NATIONAL HEALTH.
[To Mg Ennew or roe " Sezererou."1 Stae—In the Spectator for March let your contributor "S.," in an article on "National Health," in criticizing some of my views, does not correctly represent them. If you will permit me twill briefly describe some of them, as they may be-of Taint at present, seeing: that the State is about to legislate in. the interests, of the health of the people. As this legislation will involve an interference with the practice of' medicine, it is desirable .that the public should. clearly realizetthe objects of such legislation. It is taken_ for granted that medical knowledge- is so complete that it will enable wise laws to be enacted: If,.huvretves, the, matter is very carefully considered serious doubts will arise as to whether we possess: the knowledge essential. to. wise legialation.
To get a clear grasp-of the subject it is. necessary to realize exactly what, is the,aire of' such legislation. Ills, shortly, the prevention) and cure: of disease. To prevent a disease- it is necessary to,kneow. the conditions which favour its oeonrrenee.
'Po cure disease it is necessary to detest the symptoms it pro- %duces, and' to know the course it will pursue after it hes 'altered the body, and tic recognize it before it has damaged the tissues of the body.
For the sake of simplicity disease may be represented as, mourring•in four stages: First, the Predisposing Stage—that, 'is, the stage in which the individual is free from disease, but liable to, be attacked either from some inherent weakness :r from tutc outside source. Second, the Early Stage—when the disease has entered his system, but has not produced any per- ceptible alteration of tissue, when the signs the disease produces, are mainly subjective. This is also the Durable stage. Third, the Advanced Stage—when the disease hiss progressed so far that it has caused destruction or modification of tissue, and when it is revealed by the presence of a physical sign. Fourth, the Final Stage—when the individual has died, and when the tissues are subjected to a post-mortem examination.
What the State has in view is to legislate for the prevention, of disease, and for the detection and treatment of the early stage, so as to prevent the occurrence of the third stage. In the past legislation has been mainly concerned with preventive medicine, and, by putting into effect sensible hygienic laws, a certain amoutit of good has been done. But there remains a large field untouohed, as these laws of hygiene have little or no effect upon. the. majority of the diseases that impair the health of the community. It may be taken for granted that. untilit is known where a danger lies, precautions for its avoid- ance will be haphazard and ineffectual. If we do not know, where the danger from disease lies, it is not possible to take the best steps for its prevention.
When we inquire into the present knowledge of disease it will be found that the first two !stages of disease for -which legislation is intended are, to all intents and purposes, un- known. We do not know the predisposing onuses of diseeee, nor the early symptoms of the vast majority of the diseases that impair the health of the mearaunity. This has come about because a conception of medicine shish takes a restricted view of disease has become predominant all the world over, and hie concentrated attention on the later stages of disease.
I have visited schools of medicine and research institutes in many eatintries. I have been shown, magnificently equipped pathological institutes for the examination of.the tissues after the patient has died. I have seen research institutes where the behaviour of microbes was studied when cultivated in nutrient media and in guinea-pigs. I have seen elaborate methods of research attached to the wards of hospitals for the study of the diseases in patients after the tissues have been damaged, but in no place have I found any attempt made to investigate diseases before the tissues were damaged or when a microbe had gained entrance into the human body. In hos- 'theta the early stage of disease is seen in out-patient depart- ments, and here, as a rule, no attempt is made to carry on, investigation.
Disease is only revealed to us by the presence of symptoms. On its earliest invasion of the human body it rarely manifests itself by any definite physical sign. That only comet) after the tissues have been damaged. At this stage disease makes its presence known by some'disagreeable sensation, and the patient recognizes that all is not well with him. These sensations are supposed to be too, vague and indefinite, and have hitherto received scant attention. As a matter of fact, if a physician were suitably educated, he would find that a great many of these sensations give a very clear indication of their nature. It requires, however, a long training and much experience before a physician is able to recognise them. We have then this curious situation, that when a disease is easy of recogni- tion, and has damaged the tissues, the patient is taken into the ward of the hospital and thoroughly examined by the older and more skilled physicians; while on the other hand, when the disease is difficult to detect, and requires men of great experience to detect it, when the disease has not yet damaged the tissues, and when the hope of cure is at its best. the patients. are placed under the care of the least experienced and youngest member of the staff.
Your contributor "S." evidently supports the scheme re- commended by Sir Bertrand Dawson. Considering the attitude of those- who will influence legislation, no doubt some such scheme will be carried out. Such an institution as Sir Bertrand Dawson contemplates is simply an extension of the hospital system; in which the great bulk of the sick are to be treated. To give the matter a scientifie aspect groups of apeeialiabe are to be attached to the different hospitals. The expectation that a body of specialists will help to advance medicine on the lines that will prevent and cure disease certain not to he realized. Practically every specialist deals with disease after it has damaged the organs, and no specialist ever has an opportunity of seeing the patients during the pre- disposing stage or during- the early stages when there is no physical sign. It will thus be seen that such a scheme is but a perpetuation of the old methods. It resembles the behaviour of a man who discovers an escape of water in his house, and -oho contents himself with mopping up the escaped water in- stead of :searching for the leak and soldering it up. It :s manifest that if legislation is to concern itself with the health of the people it must take steps to find out the source of the diseases which afflict a community.
It will thus be seen that a totally new conception of the methods for investigation of disease is required. The methods that are suitable in recognizing the third and fourth stages of disease are totally inadequate to find out those of the first and second stages. It is towards the finding out of these. first two stages that I have devoted the greater part of my time and research. I do not pretend to have carried the matter very far, but I have reached a stage in which I recognize the necessity for an investigation of this sort, and I have been able to indi- cate certain lines which have led to the detection and better understanding of the signs of disease.—! am, Sir, dc..
New Park, St. Andrews, N.B. J. 31Acionzmv.
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