path to health and happi- ness as we have done of yore. CHAPTER III THE DOCTOR AND HIS PATIENT IN PRIVATE PRACTICE AND IN STATE PRACTICE So far we have been concerned with medical science in relationship to the health and welfare of the community as a whole ; a subject which intimately concerns each separate individual, because, as we have seen, the health of each person is dependent upon the health of others from whom his infection with disease arises. It is a remarkable fact, in view of all we know as to causation of disease, that we have allowed matters so to drift on in our civilised communities that the first line of attack and defence is manned by less than ten per cent, of the medical profession, while over ninety per cent, are intermittently engaged as work turns up, upon what might be described as a guerilla warfare with disease after the enemy has thoroughly invaded and occupied the country. Under anything approaching a normal and scientific condition of afiairs these proportions ought to be exactly reversed, and eighty to ninety per cent, of medical men should be or- ganised in a great service carrying out measures 37 38 DAWN OF THE HEALTH AGE on the offensive against disease, while the smaller proportion of ten to twenty per cent, might still be engaged in carrying out such work as arose from disease which had escaped the attention of the regular State service. Or the smaller proportion might bear the same relationship to the State service as the secon- dary school teacher does to the primary school teacher — that is to say, attend more especially to those who, better supplied with means, de- sired a separate and more exacting service from the main bulk of the population. There is little question that a national service must arise in the end out of the general sick- ness and invalidity scheme now being contem- plated by the Government. For when once conditions of medical service for the great bulk of the people have been simplified and placed on a common basis all over the country, and the payment for this medical service is made by Government out of a fund in part contributed by the workmen and in part by taxation, it wiU be obvious to the powerful and unified organisa- tion working such a scheme that both the more economical and the more scientific way of deal- ing with disease is to catch it early and stop it at its source. The scheme will, however, end in disastrous failure if it is allowed to drift as to its manage- ment into the hands of dozens of so-called Friendly Societies, all acting on different prin- ciples, and in competition with one another, THE DOCTOR AND HIS PATIENT 39 instead of being kept in the hands of the Government. The scheme is at present only intended to in- clude workmen, but later it will inevitably be extended to wives and families, after which we may expect the National Medical Service to develop rapidly by a quite obvious process of evolution in which different branches of service become speciahsed amongst the staff of the now universal system of State Medical Insurance. At the present time, however, we have to deal with the fact that over eighty per cent, of the medical profession are engaged in practice for fees or payments made by the patient, and in this chapter the object is to examine whether or not this arrangement is advantageous to individual and community; whether it is an economical system in money and in health; and, most important of aU, how it is affected by modern social and economic conditions of labour. We shaU see that for the bulk of the people its death-knell is aheady being rung, and that it is becoming so inefficient under the action of small local co-operative systems, clubs, societies, and tontines, that it is making the name of medical science a disgrace. It is turning doctors' private practices into fraudulently con- ducted business concerns in which the doctor loses aU dignity and self-respect, and the patient is cheated of that advice and treatment which he imagines is being given to him, and upon which his very life may depend. 40 DAWN OF THE HEALTH AGE Just as there is no service more valuable, and honourable, and worthy of high reward than that conscientiously rendered by a skilful doctor to his patient, so, and to the same degree, there is no greater dis-service, in fact, no greater crime, than scamped and inefficient medical attention, than want of care in diagnosis and proper treatment, or negligence in possessing that knowledge which the progress of medicine demands. Consider for a moment how helpless the patient is in the hands of the doctor, how little he is able to form any just estimate of his doctor's skill and knowledge of the matter in hand, how wholly reUant in pure faith upon his doctor, the patient must be. Strong as the Roman Catholic's belief in the infallibility of Mother Church, as represented in the father- confessor, must be the patient's reliance on Medical Science as represented by his physician. Knowledge of right or wrong in medicine the patient has none ; his only refuge is faith in his doctor. Seeing that this is so, how high ought the ideal of medical practice to be, and how great is the personal responsibility of the doctor to each patient he examines. His duty demands that his examination and care of the case shall be all that his ability and knowledge can make it. There must be no scamping of work, no hurrying, no superficiality. Now, there is, unfortunately, little question THE DOCTOE AND HIS PATIENT 41 that in a very large share of private practice in this country, and much more so in many hospitals, these conditions do not obtain, work is habitually scamped, and patients defrauded of that which they are in many cases doing their poor best to pay for, and imagine that they are getting. This holds particularly amongst practice in the working-class districts where fees are small, and the share of medical work so performed is increasing rapidly year by year, as dispensary practices go on multiplying, as clubs, tontines, and friendly societies go on flourishing and growing, and as in one way or another doctors are cheated and scamped in their fees all over the country, and forced to work under condi- tions in which good workmanship is well-nigh impossible. This statement does not apply to -aU working- class practices; there are hundreds of doctors working amongst the poor who charge fair and reasonable fees for their work, and carry out their work conscientiously and weU ; but there are also hundreds of the other type who accept fees for which good work is utterly impossible. It is this latter class who are a disgrace to the profession, and are not merely reducing it to a purely mercenary business, but are fraudulently imposing upon the poor dupes who are their patients, by taking money under false pretences. The working classes lend themselves to this chicanery by trying to obtain cheap medical 42 DAWN OF THE HEALTH AGE attention by going to the sixpenny or shilling doctor, or by trying to screw the doctor by means of their club or sick benefit society. The doctor agrees to see them for a miserable pittance, and he does see them, gives them a bottle, and nothing more. It is a very cheap system and a very nasty one. The last thing in this world to have cheap is medical advice, and the sooner the public gets to know it the better. If the layman will be a fool, let him go to a cheap tailor, or even to a cheap lawyer; he may live to learn to know better ; but never to a cheap doctor, or he may never discover his mistake. But, it may be said, the workman cannot afford the fees charged by a good doctor; let us be patient and go on with the chapter ; we may find some solution for his case also — although it is not in the voluntary club ; that club is only fit to kill him, not cure him. This system of cheap, low- class medical work in so-called dispensary practice, or by contract work for clubs, etc., is not only incapacitating and kiUing thousands of working people every year, it is thoroughly ruining, in character, moral fibre, and income, the medical profession itself. It is a debasing and malignant process, sinking deeper and spreading wider all the time, and although by working themselves to death, or by employing raw or ignorant hack assistants, a few men make big incomes, a much larger number of men are merely existing in THE DOCTOR AND HIS PATIENT 43 great poverty, and always on the verge of financial disaster. This is weU known within the profession, where the contract system is almost universally detested on account of its many vices for both practitioner and public ; but the public has not begun to realise it, and the system, on account of its cheapness, has caught on in the thickly populated manufacturing districts and towns. The medical man is caught in this whirlpool, and cannot help himself In very many districts the choice is between taking contract work — indeed, begging and toadying for it — or not doing enough practice to keep the wolf from the door. A large number of medical men are only able to curse and rail at this contract practice, and mistakenly think that the proposed Govern- mental system of sickness and invalidity in- surance would only be an extension of it. It would be worth their while to consider how it has come to pass that all these benefit socie- ties of aU types, and clubs of all species, have come into existence, and try to see what it all means, and what is the way out. Continued vituperation of a system that not only mem- bers of the medical profession, but all educated men and sociologists who have examined it, admit to be bad, serves no useful purpose. It is already suificiently damned; let us examine how it comes to be there, what it means, and what is the salvation. Let us do this not only 44 DAWN OF THE HEALTH AGE in our own interests, but in those of the un- fortunate patients who, in a different way, are suffering as much as the medical profession. The origin of these various forms of local amalgamation into medical benefit societies of all types, is the same as that which centuries ago formed our national clans and noble families ; which founded the Nations of Students in our mediaeval Universities; which united our ap- prentices into Guilds, and gave origin to our City Companies ; which gave the power to feudal chiefs, and gathered communities into free boroughs. In our own day, the same guid- ing spirit has led to combinations as diverse from each other in purpose as our Trades Unions on the one hand, and our gigantic commercial Trusts on the other. The principle, in fact, lies at the root of the whole of our civilisation, and is as deep-seated as the principle of organic evolution itself. Men have discovered that combination and unity give strength and power to carry out projects utterly impossible to the individual. Such combinations are seldom wholly good or wholly evil in their consequences, and whether on the whole they are good or evil depends upon their reaction upon the community or com- munities either employing them or affected by their influence. Some of the evils of contract medical practice to both contracting parties have been pointed out above, but there are certain compensating THE DOCTOR AND HIS PATIENT 45 advantages which might be caused to increase enormously under a better and wider system, and all or nearly all of the disadvantages might be made to disappear. In the first place, it may be pointed out that for the greater part of the wage-earning class, includiag all the unskilled and a great share of the partially skilled labour of the country, the only alternative to the Sick Club is the workhouse and Poor Law treatment or the Out-patient Department of a Charity Hos- pital, and, as we shall see in a later chapter, this is worse than the club system. The numbers of the population involved in this category run into several millions — probably thirty-eight millions would be a conservative estimate — out of our total forty-five millions. While the head of a family can himself keep at work he may possibly be able to pay low fees to a doctor for attendance on his wife or child ; but when he himself is seriously ill and has to give up work for any length of time, only for his trade-union sick pay and sick-club medical attendance he would soon be destitute. Think how many families are struggling along with the father earning eighteen shiUings a week, and occasionally out of work, and only small children still at school; how many more have to subsist on less than thirty shiUings a week all told; and how are these to make better provision against misfortune in the shape of that ill-health to which they, from their 46 DAWN OF THE HEALTH AGE environment, are more exposed than any other class in the nation, than by the few pence sub- scribed weekly to the sick-club ? They cannot possibly do more, and those better circumstanced who inveigh against the thriftlessness and extra- vagance of the poor should first of all try to put themselves in their position. If there be added some consideration of their education and development, some thought of how little chance they have ever had of seeing what thrift and pinching can ultimately produce in the way of better conditions and increased comfort, we might be able to pardon some of their short- comings. Let us think of the sordid surround- ings, the hard struggle to keep above water, the comfortlessness of it all, and the endlessness of it, and we may forgive them breaking down on pay-day and snatching an illusory happiness which a day later but sinks them deeper down. The writer is no sentimentalist, no believer in charity ; he earnestly desires the worker to participate in his own upraising. If we cannot develop moral fibre and courage in these people we cannot help them. But let us set about it aright ; do not let us ask them to undertake impossibilities under a system which is dragging them down and submerging them. If the point of view be altered so as to obtain a better per- spective, it may perhaps be seen that these vices of the poorest are part and parcel of their condition, just as certainly as the symptoms and mental attitude of the diseased man are THE DOCTOE AND HIS PATIENT 47 part of his disease. Get the system of living improved, and the individual will improve with it ; he may never be an angel, but he may be less of a devil if he be less torfliented. Biology teaches us that there are two funda- mental things in all life, the organism and its past and present environment ; the two react on each other, and probably the environment has more power in changing the organism than the organism has in altering the environment, but both can and do react. Now, in regard to the man in the slum, we men higher up out of the slum have been expecting the slum man {i.e. the organism) to do all the altering, and have not been paying enough attention to alter- ing the environment. We have had all our eyes on the human being, preaching to him of better things and trying to alter him, and when we have failed we have usually cursed him as a thing too vile to live, and left it at that. When we have touched the environment at all, we have done it usually by charity in all its many useless forms, and of these the present Poor Law is the worst. It is just about time we set about considering in a reaUy philosophical way, as a scientific people attacking a scientific problem, how to improve the creature's environ- ment and give him a better system of things to work in. Not an exotic system, be it re- marked, but a natural workaday one, which, once started, wiU go on improving itself. We can do this better if we put all our fine feel- 48 DAWN OF THE HEALTH AGE ings and sentimentality and charity in our pockets, and find out what is wrong. As an example of this very principle in one of its not least important aspects, we may take the club system of medical practice of which we have been talking, and study how to improve it. Disease and its aftermath lead to more destitu- tion, submerging of the poor, and filling of the workhouse and its accessories than anything else, so that the problem is worth tackling. If, as we have seen, joining a sick benefit club is the only insurance against ill-health that the workman can provide himself with during health, we may take it that he does not join simply to spite and defraud the doctor; it is simply a reaction to a particular environ- ment. The evils of the club system arise very simply. In the first place, the workmen are not able to pay enough to raise a sufficient sum to ade- quately repay the doctor for attending to so many. In the second place, the aggregate amount coming in annually as a fixed sum is nevertheless sufficient to tempt the doctor to undertake the club work, although in many cases he knows within his soul he is going to scamp it, both in time and attention, as com- pared with his better paid private work. Thirdly, the workers belonging to the club have elimi- nated all competition amongst themselves for the doctor's services, and have got better terms from the doctor, as far as money goes, in that he THE DOCTOK AND HIS PATIENT 49 attends them much cheaper per visit than if each of them had gone to him separately when ill. At the same time, by their union and by the annual sum they have to offer, they have turned the tables and set the doctors of the district in competition, and by going about amongst the doctors and exciting this competi- tion they have succeeded in getting their work done at the lowest possible figure per head per annum, and fondly imagine they have done a good stroke of business for themselves. The end result is that the club sweats the doctor to the last drop, and the doctor in turn scamps the club patient's case to the last inch he can go, without losing his appointment, and in this process, as pointed out earlier in the chapter, the doctor is master of the situa- tion, for he possesses knowledge, and ignorance possesses the patients. By the operation of these simple processes, and a natural reaction of cause and effect, that vicious circle is established which renders club practice the detestation even of those doctors who engage in it, and at the same time such an unknown, but none the less terrible, evil to the poor sufferers who pay, albeit as little as they can help, for the ministrations of the physician. What is the way out from all this chaos? Precisely that unified system of State insurance against sickness which so many members of the medical profession are at present deriding as an extension of club and contract practice. D 50 DAWN OF THE HEALTH AGE An extension in one sense it certainly is, but not in that nefarious sense which the pro- fession attaches to the word " contract " practice to-day. In the first place, it is proposed that not only the workman, but also the employer and the State shall contribute ; so that there must be a larger sum to pay the doctor for adequate treat- ment and attendance. In the second place, the united income of the scheme is to be disbursed by the Government ; so that the State medical oflScer becomes a State servant, dealt with directly by the State and paid by the State, which is quite different to being paid by a motley crowd of Clubs and Friendly Societies. In the next place, the Government, being in charge of the scheme, can be approached by members of the State medical service for the institution of proper and equitable conditions of service. This cannot be done at all to the tens of thou- sands of Friendly Societies, which have for their object in life setting the doctors in competition to secure, almost regardless of quality, the lowest price possible. A Government could not afford to behave in this way ; the workmen, having once paid their subscriptions, would make it obvious that they must have a properly equipped and efiicient service. A sweated service could not be this, and must inevitably tone up to the level of other national services. It is a great mistake to compare a national medical insurance worked by Government with THE DOCTOK AND HIS PATIENT 51 present conditions under the Poor Law, a system which stands condemned on many counts by all competent critics. Those defects in Poor Law administration which have caused other evils have also led to the degraded sweating of medi- cal men by Poor Law Guardians. This system is seen at its acme of shoddiness in Ireland, in the vile treatment to which medical men have there been subjected time after time by ignorant Irish Poor Law Guardians. There is no question that Boards of Poor Law Guardians are doomed, so that at the very least the officers of any public system of sickness insurance would be under more responsible bodies, administering larger areas in Boroughs and Counties. For this reason the control would be in the hands, at the very worst, of more enhghtened people than at present. It is just here, however, that the new medical service may lose much of its efficiency if it is not made a truly national one. If the new medical service is placed under municipal control it will lose its coherence, and become like a territorial army of many isolated units, instead of one unified National Army of Health. The ScyUa and Charybdis to be avoided in the projected reform are the Friendly Societies, which are very anxious to either wreck, or them- selves administer the scheme, on the one hand, and the Municipalities and other Local Autho- rities on the other. The true solution is one National Service for 52 DAWN OF THE HEALTH AGE the whole country, under a Minister of Public Health of Cabinet rank. Local conditions for hospitals and administration may be left in the hands of local authorities, but the medical officers must be appointed to a National Service and be transferable from one local centre to another, and open to promotion from one place to another. Nor would the annual sum required be at all enormous to thoroughly carry out such a national scheme of State Insurance against disease. There are just over 32,000 medical men in practice in the United Kingdom of Great Britain and Ireland. It is quite a liberal estimate to take the average income of the profession at £250 per annum ; it has been quoted at £200 per annum. On the basis of £250 each per annum, the aggregate income of the whole of the medical profession accordingly amounts to just eight million pounds. The profession is at pre- sent underpaid, when the professional training and its duration and expense are taken into account, so that if we add one-fourth more for this, so as to make the State National Medical Service attractive for good men, we arrive at the net result that the State can employ all of these 32,000 medical men at a total cost of ten millions per annum. The average annual pay for each doctor would be somewhat over £300 a year, and taking it that a junior entered at about one hundred and fifty pounds a year, this would mean a system rising on ordinary THE DOCTOR AND HIS PATIENT 53 promotions and good service to a maximum of one thousand pounds, and a small number of administrative officers at higher salaries, in the most distinguished posts. It would form a magnificent service, second to none other in the country. Also, there would be more doctors than at present to cope with working-class work. For we have supposed all the men now in practice to enter the new service on full-time work. But not more than two-thirds of those now in private practice are engaged on working-class practice. Accordingly, the national cost could either be reduced one-third in amount to six and two-third millions annually, one-third of the profession electing to remain on in private work; or, alternatively, a much more effective service could be instituted at the above cost of ten millions annually. Now, when it is remem- bered that (1) workmen contribute, (2) employers contribute, and (3) the State contributes, this amount is certainly not an excessive sum to raise for such an enormous boon as a complete full-time National Medical Service would mean to the Nation. Let us look for a moment more closely at what the necessary contributions would mean to raise this sum. There would, it is estimated, be 12,000,000 workmen participating in any scheme of compulsory State Insurance. Suppose that each of these workmen contributed only One penny a week of insurance money, and the 54 . DAWN OF THE HEALTH AGE employer contributed also one penny a week for each workman he employed: — surely not an excessively grinding tax upon either. Then the combined sum raised from these two sources would be five million two hundred thousand pounds annually, and the State would only have to add one million four hundred thousand to obtain the full and free services of the present staff of doctors working for the poor, and for a sum of four million eight hundred thou- sand could provide adequately and well for a National Medical Service sufficient to attend not merely to the workmen, but to every man, woman, and child in the whole Kingdom, and much better than is done at present. The whole scheme is not nearly as costly as the provision required under the Old Age Pen- sions Act, which, long talked of, is now an established fact; and there is no doubt that the National Medical Service would prove at least as beneficial and as popular as the Old Folks' Charter. An important fact, weU worth remembering, is that this taxation would not really be new national expenditure, but rather a great saving of money to the people. For the doctors have even now to be paid by hook or by crook in some fashion or other ; and so, although the workman had to contribute his penny a week, he would then no longer have to pay the doctor, and so would save money and provide against the evil day of illness. The gain, in disease THE DOCTOR AND HIS PATIENT 55 stopped at incipient stages and in increased health and corresponding power of his work- people, together with regularity of work less interrupted by iUness, would more than repay the employer for his contribution ; and, lastly, the immunity from infection and premature death, given by the operations of such a National Health Service, would most certainly repay many times over the general taxpayer for his moiety of the fund. Leaving the question of money, let us now glance at the economy of such a system from the scientific and sociological point of view. If the Government provides a sickness in- surance scheme such as outlined above, prac- tically aU the doctors will be paid sufficiently for full-time service for the Government, and so the system comes under a unified control. As a result, the members of the Staff can be located and assigned work according to the views of the Minister in charge of the ser- vice and his advisers. Accordingly, in the in- tervals of attending to cases of serious illness, accidents, etc., attention can be given to inspec- tion and instruction as outlined in previous chapters. The work can also be adequately divided up so that one man is not nearly idle while another is working himself to death over scamped, ill-done work; and also the whole question of hospital abuse falls away, because the doctor working inside the hospital is a fellow and colleague of the doctor at work out in the 56 DAWN OF THE HEALTH AGE slums sending in the serious cases to him, and is no longer robbing the doctor outside in practice of his livelihood. Contrast this with the present disjointed order of things, where the doctor sits idle half his time behind his red lamp and brass door- plate waiting for the patient, and the patient in the slum, ill himself and infecting others, waits and dies in the absence of the doctor whom our wretched system will not allow to come to him. Take the case of the young graduate in medicine who sets up his plate and lamp at a street corner, and waits for patients to drop in upon him. For a period varying from six months to a year, if he sets up as a shilling dispensary doctor, to one to three years in an ordinary intermediate type of general practice, or, still more, of five to ten years if he is at- tempting to become a consulting physician or surgeon — for all this period he does hardly anything, and for a still longer period his time is only very partially employed. Even the fairly busy practitioner later on, or the dispen- sary practice man who runs through cases at breakneck speed in the so-called surgery in the evening and does his round of visits in the morning, has plenty of time between whiles in which he could do other things, such as hospital work, or organised slum inspection for disease requiring removal or treatment; but our wretched, hide-bound system of private THE DOCTOR AND HIS PATIENT 57 practice, with its strange, nonsensical code of ethics and professional etiquette, requiring a modern Cervantes to set the world a-laughing at it — this monstrous system permits no latitude to the doctor; he must lie in waiting at his own home for disease to come to him. Even when it does come to him, it must come in proper guise, and all formalities must be pro- perly arranged before he can touch it. A good part of the doctor's time is even spent in secretarial work — in sending out and collecting his bills for work done, and in getting his collectors to look after bad debts for him. An exception, of course, is the ready-money, ready-made, shilling-dispensary-practice degra- dation, where the patient tips the doctor after each little attention, and carries his bottle of iU-assorted, harmless, useless physic back home with him to drink in peace while he continues uninterruptedly those evil courses which harbour and encourage his disease. How much preferable for the doctor to get his quarterly cheque from Government, and spend his time in being a doctor and looking after questions of health and disease, leaving bill-posting and fee-squeezing to those whose business it is ! Again, under our present system the doctor has absolutely no opportunity to keep himself in touch with the progress of medical science, and is apt to become a pure empiric, a quack and a charlatan, who talks about, and pre- 58 DAWN OF THE HEALTH AGE tends a knowledge of, things of which he is profoundly ignorant. The doctor in general practice may be able to read occasionally in his weekly medical journal, or once upon a time attend a meeting of a local medical society; but this cannot adequately replace practical work in laboratory or hospital. Prom this latter source of stimulus and inspiration nine-tenths of our medical men are cut off from the day they qualify and cease to be medical students, till the day of their death in harness, struggling for their living and that of those dependent upon them. The result is most deplorable, and greater than the lay public can possibly realise, or they would rise up in indignation and sweep the present system away wholesale, lock, stock, and barrel. During the last fifteen to twenty years our knowledge on both medical and surgical sides has been increasing enormously, and for the same period the great majority of practitioners have been acquiring any acquaintance with new knowledge in a second or third hand way, and without any practical teaching. Our present system provides no means by which, without losing their incomes, they can return for six months or a year to laboratory and hospital and have their minds refreshed by a post-graduate course. Many of them are so chronically steeped in ignorance that they do not even know that they require such a rejuvenation. THE DOCTOR AND HIS PATIENT 59 Nor are they to be blamed in the least ; they are rather only to be pitied, and still more to be pitied are their patients, for whom it may be frankly admitted that they are conscientiously striving to do their best. Contrast this state of affairs with what happens in the case of the medical officers of our Army and Navy and Indian Medical Services. Here there are modern, up-to-date Staff Colleges and Hospitals, to which the medical officers, after intervals of service, are allowed leave on full pay, to go and learn modern methods of diagnosis and treatment. But the unfortunate general medical prac- titioner in private practice enjoys no such luxury as this ; if he takes a short post- graduate course of two or three weeks, he must snatch it in a vacation, which he sadly needs for bodily recuperation, and no one offers to pay his fees, or work his practice and give him the money while he is taking the course. Sad to have to state, in too many cases the private practitioner has almost ceased to be a professional man at aU. He has become purely a business man, in a line of business which rarely yields more than a pittance. There are, of course, very many who have not allowed the iron to enter into their souls, and in spite of the claims of a general practice, keep up an acquaintance with scientific medi- cine and modern practice, But the system is 60 DAWN OF THE HEALTH AGE a horribly fossilising one, and the men who go asleep under it are scarcely to be blamed. Another crying evil of our present system is the multitude of extraneous things, not related to professional skill in the remotest degree, which are necessary and make for success in the profession. It is often well known to his brother practitioners that the highly successful doctor, who has the largest and best-paying practice in the town or district, is by no means the best physician or surgeon in it. In fact, he is often little better than a well-qualified quack, who knows how to play on the feelings and sentiments of the laymen upon whose bodies he practises, because of the subtle influence he possesses over their minds. The man who succeeds in general private practice is he who can best please the ladies, and who, by an affable exterior and calm pose of face, can hide the profound ignor- ance within his cranium, while his neighbour with tenfold the ability, but an abstracted or brusque manner, and without the social arts of pleasing, gets little or nothing to do. Who are the jury to decide whether the doctor's work is done well or ill, but lay people who know nothing and can be taught nothing of the case ? As to judgment by re- sults, apart from egregious mistakes amount- ing to malpractice, how can the public judge here or determine how much is due to chance and how much to the ministrations of the THE DOCTOR AND HIS PATIENT 61 doctor? If the case goes ill, an apt manner, carefully constructed statements, and sympa- thetic bearing convey the certainty that "the best possible has been done, but nature must have its course"; while if it goes well, "Oh, what skill ! how well everything was done, and what a marvellous cure the doctor made of a bad case ! " In medical practice, so much necessarily rests on causes beyond control, that all depends on the impression upon lay minds produced by the doctor's manner as to the verdict upon him. This mental influence of the doctor on patient and patient's friends is sometimes valuable, when it is not used as a cloak for ignorance, but its absence is disastrous to the career of many a man who is lacking in the small social amenities, and in what might be called professional style, and yet possesses in high degree that professional skill and acumen which is essential in the treatment of serious disease. Also, it is most unfortunate when a plausible style covers, as it often does, lack of scientific ability, and the man depending upon his powers cultivates this manner as his chief stock-in-trade, instead of keeping himself up to date in his professional skill, and so be- comes a mere charlatan, living upon the fact that most of the fees, especially in middle-class practice, are made from trivial, commonplace ailments, and calling in the consultant, or sending the case, if it is a poor patient, to 62 DAWN OF THE HEALTH AGE hospital, as soon as he gets into any difficulties for which a competent practitioner would scorn asking assistance. The final indictment against this system of private medical practice, even from the point of view of treatment and of the private patient, is the same as that which we have urged from the community's point of view in the prevention of disease, namely, that the most incompetent agent in the world for the purpose, to wit, the patient himself, sets the machinery in motion. The patient is forced to go to the doctor either because he is enduring pain or because life, on account of weakness or depression, has become a burden to him. Now, for both men and women, there are hundreds of cases where these indications only come in when it is too late to go to any doctor, and the case is beyond hope. This, too, where an earlier indication and visit to a competent doctor would have put quite a different com- plexion on the case. Many most serious diseases, such, for example, as both phthisis and cancer, are frequently un- attended by pain in their earlier stages, or even until far advanced, and it is far too late to go to the doctor when weakness and prostration have begun to supervene. From our childhood we have been brought up, most of us, to associate a visit or inspection by the doctor with most unpleasant memories ; partially due to the obnoxious habit of some THE DOCTOE AND HIS PATIENT 63 physicians of pouring vile-tasting medicines into children, when there is no indication for them, and they are probably doing more harm than good, and, in great part also, from the fact that we scarcely ever see a doctor profes- sionally unless there is something the matter either with ourselves or some one dear to us. Why so often is it left to the doctor to pro- nounce a death sentence ? Why is the doctor looked upon as a person only to be called in to exorcise disease ? Would it not be a change for the better if we could get to look upon him as the Minister of Health rather than of Disease, and evolved a corresponding system ? It is in this saner way that educated people have within the last generation grown to regard another professional man who has made a special study of one branch of surgery, viz. the dentist. We no longer wait until we have violent tooth- ache, and then rush off to the dentist to have the tooth extracted, as did our more immediate forefathers. We are learning that it is our duty to our children to take them once a year at least to the dentist to have their teeth inspected. It would be a better day for most of us, even in regard to individual health as apart from public, if we learnt that our doctors ought to be preventive officers, and if we paid them an annual fee and went to be examined, and if necessary forewarned and treated, at periodical intervals. How many men have learnt for the first 64 DAWN OF THE HEALTH AGE time that they were in the incipient or even more advanced stages of serious illness when they have gone to the doctor, as they imagined, in perfect health to be examined for life insur- ance ; and how many, taking advantage of good advice given on such an occasion, have curbed a bad habit of life, or of appetite, and stopped an inroad of disease, which they would have only found out too late if they had gone to a doctor in the ordinary course of events ? No ; the serious, unmistakable signs of disease, as visible or obvious to a laymen, often — too often — come too late to make that system, which leaves the individual sole arbiter of his health, a safe one, either for the patient himself, or for those immediately around him or dependent upon him, or for the general public. We have seen how the unattended, often undiscovered, disease of slum-land reacts back upon the general health of the community. The same thing which holds for the community holds in still higher degree for the family ; and that in all ranks, but more particularly in the lower classes, where families are huddled to- gether and overcrowded. How often do we see one sister after another in the same family dying of phthisis, or husband following wife, or wife husband, till a family is well-nigh wiped out ? This, too, occurs where all possible care to avoid infection is taken by the family after the first member has gone to the doctor and had the case diagnosed. What THE DOCTOR AND HIS PATIENT 65 is the cause of this, the most melancholy picture in all medical practice ? Nothing so much as the system which has for its fundamental basis that we do not go to our doctors until we think we are ill. The seeds of the fatal disease are often laid in the second and third members of the family before the first has been to the doctor at all. Think of it : only one person in two hundred and fifty of us at the present moment has con- sumption ; but at least one adult in every seven of us is going to die of it. All because of this nefarious, wait-tiU-you're-ill system, which no one has the courage to attack, and because we will not send doctors out to the highways and byways to find disease, and haul it apart so that they may stand between the healthy and the infected and the plague be stayed. As it is with consumption, so it is with a hundred and one other diseased conditions. Instead of having our doctors come to us while we are well, or think we are well, we refuse to go to them until we are certainly ill, and then we too often learn we have come too late. As one more instance there may be quoted cancer in women. Here the details are not suitable for placing before lay readers, but it may be pointed out that in liie earlier stages, where the surgeon could do something, there is often no pain. There is only what appears to be a harmless swelling, often coming on so slowly that it is hardly noticed, and the patient E 66 DAWN OF THE HEALTH AGE is not alarmed, or has some false modesty in going to a physician. Later, when the thing becomes more troublesome, she goes, alas, too often to be told, it is too late. Now, suppose we had established firmly that the only right principle in such cases is an early medical consultation ; and suppose, further, that which is essential for the majority of cases occurring amongst poor working women or the wives of workmen, that we had established such a National Medical Service that this consulta- tion could be obtained gratis, and as thorough and skilful as if the individual patient were paying for it, and, most important of all, with- out having to lose practically a day's work going to the Out-patient Department of a Charity Hospital. What a change this would make, what a revolution in our whole system; how many useful lives might be spared, and homes left bright on which death now casts its shadow ! CHAPTER IV OUE HOSPITAL SYSTEMS: THEIR EVILS AND ABUSES There is no virtue so well-beloved as charity, nor any to which so many counterfeits of all kinds exist, so closely resembling the real article that it is often difficult to expose the fraud. But just as matter in the wrong place is dirt, so the most admirable virtue turned from its right use becomes vice. A sincere and practical commiseration for the woes of our fellow-men leading to well- directed acts of charity or benevolence, whether given in service or in money, must always excite the admiration of the noble-minded. It is for this reason that the sentiment and lofty purpose which have founded and main- tained our Voluntary Hospital system have received so much admiration and eulogy for generations. The author has no fight to wage with such high sentiments as these, and as his own object is the alleviation of human suffering, just as is that of the philanthropist of the voluntary hospital, this common aim and objective must be his excuse for pointing out some of the limita- 67 68 DAWN OF THE HEALTH AGE tions in our present equipment for reaching our destination, and showing that our energies may perhaps better be turned into another channel of approach. In the task of destroying disease and abolish- ing destitution we require, and must have, the aid of every one in the nation who is capable of assisting ; there must be no shirking of what is eveiy one's duty, and each must be eager to do his share. The contribution to be exacted does not always mean money; sometimes it means ser- vice, skill, privation, or separation. The de- mands of disease-fighting are inexorable ; there is no royal path for any one ; disease is no respecter of persons or conditions ; we must fight it in a scientific way, or we must suffer defeat. A few lunatics, or ignoramuses, with conscientious objections, or some other form of lunacy such as faith-healing, can wreck our whole scheme, so that it cannot be voluntary ; it can only succeed when the voice of the majority of the people demands it and it is backed by a strong Government. Now, in spite of all its lofty sentiments of voluntary charity and benevolence, the curse of the voluntary hospital system — and it is a great curse — is that it is blinding the eyes of those who could most help social reform to the fact that we possess no National Hospital System. The Voluntary System is utterly in- adequate ; it is strained to its utmost limit and OUR HOSPITAL SYSTEMS 69 almost bankrupt, and yet it cannot attend to more than about fifteen to twenty per cent, of the cases requiring attention. By its very excellence in attending to this small proportion of the suffering poor, it blinds our eyes and blunts our perceptions in regard to the eighty per cent, which it does not touch at all. This is the keynote, the fundamental failure, in our hospital system, and must not be lost sight of in any detailed description of other hospital evils and abuses which follow in this chapter. A system which cannot do more than fifteen per cent., or twenty at the outside, of the work which it is intended to do, and this after genera- tions of highest effort, is a hopeless failure, and is a vice and a drawback, because it stands in the way of the introduction of a proper organised scientific effort. Even this small proportion of work done by the Voluntary Hospitals is by no means perfect, nor is it uniform in its standard throughout the country; but even if it were perfect, how by voluntary effort is it to be made to extend to deal with the eighty per cent, at least of work which is now either done most execrably by the Poor Law Authorities, or left undone altogether ? The best and warmest friends of the volun- tary system must admit that any such five- or six-fold extension is utterly impossible, and out of the question. 70 DAWN OP THE HEALTH AGE Now, from personal experience and examina- tion, the author vouches that the poor persons in the Voluntary Hospitals differ in no way or respect from the poor persons in the Poor Law Hospitals, and these again from those helpless in the slums unable to obtain admission to either type of hospital. If this be so — and it will be hard to controvert it — the whole position is illogical and utterly untenable to any thinking person. Further, it may be truly said that any person who contributes towards or endows voluntary hospitals, however good his or her intentions, is contributing to the perpetuation of a great national nuisance and great national wrong which cries aloud for redress. Such contributions indicate no true charity, but its exact opposite; there is no health in the puling sentimentality which short-sightedly relieves the case in view and wilfully neglects the nine cases, equally deserving, clamouring for attention just around the corner. Such sentimentality, by casting a spurious air of decency about the proceedings, prevents that wholesome exposure which public morality and good faith with ourselves demand. This is a public sore and festering spot, not to be plastered over with anodynes and oint- ments till it is hidden from view, and kept out of sight by repeated coatings of the oint- ment of spurious charity; the sore needs to be opened by the surgeon's knife and treated OUR HOSPITAL SYSTEMS 71 in a scientific way so that it may be healed, instead of remaining with us for ever. Let us stop dropping feeble sentimental tears over the sufferings of the poor and doling out charity to them ; let us put them under a system which will end these sufferings. In this process the first essential is the reduction of disease, and for this we must have a unified, organised system of hospitals under the direction and control of our National Medical Service. Do not turn away and say the Nation can- not afford it, for it is going to cost less by half than our present extravagant and wasteful systems of (1) Voluntary Hospitals, (2) Poor Law Hospitals, (3) Municipal Hospitals, (4) Special Hospitals, (5) Municipal Dispensaries, and, last and worst of all, (6) No Hospitals. Give us one organised system in true co-ordina- tion, instead of all this chaos, and one may ven- ture to guarantee that both disease and expense will drop to one-half together. In writing with some feeling on these evils of our present hospital systems, the author is not being carried away by imagined horrors, or dealing with matters of which he has heard from another ; he has actually seen and ex- perienced these things, and can state as an eye-witness that there is no greater mass of incongruity and absurdity and wasteful extra- vagance existing anjrwhere in all the whole fabric of our civilised institutions than the 72 DAWN OF THE HEALTH AGE British Hospitals taken as a whole. Such con- trasts of good and evil, light and shade, sanita- tion and insanitation, order and disorder, wealth of space and overcrowding, highest medical skill and practically no medical attendance, can nowhere be found in such profusion as in the wards of our hospitals. Let any one who thinks this is the per- sonal view of a crank go and pay a visit to one of our better-class Voluntary Hospitals, and then visit one of our older Poor Law Hospitals, or read, if this is not feasible, the account of the recent Eoyal Poor Law Com- mission, both Majority and Minority, as to how the poor are treated in our Poor Law Hospitals. Those who cannot do this may learn much by consulting the accounts of various hospital inspections throughout the country made by Sir Henry Burdett, K.C.B., and published in the Hospital during 1909-10. There are no arguments so telling as baldly stated facts from concrete instances, so one may contrast here two hospitals existing almost side by side in the same city, the one a Voluntary Charity Hospital and the other a Poor Law Hospital. Since these two hospitals are but a type of what exists, neither better nor worse, over the greater part of the country, and as the object is to describe existing conditions without attach- ing either praise or blame to administrators, OUK HOSPITAL SYSTEMS 73 the city and the two hospitals are described under assumed names. The statements made, however, are mainly based on the author's own personal observations of two actual institutions; and, further, they are substantially in accord with the reports of one of the greatest hospital authorities in the world, on these two institutions. The two hospitals in question are the Royal Charity Infirmary, Cottonport, and the Guardian Angel Workhouse Infirmary, Cottonport. The Royal Charity Infirmary contains just under 300 beds, and the Guardian Angel In- firmary contains close on 1000 beds. The 300 patients of the "Royal Charity," in addition to the Consulting Staff, have three visiting physicians and three visiting surgeons to in- vestigate and attend to their illnesses, while over 900 patients at the " Guardian Angel " have one visiting physician and one visiting surgeon to perform a like office. There is a Gynaecological Surgeon and an Assistant Gynae- cological Surgeon, with a resident House Sur- geon under them, to attend to gynaecological cases at the Royal Charity Infirmary; in the more than three times larger Guardian Angel Infirmary there is no gynaecologist, all gynaeco- logical operations being performed by the single visiting surgeon. There are at the Royal Charity Infirmary an ophthalmic surgeon, a laryngologist, a dermatologist, a surgeon in charge of the X-Ray Department, and four 74 DAWN OF THE HEALTH AGE medically qualified Ansesthetists — there are no such officers at the more than threefold larger Guardian Angel Infirmary, only a few hundred yards distant in the same city of Cottonport. There are, in addition to the Senior Honorary Staff of the Royal Charity Infirmary, three Hon. Assistant Surgeons and two Hon. Assistant Physicians ; there is no corresponding staff whatever at the Guardian Angel Infirmary. There are a medical registrar, a surgical registrar, three house physicians, and five house surgeons to look after the 300 patients at the Eoyal Charity Infirmary, while there are four resident medical officers all told at the Guardian Angel Infirmary to attend to nearly 1000 patients. Summing up these facts, there are twenty-one Visiting Medical Officers attached to the Royal Charity Infirmary, and ten Resident Medical Officers ; while there are two Visiting Medical Officers and four Resident Medical Officers at the Guardian Angel Infirmary ; and it may be finally reiterated that the former institution has less than 300 beds, and the latter well over 900 beds. So much for the relative Staffs of the two Hospitals : now as to equipment. The Royal Charity Infirmary is modern and up-to-date, while the Guardian Angel Infirmary is anti- quated, and in the opinion of many competent authorities, ought to have been pulled down years ago. The buildings for the 300 patients cost at least double as much as those for the OUR HOSPITAL SYSTEMS 75 1000 patients. It is difficult, without actual measurements, to estimate relative air-spaces, but there is quite double, probably treble, as much air-space per patient at the Royal Charity Infirmary as at the Guardian Angel Infirmary. The sanitary arrangements at the " Guardian Angel " scarcely can bear description. There are only two baths, pre-Roman in their appearance, for each floor of one hundred and fifty beds, and these two baths have to be used for such washing purposes, as well as the patients' bodies, which exigency requires to be done upon the spot — such, for example, as the soiled waterproof sheets from the beds. The common closets, in an open row, and the common latrine on each floor, " beggars all description," but not for the same reason as Cleopatra in her barge, although here also "a strange invisible perfume hits the sense." In contrast, the sanitary arrangements at the " Royal Charity " are all that the requirements of a modern hospital demand. Each ward possesses its own set of (1) patients' wash-up room, (2) bathroom, (3) set of separated closets, and (4) nurses' sanitary wash-out room with air- shaft to outer air. This set of four sanitary rooms is built apart from the main ward in a Sanitary Tower separated from the ward by a weU- ventilated vestibule. The whole system is walled by glazed fireclay brick, easily kept in clean condition. In the wards themselves, the floors at the 76 DAWN OF THE HEALTH AGE " Eoyal Charity " are of oak parquetry, while at the " Guardian Angel" they are of common deal, cracked, splintered, seamed, and worn everywhere till the many knots stand up like the gnarled excrescences of a gouty old age. The walls are of glazed brick at the "Eoyal Charity"; at the "Guardian Angel" they are roughly plastered and painted over. Attached to each ward of the " Eoyal Charity," these wards containing eighteen to thirty-two beds only, there are the following working accessories: (1) a small isolation ward con- taining two beds, and (2) a convalescent room for piatients able to walk about. To every two wards there is a small clinical laboratory assigned, in which chemical and bacteriological investigations and other scientific examinations relating to the cases can be carried out, and these laboratories are well fitted with scien- tific appliances. No slightest vestige of these up-to-date requirements exist at the " Guar- dian Angel," where there is no means for ex- amination or investigation in the whole vast institution. One surgeon only, the visiting surgeon, has hitherto performed all the surgical operations deemed necessary for the whole of the patients of this huge hospital (" Guardian Angel"), in- cluding all the gynaecological cases. For all these operations there are provided only two small surgical theatres situated in attics on two top floors, one for the male hospitals and OUR HOSPITAL SYSTEMS 11 one for the female hospitals. In each of these divisions there are over 400 beds, probably half of which are surgical — that is to say, there is one little, antiquated theatre for a hospital of over 400 beds, and one half the services of a single visiting surgeon. The patients at the "Guardian Angel" are anaesthetised in the operating theatre itself, and V7hen one thinks of the demands on one operating surgeon's time in such a huge insti- tution, it is probable that a previous patient is usually undergoing an operation when the next is carried into the operating theatre on stretchers. There is no passenger lift to the whole of each huge four-storied block (or, rather, three blocks arranged in the worst possible manner and buttressed up by other buildings), and hence the unfortunate patients have to be carried to and from the operating theatre on stretchers along narrow corridors and up and down steep and awkward stone staircases. It suggests forcibly to one's mind certain adaptations of the lines on the pauper's burial by Tom Hood.^ There is no steam steriliser in either of these two small theatres; there are two operating tables in each, of a most antique gridiron pat- tern, quite unadaptable for the different surgical positions ; the floor is of common boards, the furnishings of the most parsimonious character, 1 Such as : — Battle his stretcher up and down stairs ; He's only a pauper, and nobody cares. 78 DAWN OF THE HEALTH AGE and the instruments scanty and often out-of- date. On the other hand, the "Royal Charity" possesses four large operating theatres, each replete with all modern conveniences, with anaesthetising rooms attached to each ; and there are two commodious hydraulic lifts from floor to floor, and rubber-tyred trolley couches on which the patients are conveyed to and from the wards and operating theatres. With such a Staff as we have seen is pro- vided at the " Guardian Angel," it goes with- out saying that there cannot be much order or arrangement of the patients in the wards, or adequate note-taking or attention to the pro- gress of the cases. On account of an ingenious space-saving device of the architect, who pro- bably flourished and was gone before the science of bacteriology had made mudh progress, it comes to pass that the ends of several of the wards are veritable boxes, having quite blank walls without windows on three sides for at least half their length, and on the daj of the writer's visit there were phthisical and non-phthisical patients lying side by side on beds not very wide apart in these window- less ends of wards. There was a considerable number of such phthisical patients, and it was explained to me by my conductor that these patients were mixed up with the others because the phthisis wards were full. OUE HOSPITAL SYSTEMS 79 Two special wards for phthisis on the male side, and one on the female side, each with low-pitched roof, had no windows whatever to the open air on three of their walls, and the few windows on the one free side were small and high. Two of the walls were quite devoid of windows ; the third had borrowed light and air from a long, dark corridor run- ning between this ward and a fellow ward in a parallel tier with it. But this poor corridor had little of air and less of light for the wards to borrow from it. Just reflect on the above, as a ward for phthisical cases, in the year of grace, nineteen hundred and ten. When the press of phthisical cases becomes too great, the more convalescent patients, it appears, are sometimes sent over to the general workhouse.^ A visit to one of the bedrooms of this place revealed in a room little better than a cellar, with windows on two adjacent sides only, and these all tightly closed, about forty men in beds packed closely together. The atmosphere was vUe and heavy at 9 p.m. ; its condition from midnight till morning can be left to the imagination. Is it wonderful, when tuberculosis is so carefully cultivated in our midst, that our national death-roll from this plague runs up to 75,000 annually ? ^ This statement does not rest on the author's own personal observation, but on information volunteered by an o£Bcer of the institution. 80 DAWN OF THE HEALTH AGE To go on painting the comparative details of the " Eoyal Charity" and " Guardian Angel " Hospitals would only be to become weari- some ; no high colouring, no embellishment, is necessary. In these two hospitals, then, within a stone's- throw of each other in the same city, we find this obvious contrast. Both contain only poor people unable to pay for medical treatment, for that is the reiterated guarantee of all the Charity Hospitals, that they admit no one who can afford to pay; and indeed, under present conditions, that is only very elementary justice to the medical profession outside. Also, apart from ability to pay, there is no moral distinction of any kind between the two sets of patients. Examine the causes of disease in each institu- tion if you are a medical man, and you may notice the same diseases, due to the same "causes, in the one institution as in the other. In the Poor Law Institution, on the occasion of one's visit, one saw several old veterans who had served their country well in the Crimean cam- paign and later wars; respectable old chaps they seemed to be, who only had come upon dark days in their old age. There is not a thing, not a point of difference, between the two sets of patients, and hence the irresistible question arises. Why is one set treated so well, and the other set-— over three times as large, be it remembered — treated so badly? OUE HOSPITAL SYSTEMS 81 Both ways of it cannot be right; if the "Koyal Charity" treatment is the proper one to accord to poor people who cannot pay for themselves when they are ill, then we are be- having with austerity, to use a mild term, to the inmates of the " Guardian Angel." Con- trariwise, if the " Guardian Angel " treatment indicates the proper way, then we are pam- pering the inmates of the "Eoyal Charity." There is no attempt here to attach either praise or blame to the two sets of people who administer these two institutions. Could every circumstance be taken into account, the Poor Law Guardians of the " Guardian Angel " might be found to have been doing as admirable a work under highly adverse conditions of environ- ment as the better-circumstanced Committee of the " Royal Charity." That is not the question for us here at all ; there is no personal element in the matter — it is a matter of principle purely and simply. We require a unified, co-ordinated system of treating in hospital those large num- bers who are unable to pay, and this picture, in contrasts, is intended to illustrate how far we are from having any such system at present. Surely we ought to make some attempt to arrive at some principle of even-handed justice in these matters. It might possibly be argued that although there is no difference in poverty or deserts between the two sets of patients, there is a difference in the relationships of the two insti- F 82 DAWN OF THE HEALTH AGE tutions to the community, in that the " Royal Charity" is a great teaching hospital, where our future doctors are trained, and where medi- cal science is advanced, and new discoveries made of great advantage to all mankind. To this there are two obvious replies which at once rob the argument of all significance. In the first place, all this greater comfort in the Volun- tary Hospital is not necessary for the study of disease ; and, secondly, there is no reason, except a most stupid and arbitrary law or rule of the Local Government Board, why the Poor Law Hospitals should not be used for medical study, instruction, and research. A teacher of clinical medicine or surgery at a medical school would find the wealth of clinical material of Guardian Angel Poor Law Hospital, and its value for teaching, as great as that of any Voluntary Hospital in the Country. Why is this vast store of rich clinical material in our University towns throughout the country absolutely thrown away and wasted ? Can the country afford to have any but the best of clinical experience placed at the disposal of the future doctors ? Are the ofiicials of the Local Government Board afraid of the susceptibilities of the poor patients in the hospitals under their purview, that they absolutely forbid entry for medical study, both to the medical student and the practitioner of the district ? Or is it perchance that the Boards of Guardians are afraid to press OUR HOSPITAL SYSTEMS 83 home the Local Government Board to grant this boon for their districts 1 It cannot surely be the susceptibilities of the pauper patients, for that cannot be greater than that of the patients in the Voluntary Hospitals, who are equally accepting charity there. No ; we must look for some other cause for this strange order of things, this subtle distinction between the recipients of Poor Law Charity and the recipients of Voluntary Charity, which makes the diseases of the latter worthy of study, while those of the former are beneath contempt, let alone study. Is it perhaps because the officials think the diseases of paupers are quite different from those of other people? If so, they might at least appoint a Royal Commission to inquire into the matter, and then consider both Minority and Majority Report, and pigeon-hole the results for their successors in office. It cannot surely be because Hie honorary physi- cians and surgeons of the great teaching hospitals, those great guns of the profession, would feel their craft in danger were any common doctor at a Poor Law Hospital allowed to teach from the clinical material at his disposal, and that too great access to clinical material might open too many gateways to knowledge ? No ! perish the thought. The brightest thoughts always come last, and the most probable thing dawns on one when the problem seems hopeless of solution. How 84 DAWN OF THE HEALTH AGE could the present-day methods of treating Poor Law patients stand the free ingress of batches of fresh young students, free to see and to talk publicly outside of what they saw inside "i Just about as much as the hot-house plants of a conservatory could stand the cold breath of the winter winds. There would be too much moral ventilation about letting medical students into workhouse hospitals ; these institutions contain much that is best hidden from the light, and the medical student is a bit of a reformer, and an irresponsible enthusiast for justice. Open the gates of the workhouse infirmaries to the public, and the medical student who will bring the public in after him, and the whole system is exploded; it will not last out even a single parliament. If the Poor Law Authorities only admitted medical students to their hospitals, the Poor Law medical appointments would at once rise in value to members of the medical profession ; these posts could soon be filled by the best physicians and surgeons in all our large cities, where there are universities and medical schools, and the filling of them need not cost the Guar- dians a penny. The physicians and surgeons who aspired to be consultants would be tripping over one another to get appointed. This is merely pointed out as a suggestion to the proper public authorities who may want to save money; in the opinion of many sound judges, the system of paying a would-be consul- OUR HOSPITAL SYSTEMS 85 tant by bringing him into contact with students is a most abominable practice. Every official of a hospital should be paid for his duties properly in salary, and there ought to be so many such appointments that any man's posi- tion as a consultant came to depend on his real skill and knowledge, and not upon his hanging on to a hospital and getting to know and be known of students. Returning to our contrast of the Voluntary and Poor Law Hospital systems, we may now attempt to answer the oft-made criticism, why, if the Voluntary Hospitals are so much better, and many of the Poor Law Hospitals are so wretched, suggest the abolition of the Volun- tary. system, and the substitution of a Public or State system, since a public system under the Poor Law is doing so badly? The two hospitals just described might surely be taken as illustrating the advantages of a voluntary system over a publicly controlled system. The answer is that the Voluntary system is like an exotic plant which cannot be made to flourish sufficiently so that it may grow at least six- fold as large and do aU the work, and mean- while, by the place it occupies in the pubhc eye, it glozes over and palliates a great evil. By all means let us keep our Voluntary Hos- pitals for the present, if only we can remember that they are not solving a great national question which is pressing urgently for solution. Let us go on, if we must, playing at Charity 86 DAWN OF THE HEALTH AGE like children with their toys in a nursery, if only at times we will come out of the land of make-believe and see that we are not reaUy doing what we pretend we are doing. As for the Poor Law Hospital system, that is a failure, not because it is under a public system of administration, but because that system is so wretchedly devised, and has been going on upon wrong principles year after year for three generations. Under the Poor Law it is a shocking disgrace, for which, till just re- cently, your enlightened country disfranchised you, to be poor and in ill-health. It is necessary that the pauper patient should be treated just as horridly and uncomfortably as our twentieth- century state of decency of public feeling can permit, in order that the poor sick person shall not go to the Workhouse Infirmary to be a charge on the rates until the last gasp, or until poor suifering human nature can save its public degradation no longer, and crawls, or is carried by the police, into the Workhouse Hospital to die. It is a well-deserved penalty upon us that in this cheese-paring attempt to spare our pockets we save neither them nor our consciences nor reputations, but all suffer together. The few millions we seem to save in this way are ten- fold outbalanced by the cost borne by us on account of disease rampant over the country through the operation of this very system. We think, or our Boards of Guardians think OUR HOSPITAL SYSTEMS 87 for us, that a public service has been done when one junior medical man has been paid £120 to £150 a year to pretend he is properly looking after four to five hundred beds filled with sick people in a Workhouse Hospital, and no medical ofiicer at all is sent out to the slums to send the rest of them into the hospital, where, if it were properly organised, they ought to be receiving proper attention. But is it so ? In very truth we pay tenfold in cash alone for our sin of inhumanity, not to mention that upon which no value in money can ever be put, the sacrifice of those dear to us as life itself carried off by the infections cultured in workhouse and slum- land. The second great count which may be made in this indictment of our present miscellaneous congeries of hospital systems is that they are hopelessly out of touch with the medical practi- tioners throughout the country, and that this is most highly detrimental alike to the public service, to the hospitals themselves, and to the medical profession. Any layman who may think this statement is too sweeping may be invited to make in- qniries amongst two or three of his medical acquaintances, and, especially if he happens to ask a doctor who has any practice amongst working people, as most doctors have, he will very rapidly be satisfied as to the true position of affairs as between hospitals and the pro- fession. 88 DAWN OF THE HEALTH AGE If he will ask the one question, " Dr. So-and- so, what is the meaning of this hospital abuse that we hear spoken of occasionally ? " he need say no more ; he will have waved the proverbial " red rag," or " touched the button," if you prefer the simile, and " the doctor will do the rest." Just try the experiment the next time you happen to meet a genuine general medical practitioner; it is guaranteed to succeed nine times, at least, out of every ten. So it would with you, my dear reader, what- ever your profession or business may happen to be, if some one were trying to oust you out of it and do your work for nothing by means of a so-caUed charity subscribed by other people. Suppose that three-quarters at least of your income came to you from a certain set of clients, as three -fourths of the average medical practitioner's income does to him from the wage-earning classes, and that a large number of very benevolent people subscribed to set up institutions to perform the work for these clients that you had been doing before, and that on account of the charitable subscrip- tions and the conspiracy of a number of your colleagues in your own profession, this work, previously paid for to you, was now done gratuitously, and without recouping you in any shape or form, so that your income started to dwindle as your clients gradually discovered this new method of satisfying their wants. Now, one may ask, supposing you were OUE HOSPITAL SYSTEMS 89 gifted with an average human temper, what would you think of all this, and in what language would you clothe your thoughts (1) as to the charitable people, (2) as to the insti- tutions, and (3) as to your colleagues in the institutions who did your work for nothing? Perhaps some consideration of your answers to these questions may meUow your opinions of the doctor who has replied to your query as to what is "hospital abuse," and if one tells you further that, in spite of his chafed feelings, the doctor so far forgives the colleague who does his work for nothing in the hospital that he throws highly paid work in his way with assiduity, and takes him out to see his wealthier patients to earn large fees from them, as a consultant and a brother, you wiU probably grow to regard the general medical practitioner as an exemplary prototype of a charitable Christian gentleman, or — something else. In both cases you will be quite wrong; the general medical practitioner may be both these things, but that does not explain his peculiar conduct. As a matter of fact, both he and his hospital colleague, the consultant, are in the grip of a vicious circle. There is only one way out, and that is a State Medical Service, and State Hospitals for all members of the wage-earning classes. Such a system gives co-ordination between medical attendance on the wage-earners outside, and medical and surgical attendance for them 90 DAWN OF THE HEALTH AGE within the hospitals. As a result hospital abuse is done away with, because it simply cannot exist, and the doctor, whether his work lies within or without the hospital, is adequately recompensed for his labour. For the serious surgical diseases and injuries amongst the wage-earning classes, hospitals are absolutely indispensable. Major surgical opera- tions cannot be carried out efficiently and safely in the cottages of the poor, and even in the middle and upper-middle classes it is becoming increasingly recognised that surgical operations and careful nursing are best carried out in a special institution such as the private paying ward of a hospital or a nursing-home. The working classes used to dread a hospital opera- tion and preferred to pay their doctor and have it done at home, but this feeling is rapidly passing away, and in a few years will be non-existent. The change is due to many factors, such as (1) the action of medical practitioners them- selves in sending poor patients to hospital be- cause they honestly cannot contemplate carrying through a serious operation and after-nursing at the patient's own home, or, in other cases, see that the patient cannot pay for such pro- longed attendance and nursing; (2) the much- decreased mortality, under modern conditions, of surgical operations in hospitals as compared with private houses, especially amongst the poorer classes, and the better equipment and conditions of living in the voluntary hospitals OUR HOSPITAL SYSTEMS 91 making the patient's sojourn there much more comfortable than a few years ago; (3) the excessive cost of a surgical operation at home, even amongst the middle classes ; (4) the grow- ing feeling that an institution which is sup- ported in so many diverse ways, and to which even the workmen, by weekly contributions and Saturday and Sunday collections, yield their quota, is no longer a charity, but an institu- tion to which all have almost the right of entry when there is room and they have need. When Voluntary Hospitals were first insti- tuted, and indeed to within a decade or so ago, it was on the assumption that they were for the relief of the poor, meaning thereby the very poor of the labouring class ; but de- velopments have been such, both in scientific medicine and surgery, and in our general pubHc point of view with regard to hospitals, that the voluntary hospitals are now generally regarded as open to nearly all of the wage- earning class up to, at any rate, a wage-earning power of two pounds a week. Even a man earning three pounds a week will not be denied admittance for a serious surgical operation, although he may be expected to make some small contribution to the hospital funds. This state of afi'airs is most deplorable so long as the relationships of private practitioner and hospital remain unadjusted, and, by set- ting up the practitioner and hospital as rivals, is responsible for that hatred and excitement 92 DAWN OF THE HEALTH AGE throughout the profession which is almost pro- ducing a condition of war between the pro- fession and the hospitals. This condition is the inevitable result of the specialisation in surgical work which has arisen, and of the inordinately high fees which surgeons are compelled to charge for work done outside the hospital. A surgeon nowadays can make quite a comfortable income on one good opera- tion a week, which perhaps occupies no more than a couple of hours of his time all told ; and a busy surgeon with a fast motor-car can make a princely income. Nor does he usually pos- sess any of that genius for craftsmanship, or advanced knowledge of science, which might reasonably be expected to carry such a huge income as its reward. He may in intellect and ability be nothing like so fine a man as his poorer colleague in medicine, or the medical scientist who plods along upon an income of five or six hundred a year, after previous years of struggle and poverty. His art is almost purely mechanical, and even at that often does not require exceptional mani- pulative ability. The secret of the situation is that he belongs to a small close craft with a very limited entree to its ranks, and a path of some expense, anxiety, and delay at the outset. The distinguished hospital surgeon is often a man of very mediocre attainments, whom years of practice on certain lines of work has placed OUR HOSPITAL SYSTEMS 93 in a unique position. He has shown keenness and patience, and trained his hands well to manipulation, but often he has not added one line, or precept, or practical application to the craft of which he is an exponent. He has usually taken for his hobby the acquirement of guineas, a bias acquired in those years of wait- ing and difficulty when the golden ones came in but slowly. His boast is that he makes more than his rival, Mr. So-and-so ; not, alas, too often, that he has done anything to adorn the Science and Art of Surgery. His period of large income making is a shorter one than that of the physician, for after twenty years of golden harvests his palmiest days are over. It is a sad thing, both for the public interests and for surgical science itself, that it should be so converted into an article of commerce. The evil concerns more than the wage-earn- ing classes ; middle-class people with incomes of the range of, say, £400 to £800 are also hardly hit by this grotesque arrangement which renders it impossible for more than about one medical man in fifty to carry through successfully a quite straightforward surgical operation. The middle-class or professional business man has to pay the penalty when he requires to submit to a surgical operation, either upon himself or some member of his family. He has then to help to pay for all those cases which the surgeon has been doing for nothing at the hospital, and 94 DAWN OF THE HEALTH AGE has the defects of this system brought home to him, although he may hardly know what has hit him. He may wonder in a vague way why the highest possible surgical technique is always required, and he has to pay £50 to £100 for it, in addition to all the incidental expenses of preparation and nursing. He might be horrified, poor man, if he were told that the same thing was done in hospital every day for nothing ; and if he had enough knowledge to appreciate a visit to a modern hospital operating-room and surgi- cal ward, might realise that his operation could have been carried out better there, surrounded by all the appliances and accessories of the Art of Surgery, than in his suburban villa, to which the surgeon hurriedly brings such things as he thinks or foresees he may want in his hand-bag. All the upset to his household and family, too, might be spared, and his chances of recovery would brighten in purely professional hands of surgeon, doctor, and nurse. There is little or nothing in the way of inter- mediate grades between the patient who can, or is compelled to, pay much too handsomely and the patient who cannot meet these terms and is forced to be operated upon in hospital for nothing. Therein lies half the hospital abuse on the surgical side in our hospitals; and the surgical side is twice as great as the medical. Another great danger to a certain middle class of patients is the very natural jealousy of OUE HOSPITAL SYSTEMS 95 the hospital engendered in the mind of the prac- titioner by this process of robbing him of his patients. His fees all stop when the patient goes to hospital. Is it natural, therefore, that even when he knows that all the circumstances of the case demand an operation, which can only properly be carried out in a hospital, that he will be prompt to urge his patient to go to hospital without delay 1 There are very many cases, on the surgical side especially, in which palliative treatment can be pursued for a long time with varying chances of success, continually putting off the evil day, a process to which the patient is only too prone to listen with favour. Here commences a struggle between the practitioner's purse and his conscience ; to the honour of the profession, be it said, that conscience usually wins ; but why should he be subjected to any such struggle, with his feelings already at white heat against the hospitals? The practitioner is hopelessly handicapped in the struggle : all the accessories of the scene are against him. He cannot afford to own privately all the instruments and outfit necessary for proper equipment, or provide the staff of assist- ants required. He has no right of admission as an operator to the well-equipped operating theatre at the hospital, so that he himself can operate, nor can he apply after-treatment in the hospital. His patient is not allowed by the regulations to pay a reasonable fee, and remain- 96 DAWN OF THE HEALTH AGE ing under his own physician's care, who knows all about him, have a specialist to do the opera- tion in the hospital, and then pass back to the care of his own doctor, still in the hospital. In fact, unless the patient can pay like a very wealthy person, he must be treated like a pauper, and his physician as a nonentity. In this struggle, which is ever becoming more acute and bitter, of practitioner versus hospital, lives of patients are doubtless often lost, for one of two reasons — first, that the patient is sent to the hospital too late ; and secondly, that practi- tioners often operate at patients' homes under unjustifiable conditions, either as to surround- ings and means of care and nursing, or as to their own skill as operators. How frequently such instances occur it would be difiicult to estimate, but the writer himself, in quite a limited experience, has known more than one clear instance of this danger to the public. There is another aspect of hospital work which has still further embittered this question of hospital abuse, and that is the barefaced way in which many of the out-patient depart- ments of our Voluntary Hospitals are used for the purpose of defrauding the medical pro- fession. Unless the out-patient department is used on a purely consultative basis, for the purpose of giving the opinion of the hospital physician or surgeon on a case where the patient is unable to pay a consulting fee, it becomes a clear OUR HOSPITAL SYSTEMS 97 usurpation of the professional rights of the practising doctor who advises working-class people and earns his living amongst them. It will be, of course, understood that we are now discussing the defects oi our present system ; all this confusion would automatically disappear under a combined system of State Medical Officers and State Hospitals ; but so long as out-patient departments remain part of a volun- tary charitable system, and the outside practi- tioner earns his living by fees instead of receiving a salary as a State official, then the present intolerable state of affairs will remain not only unchecked, but growing in its proportions, as it rapidly is at present. It may be said, without the least hesitation, that at the present day there is no business or profession being so crushed by wrongful spolia- tion and confiscation as is the medical profes- sion ; and the irony of it is, that it is all being done in the name of charity and benevolence. If these would-be benefactors of their race would open their eyes to the fact that they are crushing out of existence one of the most humanitarian of all professions, and try to devise some plan on common-sense lines for its rehabilitation and proper recompense, they would do a great service not only to the medi- cal profession but to the poor whom they are desirous of assisting. It might be some small compensation if the poor were really benefited by this out-patient G 98 DAWN OF THE HEALTH AGE system, or if medical science were advanced by it, but the exact reverse of all this is the case. There are two disgraces on the fair name and^ reputation of medical science to-day, which do more than anything else to reduce medicine to a pseudo-science and trail it through the gutter of contempt in the eyes of all scientists, and those two disgraces are the Out-patient Departments of our Hospitals, and the Sixpenny Dispensary Practice of our Slums. There is not a pin to choose between them as they at present exist, and the sooner they are either remodelled on scientific lines or swept off the fair face of Creation, the better for mankind and our sense of decency. In both cases the times given are utterly inadequate for proper examination, care, or attention to the cases ; as for scientific study of them, or getting to know the habits and constitution of the patient, there is no attempt at such things. Think first of the absence of all the prin- ciples of sanitation in crowding a score or more of people at a given dispensary hour into the front room of a £20 to £30 house ; to be hailed out one after another at intervals into the consulting room, hastily catechised, hurriedly examined, given a bottle of medicine and sent away, after collecting the sixpence, to come back in a few days for another bottle of medicine. Think of the fate of the phthisical patient coming there habitually till he gets sick of OUR HOSPITAL SYSTEMS 99 it, and sad for it, paying his sixpence and getting sent back to infect others in his own home or elsewhere ; with no help save his useless bottle of cough mixture. Think further of the danger to the score or so of people, including several children probably, who have sat for perhaps an hour with that phthisical patient in that close, overcrowded, stuffy room waiting for their golden couple of minutes with the doctor. Think of the poor children brought there affecting one another with in- fectious diseases as they sit. Was there ever such a mad scheme as placing unexamined diseased people cheek by jowl, and as closely packed as possible, for an hour or more ? Look next at the out-patient department of a big hospital and see a similar picture. It is true much money from the charitable may have been spent on glazed brick walls and encaustic tiles, and many of our new out-patient de- partments look most beautiful and gaudy ; but the tide of filth and infection passing through them is enormous, and after all a sewer is only a sewer, even if it be lined with glazed brick. There they sit, oppressed with various ills, or with small children ill with different com- plaints, gossiping with one another by the hour, or looking utterly bored and dull, thinking perhaps of their husband's comments when he comes home from his work and finds no meal cooked for him. No doctor outside has hitherto seen them or their children, in all probability, 100 DAWN OF THE HEALTH AGE or only some sixpenny quack such as we have been describing; no one knows what disease they are harbouring, or whether there is any- thing but curiosity the matter with them at all. An ill-assorted selection they are of the rag-tag and bobtail of humanity. Suddenly the house physician or surgeon appears on the scene, attended by the three or four medical students who are his clerks or dressers, glad to escape from the boredom of attendance at the visit of the honorary physician or surgeon to the in-patients in the wards. Gaily these acolytes of the temple of Medicine scamper through the out-patients who have been wait- ing the better part of the morning, for it is getting near lunch-time, and in twenty minutes or half-an-hour the motley crowd of the morn- ing is dispersed. A few who are thought to be more serious, or more interesting, are given cards to see an Assistant Physician or Surgeon to out-patients at the attendance-hour in the afternoon, and return to waste more time there, perhaps a whole afternoon ; but the majority are packed off as rapidly as possible, with their medicine or dressings repeated for an- other week or fortnight ; and this, forsooth, is competent medical attention.^ To these poor people all who see them are 1 The mode of dealing with out-patients differs somewhat at diflferent hospitals; the above sketch is from the personal observation and experience of the author at two great teaching hospitals. OUR HOSPITAL SYSTEMS 101 doctors, though twice out of thrice they are seen by a clerk or dresser, and, perhaps, just as well attended to as if the rapid glance or shadow of a qualified man had fallen upon them. The usual crime of the out-patient department is the crime of the sixpenny dispensary — want of individual care and attention, scamping of medical work save for the occasional interest- ing case, and great wastage of public time, and danger of spread of infection. The remedy is quite obvious upon any friendly co-operative system between the practitioner outside and the hospital authorities inside. But without proper co-operation no remedy is possible. These people must be seen and attended to somehow, if not in their own in- terests, or the interests of common humanity, then in the interests of the other strata of the community. The question is, how is it to be done with- out sacrificing any one's legitimate interests, and most efi'ectively on behalf of patients and community ? The system of voluntary charity is both a failure as regards doing the work, and defrauds the private practitioner of his legitimate sphere of work and legitimate fee. He has spent, or had spent for him, a large sum of money (at least £1000) in acquiring his professional train- ing, and has given five of the best years of his life to hard study as a student of his profession. It is by no means fair that he is to be sweated at his 102 DAWN OP THE HEALTH AGE work or cheated out of it altogether. On the other hand, a large share of the required work can only be adequately and properly carried out in hospital, and these people, in the majority of cases, cannot pay for it. Yet the medical pro- fession, either inside or outside the hospital, ought not to be expected to undertake this work for nothing. Charity is charity, business is business, and the doctor has his living to make out of his profession. The problem, notwithstanding, is not an in- soluble one, provided we can only be content to leave charity out of it. Let charity tackle a problem of the right dimensions for its success- ful accomplishment, in doing extraneous and accessory things, such as endowing medical re- search, providing clinical laboratories, endow- ing research fellowships for young medical men in connection with the hospitals, subsidising the junior posts so that it is possible for men of brilliant mind but without private incomes to reach the higher hospital posts. But let charity leave alone routine work for the million. In the first place, the task is too great for such sums of money as can be so got together ; and, in the second place, simply because the thing comes by charity, and not as a legal right to which they themselves, directly or indirectly, have contri- buted their quota, this charity is a most de- moralising influence, inducing servility and destroying any weak moral fibre that may be there, instead of developing and strengthening OUE HOSPITAL SYSTEMS 103 it. Let our poor come to the hospital as an absolute legal and moral right, without any shadow of patronage or disgrace in it whatever, any more than there is in an old age pension. But do not leave the patient, or any other lay person for him, to determine when he ought to go to the hospital; that is the busi- ness of the doctor outside, and matters must be so arranged that it is not to the personal disadvantage of the doctor to send the patient to the hospital when he thinks the case requires hospital treatment. This state of affairs can obviously only be attained by arranging, by some unified and national scheme of action, for the doctor to be paid both inside and outside the hospital for professional services rendered to this huge class of our population, and we have already seen that the cost to the nation would not be ex- cessive. The last defect in the present system of hospital services which need be described is that of the present mode of appointment of medical officers to our hospitals. The method varies somewhat in Voluntary Hospitals and in Poor Law Hospitals respectively, and we shall consider the two systems separately. The manner and terms of appointment of physicians and surgeons to our Voluntary Hos- pitals may at first sight seem a trivial subject compared with the more general national issues which have hitherto been considered, but in 104 DAWN OF THE HEALTH AGE reality this question lies deep at the root of the whole matter. Because such appointments are made practi- cally for life — that is to say, subject to retirement at sixty or sixty-five years of age — and as the number of hospital posts is small compared with the number of men qualified to hold them, the majority of men in practice are cut off from the hospitals entirely. Secondly, as the modes of election are by no means calculated for selecting the best men, the service degenerates. Thirdly, in the most important set of all the Voluntary Hospitals — namely, those in which our future doctors obtain their medical and surgical train- ing — the medical school has no voice in the choice of the hospital staffs. To the men holding these appointments, however, the medical school is forced to hand over many of the most impor- tant professorships in the Faculty of Medicine, thus stultifying the work of the Faculty and reacting in a most undesirable fashion upon the teaching and advancement of medical know- ledge throughout the country. One great evil arising from lack of train- ing of a sufficient number of good operating surgeons for the service of the country has already been seen in the inordinately high fees claimed for surgical work. If a considerable number of posts at the voluntary and other hospitals were held for more limited periods, the appointments being made for periods of, say, five years, a work- OUR HOSPITAL SYSTEMS 105 ing knowledge of surgical technique would be more widely spread in the medical profession. A similar change in the physicianships is also highly desirable, in order to allow more men to keep in living touch with medical progress. It is not as if the men actually holding the hospital posts were marked o& in any way as a special order of medical priesthood by special previous training, greater intellectual endow- ment, or special genius or aptitude of any sort, from their fellows in general medical practice. Their being where they are is in most cases a matter of accident as our system of election is at present constituted. Our present system makes it essential that our future consultants must work for several years not merely with- out monetary reward, but under conditions which entail considerable outlay. Brains do not furnish the essential condition of entry to this highest caste of the doctor's profession; quite mediocre ability gets a man there, pro- vided he ha^ money and patience and can wait. Men with brains do sometimes storm this for- ~ tress, and, by undergoing great privation, fight their way forward to noble success as consul- tants and leaders in medical progress. Such men are the very salt of the profession ; but, to say the least of it, our present mode of preference to hospital appointments does not encourage such men. In what manner do we usually choose the best physician or surgeon when there is a 106 DAWN OF THE HEALTH AGE vacancy on the staff of one of our great Volun- tary Hospitals ? By hard canvassing of the members of a lay committee, who themselves usually know nothing of the relative professional abilities of the rival candidates, but are swayed by the facts of the social standing and influence of the candidate, or the candidate's friends. Fulsome testimonials as to the candidate's abilities are got together and printed by each candidate ; these are circulated, along with verbal embellishments, by each candidate's social friends amongst the electors, who are nobbled to vote one way or another by pressure, cajoling, or beseeching. We laugh at some of the ways of the Chinese, and this is our way of selecting the men who are to be leading physicians or surgeons in our great cities, and mayhap teach medical science to the coming generation of medical men. In a certain great provincial city one large general hospital has an electoral body of over one thousand members, nearly all laymen, who elect the physicians and surgeons in this way. At a recent election several gentlemen who desired the position of surgeon to the hos- pital had their claims considered by this huge electorate, and its friends in the city. With- out making any criticisms on what the actual result of the election happened to be, it might be suggested that a method which would have worked equally well, and saved enormous trouble OUE HOSPITAL SYSTEMS 107 and expense, would have been that of putting all the names of the candidates in a hat and drawing one out. It may be said that although a lay committee actually has the electoral power, it is swayed in its opinion by the medical staff of the hospital. This happily does occasionally save the situa- tion ; but in a great many cases the medical committee is not allowed any such influence, or is scared of expressing an opinion through fear of alienating or offending powerful laymen. Another great evil due to our localised systems, especially noticeable in the large Voluntary Hospitals of our great cities and towns, and most intensely of ^1 in those hospitals con- nected with medical schools, is the continued inbreeding to which we are committed in ob- taining our supplies of consultants and teachers of medical science. With few honourable ex- ceptions, we are absolutely forced to depend on local supply, and there is little or no healthy transference from one district to another. Since the assistant physicians and surgeons, almost automatically, are advanced as vacancies occur to the full physicianships and surgeon- ships, the election to these junior posts is most important. At this stage the juniors have not yet acquired those lucrative practices which fasten their seniors, like limpets or barnacles to rocks, to one city, so that they cannot be transferred when vacancies occur. An offer from Manchester might attract a promising junior 108 DAWN OF THE HEALTH AGE physician or surgeon from Liverpool, or vice versd, or London might interchange with either of these two northern cities at this free-swimming, larval stage in the development of the future consulting physician or surgeon. Very often the absence of any chance of local successions falling in, drives away most brilliant men, who see no chance in waiting on. These unlucky individuals have no opportunities elsewhere. Each hospital and school is a close corporation. Why are these things so ; why do not the senior physicians and surgeons tell the lay Hospital Committee that each post should be thrown genuinely open to the whole country, and make it their business, before each election, to find out the best possible man for the vacancy ? Possibly there might be something inartistic in having too many stars of the first order of magnitude in the same constellation. Whatever may be the reason, the fact re- mains, each place has its own little coterie, and lives in the light of its own little pre- judices ; there is no national correlation, no cohesion, nothing comparable to anything so high as the nervous development of the mollusc, in our whole system of hospitals, or the appoint- ments to all their important posts. This vicious principle invades even our Uni- versities. Here we see, on the one hand, in the scientific posts, the stimulating effect on the men and on the institution of having the whole nation to select from when a new appointment OUE HOSPITAL SYSTEMS 109 is to be made; on the other hand, when we turn to the important chairs of the final studies in the medical faculty, we find no such freedom and no such stimulus. The Universities are practically forced to appoint to important pro- fessorships those physicians and surgeons who have been appointed by the local lay committees of the hospitals as members of the hospital staff. These men need have contributed little or nothing to ovix knowledge of any branch of medicine or surgery ; and indeed, in most cases, as a matter of fact, they have made no such contributions — they have been too busy making guineas instead. Medicine and surgery have become articles of trade and commerce, and the most successful and most highly honoured con- sultant is he who makes most thousands a year. Not even in our Universities and seats of medical learning can we stem this tide of the power of the almighty guinea, and show our appreciation of scientific devotion and deserts by appointing men famous for their original work to our University posts. The important general subjects of the purely medical curriculum are medicine, surgery, mid- wifery and gynaecology, and therapeutics. To which of these, or any of the special branches of them, can a man be appointed who is not a local consultant in the same city as the University ? The candidate may not have contributed one shred to the world's store of knowledge of his subject, yet merely because he is a local man. no DAWN OF THE HEALTH AGE and has taught the alphabet of medicine to local students — at great profit to himself, be it added, from the consultation fees it has brought him — he is entitled to become the University pro- fessor and the local great expert of his subject. Tartarin of Tarascon pales into insignificance before the local glory of the local professor of a medical subject in a provincial University. Passing by a rapid transition from this sub- lime subject to the manner of appointment at the Poor Law Hospitals, we find a much simpler and less elaborate scheme. Roughly speaking, there are two types of Poor Law Hospital Medical Ofiicers. A very transi- tory whole-time officer, very hard-worked and paid £120 to £150 a year — that is why he is transitory. A very permanent part-time officer, who strongly believes in the axiom that part- time is muclx less than whole-time, who, for his part-time, is paid from £200 a year upward-^ — that is why he is permanent. ^ In addition to his position as visitor, the part-time officer usually can pick up such little unconsidered trifles as Vaccina- tion Officer to the Workhouse, and Certifier of Pauper Lunatics. In this way a nominal income of £200 may readily amount to over £500, and the visitor usually contrives to run in addition a lucrative outside practice in his unemployed spare time. This is all according to Cocker, but does it pay the British rate- payer ? The writer knows of more than one Poor Law Medical Officer, receiving £500 a year and over, who also has a large private practice and does not devote more than three hours in the day to his Poor Law work. The Local Government Board is supposed to inspect the work of these medical officers, and at its doors lies the responsibility, as the Boards of Guar- dians possess no powers of review or dismissal after one year's service. OUR HOSPITAL SYSTEMS HI The part-time visiting officer is elected by the lay Board of Guardians, the details of election being much the same as set out above for elec- tions in voluntary hospitals. There is usually a spirited competition for such posts, and the candidate after election develops a fervid admira- tion for the present administration of the Poor Law, and is a thorough believer in Boards of Guardians. This numerous class of medical men, and a similar body who hold part-time posts to small urban and rural districts as Medical Officers of Health, or as outdoor medical reUef Poor Law Officers, or Poor Law Dispensary Officers, are the most violent opponents of any deep-seated changes in the way of reform, and keep pointing out in the press that a little patching and press- ing is all that is required. The whole-time resident medical officers of the Poor Law Hospitals are quite a different set of men, not at all so contented with their lot as their official superiors, nor so impressed with the beneficent influences of our present Poor Law. For one thing, they are younger men, mostly just graduated, and unaccustomed to Workhouse ways, and youth is both sympathetic and fond of change. Also, they have not, time to become truly enamoured of the noble service to which they belong. In entering it they have usually had no thought of continuing in it, as most young men who enter other public services have. 112 DAWN OF THE HEALTH AGE They only want a little more hospital work and experience, and they know that in the Poorhouse Service they can get it in plenty, so they go to it for a brief period of six months to a year, just as they would to a locum. In fact, there is no prospect whatever for young men in this service as a permanency. Their salary never increases, there is no pro- motion from one place to another, and when a part-time visiting appointment falls vacant they have no claim on it, even if they have been there as resident for ten years. There is, in fact, no real Poor Law Medical Service ; the six hundred and forty odd Poor Law Unions in England and Wales are ab- solutely independent, have nothing to do with one another, and know no more of one an- other officially than two next-door neighbours in a London suburb. The chief products of our Poor Law system, in its hospitals as elsewhere, are disease, de- moralisation, and destitution, and those who talk of schemes of reconstruction destroying the moral fibre, self-help, and independence of the poor had better go and visit our Workhouses and learn facts as to the hopeless failure of the present system of repression and mismanage- ment, when they will probably return prepared to vote for some organised national method for dealing with the greatest national problem of our time. Until our hospital systems are organised and OUK HOSPITAL SYSTEMS 113 unified and placed in hon accord with the medical profession outside — the latter having also been nationalised and set to hunt out, isolate, and suppress disease — ^we may expect to continue to be ravaged by infection. But remember that science has already taught us how most diseases may be conquered, when we are ready to take concerted action for the common weal. H CHAPTER V THE WARFARE WITH THE GREAT WHITE PLAGUE A DISEASE which claims seventy-five thousand victims every year, year in, year out, in these Islands of ours alone, is too all-pervading to have escaped incidental mentioning in these pages already. But, when our design is to disclose a feasible, practical method, not of any inordinate cost, whereby this horrible plague can be eradicated in a period of not more than ten years, the subject is assuredly worth a chapter to itself. When the great bacteriologist who has recently been taken from us, Eobert Koch, made the memorable discovery of the bacillus of tuberculosis, and proved that this organism was the one and only cause of the disease known as consumption or phthisis, one of the greatest advances of modern medicine commenced, and one fraught with the highest advantage for mankind. Diseases rapidly became correlated and under- stood which before were thought to be quite distinct and separate entities. Consumption was soon realised to be due entirely to the THE GEE AT WHITE PLAGUE 115 ravages of this organism in the lung substance, a favourite elective seat for its growth in the body, and the same organism growing in the skin was found to be the cause of the dreadfully disfiguring and intractable disease known as lupus, A very common condition, due to decay in the substance of bones, giving rise, according to its situation, to caries of the spine, to hip- joint disease, or to chronic disease of the other joints, was found also to be tuberculosis. A malady, commonest in children, but occurring also in adults, and known as tabes mesenterica, or consumption of the bowel, was definitely tracked to its source and again shown to be caused by the same microscopic organism. One common form of a rapidly fatal inflammatory condition of the lining membrane of the brain, known as meningitis, was also traced to that same ubiquitous microbe which Koch's genius had discovered to be the one and only cause of consumption of the lungs. The changes caused by the growth of this organism vary in appearance to the naked eye, according to the seat of its growth in the body, and this had put off the track earlier pathologists or morbid anatomists, for in those days medical science revolved around anatomy. Not to go on multiplying examples, we can easily see how this unifying and vivifying discovery cast a flood of light into many dark corners. The first essential in battling with disease is 116 DAWN OF THE HEALTH AGE to discover the cause of it. It is necessary to know who your enemy is, and where he is, before you can very efficiently strike him; and when you do know that, the next thing is to hit him before he hits you, or is in possession of your fortress. It is not necessary to put a bullet into each of the enemy's soldiers to win the fight; medication which works on this plan too often kills all the friendly soldiers at the same time. The location of the enemy by Koch's discovery has opened the way to rational methods of attack upon all forms of tubercular disease, making it possible to give sound advice as to treatment and prevention, and it is largely due to this good influence that the death-rate from pulmonary tuberculosis has fallen so much in recent years, that so many less visages are scarred and disfigured by lupus than formerly, and that cripples with stiff and useless joints, curved spines, or absent limbs are so much rarer than before. Conservative surgery, as well as conservative medicine, owes much to Koch's great discovery. The great disappointment of all the world, and for many hundreds of thousands despair, which followed the failure of Koch's tuberculin as a remedial agent for the individual infected with consumption, dimmed in the eyes of the lay world the lustre of Koch's achievement, and robbed him in the public gaze of that effulgence of glory which ought then to have been, and THE GREAT WHITE PLAGUE 117 must henceforward for all time be his, for the discovery of the organism of the disease. This discovery has already saved hundreds of thousands of lives, and, as the years pass away, will go on saving, and still saving, throughout the coming centuries. Thanks to Koch, we know, beyond cavil or perchance, that tuberculosis in all its forms is an infectious disease, like smallpox and typhoid and typhus fever, and, like them, can be subjected and held in thrall. The individual knows now, what he could never be told before, that no one born into this world of ours need die of consumption because his father or mother died from it. In fact, if he is already uninfected, his chance of escape is as good as that of any other individual. There is no immunity against consumption, and, apart from greater chances of infection and want of resistance in the poorer classes, no predisposition has been clearly proven. As far as the national aspects of the problem are concerned, we are the absolute masters of our own destinies. If we, as a nation, are pre- pared to take action, there need be no tuber- culosis throughout the length and breadth of the land within ten years' time. Any sporadic or chance case tm'ning up after that time can be controlled as easily as we now control small- pox or typhus fever, and we do not even re- quire vaccination of everybody to secure this consummation. 118 DAWN OF THE HEALTH AGE This is no fairy tale, or dream of imagination ; it is a definite scientific result, which our pre- sent knowledge gives assurance would inevitably follow an equally definite scientific course which is absolutely possible to carry out. Our training in medicine and methods of studying medical science has given our minds such a bias that it is our most deeply rooted conviction that the first thing we must do is to find a cure for each disease. All our study of causation, and our main conceptions as to the use and value of all those sciences allied to medicine, are grouped around this most funda- mentally erroneous dogma that our main object is to cure disease, and to find out cures at all hazards. We are fundamentally and by nature " medicine men " as assuredly as were witches, charmers, exorcists, and barber-leeches in the old days, and as are all cow-doctors, herbalists, faith-healers, and quack-medicine-vendors in our own days. The public has been brought up on it aU, far more than it has on its mothers' milk, and the medical profession caters for this depraved appetite for drugs and charms, and panders to it everywhere. The patient wants a drug or a rub; or a plaster or an ointment ; or a pill or a powder ; or an injection or a snuff ; or a gargle or some- thing else ; anything to get the disease exorcised out of him. But he will not pay, even in taxes, to have the disease kept away from him ; nor THE GREAT WHITE PLAGUE 119 take the trouble to avoid it, when he is told how to do so. How we misread and misapply the lessons of Nature here, in giving all care to the individual and neglecting the species ! Nature never does this — her care is for the species; there she is most careful ; as to the individual, she is a very prodigal. Would it not be worth while to copy this example, and save the species from tuber- culosis by improving the environment? Only a small percentage of the individuals already attacked can be saved as we work at pre- sent ; that percentage can be much increased, and in addition infection of new cases can be stopped, if we at once stop working on the individual treat- ment lines, and start working on species lines. In order that the tremendous force of this may be felt, it may be reiterated that of the present population of these Islands, not more than one individual in two hundred to three hundred at the present identical moment (as you read this) is suffering from tuberculosis, or need die of tuberculosis'; but as we are going on, and unless something is done to arrest it, one adult individual out of every seven is going to die from tuberculosis.^ ' According to the Decennial Report (1891-1900) of the Registrar-General of Births, Deaths, and Marriages, 1908, Pt. 2, p. xci., eleven per cent, of all deaths, or one innine,a,ve due to tuber- culosis. If allowance be made for our great infantile death-rate, the death-rate from tuberculosis of all adults rises to about one in seven. In males, engaged in occupations, between the ages of fifteen and sixty-five, the rate for consumption alone rises in some trades to over one in th/ree dying from all causes. 120 DAWN OF THE HEALTH AGE The statement has been made above that the failure of Koch's tuberculin as a treatment caused bitter disappointment. Koch undoubt- edly made a mistake by his haste ; all geniuses do make mistakes, and the great German scientist was no exception. That man who has never made a mistake has never done much in the World, or for the World. We, also, have all heen making mistakes over this tuberculin business ; many unavailing tears have been shed over it ; let us take a different look at the problem. Had Koch's tuberculin been as great a suc- cess as any specific cure in the whole range of modern medicine, tuberculosis would have been just as rampant as it is to-day. One cannot suppress disease by discovering specific cures. In fact, had Koch's tuberculin been a suc- cess, we should probably be suffering now from more prevalence of tuberculosis, simply because we should have still more neglected precau- tionary and preventive measures than we have done. Let us not pass too hurriedly away from the above remarkable statement, that the discovery of specific remedies will not remove diseases but rather tend to perpetuate them. It sounds like a dangerous heresy, and is there- fore worthy of some examination. Here is another statement more remarkable still : — ^The possession of a most powerful specific remedy for a given disease, mth our present-day modes of practice and em,ploying THE GEEAT WHITE PLAGUE 121 it, may produce little or no effect upon the death-rate from the disease. If these two statements can be proven to be true, surely it is worth while to discover what is wrong, and if possible right the wrong, otherwise there is little purpose going on dis- covering remedies. It is proposed now to consider the effects of the best and universally acknowledged specific remedies we possess in relationship to the above statements. The simplest example to commence with is the action of iron in all forms in the type of anaemia known as chlorosis. Here we have to do with a specific remedy of such undoubted power that there are not more than two or three others such in the whole range of medi- cine. But does the knowledge of this specific remedy in the least degree diminish the incid- ence of chlorosis, or remove the plague from our midst ? Not in the least ; a very brief common- sense consideration of the problem shows that it cannot do so. An attack of chlorosis can be cut short in a given individual by treatment with iron salts, and if the individual changes her course of living, and goes on upon new hygienic conditions of diet and life and en- vironment, the disease can be kept in most cases from recurring. The specific remedy is good for the individual, but it has absolutely no effect upon the plague of the disease amongst the species. There will 122 DAWN OF THE HEALTH AGE not be one case the less of chlorosis occurring for all the iron treatment in the world. Chlorosis has considerably abated in recent years, but we have to search for the cause of this good result in other things than any treat- ment by a specific. While chlorosis is sometimes seen in rapidly growing or neurotic girls of the better classes, it is essentially a disease of hard-worked, badly housed, and badly nourished girls and young women, of the working classes. It is a disease of the domestic servant and shop-girl, and indoor female worker. To quote an eminent authority, Professor Osier: "The disease is most common among the ill-fed, overworked girls of large towns, who are confined all day in close, badly lighted rooms, or have to do much stair climbing." , . . " Lack of proper exercise and of fresh air, and the use of improper food, are important factors." Now, how can any specific remedy, however beneficial to the individual, interfere with the vicious factors which produce chlorosis, followed by all the other fatal maladies, such as heart affections and tuberculosis, to which the en- feebled condition gives the inlet. Not all the remedies of the most distinguished physician or most notorious nostrum-vendor can touch this problem. All the Blaud's pills ever manufactured, and the many millions of purga- tive Pink Pills for Pale People, might as well be poured down the sink, as far as stopping the THE GREAT WHITE PLAGUE 123 attack of this disease on the young womanhood of the community is concerned. This type of anaemia is abating because we are stopping the building of cellar and base- ment kitchens ; the product of the days of snobs, when we could not live on the same floor as our maid-servants, and they had to run to underground burrows when we did not require their attentions. The lot of the shop- girl and workroom-girl has also improved. The State insists on workshops being ventilated and above-ground, and proper hours being kept. Still better things may be expected when "living-in" is made illegal. It takes no pro- fessional training to see which treatment is better for removing the disease chlorosis : treat- ment by drugs, or treatment by hygiene. The iron treatment, combined with other things, is excellent for a chlorotic case; but there will not be one case less of chlorosis on account of it in a thousand years ; on the other hand, improved conditions of living, working, and feeding have saved thousands from chloro- sis, and will continue to do so still more as we become more civilised. The next disease which we shall take as an example of this principle is one with which masses of the population of this country are riddled and destroyed in health and life itself. Like tuberculosis, it forms not one disease but many in its varying manifestations, and directly and indirectly, under many fanciful names, it 124 DAWN OF THE HEALTH AGE kills nearly as many as tuberculosis. Like tuber- culosis, it is an infectious disease, only pos- sible of propagation because infected individuals by the tens of thousands exist in our midst, and no attempt whatever is made to isolate them or prevent them from transmitting the disease to others. Unlike the victims of phthisis, these diseased individuals knovp full well that they are passing on the contagion of this dread dis- ease to their fellows ; yet the community allows this criminality, this villainy, to go on without moving hand or foot to prevent it. The most ghastly and fatal of our nervous diseases, including locomotor ataxy or tahes dorsalis, and general paresis or general paraly- sis of the insane, have now been shown to be due to the infective organism which is the only cause of this disease, that is blighting the lives of thousands of us. Would to Heaven that the false sentiment- ality of the age could be thrown to the winds, and this loathsome disease attacked as it ought to be by the community ! If we could only teach people that the Sin and the Crime consists not in speaking of this disease, but in conceal- ing it and passing it on to those who are most innocent of all offence ! There is one way only in which we can save ourselves and our children and our children's children from this curse, and that is the same identical way in which we can rid ourselves of tuberculosis. They are both infectious diseases THE GEEAT WHITE PLAGUE 125 of chroaic type, and there is one way, and but one, by which a civilised country can rid itself of them. In a single sentence, that way is, a National Medical Service, with compulsory powers of segregation of the unhealthy from the healthy. In our present condition of education and civilisation one dare not, however, even men- tion the name of this disease in a book intended for general readers. So it shall be spoken of here by a name in fairly general use by medical men, viz., as " specific disease." The name suits the present purpose well, since it indicates that there is a " specific " treatment for this disease, which makes it the " specific disease " pa/r excel- lence. The medical profession has known for very many years two drugs which are specifics for this "specific disease" at different stages. Treatment by mercury or its compounds in the earlier stages is a definite cure nearly always successful when properly and adequately applied ; and similarly a substance called the iodide of potassium is specific in removing certain mani- festations of the disease, which occur several years later in improperly treated cases. Here, then, if anywhere in all medicine, is a disease with its cure found out and well known. If disease can be eradicated by finding out a cure for it, this disease ought to be eradicable. What are the facts? The disease is as wide- spread as ever, and shows no diminution. In 126 DAWN OF THE HEALTH AGE out-patient or in-patient department of any of our hospitals, there are more patients with " specific disease" than with phthisis. Doctors in practice see and treat, by means of these specific cures, more cases of it than perhaps any other disease. They often cure it, too, as far as the individual who pays them is concerned ; but meanwhile the brand has been passed along, and the disease laughs at aU our puny efforts with " specifics." When are we going to be manly enough to attack it in the only way that can get rid of it ? The next instance which may be taken to illustrate the principle under discussion is one of the most glorious triumphs of modern scien- tific medicine, namely, Behring's discovery of the antitoxin of diphtheria. Diphtheria kiUs in fatal cases by a most virulent poison, called a toxin, which the diph- theria germ produces where it grows in the throat, and this poison then is taken up into the blood and, passing round, poisons the heart and nervous system. The poison is most ex- cessively deadly, as much so as snake venom, so that a small patch of diphtheritic growth in the throat can produce enough of this chemical poison to poison the whole body of the patient and cause death. It is, strange to say, just this highly poisonous character that enables us to prepare the antidote, or antitoxin as it is called, because there is very little of the poison, and therefore it takes very THE GEEAT WHITE PLAGUE 127 little of the antidote to neutralise it. In other diseases there are formed much larger quan- tities of lower grade poisons, and we cannot prepare or administer sufficient amounts of the "anti"bodyto neutralise them. That is why we caimot extend the antitoxin cure for diph- theria to other infectious diseases ; it has only been capable of extension to others, such as lock- jaw, for example, where the disease poison is> a very intense one, acting in minute quantities. The diphtheria antidote, or antitoxin, is made by choosing out a more r6sistant animal against diphtheria, such as the horse, and injecting into this animal the dead bodies of the diphtheria organism containing plenty of the diphtheria poison. This sets up a chemical reaction in the horse's body, in which the antidote is manu- factured to neutralise the poison. Some excess of the antidote is made by the horse's body during this process, and this excess is present in the fluid part of the horse's blood. On now drawing off some of the horse's blood, which can be done almost painlessly by opening a vein in the neck, the horse going on quietly eating all the time, and by separating afterwards the fluid part of the horse's blood, the specific remedy for diphtheria is obtained, called " diph- theria antitoxin." So much by way of prefatory explanation ; the next point is that, by general accord of the medical profession throughout the whole world, it is agreed that this treatment is most efficient, 128 DAWN OF THE HEALTH AGE and indeed specific for diphtheria. The mor- tality rate of cases properly treated with anti- toxin at an early stage is enormously less than that of untreated cases. In fact, we have a specific cure here by an organic or bio-chemical drug, as great as the two we have just discussed previously. Any- thing which follows is meant as no disparage- ment of this brilliant discovery, but merely by admitting the intrinsic value of diphtheria anti- toxin, applied properly in sufficient amount at the right time as a specific cure for each case of diphtheria, to drive home d fortiori that a disease cannot be eradicated by means of a cure, but will continue to be a plague to the com- munity, and will still go on destroying valuable lives, until a proper system of dealing with it is devised. In cases occurring in well-to-do families, almost as soon as the child is ill the doctor is sent for, and diphtheria being diagnosed, the antitoxic treatment is at once efficiently applied without waiting to take any chances as to whether the case is going to be a mild or a serious one. The consequence is an enormous decrease in the diphtheria death-rate in this class of practice. Diphtheria antitoxin is the sheet-anchor of the practitioner attending to the middle classes, and he recognises and owns it everywhere. But contrast this with what happens in the case of the poor. Here the child is allowed to THE GREAT WHITE PLAGUE 129 go about with its sore throat and illness for two or three days ; the mother may be out all day at work, or, failing this, may have all the work at home to do for her own large family, husband, and probably lodgers; all the cook- ing, washing, and cleaning to do for the entire household. Little wonder that each child can- not receive as much care and attention as in a middle-class family. One of the children goes about with a sore throat, supposed to be an ordinary sore throat of a rather bad type. This throat is treated with domestic remedies and according to the advice of all and sundry of the neighbour women, who come with their children in arms, and at their knee, to look at this mysterious sore throat and, incidentally, get their children infected. Probably for a day or two the child goes to school with " only a sore throat," giving rise to a crop of bad sore throats in the neighbour- hood. Finally the poison of the diphtheria germ, circulating in the blood, makes the child so iU that at last a doctor is sent for, who diagnoses diphtheria, and may at once give "antitoxin" (it is necessarily a very expensive substance, from its mode of preparation), or may notify the case and have it removed to a muni- cipal infectious disease hospital, when at last it gets its first dose of antitoxin.^ It is obvious ' No antitoxin is allowed in most Poor Law Infirmaries, to the many cases of diphtheria treated there. See Poor Law Commission Keport. I 130 DAWN OF THE HEALTH AGE that the poison has a long start of the anti- dote, and it is little wonder, since the large majority of cases of diphtheria in the country are treated in this latter way, that the death- rate from diphtheria has only slightly de- creased since the introduction of the antitoxin treatment. Our present system of administration and treatment of infectious diseases amongst the working classes is responsible for this more than partial failure to adequately decrease the death-rate from diphtheria. The facts of the diphtheria death-rate furnish the proof for the second proposition stated above, viz. that "the possession of a most powerful specific remedy for a given disease, iviih our present-day modes of practice and employing it, may produce little or no effect upon the death-rate from the disease." Here, at five-year intervals, are the total numbers of deaths from diphtheria (excluding croup) recorded annually in each year men- tioned in the United Kingdom. It may be mentioned that in the earlier years a certain number of cases of diphtheria were probably recorded as " croup " on account of less per- fect means of diagnosis, but this does not so materially vitiate the comparison as to destroy the proof of the principle mentioned above. THE GEE AT WHITE PLAGUE 131 Total Annual Deaths from Diphtheria in United Kingdom Year Deaths 1881 4,292 1886 5,017 1891 6,147 1896 9,987 1901 10,013 1906 7,258 So much for the death-rate; now as to the incidence of the disease, which is the impor- tant criterion on our scientific methods, and that which matters as far as the health of the race is concerned. Here, so far as statistics can be found, there is no diminution whatever. Nor, if we will only look at the problem in a philosophical and logical way, can there be any reasonable expectation of any decrease. Granting that a specific remedy can cut short an attack and save an individual patient, and that so, when we learn to apply our remedy all round, and at the proper time, and in the proper way, the death-rate may and must fall ; yet this has nothing to do with the incidence of fresh cases unless the specific remedy cuts out the disease before it is infectious, and that is a very long cry from where we stand. During the days when the diphtheritic child is going to school; when it is being doctored by the mother in the midst of its brothers and sisters, in' a two or three room tenement, and sleeping with some of them in the same bed at night ; 132 DAWN OF THE HEALTH AGE when it is being visited and prescribed for by the neighbour wives accompanied by their children, who try to see into its throat at the same time as the mothers ; during all this time where does the specific remedy come. into the problem? Until our united wisdom discovers some way of removing children suffering from diphtheria to isolation conditions at once without waiting till the case is brought in the present orthodox way under the notice of the doctor, children are going to continue dying of diphtheria by the thousand. When we do find out how to do our work, then Behring's discovery will help us to cure the individual case from slum as at pre- sent in villa, and more rapidly to eradicate the disease ; till then, the big death-roll continues. The most illustrative case of all is that with which we shall conclude our examination of medication versus hygiene in the warfare with disease. The subject is almost as fascinating as a romance in its entrancing interest; it is the story of the combat of modern science with malaria. Fortunately for the inhabitants of the United Kingdom, our well-drained soil and climatic conditions at present preserve us free from the ague or malaria ; although in earlier days it was common enough in the Fen Country. In other regions of the earth, over extensive areas, it attacks millions of people and does enormous damage, not only by the great death-roll directly due to the disease itself, but by the lowering of THE GEEAT WHITE PLAGUE 133 vitality induced by repeated attacks so producing continually ill-health and diminished resistance to other diseases. In ancient days malatia was one of the most prominent diseases amidst the Romans, and probably did much to sap the vigour and physique of that dominant race towards its decline. Malaria is still the scourge of modern Italy; hundreds of thou- sands of the inhabitants of the United States of America are afflicted by it ; it has earned for West Africa the appellation of " the white man's' grave " ; and thousands of the natives of India die annually directly from its ravages. Yet this is the disease to which we have known a specific, in quinine, for the past two hundred and seventy years. A South American Indian used Cinchona, or Jesuits' bark, to cure a Jesuit missionary pros- trated by fever. The same bark was used as a cure for the Countess of Cinchon in 1688. Afterwards the Jesuit brotherhood disseminated a knowledge of its virtues throughout Europe. Long researches, into the details of which we cannot here enter, laid bare the fact that this activity of the bark was due to a substance contained in it called quinine. This substance forms beautiful white salts with certain acids, and nowadays these salts are isolated in large quantities and used medicinally in this country, and exported abroad to malaria-ridden countries such as India and West and Central Africa, Small amounts of this active principle, quinine, 134 D^WN OF THE HEALTH AGE can be made to take the place of very much greater quantities of bark extract, and in the form of powder and tablets, quinine is an essen- tial in all expeditions for exploration, settlement, or sport undertaken by white men in the tropics, and in all tropical and sub-tropical colonies or stations inhabited by white men. For most ordinary attacks of malaria, quinine is an absolute specific ; but with prolonged exposure to infection and recurrent attacks it loses its power, and there are some cases espe- cially resistant to it. It may, however, be placed amongst the four or five true specifics known to medicine. All this progress and discovery of the specific remedy had been realised purely empirically, without any real experimental knowledge having been obtained, apart from theorising, as to how malaria was caused. We shall now trace out in brief outline how the cause of malaria was discovered ; how man was shown to become infected by a peculiar and interesting agent, and how this discovery, by showing the rational way to avoid infection, has almost banished malaria from districts where it was a veritable scourge. The name of the disease, malaria, shows that it was early associated in men's minds with bad air ; for centuries it was believed to be due to " miasmata " or stagnant vapours arising from the marshes. But it has remained for the scientific work of the experimental medicine THE GKEAT WHITE PLAGUE 135 of the immediate past generation to clear up this riddle of the ages as to the true origin and nature of malarial fever. The most remarkable symptom of the disease which puzzled the physicians for centuries, namely, the ordered sequence of events in each attack, first became capable of being understood when the scientific work had laid bare the true causation of the disease. The characteristic symptom of malarial fever is the onset at regular intervals of time of acute attacks, each with a rhythmic sequence of events, at regular periods. Between these attacks the patient is fairly well, though somewhat ex- hausted. In each attack there is a cold stage, a hot stage, and then a stage of excessive perspira- tion followed by relief from pain and other symptoms. There is no real drop in body temperature when the patient is complaining of cold, but rather a rise, yet the patient feels intensely cold ; the teeth chatter, and he shivers at intervals most violently ; the skin is shrivelled and the face and hands blue ; there are agonis- ing pains in the back and limbs. After a variable period up to three hours, this phase is succeeded rapidly by the hot stage, in which the face becomes flushed, but as yet there is no perspiration ; there is racking head- ache, and sometimes delirium, and the patient feels restless and burning hot all over. This agonising stage lasts from one to four or five 136 DAWN OF THE HEALTH AGE hours, when a blessed relief comes with the sweating stage, in which the patient loses the severe pain and becomes tired and sleepy, tem- perature falls, and pulse and respiration slack oif as the attack dies down. The explanation of this sequence was given when Laveran, a French observer, discovered that malaria was due to a minute organism existing in the blood and undergoing a life- cycle of changes corresponding in its time period to these rhythmic onsets of fever. Each generation of this blood parasite dis- covered by Laveran bursts out, or spores, at a certain time, and this it is which causes the malarial attack. The next malarial attack occurs when the next sporing or swarming occurs, again discharging poison into the blood. The blood normally contains, suspended in its fluid, immense numbers of little bodies called red blood corpuscles, and it is in these blood corpuscles that Laveran's parasites live and grow. At a certain stage they break the cor- puscles up simultaneously, so destroying a cer- tain percentage of the patient's blood, and also carrying out poisonous substances into thfe cir- culation. Then there is an attack. At the same time the living parasitic spores so set free begin to enter fresh corpuscles of the blood, and start a new cycle, the consumma- tion of which is a fresh outbreak and a fresh attack, and so the cycle continues to be re- peated. THE GEEAT WHITE PLAGUE 137 The remainder of the problem, although strongly reminiscent of King George the Third and a simple problem of cookery connected with apple dumplings, defeated the best efforts of scientists for many years. With its solu- tion came the first practical victories in the warfare with malaria. The still unsolved part of the puzzle was how the malarial parasite of Laveran got into the blood-corpuscles, and what was the connection with the marshes. Two British observers have shared the honour of supplying this portion of the history in quite recent years, the original suggestion being made by Sir Patrick Manson, and the patient and brilliant work of Ronald Ross supplying the accurate proof. The most carefully elaborated work of Ross demonstrated that the above- mentioned sporulating cycle occurring in human blood did not form the complete life-cycle of the parasite, but had to be refreshed and sup- plemented after a certain number of generations, by a sexual cycle, according to a very well- known law for many lowly animal organisms. This second cycle was shown by Ross to occur in the stomachs of certain species of mosquitoes of a particular genus called Ano- pheles, which breeds in the marshes and small ponds and puddles near malaria-ridden districts. Many species of mosquito are quite harmless, being unsuitable for this refreshing of the strain of parasite, but a particular species of mosquito of this genus Anopheles was examined 138 DAWN OF THE HEALTH AGE at different periods, after feeding on malarial blood, by Koss, and the mosquito was found to develop this special cycle of the malarial parasite in glands of the stomach. It was shown that a mosquito of the right species, a certain time after biting a patient, became infective, and was capable now of carry- ing malaria to another human being, but only after the parasite had undergone the necessary metamorphoses in the mosquito's stomach. The minute and careful work necessary to show such changes going on in the glands of a structure so delicate as the stomach of a mosquito, can be appreciated. Another point of view of great beauty is the exquisite bio- chemical adaptation in Nature which requires one particular breed of mosquito in order to provide just the proper chemical nutrition for the induction of this particular cycle of life in the malarial parasite, a cycle most essen- tially different from the cycle occurring in human blood, and giving rise to the patient's attacks. The exquisite beauty of this adaptation, from the bio-chemist's point of view, wiU be appre- ciated when it is stated that the, as yet unknown but quite certainly existent, organism of yellow- fever is borne by a different kind or genus of mosquito known as Stegomyia. Let us turn now to what intimately concerns us here, namely, the application of the reflected light of the successes in this problem of attack THE GKEAT WHITE PLAGUE 139 upon malaria to the attack on the consumption problem in our own country. The initial intention in quoting malaria was to show that here, where for generations one of the best, if not indeed the most notable, specifics of all medicine, had existed and been universally applied, the disease had still gone on rampantly ravaging, without abatement, the populaces of the countries. Quinine had been of very great and undeniable advantage to the individual, but of little or none to the race. Let us now carry our account of malaria one step farther and see how we can reap a great lesson for application to the huge problem of tuberculosis. It is clear, even from the short outline given above, that the only way, under natural con- ditions, in which a new individual in a malarial country can be stricken by malaria, is by being bitten by the right species of mosquito, viz. by the Anopheles. This is confirmed by the well- substantiated discovery that, marshes or no marshes, where there are no Anopheles mos- quitoes there is no malaria. The logical out- come is that if we can prevent people being bitten by these mosquitoes in any way — either by protecting, by mosquito netting, etc., from the insects, or, preferably, and more perfectly, by ridding the district of the disease-bearing Anopheles — then we simply cut off malaria. Let us carry in our minds here the corre- sponding parallel for tuberculosis; here, there 140 DAWN OF THE HEALTH AGE is no intermediate thing in the way of a mos- quito, but it is just as true that no person in this World gets consumption otherwise than from another consumptive, and if we segregate off consumptives by themselves, in many ways an easier problem and less expensive than removing mosquitoes from a district of country, we shall undoubtedly reap all those advantages which are about to be described in relationship to malaria, and in a surprisingly short period tuber- culosis will be almost unknown. Space forbids entering into the details of the several successful campaigns against malaria by mosquito destruction, the only rational method ; but it may be stated that in no instance where the somewhat difficult problems of thorough drainage have been solved, or removal of dwell- ings from the vicinity of mosquito-rearing swamps has been effected, has there failed of reaping the due reward in decrease of malaria and death from malarial fever; and, in some instances, districts which were previously deci- mated, such as Ismailia in Egypt, and Conakry on the West Coast of A&ica, are now almost free from the scourge. The problem of practical sanitation is made somewhat lighter by the fact that the parasite- bearing mosquitoes do not fly far from the shallow pools in which they deposit their eggs, so that they may be swarming in a particular spot, and another district, a few hundred yards or a quarter of a mile away, may be quite free THE GEEAT WHITE PLAGUE 141 from them. A second factor of assistance is that the larvae, in order to develop farther, must at a certain stage reach the air at the surface of the water, and hence by sprinkling petroleum or creosote over the pools and marshes their development may be prevented. The hygienic measures indicated in fighting malaria are accordingly drainage and filling up of pools around houses, looking after cisterns and other water surfaces, and disinfection of surfaces of water by oil where removal is im- possible, within, say, a radius of one mile around a given town or community which it is desired to protect. Some towns and situations are more ideally placed for such treatment than others, and in certain test cases, where communities were decimated by malaria, and where surface con- ditions and isolation lent themselves to treat- ment by the above methods, the disease has been practically stamped out. It may be added, as a particularly interesting example, that in Central America the main obstacle to comple- tion of the great undertaking of the Panama Canal was the health of the workmen, and that now malaria and yeUow-fever (which, as mentioned above, is also a mosquito-borne dis- ease) have been almost crushed out in this district by the American Medical Service, the work is being pushed forward to completion under healthy conditions. When this great Panama Canal is at length opened, it will be 142 DAWN OF THE HEALTH AGE a united triumph for both Engineering and Medical Science, The methods to conquer tuberculosis must be conceived on somewhat different lines ; each disease has its own problems of detail, but essentially the rationale must be the same. When we know how a disease is spread, and that it possesses no other method of attack unknown to us, then we must throw all the strength of our Medical Service and the know- ledge of our science into stopping the means of spread, instead of supinely contenting our- selves with tinkering the individual. Inciden- tally, however, the actual victim of attack is given a better chance than ever before when our scheme is laid on these new scientific lines. Returning now to the summing up of our main proposition regarding specific cures for disease, we have demonstrated by taking the four best established specific cures in all medi- cine — viz. (1) iron in ansemia, (2) mercury in " specific disease," (3) antitoxin in diphtheria, and (4) quinine in malaria — that in none of these cases is the race relieved from suffering and death by the existence of a cure for the individual. The fact, now we have found it, and proved it, and tested it, is worth reiterating and dinning into the ears of the World, so that it may awake from drugging itself to sleep and death. There is only one way given under Heaven THE GREAT WHITE PLAGUE 143 by which disease can be abolished, and a finer and fitter race evolved, and that is by stopping the causes of disease, and throwing all our force into the resistance of its spread. If we are brave enough to do this, we shall, it is true, save millions of money every year, but we shall also achieve something nobler and grander than this which cannot be stamped upon coins of gold or written down on cheques or bank-notes. Coming now to the details of a rational national attack upon the disease, tuberculosis, we may first of aU sketch what is at present being done in the way of attack. We possess certain hospitals provided by the charitable for consumption, and certain sanatoria in healthy districts, both for those who can pay and also for a few of those who cannot. What are these institutions doing to-day for the consumptive patient and for the community ; are our efforts anything like commensurate, or are we merely wasting time and money on a little child's play? The orthodox position taken up by the medical profession and by Medical Ofiicers of Health in regard to the danger of infection by tuberculosis, is well illustrated by the following extracts from the Annual Eeport of the Medical Ofiicer of Health^of^ great English city. These extracts are quoted here, not in order to criticise any one person's views, but because they so clearly represent a widespread doctrine 144 DAWN OF THE HEALTH AGE which it is thought desirable to examine care- fully in the public interest. "The susceptibility of the individual who inhales or swallows the bacilli varies ; constitu- tional predisposition, the habits, the occupation, the intemperance of the exposed person may prepare the way for it. In numberless cases the likelihood is that the bacillus is swallowed or inhaled without any ill effect." "It will be seen, therefore, that the consump- tive patient must not be always and under aU circumstances regarded as a source of danger to others." "Forms of tuberculosis other than phthisis may be regarded as practically non-infectious." ' " The large majority of the cases of phthisis come under the same category, whilst the remainder are infectious only under circumstances favour- able to infection, and have little, if any, tendency to spread where reasonable precautions can be adopted." It may be remarked that elsewhere it is stated in the same report that "A careless patient in bad surroundings may easily become a source of infection." The very danger of some of these statements lies in the fact that they are true, such as that " the consumptive patient must not be always and under all circumstances regarded as a source of danger to others." This is perfectly true, * This statement standing alone may be accepted ; it is quoted in order to be able to properly quote the context. THE GEEAT WHITE PLAGUE 145 but stated in this way and brought to the attention of laymen, it may easily induce a false sense of security which may be of great danger. It may readily induce slackness of action in removing cases of danger, if the danger is taken so lightly. Any patient producing sputum containing tubercular germs and living at large in the community is a very great source of danger indeed, and amongst the poorer classes probably three cases out of four possess this criterion of danger. If we except a possible small percentage of infection carried in milk, all infection comes directly from other tuber- cular patients. After all, we are dealing with an infectious disease, even if it be a chronic one. If we could only see the patients hit by the infection in phthisis as we do in smallpox, the present order of things would not long be tole- rated. There is no possible doubt that they are hit just as much as they would be by smallpox, but phthisis is insidious in its onset, and so we blink at the cause and do not remove it. The statement that "In numberless cases the likelihood is that the bacillus is swallowed or inhaled without any iU effect " crystallises a common doctrine that all the time we are swallowing various deadly germs which do us no harm because we have a strong resist- ance, or immunity, as it is called. This is carrying the immunity doctrine to an entirely unwarrantable extent. There exists no clear evidence regarding immunity, either natural or K 146 DAWN OF THE HEALTH AGE acquired, in the case of phthisis. All the experimental evidence of the bacteriological laboratory lies in the opposite direction. It appears to be true of phthisis, as of pneumonia, that, instead of protecting, one attack, if any- thing, predisposes to another. At any rate, there is much evidence accumulating that num- bers of sanatorium cures which apparently re- lapse are truly re-infections with the disease. The evidence from thousands of autopsies has shown the existence of old healed tubercular injuries in the bodies of people dying from other diseases. This shows that we all pos- sess powers of resistance against tuberculosis, and that many people, if not all, are capable of infection with the disease; but there is no clear evidence that some individuals possess enormous resistance and others very feeble powers of resistance. Repeated deaths in the same family do not prove this ; they only prove closer proximity, and hence more efficient and repeated infection. The Appendix at the end of the book on relative death-rates in diflferent occupations proves this clearly ; for example, one printer in every three dies of phthisis, but only one clergyman in every twenty-six dies of it. Surely, such figures can only mean that the printer in his occupation runs, for some reason, about nine times as much chance of infection as the clergyman in his, and not that the clergyman's body possesses naturally ninefold the immunity of the printer's body. THE GEEAT WHITE PLAGUE 147 In any case, whatever we may believe re- garding immunity, this point is aside from the main issue, which is that there is such a great number of us open to infection by our fellows, and, under present wrong conditions, so often subjected to infection, that seventy-five thou- sand of us die every year. It matters not to the argument that ten times as many may be infected each year and recover on account of better resistance ; both those who die, and those who escape from the jaws of death, were in- fected by other sufferers, and by inhaling or swallowing tubercle bacilli. No one of any scientific authority has ever claimed that tubercle bacilli are to be found in mouth or sputum except in the case of individuals suffering from tuberculosis. On what possible scientific ground, then, can the opinion be based that the tubercle bacillus can be swallowed or inhaled without any ill effect? There is no such scientific ground, and the present writer ventures to make the counter statement that in over seventy thousand cases every yea/r in this country alone people die because they have swallowed or inhaled living tubercle bacilli, produced and cultured in the luTigs of consumptive patients living or work- ing near them. The further statement may be added that each of these seventy thousand people induces the disease in one other person before he dies, and that in this way a new 148 DAWN OF THE HEALTH AGE seventy thousand people are prepared for next year's sacrifice to this disease. These are facts that the inhabitants of the country have to deal with, and not fancies. There is no doubt that in the earlier stages the consumptive is not so dangerous as later, and also that the educated consumptive is less dangerous than the ignorant consumptive; but the dreadful average is that, one with another, each consumptive starts a new victim on the road to death before he himself departs. The statement has all the crushing force of a mathe- matical demonstration : how otherwise is the disease kept up ? Is it done by the milk of a small number of tuberculous cows ? Why, then, not have them slaughtered at once ? Every tubercular animal in the country ought, of course, to be slaughtered at once, and perchance with more energy and inspection we could find annually a few more than we do now; but, surely, we do not believe that any serious per- centage of phthisis is carried in this way. The only remaining way is from one human being to another. One final criticism of the statement that the large majority of the cases of phthisis are practically non-infectious, whilst the remainder are infectious only under circumstances favour- able to infection, and have little if any tendency to spread where reasonable precautions can be adopted. The accuracy of this may be ques- tioned ; but, if true, surely the logical reply is. THE GEE AT WHITE PLAGUE 149 why not isolate the small minority which are infectious under unfavourable circumstances, or adopt such reasonable precautions that the disease loses its tendency to spread? These statements need not have detained us so long were it not that they reflect the current orthodox view of many people keenly interested in this great problem and truly anxious for its solution. One can also recognise and honour the kindly spirit which, on account of the attitude of the public towards the consumptive patient, tends to allay the growing feeling that it is unsafe to work or associate closely with the sufferers from this disease, StiU, with all desire to make the lot of the consumptive a happier one and his life easier, objects which can be attained in other and safer ways, we must be most careful that we look also at the side of the case of the healthy members of the community, and safeguard them from death, and their families from destitution. It is necessary here that we should not let a weak sentimentality run away with us, and this public distrust of the consumptive is a most salutary public feeling. There is no doubt whatever that an operative or worker, in nearly all workshops and indoor occupations, who is at that stage of the disease that he is producing sputum is a real danger, and a great danger, to other workers aU around him. To the personal knowledge of the writer, there are 150 DAWN OF THE HEALTH AGE hundreds of such consumptive workers in tex- tile works, many of them weavers who suck the shuttles in threading them, these shuttles being later redistributed and reaching other workers, and the danger of employment of these workers to other workers in the same shop is enormous. Until some national scheme is devised, let workers subscribe funds to send their con- sumptive co-workers to sanatoria, and let them demand a certificate of freedom from infectivity before such workers are re-admitted to work in the shop. But it is pure folly and madness to keep on working beside them, and the Board of Trade ought to see that it is stopped. Workpeople ought to strike against present conditions, both on account of the sick people and on their own account. Present conditions consign the sick to a living death, and the healthy to be ready to step into the ranks of death in turn. The view that the germs of consumption are being swallowed daily by all of us in the dust from our roads without injury or infection, on account of our great virility and powers of resistance, while most comforting to the strong, is probably, indeed almost certainly, a pure myth. If it were so, that we so swallowed and inhaled live tuberculosis germs, the popula- tion of the earth would have rapidly dwindled, especially since the advent of the motor-car ; but there is no shred or tatter of scientific evidence for this view. The most expert bacteriologist THE GREAT WHITE PLAGUE 151 would frequently fail to obtain live tuberculosis germs from blown road dust. It would be a very bad day for us aU if they were present. The tubercular infection is usually carried roimd from man to man much fresher than this, and while it is aU-important, so long as thousands of dangerous sputum-producing consumptives are allowed free in our midst, that they should be taught not to spit, do let us remember that this regulation alone is but playing at things, and that there are a hundred and one ways in which the phthisical patient passes on the living germs, many of them much more dan- gerous than spitting. Fortunately for us, the bacillus of tuber- culosis is an exceedingly delicate organism, of which the vitality is more readily destroyed than that of most of the micro-organisms of disease. In the laboratory it can only be grown upon special culture media, refusing to grow on ordinary nutrients upon which most of our ordinary disease-producing microbes flourish. It is very delicate and *slow in its growth, and perishes readily under variations of external conditions. Sunlight destroys it rapidly, like most other bacteria, and it is nearly always kUled by complete drying. It is hence ex- ceedingly probable that a great deal of con- sumption is borne by moist sputum, or by sputum not long exposed to air and light, from patient to patient. It is those brought very close to the consumptive, and living the same 152 DAWN DF THE HEALTH AGE life as the consumptive, inhabiting the same small rooms, sleeping in the same bed, using the same vessels for eating or drinking, handling the same articles and the same tools, who are most liable to infection. The evidence as to non-infection of physicians and nurses in chest hospitals does not run counter to this at all. Patients live an entirely different Ufe at hospital as to sanitary regime, reception of sputum in special vessels into antiseptics, washing of the hands, etc. Again, the nurses and doctors handle but little that is previously handled by the patients, eating utensils are thoroughly cleansed, and the same things are not used by nurses and patients. The whole life is different from the patient's home-life, and the relations to him of doctor and nurse are essentially different from the relations of his relatives, friends, and co-workers. Such evidence is worth nothing; one might as well claim, because doctors and nurses do not contract typhoid fever from a patient, that in the good old days, when we treated typhoid as we now treat consumption, a typhoid patient could not infect persons in his neighbourhood ; and tubercular infection, from what we know as to the two channels of infection, is obviously more easily distributed than typhoid, which can only come fi:om faecal contamination. The lay public probably but feebly realises how little is done at present by either Public THE GREAT WHITE PLAGUE 153 Health Authorities or Hospital Authorities to stop the spread of consumption, and how little powers they possess to enable them to stop the dangerous consumptive from going forth unhealed to lay death-traps for the rest of the community. It is well that the matter should be set forth in black and white before the general public, and our public bodies and legislators, so that there may no longer be the excuse that "We did not know that these things were so." It may be stated at the outset, to prevent any misunderstanding, that no blame attaches to any particular person or any institution here given as an example or a concrete case ; the things portrayed below are done everywhere throughout the length and breadth of the land, and there is no legislation and no organisation to prevent their being done. Let us commence with a personal experience of a concrete case, the patient coming from one of the best and most scientifically conducted Consumptive Hospitals in the Kingdom — an institution with a fine laboratory, efiicient staff, and all clinical facilities ; but what avail all these good things if the patient himself is to be sole arbiter and judge of when he is to leave hospital and cast himself forth free again into the great sea of humanity ? The case related simply came under the author's notice from this institution, and the 154 DAWN OF THE HEALTH AGE sjiudy of that case first awakened his mind, and allowed him to perceive how we are every- where working at present, and how futile all our labours mu