What  Kind Of Service Might We Have?

it would be quite useless to discuss the theoretical basis of a perfect medical service without some idea of what medical science may be expected to do both for the individual citizen and for the community as a whole. If all that medicine could do was to make tentative attempts at diagnosis without any clear conception of the cause of disease and to administer palliatives aimed at suppressing symptoms it would probably not matter what form of service we had, the results would still be poor. If, on the other hand, medicine was an exact mathematical science by means of which any fully qualified doctor could make an absolutely certain diagnosis in any given case, and apply remedies which research and experience had shown to be infallible, the form of medical service would be of little importance so long as the education of the doctors was efficient. As it is, however,  medical science  has still many problems to  solve; the  accuracy of the  diagnosis  made by the  average  doctor depends on many different factors, and the line of treatment to be followed is seldom so completely standardized that it can be carried out without personal control. Under these circumstances most doctors require the constant assistance of others in order that the accuracy of their diagnosis may be increased and that the certainty of cure resulting from their treatment may be improved, and the form of the medical service therefore becomes one of vital importance. If that form denies to the individual doctor any knowledge that is possessed by other doctors or the assistance of all the experts who are now employed in the medical field, the medical service given to the individual patient will fall far short of what might be achieved. If the form of service prevents or hinders research into medical problems, and if there is a failure on the part of the profession or of the State to apply discoveries and generally accepted medical opinions, the service given to the community and to the State will be much less efficient than could be attained. It is necessary therefore to consider briefly what the achievements of medical science would enable an organized medical system to do in respect of those points which we have laid down as the principles of a medical service. The most important feature of medicine is the diagnosis of disease, for without that correct treatment is manifestly impossible. Diagnosis depends on two points, the recognition of the cause of disease and the knowledge of the doctor of the signs and symptoms which that disease will produce. Diagnosis therefore depends on the working out by those medical men who engage in research of the exact cause of every disease, and on a medical educational system which will ensure that no man will enter the profession who does not profess a desire to carry out his important functions with the greatest possible efficiency and will also ensure that no one can enter medical practice who does not already possess a certain minimum of medical know­ledge.

So far as causation of disease is concerned we can claim that medicine has reached a point at which the exact cause of a large number of diseases is accurately known, and at which from that knowledge general principles can be laid down as to the line of approach which will lead to the discovery of the causes of all diseases. It is worth turning aside for the moment to note that there is no one cause of disease in the human body. There are a number of unorthodox healing cults which claim that all diseases are caused by a single factor, either a deficiency in the bodily frame of the patient, in his spiritual make-up, or in his diet. These cults are based on entirely false conceptions of the functioning of the human body, and their denial of scientific methods of experiment and observation should be enough to indicate the falsity of their view. Nevertheless they still do considerable harm because the false advice they give leads to delay in the appropriate medical treatment and, in many cases, has caused preventable deaths.

The main causes of disease recognized by medical science consist of defects in the bodily structure, either congenital or acquired, alterations in the normal working of the tissues of the body from the actions of noxious agents, attacks on the body by bacteria and parasites of various types, and incorrect feeding due to the absence of essential elements in the diet, and other environ­mental factors. Under each of these headings there are a very large number of diseases and it is the job of the medical man to know which of these has been traced to its source, and which are still the subject of research that may lead to a scientific naming of the exact cause.

If each of these diseases produced a particular symptom which did not occur with any of the others, diagnosis would be easy. The fact is, however, that many of them produce signs and | symptoms which are common to a large number; for example, fever (a raising of the body temperature above normal) is a very common feature of a large number of diseases, and correct diagnosis therefore depends on the recognition and assessment J of all the signs and symptoms that may be present. Quite a large number of diseases produce a clinical picture which is so constant that their diagnosis is easy and quick. Many produce symptoms which can only be noted over a period of time and by very careful observation and in this group a further compli­cating factor must be taken into consideration. The reaction of every individual to a disease is different. What the doctor regards as a typical case, for example, of pneumonia, is an average view of a large number of cases, but the individual patient attacked by the same germ may react in a way that is so far from the average as to be almost unrecognizable. It is in such cases that the general practitioner calls for the help of specialists, who are either able to apply tests which are outside the G.P.’s capabilities, or who have acquired special experience in a particular type of disease, which will enable them to interpret with greater accuracy signs which the general practitioner, even if he has noted them, cannot interpret. It is for this reason that the medical profession has become divided up into so many specialist groups, and there is a general recognition that these divisions are necessary and lead to an almost perfect accuracy of diagnosis in all cases in which full specialist services have been used.

Diagnosis must not, however, be taken as the only important aim of medicine in the examination of the human body. In its most perfect form the examination of the body should enable a doctor either to say that every organ of the body is functioning normally, or to detect variations which are so small that the patient is unaware of any defect or disease. In order to carry medical examination to such a fine point as this, a very clear understanding of what constitutes a normal body is required, and very exact methods of test must be employed. These tests will include not only those that can be done by the fingers and the stethoscope of the physician but also the carrying out of chemical analysis of the blood and of the excretory products of the body. In these matters medicine does approach a mathematical science, for much of the chemistry of the human body has now been carried out in such a large number of cases that we have an accurate picture of what is normal, and the methods now employed allow of the detection of quite small variations. Undoubtedly there are new discoveries to be made in this field, but even those tests which we now employ would enable a certificate of normality to be given with a very high degree of confidence.

The examination of the blood by chemical means is not the only way in which that element gives information about the rest of the body. It is, for example, of vital importance to health that there should be in the blood the normal number of red blood cells and that they should be normal in every way. The detection of departures from normal is now a very simple matter, and one which is in ever increasing use among medical men. The blood also conveys information about some of the infectious diseases and enables, to quote two examples, the diagnosis of such widely different diseases as typhoid fever and syphilis to be made a certainty.

It can be claimed therefore that the detection of variations from normal and the diagnosis of disease have reached a fairly high degree of accuracy. The recognition of the different causes of disease has made exact treatment increasingly easy. The evolution of the correct treatment is, however, not a simple matter nor one in which the general practitioner can engage, for it involves the work not only of medical specialists but very often of chemists and physicists. To the former we owe the perfection of such remedies as the sulphanilamides which destroy powerful germs such as the pneumococcus, the meningococcus and the gonococcus and of the arsenical preparations which cure syphilis. To the latter we owe much in the use of X-rays and radium for the treatment of cancer and similar conditions. The aim of medical science is, of course, to obtain a specific remedy for each disease so that with accurate diagnosis, and provided that the reaction of the individual patient is not too greatly different from the average, a cure can be guaranteed. The search for these specific remedies has gone very far afield, and were they not based on scientific and rational observations one might be tempted to classify them with some of the mysteries of the witch doctor. They include such widely varying products as derivatives of gold for the treatment of tuberculosis, extracts from the liver of animals which cure pernicious anaemia, sera derived from the blood of horses which save the lives of those inflicted with diphtheria, tetanus and other diseases, scientific preparations which reproduce the minute quantities of mysterious chemicals produced by the endocrine glands or forming the all important vitamins, and blood taken from healthy human beings, dried and preserved, for transfusion at any time into those who are in danger from bleeding.

Surgery has not been behind the rest of medicine in making advances in treatment, and there are to-day few parts of the body which are not susceptible to the surgeon’s knife, and while an ever increasing list of parts of the body which can safely be removed is compiled the aim of the modern surgeon is to preserve and restore as much of the human body as is possible. Methods of treating wounds arising in war already show great advances, and not only is the technique of our finer surgeons an improve­ment over that of previous generations, but the number of surgeons who can carry out the most intricate operations is very much greater.

These examples illustrate the stage that has been reached in our disease services, but we have already agreed that the future of medicine and the final fulfilment of its part in the develop­ment of the human race lies in the prevention of disease. Even when complete success has been won in discovering remedies for all those diseases that attack man from outside there will still remain many problems to be solved before perfection of health can be guaranteed. The important question to be asked, therefore, is how far can medicine put forward and carry out a programme of positive health for everyone.

This involves us in consideration of all those hereditary factors which influence the physical and mental make-up of every individual. We have slowly acquired knowledge of the way in which characters are handed on from parents to children and it has been clearly shown that there are many defects and departures from the normal which are inherited in accordance with very definite rules. It is already possible to say that people with certain defects should not have children, and the hope of medicine is that the day will come when it will be possible to suggest ways in which not only will bad or weak characteristics be prevented but, by a process of selection, a higher and better race may be developed.

These questions are naturally linked with such things as birth control and the permissibility of therapeutic abortion. While the former is almost universally made use of, and the latter is recognized in some communities, neither question has yet won its freedom from religious and political superstitions, but it is absolutely essential for the improvement of the health of the individual and of the race that they should be regarded as purely medical and scientific questions. From that angle there is no doubt that the medical profession stands condemned for its failure to establish the best and simplest methods of controlling pregnancy, and for refusing to advise the people on these matters. The spread of knowledge has been the work of individuals and relatively small groups, but in any positive national health programme contraception will take its place as an important factor in maintaining the birth-rate and preserving the health of mothers.

The health of mother and child has already been recognized as of primary importance in the health of the nation, and is the only branch of medicine in which really national attempts at improvement have been made. Nevertheless there is still much to be done, for the problem of bringing healthy children into the world and maintaining the health of the mothers cannot be dealt with simply by setting up clinics for ante- and post-natal care or for infant welfare; it involves economic and environmental problems as well as the development of a maternity service which will guarantee that all births take place under ideal conditions and with the assistance of fully qualified personnel.

In addition to the hereditary defects which, as already noted, are handed on according to clearly denned rules and pass from one generation to another, there are congenital diseases which affect the offspring of those who themselves suffer from the disease. In particular venereal disease continues to take its toll of infant life but can be largely eradicated when every woman comes under the ante-natal care of experts who can be on the look-out for the disease and apply the necessary treatment.

Positive health both for the individual and for the community involves other and much wider environmental factors. Of these the chief is nutrition, a science which has developed with tremendous rapidity in the last twenty years. With the knowledge that we now possess it is almost unbearably appalling to think back over the past few centuries and realize how much disease and death must have been caused by lack of proper food. So closely related is disease to malnutrition that it is almost certain that even in this country since the industrial revolution began more people have died as the result of lack of food than from all other causes, but the amount of misery and ill-health due to the same cause is beyond calculation.

The science of nutrition has now demonstrated that not only must every individual have a certain amount of food but that they must obtain more than a mere bulk of things for eating; they must obtain very definite minimum amounts of a large number of chemical substances which unfortunately are far from evenly divided throughout the different foodstuffs. Under modern conditions of food preservation, selection and prepara­tion, it is possible for even those who can afford an ample diet to be in danger of a shortage of certain factors. Under our \ present economic system it is accepted by all nutritional ex­perts that at least one quarter of the people of this country never have enough to eat, and probably half the population has a diet which gives so narrow a margin of supply of certain vitamins and chemicals that real health is very difficult to attain. In this matter only a section of the medical profession has been alive to its duty and to the part which medicine should play in such problems. A medical service designed to ensure positive health for everyone would long ago have compelled our State authorities to ensure an optimum diet for all; instead of that the British Medical Association contented itself with countering the revela­tion that millions of people were receiving too little food by calculating the minimum cost of the barest diet on which health could be maintained, giving in this way assistance to those who were anxious to avoid a rational nutritional policy an opportunity to escape from the scientific facts.

A consideration of nutrition, however, would carry those responsible for a positive health programme into other important subjects, for one cannot discuss nutrition without considering the agricultural policy of the country, without deciding whether it is better to grow food here or to import it from abroad, without indeed considering the whole national policy in relation to over­seas trade, and without deciding (if the investigation revealed such a fact) that the political and economic policy of the country was not that likely to preserve the health of the nation.

Next to food man’s chief need is for shelter, and it has for long been recognized that there is a considerable responsibility thrown on the medical profession in the matter of housing. Since the last war much of the rehousing of the working class has been under the control of Medical Officers of Health and of the Ministry of Health, and there has therefore been a recognition of the fact that health is intimately linked with housing, but the medical profession as a whole has made no effort to lay down what it considers the requisites for healthy housing conditions, and Medical Officers of Health have very often had to take official responsibility for housing schemes which on medical grounds should have been condemned, nor has the medical profession as a united body done anything to bring about the condemnation of the terrible housing conditions that still exist in most of our large cities. It is one of the most curious phenomena in the psychology of doctors that they can go day after day into houses where the conditions make for disease and prevent recovery, without making any protest against this frustration of their efforts; their minds have been so conditioned that they regard such a question as political, and fail to see, as the great Professor Virchow saw, that “Medicine is a social science and politics is nothing else but medicine on a large scale”. The medical man who is content to try and treat a tuberculous patient in a house where the conditions have probably initiated the disease, will certainly prevent its cure, and may cause it to spread to other members of the family, is doing his duty neither politically nor as a doctor. Before we can have a positive health programme the profession must demand that our present cities are removed almost completely and replaced by places in which health is possible.

The latter consideration carries us still farther afield for it is not enough that medical men should consider the ideal house for the individual citizen, they must also insist on the dictatorial nature of our medical needs in relation to town planning, to leisure, and to our whole industrial system. Industrial methods may have a very deleterious effect on health, and many industrial processes are actually dangerous. In the past fifty years many attempts have been made to improve factory conditions and to ensure safety from accidents and other hazards, but the question has never been dealt with fully or sufficiently strongly. In many industries it should be the doctor rather than the factory manager who dictates the conditions under which the employees should work and the hours that they should spend in the factory.

Positive health is not only an individual problem, for one of the dangers which every individual faces is that of epidemic diseases. With the recognition of the bacterial cause of many epidemic diseases, methods have been devised that have enabled much of the danger from such epidemics to be avoided; notable examples are the way in which countries infested by malaria or yellow fever have been rendered relatively safe. Many civilized countries have by sanitary methods freed themselves to a large extent from plague, cholera, typhus and typhoid fever, but were still powerless before an epidemic of influenza such as swept the world in 1918. So long as any of the ordinary epidemic diseases remain in any country in the world there is a danger that they will once more spread to other countries. Medicine has not been slow to exchange knowledge, but epidemic diseases will only be eradicated when the medical services of different countries are so interlocked that there is no gap in the defences through which these diseases may spread.

The last factor we should mention in this connection is that of the control of social diseases such as tuberculosis and venereal disease. While the State recognizes that a person with diphtheria or scarlet fever is a danger to the rest of the community and takes steps to isolate him, people with open tuberculosis or with any of the venereal diseases are allowed to mix freely with others, and may convey the disease without any medical or legal interference. Tuberculosis as a disease can only be controlled when it is recognized that a person who contracts this disease is worthy of pity and must not be penalized economically because of the disease; in other words we must arrange that a person discovered to have this disease will be freed from economic worries both for himself and for his dependants, so that treat­ment can be initiated at an early stage and carried on for as many months or years as may be necessary. In the case of venereal disease we are still handicapped by the religious conception that there is something sinful in all matters connected with sex, and that this disease is a punishment for those whose sin had been greater than the average. No medical man who understands the scientific basis of the causes of disease could accept such a point of view, but it becomes absurd in the eyes of all but the most superstitious when we realize that probably more than half of those suffering from this disease contract it in the most innocent fashion, and that very large numbers of the sufferers are children who were infected before birth. Fortunately venereal disease, whatever its type, is very susceptible to modern methods of treatment, and when by the education of the public we reach a stage where it can be dealt with precisely like any other infectious disease there is no reason why we should not get rid of it almost entirely.

This summary of the present technical position is necessarily brief but has shown that if the organizational basis of medicine reflected the present stage of medical knowledge we would be able to provide a much finer disease-treatment service; and to lay the foundation for those changes in medicine which would lead to a system of positive health for all.