Although this book is concerned with the study of Health and with the experimental investigation of the technique required for its cultivation—a procedure distinct in principle, aim and methods from the study and practice of Sickness—it would be incomplete without reference to results of a clinical nature that have emerged from the use of these new methods. Periodic health overhaul of member-families has yielded ascertainable facts in the clinical field about which a definite statement can be made. When dealing with such material we pass into the realm of pathology, so that it becomes necessary to set aside for the moment the functional considerations already put forward, and to consider the contents of the first two sections of this chapter mainly from the point of view of traditional Medicine.
In 1938, under the title of “Biologists in Search of Material”, we published a review of the first 500 families overhauled. Since that date we have had a further 2 1/4 years’ experience in the use of the same technique on the same and on similar material; i.e. on families who have continued as members from the time of the first report and on others joining later. A review of this material has now been made by the senior members of the Staff working together in close co-operation since the outbreak of war.
This second review was of 1,206 families, comprising 4,002 individuals of all ages. The overhauls were conducted according to the methods described in detail in “Biologists in Search of Material” and amplified in this book by a description of the various ‘family consultations’ the technique of which has been evolving gradually as our experience has grown.
In 4 1/2 years, of the 1,206 families examined, 877 families had one overhaul, 227 had two overhauls, 96 had three overhauls, and 6 had four overhauls, at intervals of a year to eighteen months. The overhaul in each case was a complete one, including laboratory investigation and personal examination of each member of the family, followed by a family consultation. As part of the routine of examination, all infants were seen weekly till taking table-food and later fortnightly until walking; monthly till between 3 and 4 years old, when the interval extended to three-monthly. During school years the children were usually seen at six-monthly intervals, but it must be recalled that all children using the Centre came within daily observation of the staff. The special care of the family during the course of pregnancy is described in detail in chapter VIII. Besides this routine procedure, between the regular overhauls of each family these same individuals were also examined :—
- on discharge from medical care after any intercurrent illness;
- at their own request if suspecting anything wrong;
- at our request on noticing any abnormality in any member whilst in the club.
In addition, many had extra family consultations and special ‘parental’ consultations to be described later in this book.
The pathological conditions found in the course of examination, and their incidence among the populace, run so closely parallel in our first and second reviews, and the second confirms so closely the findings of the first review published in “Biologists in Search of Material”, that we do not propose to burden the reader again with a full account and discussion of them, but shall proceed here to discuss only certain aspects of these findings which have a bearing upon the question of medical administration in general.
The first and outstanding finding is that from a total of 3911 individuals of all ages, [This figure excludes the 91 infants born within the membership of their parents, and on whom the Centre therefore had its influence before birth.] 3353 (90.85%) at first overhaul were found to have something the matter with them, i.e. some physiological defect, deficiency or aberration, As the district from which these families were drawn was chosen because it did not contain a social-problem group of the populace, but on the contrary one that was considered likely to yield a relatively healthy populace, this finding is an arresting one. It indicates that the field in which modern medical science could be applied with benefit is far greater than that at present visualised by the most advanced advocates of a rational medical service.
In view of the indications from many other sources of a greater prevalence of disorder than is usually recognised, this finding cannot be disregarded on the score of being a solitary and unique survey of its kind. [See for example Medical Examination of 1592 Workers, Morris. J. N., Lancet. Jan. II, 41, p. 51. ] In 1941 among the first batch of American recruits, 50% were rejected as being unfit for admission to the U.S. Army, and in the opinion of the authorities it was unlikely that more than 10% of the rejects could be made fit for service. [ Final Report of Temporary National P.C. Committee. U.S.A. 77th Congress.1st Series. Senate Document No. 3589. ] This indicates that the disorders found were not of a merely transitory nature, and leads to the conclusion that our findings are not peculiar to Peckham, nor even to the British Isles. It is a general, not a local phenomenon that we have encountered. The interest of the findings on the U.S.A. Army recruits is that the 50% of rejects were all young men; that is to say they were of an age when the health of the individual is usually regarded as likely to reach a relatively high level. Amongst our own populace the incidence of disorder in males at this age as compared with other ages can be seen from chart Ia. Let us examine more closely this 90% of our members with something wrong. Approached from the clinical point of view there is nothing remarkable about the disorders found. In spite of the fact that these individuals were going about their daily work their disorders are just those listed in any text-book of Medicine, the defects ranging from the most trivial to the most serious condition. It is then not the seriousness of his disorder that immobilises the individual, nor, as we shall see, that converts him into a ‘patient’.
Approaching our members through health overhaul, we were faced not with ‘patients’ but with the man in the street. Our experience therefore differed widely from that of the clinician. It was for this reason that as well as classifying the disorders from the clinical standpoint which is an objective one, [Biologists in Search of Material. Section III, Part I, p. 53-76.] we were led to make a second classification according to the reaction of the individual himself to his condition; i.e. a subjective one. [Ibid. Section III. Part II, p. 77-91. ] This second method of classification has presented us with medical problems in an entirely new and interesting light.
Classified from the subjective point of view, the individuals over 5 years of age [It is not possible to arrive at any subjective classification of individuals under 5 years of age.] examined by us fall into three categories:—
- Those in whom disorder is accompanied by disease.
- Those in whom disorder is associated with a sense of well-being.
- Those without any signs of disorder {?the healthy). If, of the total of 1,206 families examined in this our second review, 500 families are taken at random for comparison with the 500 families examined in “Biologists in Search of Material”, we find in individuals of 5 years of age and over, the relative proportion in disease, in well-being, or without disorder to be very much the same.
| 1st 500 families | 2nd 500 families | |
| Disease | 31.6% | 21.3% |
| Well-being | 59.0% | 68.5% |
| Without disorder | 9.4% | 10.2% |
Disease
In considering this category, we cannot do better than quote from our previous Report:—”The word ‘disease’ is used very loosely, not only by the public but also in most medical textbooks. ‘Disease’ may mean
- the subjective state of the patient,
- the objective findings of the professional diagnostician, or
- both the objective findings and the subjective state as though they were either interchangeable or one and the same thing.
To avoid this confusion here we shall use the word ‘disease’ to mean only the subjective state of the sufferer. The objective facts discovered by the professional diagnostician we shall term ‘disorder’. To this definition we shall adhere strictly throughout this book.The condition of disease, then, arises from a disorder or disorders, that have led to pain, to discomfort, to disability, or to limitation of action in the occupational, family or social life of the individual. One or other of these states is always present before the sufferer becomes aware of his ‘disease’. Though all disorder is not accompanied by disease, all disease has, of course, its underlying disorder. The sufferer’s appreciation of his disease, however, may give him no indication of the nature, nor gauge of the severity of the disorder. He may suffer what to him is serious disease from a trivial disorder, e.g. nettle rash, fissure in ano; or the slightest symptom from the most serious disorder such as cancer.
The relative numbers are as follows :
| 1st survey | 2nd survey | |
| Disease | 484 | 328 |
| Well-being | 902 | 1052 |
| Without disorder | 144 | 156 |
| 1530 | 1536 |
For an analysis of the age and sex distribution of disease, well-being and those without disorder in the second survey, see chart II
What then is the value of the distinction we make between these two states, disease and disorder? Its importance lies in the fact that it is upon the degree of the patient’s disease that hangs his decision to take action for the removal of his disorder. It is disease, in fact, that converts the individual into a ‘patient’; not disorder. The patient gives little or no consideration to the disorder underlying his disease; it is disability and interference with his actions that leads him to recognise that something is amiss, and that consequently leads him to decide that treatment is necessary. So under the existing regime, it is inevitable that the ignorant patient is the primary diagnostician of the existence of his sickness.
The medical services of the Nation (with the possible exception of the School Medical Service and the Child Welfare and Maternity Services [It is claimed by us that both infant and expectant mother are in fact converted into ‘patients’ by the circumstances of the existing provisions made for their Welfare: e.g. congregation in Clinics and Hospitals with a clinical atmosphere and approach.]) are designed for this ‘patient’: that is to say for those in the subjective category of disease. That the doctor has no means of coming into contact with the man in the street until by seeking advice the man constitutes himself a patient, makes this clear.
In our two surveys, we find some 25% of individuals in disease. In the face of the great advance in medical science, we must presume that these individuals in disease could derive benefit from skilled diagnosis and treatment, and, in view of the ever increasing facilities for treatment, it would be reasonable to suppose that they were doing so. In fact, however, less than one-half of those in the category of disease were receiving medical care. [ In the survey of the 1st 500 families, of 484 individuals in disease, 121 only were in receipt of medical treatment; in the second 500 families, of 328 individuals in disease 124 were under medical care.] The remainder, though conscious of disease, were not in contact with any diagnostic or therapeutic agency, nor were they receiving any medical attention. Without going into the reasons for this situation, already discussed in “Biologists in Search of Material”, let us look at it from the point of view of national sickness and of medical administration in general. The first point that would seem clear is that what purport to be the statistics of national sickness do not, in fact, represent the total incidence even of self-acknowledged sickness in the population, for the statistics are gathered from the number of patients encountered by the medical profession. These national statistics of sickness represent, in fact, only the incidence of medically diagnosed and treated sickness. Where the statistics are being used purely as a measure of the relative incidence of sickness, in one year as compared with another, or one nation as compared with another, this is of course a small point. As long as Medicine is conducted on much the same lines throughout this country and in all other countries, the old methods may well continue to serve this purpose; but directly any one country begins systematically to apply periodic health overhaul to its families, or even periodic medical overhaul to its individuals, the figures will immediately take on an entirely different aspect. They will no longer be comparable with the old ones nor with those of other countries.
Much more important, however, is the fact that if less than half those conscious of disease are seeking treatment, there must inevitably be occurring a considerable and unnecessary time lag between the recognition of his disease by the patient and the date at which he obtains treatment for it. This is confirmed by the average length of history of symptoms given by the patient when he does finally seek medical advice. So many-conditions easily curable in their initial stages are, by delay in obtaining treatment, unwittingly but irrevocably being converted into chronic and incurable conditions, thereby adding quite unnecessarily to the length and extent of the treatment required when the patient does eventually reach the doctor.The Centre’s contact with the ordinary citizen discloses neatly for our attention this unnecessary source of chronicity of sickness. It is chronicity more than any other factor that piles up the cost of the medical services of the Nation ; creates a cumulative loss of working hours and diminution of efficiency in industry; wears down the natural reserves of the individual and continuously robs the family—and therefore the Nation—of its heritage of health.
There is also another side to the question of chronicity—the doctor’s outlook. This time-lag militates against the efficient application of modern medical science and thereby prevents the doctor from doing the best work of which he is capable. In the medical profession this is realised to the full. Many efforts have been made to prevail upon the patient to bring his complaints earlier for diagnosis and treatment. But, in the present system of medical organisation, it has not been found possible to do more to facilitate earlier treatment than to create more and better clinics and to distribute them further and wider afield (vide the early treatment of cancer). The effect of these measures is undoubtedly to make it easier for those who seek treatment to find it, and that is to be welcomed. It does not, however, touch the main question which disturbs the medical profession, for it does not help the doctor to get into touch with the case as early as he could successfully diagnose and treat it.
Although, as we have stated, we found less than half of those suffering from disease to be under medical care at the time of examination, after overhaul in the Centre all, without difficulty, were brought to seek treatment. Thus the Centre’s approach —which is not through clinical medicine—is a completely satisfactory one for bringing all individuals suffering from disease to treatment. It is in fact the only efficient method that has been found for the curtailment of chronicity.
Hence we must conclude that although the provisions necessary for dealing with sickness cannot produce health, the organisation necessary for the cultivation of health automatically leads to the rational treatment of all those in disease.
WELL-BEING
In the second specimen of 500 families, 68.5% of the individuals fell into the category of ‘well-being’. All these individuals seemingly well, had something which we could determine as disorder. They themselves however were oblivious of their disorders; i.e. free from disease. Indeed the majority stoutly asserted that they were in their usual health—”quite well” as they themselves put it.
There is the young childless wife looking physically well, who on examination is found to have a large abdominal tumour. There is the schoolgirl leading an ordinary life of work and play who has an undisclosed nephritis with intermittent attacks of haematuria, overlooked by her mother and escaping notice at the school doctor’s intermittent visits. There is the family the members of which as they enter the consulting room all demonstrate an avitaminosis of which they themselves are entirely unaware. There are families every member of which is infested with worms, but where only one child (if any) is known to be so infested and is receiving treatment. This child of course is open to continuous re-infestation from the others who go untreated. Cancer affords a very good example of a disorder that can be unknown to the individual though easily diagnosable by the skilled physician. During the course of four years, four such cases of early cancer were detected, and as far as our observation carries us were cured; and two pre-cancerous states in women received radical attention from the gynaecologist. In four of these cases the individuals concerned were unaware of there being anything wrong; the remaining two complained of some quite trivial disturbance mentioned because they happened to be coming to their periodic health overhaul, but about which they would not otherwise have thought of seeking advice. Perhaps the most interesting of these cases was that of a man who was noticed at the overhaul to be slightly husky. Neither he nor his wife were aware of this insidious change of voice. The doctor was led to pay attention to it because, having overhauled the man at intervals for 12 years, he recognised it as of recent origin. On examination a small papilloma was found on one of the vocal chords. Malignancy was at once suspected and confirmed by section and histological examination at a London Throat Hospital. No glands were yet present; i.e. the growth had not spread beyond the vocal chords. Radium was applied. Eighteen months later, at the outbreak of war—the last date on which he was seen—the man was still completely free of any further signs. Cancer has been taken here as an example because much is made by the public and by the medical profession alike of the ‘cancer problem’. The medical profession however is fully aware that all disorders can be equally insidious.
All the instances that we have cited above are those in which the presence of disorder was not recognisable either by the individual or by his family. There were, however, other disorders found in individuals in this category of well-being which, causing no continuous suffering, were consequently ignored. “Oh! I never think anything about that, it never interferes with my job”. So these individuals carry their disorders about with them year in year out without attempting to secure their removal. It is hardly necessary to give examples of conditions of this nature, for they are so common :—carious teeth, running ears, chronic nasal catarrh, corns, bunions, varicose veins, constipation. Every type of disorder, in fact, is to be found in this class of individual who is unaware of or disregards his disorder. The nature of the disorders found in this category of well-being varies in no way from that found amongst individuals falling into the category of disease. Thus it is not the nature of the disorder that determines whether disease will ensue or not, but the nature of the individual’s response to that disorder.
Why then do individuals with even manifest and obvious disorder not necessarily suffer disease? The reason, well known in medical science, is that the body has an immense power of adaptation to its circumstances by which it can ‘compensate’ for defects and deficiencies as they arise. As long as this process of compensation is being efficiently carried out, disease and discomfort do not afflict the individual. He remains in ‘well-being’. Well-being thus represents the individual’s capacity adequately to sustain a compensative existence.
In earlier chapters of this book we have given much attention to the relationship of the functioning organism to the environment, showing how instant and versatile is the interchange that exists between them in mutual synthesis; i.e. in health. We must now turn to the organism itself and consider its own inherent flexibility and buoyancy—of which we shall later see the supreme evidence in pregnancy. The adaptability which these characterstics give is derived from the inherent endogenous reserves of living material. By means of these reserves the living machine is capable of instant self-adjustment to strains and stresses as they fall upon it. If one organ or system is smitten, other organs or systems of the body instantly contribute of their reserves thereby maintaining the equilibrium of the body as a whole. In doing so they cover up the defect, but meanwhile—and this is the important fact—the insidious consumption of the body’s wealth goes on.
For many generations the use of this natural power of compensation has been the good physician’s most valuable method of therapy. Is the kidney disordered? Then call in the skin, the lungs, the bowels, to sustain the burden of excretion. So sweating, purges, expectorants, etc., are prescribed as assistants in Nature’s own method of adjustment. Moreover, the physician orders a ‘gentle life’ or a specified climate. This also is in line with Nature’s process of compensation, for not only does the threatened living entity consume its own reserves in order to maintain its equilibrium, but sub-consciously and imperceptibly it retreats from the situation in which it finds itself, thereby shielding its incompetence from the diversity of the environment. Perhaps the great underlying truth of psychological medicine, namely that the most delicate signs and indications of disorder are to be found in psychological rather than in clinical manifestations, is only another aspect of the compensative mechanism. In this case, as well as using up his endogenous reserves, the individual is also using the environmental apparatus as a compensative mechanism to preserve his entity. He circumscribes his excursion in order to maintain himself in balance—but on a lower level. Thus in compensative existence he is no longer, as in health, using all his reserves to encounter ceaseless change in the environment, but must use them to counter the changes and defects of his own mechanism. And, while the defects remain so adjusted he retains his sense of well-being.
As the individual moves into this compensative existence, he begins imperceptibly to weigh the balance of his reserves before taking action, and unconsciously to exclude the liability of encountering stimulus from the environment lest he be tempted to do more than he can. So, watching him in action, as in the Centre we can do so well, we see him beginning to change his ways. It is an insidious process^ the individual himself usually remaining unaware of what is happening. Indeed at the height of early compensation he may even experience a sense of buoyancy—of extreme well-being—for, having just released his gear-handle from the forward position (of health) into the quiet retreat of compensative existence, he reaps the satisfaction of ‘achievement’. His desires always running parallel to his inherent capacities he may continue unaware of his predicament even when the wealth of his reserves nearing exhaustion, he is on the brink of physiological bankruptcy.
But it might be asked, since compensation represents the body’s apt use of its reserves, is not compensative existence, or well-being, akin to health itself? We must not, like the individual inured to his disorder, be deceived about this. Reserves that are occupied in continuous uni-directional adjustment of a disorder, as is the case in compensative existence, are fixed or mortgaged reserves. They are now no longer available for use in the ever-varying interplay of organism and environment in the spontaneity of mutual synthesis. So compensated disorder constitutes a limitation of functional capacity for action and hence a threat to the organism and to its parts, even though the operation of the mechanism that counters the threat is an expression of an operational capacity for health.
It is true that the more responsive and versatile the individual, i.e. the more ‘healthy’ he is, the more instantaneously and unconsciously will his reserves be called into play. But in proportion to the efficiency with which they operate compensating for defective functioning, they mask the disorder, while the individual with tin.1 disorder so cloaked continues free from disease. But meanwhile the disorder goes on its course silently undermining leis constitution and passing unheeded from what is probably an easily removable early stage to intractable chronicity. From the point of view of the cultivation of health, our concern is not so much with the fact that this chronicity is making the ultimate eradication of the disorder more difficult—which is indisputable—as that this protracted period of limitation of function is robbing the individual, probably for ever, of his potentiality for continued growth and development; i.e. for health.
Nevertheless from the standpoint of the clinician, is not compensative existence a highly desirable condition? In the old days when very little was known of the aetiology of disease. and while there was consequently little possibility of rational therapy, to engage the body’s power of compensation was the best the physician could do for his patient. Now however that the progress of medical science has thrown such a flood of light on the nature, on the diagnosis and on the treatment of disorders, any inherent mechanism tending to cloak the earliest signs takes on a very different aspect. The more slow and ‘silent’ the progress of the disorder, the deeper it bites into the constitution before it is discovered, making rational medical therapeutic adjustment at some subsequent period only the more difficult. As a therapy, therefore, the power of compensation must now be used with much discretion, and only in those cases where the disorder is ineradicable. In other circumstances compensation—stealthy thief of the body’s riches—is as much a snare to the clinician as it is a hindrance to the health practitioner.
But, during the fifteen years that we have been studying health, it has been our experience that the medical practitioner and the specialist regard this state of well-being to which they return their patients after illness, as that of health. “Come back if you notice anything wrong” is a very usual phrase of a careful doctor. That is to say he is satisfied as long as his therapeutic efforts convert a decompensated disorder into a compensated one. The patient himself connives at this, for how often will he insist upon leaving his bed and dismissing his doctor the moment his compensation is re-established and his subjective sense of well-being re-asserts itself. While this position is in keeping with traditional medicine, it is not in keeping with the advances of modern medical science.
As we have already stated, on discharge from medical treatment all members of the Centre come up for health overhaul. Almost without exception, it is found that though the disorders for which they sought treatment have been removed, the condition of their health has much deteriorated. This fact is either unrecognised or ignored by the clinician; and the more serious the disorder that has received treatment, usually the less the attention given to the reestablishment of the sometime patient. We have found that patients returned from medical care of major disorders such for instance as pneumonia or jaundice, from operations, and above all those recovering from infectious fevers, are rarely in a condition to carry on their everyday occupations to which they have been returned by the medical profession. On reoverhaul of such individuals, known to us to have been in adjustment before the onset of their illness, we have consistently found not only a general state of lowered tone, but a host of minor disorders and deficiencies such as anaemia—that is to say iron deficiency well below the accepted clinical normals—, leucopenia, avitaminosis, lowered blood sugar, muscular atony, chronic otorrhoea, constipation, bladder troubles, etc. This return of the individual to work in a condition of diminished health (devitalisation) after a period of sickness and inactivity, is unscientific, diseconomic and, in the present state of our knowledge an unjustifiable procedure.The discovery that efficient compensation is accompanied by a sense of well-being—which is not health—is, we believe, a major contribution to medical science. The features of this state of well-being, or compensative existence, that make it a menace, may be summed up as follows:—
- The masking of the onset and presence of disorder:—a serious concern to the clinician (Sickness).
- The loss of the reserves for use in mutual synthesis with the environment:—a serious concern to the biologist (Health).
It is significant that this category of persons in well-being should include by far the largest section of those examined. From this finding we must infer that these people form the unseen source from which the sick endlessly flow to occupy the attention of the medical profession and in the later stages of their chronicity to fill the ever-increasing number of hospital beds. It thus becomes of arresting importance at this time when future developments in medical administration are under consideration, that the Centre with its health overhaul of the family reaching out beyond disease into the realm of hidden disorders, provides circumstances which bring all diagnosable disorders to the medical scientist at the earliest moment he can diagnose them, whether they are causing the individual disease or not. Our experience has taught us that ultimately nothing short of periodic health overhaul on a national scale can lead to the rational application of medical science for the. elimination of Sickness.
Diagnosis of the Early Case.
There are certain important features of periodic health overhaul as carried out in the Centre which are essential to its success as a net with which to catch disorder, —important, that is to say, from the point of view of the clinician and the Sickness Services as distinct from the demands of Health. The first of these is the approach through the family rather than through the individual as is elsewhere the universal custom.
Often an individual’s disorder cannot be diagnosed efficiently without knowledge of his family. One symptom may occur in one member of a family and may appear trivial until seen against its family background, while its aetiology may remain obscure, even to the doctor, without a knowledge of the other individuals of that family found to have other and often cryptic signs of the same disorder. Only when all are assembled does a recognisable clinical syndrome emerge. Nutritional deficiencies are notably in this category; endocrine disturbances afford another striking example. Personal knowledge of the constitution of the parents —that great asset of the family practitioner of the past—in these days of scientific medicine needs to be, not relegated to the scrapheap as outworn, but reinforced by knowledge derived from methods of precision capable of substantiating primary intuitive clinical wisdom. What is true for diagnosis is also in a large measure true for adequate treatment ; contact with the whole family is an essential.
An example might well be given here to illustrate the importance of a knowledge of the whole family. A family consisting of mother, father and two children and the grown-up son of the mother by a first marriage, joined the Centre. Their membership came about through the small son of 10 years who first came as a guest of another member-family. This boy impelled his mother to come and join the Centre. She came, but in great trouble knowing that she would not be able to persuade her husband, with whom recently she had not been on speaking terms, to come. No, it was as she feared. The doctor, whom she finally saw in the hope of overcoming the rule of family membership, was adamant. The mother and son could not join alone. It was then decided that the importunate son should bring his father alone to see the Centre and to meet the man doctor. The boy succeeded ; the father was won over on condition that he need only appear for his overhaul and family consultation, but at no other time. As in the Centre the members are free to come and go as they choose this constituted no difficulty, so the family joined.
At the laboratory examination the daughter of 15 years was found to have diabetes, and it was disclosed that she was under continuous treatment at a diabetic clinic. This girl’s diabetes turned out to be the cause of the trouble between husband and wife, the father accusing the mother of having introduced diabetes into “his family” through her “inherited tendencies”.
At the family consultation they heard that the boy of 10, on repeated examination, had been found to have a high blood-sugar, and that the father not only had a high blood-sugar but a low sugar tolerance and some sugar in the urine. Only the mother and her son by the first marriage were free from any sugar imbalance! As well as a complete reconciliation occurring between the parents when the facts were made known, there resulted a re-organisation of the family diet. Whereas before the consultation 7 lbs. of sugar were being consumed weekly— besides sweets not accounted for—subsequently this was reduced to 2 Ibs., and the imbalance disappeared from both father and son. The family consultation, in fact, became a solvent for both biochemical and social disorder in this family.
Our point here is that by examination of the whole family we gained a knowledge of the direction in which disorder was likely to occur in the event of long-continued habit, or in the event of any continued or unusual strain. The circumstances of the Centre made—not drugs—but knowledge available to this family, and so placed them in a position to forestall what was at least a dangerous habit for them. Only the girl had incurable diabetes: the father and son had merely a sugar imbalance which would have been considered of no importance apart from the setting in which it was encountered, but which, in the family circumstances. called for timely re-adjustment.
It is unfortunate that the mire of sickness is so much more spectacular than its prevention. We do not claim that the father would have developed diabetes in his declining years or that the boy would have become a confirmed diabetic, but clearly this is a case where knowledge of the whole family led to discretionary action of a valuable nature for the prevention of sickness. This case, as the reader will have noticed, had its socio-pathological1 aspect in the quarrel between the parents. This also was brought into solution through the health overhaul of the family.
The Centre not only provides contact with the whole family but. as a result of regular overhaul, provides a complete and cumulative dossier of the physical, mental and social condition of every individual of the family. In this respect the Centre organisation presents a strong contrast to the general practitioner service. The ‘family’ practitioner, as we have seen, can only contact the family in sickness—for the one exception to this, ante-natal and maternity work, is now to a very great extent lost to him, at any rate in urban practice. So he can have no knowledge of the individual until that individual becomes, a ‘patient’. The statement so frequently advanced, that general practice as it stands affords a suitable basis for a Health Service, is therefore inaccurate and misleading.
A second important point of administration is that the staff of a Health Centre must be people of high technical skill and experience in the detection of early disorder:—a subject far more difficult than the diagnosis of established disease where the patient complains, the symptoms have taken on a pronounced character, and the examiner can proceed from a definite locus of disorder. Skill in diagnosis of the presence of early disorder in the uncomplaining man in the street, like skill in other branches of Medicine, must come from practice—in this case, from continuous contact with uncomplaining individuals. At the present time, as we have shown, apart from the Centre organisation this type of material is nowhere available either to the doctor or to the student. No organisation other than one in which the presumed healthy present themselves for review can provide the material suitable for gaining experience in this coming branch of medical science.
Treatment of the Early Case
When we come to consideration of the treatment of early disorder, the position is even more difficult. Treatment is not the work of the health practitioner, but it is essential to him that treatment should be adequately performed in order that the potentiality for health may be developed. Experience has shown us that there is at the present time the greatest difficulty in finding the necessary facilities for the investigation and treatment of the early case in the established Medical Services.It must be remembered that when an individual is already incapacitated by manifest disorder, he is obliged to submit to inconveniences likely to lead to his cure. With an individual not so incapacitated it is essentially different. We have found that the overwhelming majority of those with disorder will gladly be treated if the treatment will not interfere with their work. Quite other circumstances than those at present in vogue in clinics and Hospitals are necessary to reassure the individual that his treatment will not force undue incapacity upon him, for existing provisions do not allow of the patient’s convenience being taken into consideration. The need for special provision both for the diagnosis and treatment of this type of early ‘case’ was acutely foreseen by the late Sir Walter Fletcher, who recognised that the establishment of the Health Centre would involve the necessity for a special (clinical) Research Department for the investigation of the early case with which the existing medical and research institutions are not at present familiar and with which they are not in a position to deal. This need for extended clinical facilities of a new sort for compensated disorder has become daily more apparent as the Centre’s membership has grown. Had it not been for the lively and sympathetic interest of members of certain of the teaching Hospitals, who were prepared to modify their usual routine to meet the necessities of an exceptional situation, we should have had to wait and to watch early and suspected disorders slowly degenerate into frank disease before being able to secure scientific medical attention for them.
The Biologist ‘Doctor’.
Having hitherto had relatively little practice with the earliest signs of disorder, it is by no means always possible for either biologist or clinician to make an immediate diagnosis between health and sickness. For example, out of six cases suspected of cancer other than those cited earlier in this chapter, four turned out to be of a simple nature, while the other two cases which ultimately proved to be cancerous necessitated three visits each to the surgeon at intervals of not less than a month before the final diagnosis of malignancy could be established. Thus in its earliest stages even cancer cannot always be recognised as such by the diagnostician. But where periodic health overhaul is the routine, any condition which is the least suspicious can be watched by the Centre’s doctor who—there for health rather than for sickness—can make his observations without arousing apprehension, perhaps unnecessarily, in the individual’s mind. As Health doctor, he is in a very different position than would be the doctors of the Cancer Clinics which it has been suggested should be set up for the early detection of that disease.It is necessary that the (medical) staff of a Health Centre should be not only skilled in the detection of early disorder, but also that they should be conversant with the wide range of variation in the expression of function. The biologist has to learn to diagnose health. Without this, any variation outside the limits of the clinician’s ‘normal’ will, often erroneously, be taken for disorder, with the result that the individual will be rendered an invalid without justification.
An example of such a situation can be seen in a man with a raised blood pressure. At his first overhaul, at 39 years of age, his blood pressure was 145. At his second overhaul the following year, it was found on repeated examination to be 160. During the year the man had changed his habit of life, and from being a manual worker and active boxer in his leisure, he had become a sedentary worker with no time for his hobby. But with the change in his circumstances he had not changed his diet nor his food intake, so had begun to store fat, which he had previously worked off in daily turnover. This explanation of the findings at the family consultation not only put the man wise to the real position, but also his wife—who was in the habit of pressing her good dinners upon him. With one or two intermediate laboratory examinations and with the co-operation of his wife the adjustment was effected to the satisfaction of all concerned, and there was no further rise in the now adjusted blood pressure. But the older an individual grows, the more inured does he become in his tendencies and habits, and thus the less versatile in spontaneous adjustment. Another ten years of raised blood-pressure and at 50 this man would probably have acquired an irreversible hyperpiesis—by that time an established clinical disorder. But to diagnose it as a case of high blood pressure at 40 would have been a grave error liable to induce psychological disorder with a socio-pathological sequel not only for the man himself but for the whole family.
Judgment that can only arise out of training and experience is essential in the ‘biologist’ doctor conducting the periodic health overhaul. It is not work for the novice. There is no reason, however, to believe that it is less easy to acquire the necessary competence in biological practice (health) than in clinical practice, if the student during some part of his training is presented with suitable material on which to begin the study of health. At some time during his training he must in future have the opportunity of learning the laws of health and of seeing and studying the healthy, as well as—and as systematically as—he learns the laws of pathology and studies the sick. It is clear that study of the healthy cannot be pursued in the Teaching Hospitals. Both the material for study and the training necessary are different for the two branches—Health and Sickness.
The Effect of the Removal of Early Disorder
Certain queries likely to have arisen in the reader’s mind may perhaps call for answer. The first is—Can Medicine really help the man in the street before he is driven by disease to seek the help of the doctor?
In adults in whom disorder was removed, whether it were a grumbling appendix or an unrecognised goitre affecting the heart, breathing or nervous system, the relief was instantaneous. “Now I know I have had something the matter for a long time”, is a very usual remark as the individual begins to resume the activity of his earlier years. And, the earlier the removal the greater this sense of relief, for it is likely that the subject of the disorder will still be resisting a retreat from his environment although he may already have been using his reserves for compensating the disorder. Thus the subjective effect on the individual offers an immediate answer in the affirmative to this question.
But, we know from the nature of ‘well-being’ that it is unwise to accept subjective evidence alone as an indication of progress towards health. Have we any objective evidence of improvement following removal of disorder?
In the Centre where day by day the action of its members was visible to the observer, we had abundant evidence in a change in the individual’s action associated with removal of his disorder, to corroborate the subjective evidence of the individual himself. For example, four days after the efficient de-infestation of a child with worms, a change in that child’s actions was apparent to Staff and parents alike. It was manifest in increased power of concentration, better co-ordination of his action, in a change in his attitude to his parents and an increasing ability to associate satisfactorily with his playmates. So consistently was this observed in the case of worm infestation, [For incidence of worm infestation in families examined, see below.] that assistants not medically trained grew to be able to report—at some later date—that the child should be re-examined for a recurrence of the trouble. The accuracy of their observation was confirmed by re-examination of the stool with the discovery of renewed presence of the ova. Observations of action are however difficult to record consistently, and at present defy measurement, so that they cannot as yet be stated in any statistical form. There is room for a great deal of study in this subject now that a field of observation has been created.
Again, it would seem easy enough to take families at their first periodic health overhaul and compare their condition with that found at subsequent overhauls, and note the diminution of disorder found in the latter. But such a comparison is by no means a simple one. Cancer might have been discovered in an individual at first overhaul and subsequently removed, but on returning at second overhaul with no sign of recurrence of the cancer he might be in the middle of an attack of fish poisoning. Both these conditions—one grave, the other transient and comparatively trivial—take him out of the category of those without disorder, and leave us without evidence of a change in his health. How difficult, then, as yet to give any useful statistical picture whether based upon subjective or objective findings.
Here is another example of the kind of dilemma encountered in attempting an assessment of this order. A family of four at first overhaul have certain disorders, e.g. mother; varicose veins, obesity, bunions and an iron deficiency (70% haemoglobin); father: chronic otorrhosa and carious teeth; girl of 12 : constipation, rough skin and an iron deficiency (75% Hb); boy of 16: acne, enlarged tonsils, blepharitis and carious teeth. All have signs—different in each case—of vitamin deficiency. The family is keen to be ‘fit’ and takes trouble to be rid of the disorders that have been found—none of them usually called serious. They all decide to take a course of vitamins. Three weeks after beginning the course they feel much better. Six weeks later the father develops a boil. Three weeks later still the boy develops series of boils. They are miserable with the painful condition. Are they now worse or better? How can the boils be assessed against the constipation, acne and blepharitis that have disappeared? One is acutely painful; the others they took no notice of. If they continue with the vitamins the boils subside and no further crop appears. They again feel well, better than ever. But had they stopped the vitamins when the boils came, gradually the original painless symptoms of avitamonis would have reappeared. The explanation for this seems to be that the vitamins raise the resistance of the body to germs of low virulence which in his initially low state the individual had been tolerating. This toleration is yet another aspect of compensation. Once the resistance is raised, the body will no longer tolerate the invading germs and a fight ensues—emerging as a crop of boils. When raised still further, the invaders are permanently cast out and no further boils ensue. Tolerance in this case is a manifestation of failure to function; intolerance a sign of growing health—of functional action.
But supposing for instance that the family had delayed taking action for nine months, then at the second overhaul they would have been in the middle of their attack of boils. It would be equivocal to record the family in its moment of pain and discomfort as in better health than at the first overhaul, and yet inaccurate to record them as in less good health! The ground on which we tread here is treacherous and shifting. It must remain so until the study of Function has disclosed methods of measurement of health distinct from the clinical methods of assessment of disorder. It is with methods for the measurement of health that the Peckham Experiment is specifically concerned.
Then again many disorders are removable with great advantage to the individual concerned, but the underlying diathesis that caused the disorder may remain—ineradicable. Endocrine disorders, some allergic states, rickets, are of this order. This means that to achieve health nothing short of attention to the breeding of the next generation is of any good.
The investigation of the effects of removal of disorder in its early stages is one which essentially needs the elapse of years for its completion. Up till now we have had too short a time to come to any satisfactory means of measurement of health. But we have had more than enough experience to indicate that routine periodic health overhaul in conjunction with an environment capable of the subsequent educement of function such as the Centre provides, is a practical measure of immense value in moving towards health. We must already claim that enhanced vitality, and a wider measure of freedom from sickness, can be attained through periodic health overhaul of families in the circumstances provided by the Centre.
Whether such results would be obtainable from periodic medical overhaul carried out merely with the intention of disclosing disorder and accompanied only by clinical measures for removal of the disorders in a situation where there was no possibility of changing the nature of the environment out of which the disorders arose, is another question. It is one we are not in a position to answer, because membership of the Centre which led to overhaul, also inevitably implied contact with an environment capable of educing function after cure, so that the liability of ‘seven devils’ entering in was in fact minimised. Knowing the inertia of habit, we suspect that this is a very important proviso and that if advantage is not taken of the moment of release to present the individual with circumstances which allow of a more fully functioning existence, relapse will easily follow the initial rebound towards health after removal of the disorder. But that would be only another argument for the establishment of cultural Health Centres as the setting in which to carry out the periodic health overhaul of families—which we have already shown to be essential for the rational conduct of modern scientific medicine.
Costs
A second question which may arise in the mind of the reader is:—But even though periodic health overhaul as carried out in the Centre would lead to removal of disorder earlier than is now possible, would not the cost be so great as to make it impracticable? A carefully checked estimate of costs based on our first three years’ experience shows that the cost of overhaul need be no more than 1s. 2d. per week per family. The cost of the periodic health overhaul.compares very favourably with, for instance, the cost of the School Medical examinations which are far more cursory, less frequent and include no laboratory investigation in the routine examination, providing only for certain tests to be carried out after the suspicion of disorder has been aroused by clinical inspection of the child.
The emergence of the Centre as a type organisation would seem thus to be of arresting importance at this juncture when re-organisation of the Medical Services of the country is under discussion. The Peckham Experiment has demonstrated that periodic health overhaul is an efficient means of overcoming the present deadlock. It effects easy, natural and continuous contact between the unsuspecting man-in-the-street and the skilled diagnostician thereby bringing to the man-in-the-street the fruits of modern advances in medical science, and to the medical profession the optimum conditions for the exercise of its ever increasing skill. Nothing short of periodic health overhaul of the family on a wide scale can meet these two primary needs for reduction of the national sickness.
3 HEALTH
It will have become obvious to the reader that crucial though the above conclusions are for the rational care of the sick, they are merely incidental to our main purpose which is the study and promotion of Health. To that subject let us now return.
Just as the prism disperses sunlight into a spectrum of primary qualities or colours, and of primary quantities or wave-lengths, so the Centre technique as a whole—not merely the periodic health overhaul—is a prism that separates out for us three categories of existence: Health, Well-being and Disease—or Living, Survival and Dying.
It is health we set out to study, and it is useless to attempt to apply measurements for health, i.e. functional standards, to those who are already disordered or diseased. The biologist must concentrate attention upon those in whom no disease or usorder can be found. He must cultivate the leaven in the lump; that is to say the Living in society.
Now it is common to assume that those who are not sick are healthy. Not only is that far from being the case as we have town, but such complacency with clinical or sickroom standards of fitness is dangerously misleading. This fact, which we have been pressing on the public for fifteen years, is now becoming widely recognised. Substantiation comes from other quarters than our own. Nutritional surveys, for example, have demonstrated that clinical standards do not constitute any criterion of health. In the school medical service where the doctor is not reviewing ‘patients’ but uncomplaining individuals, the school medical officer often finds that his experience is at variance with accepted clinical standards.
But what standards other than the clinical ones are available for the assessment of health? There are two. One consists of the very carefully established standards adopted by the physiologist. These are directed to the assessment of the efficiency of the organs of the body and of the efficiency of the body as a whole for a given purpose. Those physiological standards correspond roughly to the bench-test standards of the engineer.
The other type consists of functional standards. These are as yet very tentative where indeed they exist at all. This however is to be expected, for the study of function has only just begun. As we saw earlier in the discussion on function in chapter 1, functional standards can have no analogy with physiological standards—the bench-test type—and not even with those analogous to the ‘road-test’ standards of the engineer—the physiologist’s tests for determining the working efficiency of the assembled machine, for all such standards are directed to assessing an objective efficiency.
In Biology (function) the standards can only be based upon a subjective efficiency: whether, for example, the tree is an efficient expression or manifest of the seed from which it springs; the man an efficient expression or manifest of the child he once was; whether society is an efficient expression or manifest of the families from which it springs. And so on.
What, then, are the facts as determined by the use of these two sets of standards and methods? Working on a physiological basis, in our survey of 1,206 families we find 9.2% of the people without defects or deficiencies of a tangible and measurable order—and this figure includes infants who have not had time to acquire the chronic disorders derived from ingrained habituation. There were 358 individuals found to be without any discoverable disorder in a total of 3911 examined. See chart I above. But this does not mean that this 9.2% are actively fit and healthy ie that they fall into the category of the functionally efficient. For example, a youth may have a normally working heart physiologically efficient, but when called upon to perform a simple but unusual task, it flutters and staggers under the stimulus. A good heart—but not co-ordinated to meet the emergencies of everyday life without being upset in its rhythm or disturbing its economy of effort! Or again, a good heart and good lungs and good musculature may have been trained to some special task—running or gymnastics, for example—and may yet fail to meet some simple emergency with becoming calm co-ordination. An A1 Metropolitan policeman faints as his wife is carried off to her confinement, for example. A man habitually trained to muscular effort falls down dead suddenly on slight exertion in the prime of life. ‘Athlete’s heart’ affords an extreme example of this order. His response to effort in the physiological laboratory the week before may have been of a high order of physiological efficiency. A week later his efficiency for living is demonstrated to be nil. Physiological normality in fact does not necessarily go hand in hand with functional efficiency. This has been recognised for years now in the assessment of fitness for flight in air pilots, whose functional co-ordination should be of a very high order. It is just this functional co-ordination of action that marks the distinction between intrepidity and foolhardiness. Indeed, foolhardiness, which usually arises from a consciousness of physiological efficiency, may cover a multitude of functional inefficiencies. Foolhardiness, often praiseworthy in itself, slaughtered the flower of the physiologically fit in the last war. It was this fact that inspired Flack to inaugurate the Air Force Research into the assessment of fitness on another basis—a functional basis. Alas! Flack’s enthusiasm died with him, or the science of Biology might have been further advanced to assist in the present crisis in national affairs, to meet which intrepidity is the prime need, the functional characteristic of the intrepid is their power spontaneously to deal with events however unfamiliar, however foreign—for they are responsive to any and every change, and lot merely to foreseen and pre-judged changes.
Intrepidity, it would seem, now but rarely springs spontaneously from the social soil. We have reason to suspect that this is because there is little life in that soil. Hence the despairing search for leaders in every walk of life. When we say a man is a natural leader, we are expressing the fact that he has an inclusive (subjective) co-ordination of his reflexes and sensations, i.e. that he is both physiologically and functionally healthy. It is often said that the leader is born, not made. This assumption is in fact a confession of our ignorance, first of the necessity of cultivating, and second of how to cultivate this inclusiveness ; it is also a confession that the methods already tried—the methods of training—have failed to produce leadership. While the assumption is wrong there are, however, good grounds for it, for, as biology is rapidly teaching us, the foundations of health are laid down in foetal life and infancy and built up through specific nurture during childhood and adolescence. That is to say, health is not merely a genetic characteristic; it is also a nurtured characteristic and, as such, is inevitably handed on from parent to child. So, a healthy family is more likely than an unhealthy one to create an intimate environment favourable to the acquisition of health, and in that sense the odds are in favour of an inherited ‘tradition’ of health. But that is not what is usually implied in “born not made”.
Health and intrepidity are, then, not merely inherited. From the beginning of life (i.e., conception) onwards, by the assimilation of vital nutritive factors from the parental soil—the physical and social environment—they are acquired through the nurture that proceeds from the functional organisation of the family.
So for the attainment of health, the importance of making use of biological standards which take account of the organism and its environment and of the relationship between the two is obvious.
Applying such biological standards as we at present can, and from such observations as we have been able to make on the 9% of our populace who are physiologically normal, it appears that but few even of these can be classified as functionally fit and healthy. Though physiologically normal, they are in a state of suspended function, or ‘survival’. They have the capabilities for action but lack the co-ordination to make action effective. Of this, they are often all too conscious; we see them shyly sinking into inactivity later to become apathy, or, urged on by the consciousness of physiological fitness, adopting a neck thing foolhardiness and rashly attempting the barely possible.
How is it that this can occur? What factors are present or absent from the environment of these people that inhibit growth and emergence of capacity and their enjoyment of their state of physiological fitness? We have already at the Centre succeeded in demonstrating that it is not due to any lack of potentiality. Indeed, the machine may be supercharged with physiological virility. The cause or causes lie elsewhere. Are there any clues that we can follow?
We shall record later that a considerable proportion of young individuals—children and adolescents—who on joining the Centre are functionally inefficient, begin to blossom into co-ordinate action, throw off their apathy (often mis-called ‘stupidity’) and dissolve their shyness in geniality, or translate rude impetuosity (often mis-called ‘viciousness’) into calm deliberation, once their families begin to be integrated into the social life around them in the Centre.
The importance of this observation is that it has appeared to be the movement of the whole family into a social sphere of action that has given the initial momentum to the latent capacity of the individual child. In other words, it is familiar nurture that they need, for of ‘nature’ they have plenty.
In confirmation of this, we also find that those few individuals who do exercise their capacity in co-ordination, the intrepid, are members of families with a marked social integration. And further, that among the functionally inefficient, those whose families cannot fit themselves into the social life tend to show no such improvement.
We have in earlier reports drawn attention to the fact that the effectiveness of the existing methods of education has been observed by us to vary directly with the degree of social integration of the family from which the child comes. In watching the course of children leaving school at fourteen, we find that their progress tends to be spontaneously continuous, even without any continuation school assistance, in families with a high social integration; whereas it ceases almost abruptly, even with every institutional assistance, in families with little or no social integration. By seventeen, children of this latter group may have almost forgotten how to read and to count. It is the functional efficiency of the family which produces the ‘digestive ferment’ and is the formative and synthesising factor in education; and not the mere knowledge purveyed by training. Like the process of nutrition, Education appears in fact to depend on the efficiency of utilisation as well as, and as much as, upon the nature of the diet available.
It is not of course claimed that the integration of the family, within itself and with society, is the only means of activating potential capacity. The absence of integration may, as we know, to some extent be remedied—though it cannot be cured—by training. We claim however that integration of the family developing in mutual synthesis with its environment will prove to be the biologically economic way of developing human potentiality—the way of health. If what we as biologists regard as the grown mature organism, the family, can find the wherewithal to operate on and to synthesise, then the immature individual growing up within that family will participate in that experience and in so doing will spontaneously acquire a natural appetite for, and power to, digest his own experience as that unfolds. The family, in fact, is the natural ‘organ’ for predigestion of all experience which reaches the child from the environment, not only during gestation and lactation, but until the young leave the nest.
So, functional efficiency is something which is derived from within the plant or the animal, in circumstances where the soil in which it is growing contains the essential nutritive elements ; i.e. where the soil is as living as the growing plant or animal itself. Everywhere the biologist finds Nature using specific nurture, i.e. familial nurture, to lead the young on to the ability to digest and utilise the non-specific and the foreign experience. It is the family then that Nature places at our disposal, not only for the propagation of variations in the species, but also as her instrument for the cultivation of functional efficiency.
So health does not demand education of the individual, nor education of the populace—the two accepted and popular methods—but education of the family as a live functioning organism. Health in the past has emerged sporadically, where good seed has fallen into good soil. The time for that is now past. The seed may no longer be cast to the wind to settle where it can.
Tilling the familial and social soil of man is becoming a science and art to be acquired with all the assiduity-and more- given the study of physical phenomena and to the study and cultivation of his plants and beasts. Whether it is sought in virgin ground or in the weeded fallow from which disorder cleared Health is a cultivator’s problem, and that can ultimately be no other than the biologist.