Health and disease

The
Home University Library

m

^

^

HEALTH AND DISEASE . . ^

THE

HOME UNIVERSITY LIBRARY

OF MODERN KNOWLEDGE

Editors of
THE HOME UNIVERSITY LIBRARY

OF MODERN KNOWLEDGE
Rt. Hon. H. A. L. Fisher, M.A., F.B.A.
Prop. Gilbert Murray, Litt.D., LL.D., F.B,A.
Prof. J. Arthur Thomson, M.A., LL.D.

For list oj volumes in the Library see end of hook*

HEALTH AND DISEASE

"By
W. LESLIE MACKENZIE

M.A., M.D., D.P.H., F.R.C.P.Ed.

MEDICAL MEMBER OF THE LOCAL
GOVERNMENT BOARD FOR SCOTLAND
AUTHOR OF "MEDICAL INSPECTION
OF SCHOOL CHILDREN," "HEALTH
OF THE SCHOOL CHILD "

^%

THORNTON BUTTERWORTH LIMITED
15 BEDFORD STREET, LONDON, W.C.2

iisMd .
Impression .
Third Impression ,

. June, igiz

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All Rights Reserved

MADE AND PRINTED IN GREAT BRITAIN

CONTENTS

Tiom

What is Health? 7

The Causes op Death — their Nahino

AND Classification .... 23

Death-eates and their Interpretation 41

Fever, Infectious Disease, and Epidemics 52
Study of a Toxic Infection and its

Antitoxin 70

VI How Antitoxins are Produced and

Prepared 91

VII Immunity — Natural and Acquired . 100
VIII A Discussion of the Tubercular Dia-
thesis 114

IX The Administrative Aspects op Tuber-
culosis . 134

X The International Infections — Plaque,

Cholera, and Yellow Fever . . 155

XI Other Preventable Diseases . . 170

XII The Hygienics of a Staple Food — Milk 180

XIII The House as Immediate Family En-

vironment OR Home .... 197

XIV Disease and Destitution . . . 214
XV Insurance Methods op Preventing

Sickness 220

XVI The Evolution of the Health Movement 231

Note on Books 253

ft

HEALTH ATO DISEASE

CHAPTER I

WHAT IS HEALTH ?

" And what a strong, healthy man he
looked I " This was the comment at the
funeral of a burly farmer. He was of middle
age ; ruddy in countenance ; muscular ; of
large bone, deep chest, irrepressible activity.
His laugh was strong and clear. His eye was
active. He knew no fatigue. He took more
than his share in business, in social life, in
public affairs. From the cradle, he had
enjoyed good nurture. In his youth, he had
been an all-round athlete. As he grew older,
he turned his energies to the more complex
matters of life. Every one said of him, —
" Here is a strong, healthy man." Yet, under
fifty, he suddenly took pneumonia and in
three or four days was dead.

" What a thin, pale creature he looks ! "
This was the common remark about a dis-

8 HEALTH AND DISEASE

tinguished physician. Like the farmer, he
had come of good stock. He had been well
nurtured in infancy. He had enjoyed all
the advantages of physical and general
education. But he had always been more or
less high strung and " delicate." He had
been persevering and studious at College ;
he became an accomplished man ; he had an
eye for details ; he had skill in speculation.
Early in his day, he set himself to analyse
the conditions of long life. He concluded
that the climax of health was a healthy brain.
The condition of maintaining it he found to
be regular habits of food, sleep, and exercise.
He established, by a study of his own nature,
certain normals of life. These, once deter-
mined, he kept to rigidly, seeing always
through the day to the day after. He decided
that to maintain elasticity of brain was a
greater total gain than to go under to the
impulses of the hour. In a word, he fulfillec ,
as nearly as the conditions of climate, educa-
ion, and duty permitted, the aims of the
" simple life." He lived at low pressure. He
achieved a great reputation. He died at the
age of ninety-four. In this country, such an
age is accounted " advanced."

These two are extremes. But let us look
round on the society of every day. Here is
a beautiful child of ten. From earliest

WHAT IS HEALTH ? 9

observation she was called clever. She was
always in advance of the children of her age.
She came rapidly to the front at schooL
She was alert, keen, energetic. Her blue
eyes were bright ; her complexion pure
" pink and white '* ; her eyelashes were long ;
her form was slim and thin. You could
see the blue veins in her temples. She was
in fact a perfect specimen of the " fairy "
type. But, in an outbreak of diphtheria at
school, she caught the disease and died within
a week. After death her body was found
saturated with tuberculosis.

Or again, take note of this lithe, handsome
man, the incarnation of activity, ready-
witted, fit for great work in any line of life.
He is full of splendid schemes. He is perhaps
somewhat boastful, outraging his friends by
the extravagance of his ideas, embarrassing
his enemies by the cleverness of his intrigues ;
talking, inventing, travelling, gathering ex-
perience from every civilisation. But he
carries within him a remnant of a terrible
infection. He may die suddenly, or pass
through a long vegetative life in an asylum.
He may live for years ; but, with his present
record, no insurance company would accept
his life.

Or turn once more to contemplate this
stalwart, self-possessed, learned man, who,

10 HEALTH AND DISEASE

able and moderately persevering, has come
healthily forward through the forties into the
fifties. He has not stinted himself of the
good things of life ; but he has never been
seriously ill and never had to miss either a
day's work or a day's enjoyment. See him
again a year later. What is it that has
dethroned the expression of his countenance,
the mastery in his action, the purpose behind
all his days ? A small swelling appeared at
the side of his tongue. At first he thought
nothing of it ; then, being a doctor, he began
to have uneasy suspicions, but put away a
certain obsession ; at last he took courage to
submit himself to a surgeon. The diagnosis
was — cancer. Within a day, the surgeon
excised the tumour. For somewhat more
than a year, there was no recurrence of ths
growth. But soon a slight swelling began to
appear in the glands of the neck. In less
than a year more, he died of exhaustion.

And so, through illimitable variations,
man after man, sooner or later, comes to the
gates of death. Health ? Disease ? What
are these ? In all the cases described health
seemed to be the name for the personal con-
dition ; yet in every case disease was already
in possession. The powerful farmer died of
strenuous living, going down like a felled
ox after a night's chill exposure, because

WHAT IS HEALTH ? 11

the pneumococcus, the infective agent of
pneumonia, suddenly found the conditions
that enabled it to move from its harmless
colony in the mouth into the wider ranges of
the bodily system. The old physician, by
living at low pressure, watching with care the
organs of absorption and excretion, under-
eating rather than over-eating, never over
stimulating, lived on nearly to a hundred,
and died of " old age." If Metchnikoff, the
wizard of the Pasteur Institute of Paris, be
right, old age is a genuine disease. Even in
this careful physician, it had probably begun
before middle age ; it crept stealthily on
until function after function was impaired ;
it ended by starving out of their energies all
the nutritive director cells of the brain.
" Advancing old age " takes, in the world of
Metchnikoff's ideas, a perfectly definite, con-
crete meaning. It means a progressive dis-
ease of the arteries, and it necessarily ends
in death. The pretty young child any doctor
would at once recognise as a case of tuber-
culosis— a subtle parasitic infection, which
is not incompatible with the most brilliant
mental achievements. Indeed, sometimes it
has been maintained that the toxins of
tuberculosis are, at certain stages of life, a
potent stimulant of latent nerve energies,
and may, within limits, be an ultimate

12 HEALTH AND DISEASE

advantage to the individual and the race.
This is speculation ; yet so complex are the
problems of health that no speculation may-
be lightly set aside. Then the lithe, panther-
like man, whose energies seemed inexhaust-
ible, had contracted syphilis in early days. It
had been imperfectly cured ; it had affected
his arteries ; it had affected his nerves ; it
had paved the way for general paralysis.

These are cases of apparent health. How
shall we test the reality ?

Let it be said at once that, in the absolute
sense, there is no health. What we so name
is entirely relative to the conditions of life.
If a man remained perfectly " healthy," he
would live for ever. But no man lives for
ever. It follows that no man lives a com-
plete life of perfect health. The idea oi
absolute health, therefore, may be cast
aside as an illusion, a mere working concept,
an ideal that is unrelated to reality. It
comes of our invincible tendency to project
our hopes on the screen of the future. The
tendency, being a necessary illusion, will
continue for all time to do its work in each
generation. It is the note of youth, when
the claim to health is strongest ; it is the
note of middle age, when the fear of lost
health begins ; it is the note of mature age.

WHAT IS HEALTH ? 18

when the memories of youth begin once
more to predominate. None the less science
has no place for an ideal of absolute health.
All that science, which is the sum of experi-
ence, permits us to entertain, is a normal
balance of functions relative to a place in
the world.

If you would know how this normal is
determined, how real it is in the business of
life, look over carefully the health-schedule
of a life insurance company. There, when a
man asks to be insured, he will find himself
regarded from a hundred standpoints. The
object of the insurance is to make easier,
by co-operation, a money provision for his
old age. As the world must go on, men die
one after another, not all at once. Out of
this simple fact the insurance companies,
working by elaborate systems of probability,
provide immense benefits for the man's old
age without any fear of a bad debt. But,
to do so, they must take only " selected
lives." It is in the selection of the life that
the insurer finds in how many relations he
stands to the society that makes an in-
surance on his life possible. His whole
object is " money on easy terms." The
insurance company's whole object is " long
life to the applicant."

Let us glance at some of the questions

14 HEALTH AND DISEASE

asked. He must declare his age, his occupa-
tion, his residence, often his race and
nationality. He must go back over his
personal life and declare all diseases, great
and small, that he has suffered from. He
must detail his habits of food, of drink, of
work, of relaxation, of exercise, of travel.
He must, in a word, sketch, in terms of
common life, all the conditions that affect,
negatively or positively, his probable length
of days. But the record does not end there.
He is closely questioned about his father,
his mother, his brothers, his sisters, his
relatives on the father's side, his relatives
on the mother's side, and he must declare
all the diseases they were known to suffer
from ; whether they were healthy in living ;
if dead, what the causes of death were ;
what the length of illness was ; what their
circumstances in life were ; their nurture,
their education, their localities ; what their
exposures to danger and disease have been,
and as many other details as a " full family
history " should contain. In a word, he
must give data for an estimate of his
" heredity." Further, he must satisfy the
examiner as to his future. He must indi-
cate where he is to live, — in a temperate
climate or a tropical climate, in a healthy
country or a country full of disease. If he

WHAT IS HEALTH ? 15

is to go abroad, he must give data for esti-
mating the future risk of exposure to malaria,
tuberculosis, plague, cholera, yellow fever,
and the mass of other fatal tropical diseases.
If he stays at home, he must tell whether
his occupation shall be indoor or * outdoor,
healthy or unhealthy.

But, in all this, the examiner is merely
accumulating data for an estimate of prob-
ability. He accepts, for what they are
worth, the statements of the applicant. He
will now put them to the test. To test
his food habits, he examines the teeth, the
tongue, the stomach, the liver, the bowels.
He goes systematically over every physio-
logical system of the body, — the skin, the
muscular system, the alimentary system,
the circulatory system, the respiratory
system, the nervous system. He examines
the heart and blood-vessels directly. He
tests and records the heart sounds ; he tests
and records the rate of the pulse, its regu-
larity, its pressure ; he tests by special
apparatus the general blood-pressure. He
examines the lungs minutely, back and
front, above and below. He tests their
resonance, the incoming and outgoing of the
breath, the presence or absence of pleurisy,
of bronchitis, or pneumonia, or tuberculosis,
or any other condition affecting respiration.

16 HEALTH AND DISEASE

He cross-examines the applicant on all his
past ailments. He overhauls the nervous
system, — motion, sensation, co-ordination.
He examines the joints, too, and satisfies
himself of the healthiness of every bone or
practically every bone in the skeleton. And
so he passes over every organ of the body,
testing each for any condition that might
tend to shorten life. Even this does not
end the examination. The examiner tests
the secretion of the kidneys ; for some form
of kidney disease is not incompatible with
temporary appearances of health.

When the examiner marshals his data, he
is able, from the wide range of experience
now available in organised medicine, to
estimate the chances of long life. Thcj
insurance companies, basing their scrutiny'
on a still wider experience of recorded lif(;
and death, fix a margin of safety, and so
arrange their benefits that there shall be no
loss on the total. That, on the whole, they
succeed, is obvious from the history of
insurance. That, on the whole, they give
satisfaction to the insurers, is obvious from
the steady extension of insurance methods.
But it is on the infinitely careful scientific
scrutiny made possible by modern medicine
that the immense superstructures of these
financial institutions have been reared. To

WHAT IS HEALTH ? 17

them, health has, therefore, a concrete
significance. They are " men of business."
They mean to make health " pay."

But the applicant for insurance believes
himself to be without physiological flaw.
He may be undeceived ; but he may be
confirmed. In either case, it is health he
seeks to prove. But he is not the best sub-
ject for analysis. True, no man is entirely
normal ; but health can be best understood
from its contrast. Let us consider a case
of disease.

What does the physician ask when he is
called in ? If he is systematic and the patient
is a stranger, he finds out substantially the
same details as the examiner for insurance.
They are all relevant to almost any illness ;
but they are not all of equal importance in
a given illness. Many of them may, there-
fore, be taken for granted or ascertained at
leisure. The problem of the moment is not
to accumulate data for an estimate of prob-
ability ; it is to analyse a problem with a
view to immediate action. The physician,
therefore, is punctilious as to the length of
the illness, the day it began, when it became
severe, when it reached, in the patient's
feelings, the climax that urged him to summon
the doctor. He notes, silently, the posture,

18 HEALTH AND DISEASE

^

the expression, the complexion, the state of
excitement or collapse, and the multitude of
other fine shades that only experience enables
a man to recognise. These signs, minute
though they be, are of immense value. The
face, as it appears in enteric fever, has one
expression ; as it appears in typhus fever, it
has another; as it appears in plague, it has
yet another. Each of them has a significance
for the skilled observer. To an old physician
the face tells a hundred tales. He has read
them a thousand times. He knows every
shade of meaning from " the soft play of
life " to the terror of the last agony. A
gallery of the faces of disease would repre-
sent every shade of tragic expression.

When he is satisfied of his dates, the
physician comes closer to the facts. He asks
about pain, about exposure to infection,
about the regularity of habits, about food,
about work, about exercise. Then he pro-
ceeds to experiment. He feels and counts
the pulse ; he watches and counts the
respirations ; he takes the temperature. By
these he is guided to particular examinations
of lungs, of heart, of kidney, of nervous
system, of digestive organs. Perhaps he
makes no diagnosis of a definite disease ; but,
from his scrutiny, he can tell whether disease
is present or not.

WHAT IS HEALTH? 19

On what presuppositions does he proceed ?
His questions have each a definite purpose.
Each presupposes a normal condition, and
he is seeking to ascertain if there is anything
abnormal. When he counts the pulse, he
assumes that, in the adult, the pulse-beats
number about seventy to the minute. But
he knows that the pulse, even in normal
health, varies rapidly. It may be affected
by nervousness, by the sudden increase of
the patient's attention, by a passing fear, by
the posture, by a recent meal, and by many
other circumstances. All these he allows for ;
but from the simple contact of the finger, he
can learn the rate, the rhythm, the volume
of blood passing through the artery, the
force of the impulse that drives it, the length
of each wave, and the wave variations. He
can ascertain the blood-pressure, which is of
primary physiological importance. He can
know directly whether the arteries are dis-
eased or not. He can judge provisionally
whether the heart is normal ; whether the
temperature is raised ; whether poisons are
affecting the system, and an endless variety
of other points. But all presuppose a normal
pulse.

It is the same in the temperature experi-
ment. If the temperature of the body
exceeds 98-4° Fahrenheit (37° Centigrade),

20 HEALTH AND DISEASE

he looks for some special reason. Fever
begins when the temperature exceeds 99°
Fahrenheit. The temperature of the body
varies between well-ascertained limits, — nor-
mally, in the morning it is low, perhaps as
low as 97° ; in the evening it is higher,
approaching, perhaps, 99°. It is the most
sensitive index of disease. A temperature
of 103° means definite fever ; a temperature
of 106° means danger ; a temperature of
109° usually means death. Temperatures
above and below " normal " are compatible
with life ; but only for a time, and in par-
ticular diseases. If, with a temperature of
104°, whether the cause be known or not,
any individual follows his ordinary work, he
will probably die. Usually, such a tempera-
ture entirely disables him.

The pulse, the respiration, and the tem-
perature, as a rule, vary together. Any one is
a provisional index to any other. They are
the most convenient normals for experimental
tests at the bedside. In a multitude of cases
they are all the physician needs to lead him
straight to the definite cause of the disorder.
Often, however, they are inadequate ; and
then, even for the ends of immediate action,
he must proceed to a minute study of other
normals. To every shade and variety of the
" thousand ills,'- some normal function of

WHAT IS HEALTH? 21

the body as a whole or of some special organ
definitely corresponds. To ascertain these
normals is the work of physiology ; to restore
any departure from them is the work of
curative medicine ; to prevent any depart-
ure from them is the work of preventive
medicine.

What, then, is a " normal " ? The action
of an organ varies within certain limits
without impairing the organ's elasticity or
structure.

In exercise, the heart may, in a few seconds,
rise from sixty beats a minute to one hundred
and twenty or more beats a minute. At the
end of the exercise, it returns in a few minutes
to the rate it started from. It suffers no
damage ; it retains its elasticity ; it maintains
its nutrition and its power of contraction.
Under the microscope, no fibre would be found
injured. It responds readily to every test.
And this is true of every normal heart. The
moment the elasticity is impaired or the
structure damaged, there is disease. If the
heart becomes " irritable," if palpitation
continues beyond an ascertainable average
of minutes, if excitement interferes with
the regularity of its beat, the exercise has
ended in disease.

For every organ of the body, there is a
similar average of function. For every group

HEALTH AND DISEASE

1

of organs, there is an average of function.
For the body as a whole, there is a balance
of average functions. As the branch of a
tree sways this way and that in the wind
without losing the power to come back to
rest, so co-ordinated organs of the body vary
this way and that in response to the infinitely
varied needs of the environment, and yet
return uninjured to their co-ordinated balance.
And the body is an infinitely complex aggre-
gation of growing structures. It is never at
rest. Of the millions of cells that compose
it, millions are dying every hour, millions
more are taking their places. But there is a
"moving equilibrium" of the whole. The
*' moving equilibrium " has its index in an
average temperature, an average pulse, an
average respiration, average excretion, and a
thousand other averages that constitute the
special work of the anatomical, physiological,
and medical laboratories. Health is the
name we give to the total average of the
highest physiological efficiency. The organism
as a whole must maintain its place in the
struggle for life. It is by maintaining the
physiological normals that the organism main-
tains its place in the struggle. The main-
tenance of the physiological normals at their
highest potency is health. Any departure
from the normal that destroys the structure

THE CAUSES OF DEATH 23

of an organ or impairs its capacity to repeat
its function is disease.

The objective signs of health are such as
these, — readiness to act without external
stimulus, capacity to act for prolonged periods
without fatigue, regularity in the daily
physiological cycles — cycles of appetite, cycles
of muscular action, cycles of excretion, cycles
of sleep. And there are many minor signs.

Subjectively, the healthy man has a feel-
ing of satisfaction and ease in his activities,
a general feeling of well-being, freedom from
a sense of effort, freedom from the sense of
environmental oppression, freedom from the
feeling of being obsessed by his work, freedom
from inner incontrollable moods or tempers.
Every healthy man, in the dialect of his own
philosophy, says —

" God's in His heaven,
All's right with the world."

CHAPTER II

THE CAUSES OF DEATH — ^THEIR NAMING AND
CLASSIFICATION

Let us visit a Hospital for Sick Children
and walk round with the surgeon.

24 HEALTH AND DISEASE

Here are children of any age, from a few
months to fourteen or fifteen years. This,
the youngest, was born with club-foot, an
imperfect development that growth will never
by itself correct. An operation, at this stage
trivial, will prevent a lifelong disablement.
Another, somewhat older, suffers from knock-
knee. Now or at some later stage an opera-
tion, the brilliant invention of a great surgeon,
will straighten out the deformity. These
are defects rather than diseases. They are
not causes of death directly ; but indirectly
they may be causes of defeat in the race of
life. For they incapacitate the patient for
many occupations, and may lead him, in early
life, into neglect and destitution.

A third child, old enough to be at school,
has difficulty in breathing through the nose,
chokes in his sleep, and shows signs of de-
fective nutrition. He suffers from enlarged
tonsils and adenoids (gland-like structures)
in the upper part of the throat. These he
will get removed by the surgeon, and forthwith
he will gain in weight and vigour. Another
has " bow-legs." His wrists and some other
joints are swollen. His ribs have curious
little knots in certain places. His chest
is somewhat misshapen. His head is un-
usually square and perhaps somewhat large
for his years. He suffers from rickets. The

THE CAUSES OF DEATH 25

disease has spontaneously stopped ; but the
effects of it have remained and, unless partially
corrected by surgery, will remain through life.
He will grow into a strong man, but he may
be somewhat deformed. His disease is a
subtle and unexplained disease of nutrition,
begun before his birth. His mother may
have suffered from it ; but it is not necessarily
an inherited disease. It may be due to food,
or poisoning, or a failure of the orgnnism to
take in the correct quantity of lime from the
food. Briefly, the cause is undetermined.
But he is one of hundreds of thousands in the
great cities. In one great city in Scotland,
if you go where you can see poor children,
you will find in half an hour a score of such
cases.

Then observe the next bed. It is slightly
tilted upwards ; it has a weight hanging over
the end ; there is a child lying flat with a
splint fixed along nearly the whole length of
the body. This is a case of hip- joint disease,
one of the innumerable forms of tuberculosis.
Possibly, operation may be necessary if an
abscess forms. Possibly, perfect rest may
stop the mischief. In either case, the treat-
ment will take months. In the next bed lies
a case of spine disease, — another case of
tuberculosis. In another case, it is the knee
that is affected ; in another, the wrist ; and,

26 HEALTH AND DISEASE

^

\t you look farther along, it is the skin. All
|:e tubercular. Tuberculosis may affect any
organ in the body ; but the disabling effects
of it are most manifest when it appears in
the bones. In the skin case, the form of
tuberculosis runs a slow, long course ; it has
been going on, perhaps, for five or ten years ;
it may end in death. The name given to it
is lupus, probably because it seems to eat
away the tissue. Fortunately, it can now be
cured, and the cure of it is one of the triumphs
of modern bacteriology.

Farther along lies a child with curiously
clouded eyes, sunken nose, and some other
deformities of the bones. This is a case of
syphilitic infection. His eyes are probably
damaged for life ; the destroyed bones will
never be restored ; other hidden destructions
may have taken place ; he may live for many
years, but he may never become a healthy
man. This terribly merciless disease attacks
every organ of the body. It can be cured,
but the cure often comes too late.

Let us now glance at a medical ward. In
the first cot lies a child with lung disease —
possibly tuberculosis of the lungs, possibly
inflammation of the lungs (pneumonia), pos-
sibly bronchitis. Its after-history of health
and fitness will depend much on which of the
three diseases it suffers from. In other cots

THE CAUSES OF DEATH 27

lie cases of malnutrition, due, perhaps, to
wrong feeding in early infancy, or to some
defect in the digestive glands. There are cases
of bloodlessness, of rheumatism, of heart
disease.

These are a few of " the causes of death "
that a visitor may see at any time in a
hospital for children. The out-patient depart-
ments furnish masses of similar ailments ;
some are less serious, but all are pulling the
organism down. Every disease is paid for
by its own special form of unfitness. No
disease entirely passes. After some diseases,
definite disablements remain for life ; of
others, there are traces that impair vitality ;
but of others, the effect is to adapt the
organism better to its environment. These,
meanwhile, we may leave unvisited. They
are the acute infectious diseases. As a rule,
one attack protects a child against a second
attack.

If you go to a general Hospital for Adults,
you will find many of the same diseases still
at work. To maintain continuity of interest,
let us imagine that the sick adults now to be
seen are the same sick children ten, twenty, or
thirty years older. This is simpler than post-
poning our visit for ten or twenty years ;
because, in so long a period, the names of

28 HEALTH AND DISEASE

1

many diseases will change ; some of the
diseases will have lessened to vanishing
point ; new diseases or new ways of treating
them will have come to light.

On this occasion let us go round with the
physician. The first case is a man who for
months has been wasting away for no reason
that can be discovered. He suffers from
indigestion, but his trouble is not a digestive
disease. He has lost flesh, energy, and interest.
He shows a marked pallor of countenance,
unusual depression, a strained and anxious
aspect. He is probably suffering from some
malignant disease ; possibly cancer of the
stomach. There are many such " malignant
tumours " ; there are many theories of their
origin ; but there is no explanation. Almost
every pathological laboratory in the world
has some man searching for the cause of
malignant diseases. A hundred times cures
have been announced, only to be a hundred
times discredited. Such malignant tumours
may occur almost anywhere in the body, —
in the skin, in the lining of the stomach, in
the lining of the bowels, in the bones, in the
lungs, in the muscles, in the nerves, in the
brain. There are many varieties, each taking
its character from the tissue of the part
affected ; but they are all malignant in
varying degrees. They may be cut out ;

THE CAUSES OF DEATH 29

but they grow again. Occasionally, once
cut out, they never reappear. Occasionally,
too, when treated by the X-rays or Radium
they shrivel up and disappear. And there
are many instances where the growth is so
slow as almost to lose its character of malig-
nancy. When the cause and the cure of
cancer and the other malignant tumours are
discovered, mankind will be saved from a
great terror.

But note here a case of rheumatic fever —
a very acute illness, with high temperature,
rapid pulse, great pain in the joints, depres-
sion and helplessness. It often affects the
lining of the heart, external or internal ; so
producing imperfection of the heart valves
or disease of the external heart-lining, and
damaging the organ, perhaps, for the whole
lifetime. The disease is curable ; in some
degree, it is even preventable ; but it is one
of the most disabling, and, ultimately, one of
the most deadly, in the whole list. It may
recur several times, every time increasing
the damage. A heart so damaged may
partially recover ; it attains to a certain
plane of relatively healthy function ; it may
enable the man to follow his calling ; but it
will never permit him the same latitude of
physical labour, or exercise, or personal
exposure. Tens of thousands in the British

80 HEALTH AND DISEASE

1

Islands are moving about with hearts once
damaged by rheumatism. To this cause
many of the sudden deaths are due. Any
sudden exertion breaks down the partially re-
stored heart and ends in greater disablement
or in sudden death. Nor is this all. A heart
so damaged may, through its intimate con-
nections with the lungs and stomach, produce
a chronic congestion of the breathing tubes,
a chronic catarrh of the stomach, and possibly
catarrh of the kidneys. Shortness of breath
is a common symptom, because the damaged
lung cannot do its work at the normal rate.
If we followed up all the causes and conse-
quences of rheumatic fever, we should have
to describe diseases in many of the membranes
and organs of the body.

Let us pass on to this case of lead poison-
ing. You notice that the patient cannot
shake hands. He suffers from wrist-drop.
His hand seems pulled in. This is because,
at his trade as a painter, he has failed to
keep his nails clean, or in some other way
has succeeded in absorbing lead into the
system. Lead affects the nerves that supply
the hand, thus causing degeneration and
paralysis. There are many other symptoms
of chronic lead poisoning ; but wrist-drop is
the most striking. The disease is curable,
if caught in time. It is, too, preventable.

THE CAUSES OF DEATH 31

and ought not to occur. But it does occur
in many occupations.

But who is this that is breathing so noisily ?
He was picked up unconscious on the street ;
his face very congested and somewhat drawn
to one side. The physician tells us that a
vessel in the brain has burst. This is
apoplexy or cerebral haemorrhage. When
consciousness returns, he will find one arm
or leg absolutely without power ; he can
feel with them, but he cannot move them.
And when he tries to speak, he will mumble
and break his words. The clot in the brain
due to the burst artery presses on the motor
areas, interrupts the nerve paths from the
brain to the limbs, and so produces paralysis.
He will partially recover ; but he will never
be the same man again. The causes of his
ailment are various ; but the ailment itself will
be classed as a disease of the nervous system.

In looking at the case of rheumatism, we
have already seen diseases of the heart, which
is the chief organ of the circulatory system.
Here sits another case of heart disease. He
suffers, at irregular intervals, from violent
spasms of heart pain. He feels as if dying.
When the spasm passes he is more or less
exhausted, but, often, he is able to follow
his duty. Sooner or later the spasms of
pain will end in death. After death his

82 HEALTH AND DISEASE

heart will be found badly diseased ; the
valves of it may be found imperfect ; the
arteries that supplied it with nourishment
will be found hard and inelastic. ) Near him
is a man whose arteries are already far
advanced in disease, hardened, robbed of their
elasticity, ready to burst at any increase of
pressure, slowing down the man's heart and
with it his whole life. The condition, by
care in early life, by the prevention of putre-
faction in the bowels, by the careful adjust-
ment of labour to capacity, by a judicious use
of certain drugs, may be delayed and par-
tially prevented ; but, as we now see it, it
is without remedy and may go on till the
brain fails, producing senile imbecility and,
one day, death.

Of diseases of the respiratory system there
are many — pneumonia or inflammation of the
lungs in several varieties, bronchitis, asthma,
inflammation of the larnyx, not to speak
of tuberculosis of the lungs, which, however,
is an infectious disease, and will be studied
more fully by itself. Many of the respiratoiy
diseases are preventable ; some of them
being due to dust, some to a specific microbe ;
some to carelessness of clothing and ex-
posure. Respiratory diseases account for
the great mass of deaths.

There are, too, diseases of the digestive

THE CAUSES OF DEATH 33

system. Every organ of the alimentary
tract may furnish some disease that ends in
death. The mouth harbours many species
of infective germs ; some of them, it is said,
are the specific cause of a deadly form of
anaemia, and nearly all of them tend to pro-
duce one form or another of body poisoning.
The tonsils, apart from recurrent inflamma-
tion, may be the seat of scarlet fever, or
diphtheria, and may be an index of certain
rheumatic conditions. The stomach with
its many inflammatory and other diseases, the
bowels with their inflammations and ulcers,
the appendix with its many varieties of
appendicitis, the liver with its congestions,
or gall-stones, or tumours, or specific diseases,
the external lining of the bowels with its
inflammations, tubercular or other, — may all
provide causes of death.

It would take us a disproportionate time
even to name the classes of disease that yet
remain, — the diseases of the urinary system,
the diseases of pregnancy and child-birth,
the diseases of the skin, diseases of the
organs of locomotion, the diseases of early
infancy, not to mention the causes of death
by violence or accident. This, no less than
all that we have named, are to be found in
every large general hospital. They afford
endless material for the curative methods

84 HEALTH AND DISEASE

both of the physician and of the surgeon.
There is not an organ of the body that may
not need skilled attention. And, if you
look at the ages marked on the bed-charts,
you will find that they vary from childhood
or adolescence to extreme old age. Every
stage of life has its predominating diseases,
but no stage is free from disease. Here,
the cause of disease is some poison like lead ;
there, it is over-exertion. Here, a disease
may come from improper feeding and in-
sufficient elimination of waste ; there, it
may come from under-feeding and inability
to withstand enforced exertion. This girl
is anaemic because she is confined in a light-
less room all day, or lives on an ill -balanced
diet, or works among lead salts. That man
suffers from over-growth of the heart, be-
cause for years he has been over-worked and
under-fed. But of the causes of disease there
is no end. Every man and every organ he
possesses must respond in some way to the
environment if he is to live at all ; every
organ therefore has to meet, in due season,
its risks of over-pressure, of poisoning, or of
some other form of super-action or perverted
nutrition.

But it is not, for the moment, the causes
of disease we wish to emphasise. It is rather
that this chaos of activities, this unending

I

THE CAUSES OF DEATH 85

procession of diseases and defects, must have
names, and must be classified. Otherwise,
it would be impossible for science to master
any of the causes of death.

Before searching for any principle to guide
us in naming and classifying this chaotic
mass of diseases, let us look for a moment
into one hospital more — the Infirmary belong-
ing to an English Workhouse or the Sick
Wards of a Scottish Poorhouse. In these are
collected the diseases of destitution, and the
patients are a vast multitude. A glance
proves that they have lived on a lower plane
of health ; they are living now among more
chronic diseases. Acute illnesses, like rheu-
matic fever, or appendicitis, are conspicuous
by their rarity. Here the day is filled with
the superabundance of old-standing heart
disease, incurable paralysis of many varieties,
incurable affections of the bones and joints,
incurable blindness, incurable kidney disease,
incurable results of syphilis, old leg-ulcers
that need constant cleaning, running sores of
bone that need constant dressing, the de-
crepitude of age, or the feeble-mindedness of
youth,'' sometimes idiocy or imbecility in
many grades and varieties, or epilepsy, or
harmless forms of insanity, or disabling and
incurable gout, or rheumatism, or brain
disease, or spine disease, or some other of the
b2

86 HEALTH AND DISEASE

thousand and one varieties of chronic disorder.
There are, too, many malignant diseases,
which are long beyond surgical or medical
aid. All these diseases can be classified
under the same heads as in the other hospitals ;
but with a difference. The patients now
visible are all on the waiting list for the grave.
They drop off rapidly one by one : here, of
senile feebleness ; there, of sudden heart
failure or apoplexy. The men are old at
fifty ; the women, senile. There is no green
old age in the poorhouse. These are they
that have dropped out of citizenship. They
have lost touch with their fellows ; they live
through the day without purpose, and when
they die, they are buried by some one and their
beds are filled again.

To widen our knowledge of the classes of
disease, we ought to visit an Asylum for the
Insane. A special field so vast would need
a special list of names for the many diseases
to be found there. The general word
" insanity " covers a multitude of special
diseases. Let us be content here to call
them " mental diseases."

Nor shall we concern ourselves till later
with the infectious diseases ; for they need
special study.

How then shall we name and classify all

THE CAUSES OF DEATH 37

these departures from the normal, these
palpable, visible, definable states of body ?
The names come to us often with a long
history ; many of them are derived from
Latin or Greek ; but every one of them
symbolises some state as clear to the physician
and the surgeon as the eye or the hand is to
the physiologist. But the kind of classi-
fication depends on the end to be served. It
is said of a distinguished Aberdeen surgeon
that, when he found something wrong with a
knee-joint, he was content to say — " There
is some infernal bobbery going on in that
joint." This was fifty years ago. It was
enough, in those days, to justify a surgical
operation, and the surgeon achieved great
things surgically. The science of diseased
organs was then in its infancy. To-day the
youngest surgeon that handles a knife knows
in nine cases out of ten the precise nature of
the condition he has to deal with, the course
it will run if he does not operate, and the
prospect of cure if he does. That he should
be able to bring such knowledge to bear he
owes largely to the fact that, for nearly sixty
years, the causes of death have been carefully
registered. In his reports weekly, monthly,
quarterly, and yearly, the Registrar-General
for each country places on record the numbers
of those that die and the diseases that cause

38 HEALTH AND DISEASE

their death. To these reports every student
of disease turns ; from them he takes his
data for the ends of medical, or surgical,
or hygienic study, or for the purposes of
insurance, or social research.

Since, however, the purposes of the classi-
fication are thus so various, the difficulties
of satisfactory classification are enormous.
Recently, under the leadership of France,
an international Nomenclature of Diseases
has been produced. This Nomenclature is
the result of criticism and sifted experience.
It has been adopted by some twenty nations
or communities. It thus becomes an inter-
national code to facilitate the comparative
study of disease and health. Not all diseases
are here named ; but all diseases are here
provided with a class name. No departure
from the normal will fail to find a general
heading to suit it.

In this Nomenclature there are fourteen
main blocks of disease. There are the general
diseases, which include fifty-nine special
classes ; among these are all the infectious
diseases, some thirty-two in all ; the cancer-
ous diseases ; acute rheumatism ; scurvy ;
diabetes ; alcoholism, and other intoxications
of various kinds. The second block includes
the diseases of the nervous system and of
the organs of sense. Then there are the

THE CAUSES OF DEATH 39

affections of the circulatory system ; of
the respiratory system ; of the digestive
system ; of the genito-urinary system ; the
puerperal state ; the affections of the skin ;
affections of the bones and organs of loco-
motion ; imperfect developments and mon-
strosities ; diseases of the new-born ; diseases
of old age ; diseases due to external causes,
such as violence ; and a final class of badly
defined diseases. The sub-classes number
about one hundred and ninety. If each
morbid condition received a special name, the
list of names would far exceed a thousand.

What is the use of this elaborately sub-
divided Nomenclature of Diseases ? To
answer is easy. It enables the Doctor to
keep an exact record of the diseases he treats.
It enables him to enter in a death certificate,
as required by law, the primary and secondary
causes of death. It enables the local Regis-
trars all over the country to keep with exact-
ness the Register of Deaths for every locality.
It enables the Registrar-General to bring all
the facts for each cause of death into a single
Register. From the large numbers thus
collected, he is able to calculate the death-
rates due to each disease, to each group of
diseases, to each great class of diseases, to
the whole collection of diseases. From the
death-rates, he can infer the disease-rates of

40 HEALTH AND DISEASE

every locality. He thus provides for the
whole community an index of health. This
index is the guide of all social progress.
From it the individual citizen knows of the
healthiness or unhealthiness of his village, or
parish, or town, or city. From it the insur-
ance companies draw data for their life-
tables From it the municipal world takes
guidance in the cleaning of towns, in the
reduction of overcrowding, in the rebuild-
ing of unhealthy areas, and in the planning
of cities. Without these sixty years of
carefully calculated figures, the public health
movement would be a movement in the dark.
This is confirmed by the practice of every
civilised country. No department of State
activity can show greater justification than
the department of statistics. The record of
national health is the test of national progress.

It is for these reasons that so much detail
is given here without apology. Every citizen
should study national health records. He
will gain from them a new significance for
every form of social activity.

But the details given have a further purpose.
They show the great dividing lines of disease.
Each social organisation must choose for
itself the divisions that suit its purpose ; but,
in the study of health and disease, there is
one fundamental division, namely, the division

. DEATH-RATES— INTERPRETATION 41

between preventable and non-preventable
diseases. From our point of view, the pro-
gress of society is a progress from disease to
health. To prevent disease is to promote
health. But to prevent disease needs a know-
ledge not only of the methods of prevention,
but also of the diseases that are preventable.
Before, however, the significance of preven-
tion can be understood, the death-rate must
be studied in somewhat greater detail.

CHAPTER III

DEATH-RATES AND THEIR INTERPRETATION

" In the year 1908, the deaths from all
causes in England and Wales corresponded
to a rate of 14-683 per 1000 living at all ages
and of both sexes. This rate is the lowest
on record, and is below the average rate in
the five-year period ended 1907 by 5 per
cent."

What does this extremely condensed state-
ment mean ? It is taken from The Seventy-
fiirst Annual Report of the Registrar-General
for England and Wales. These figures, which

42 HEALTH AND DISEASE

read so simply, represent a year's collection
of facts in the provinces and months of cal-
culation at the centre. The two sentences,
therefore, deserve a careful analysis.

In the England and Wales of 1908, the
deaths of 520,426 persons were registered.
Of these, 268,714 were males and 251,742
were females. This is the first crude fact
to be realised. It tells us little by itself ;
but nothing can be understood without it.
Further, the population of England and Wales
in the same year was not ascertained exactly,
because 1908 was not a census year. On
the basis, however, of the census of 1901, an
estimate of the population was made. It
was reckoned that, at the middle of 1908,
the population amounted to 35,348,780, of
whom 17,071,524 were males and 18,277,256
were females. This is the second crude fact
to be realised. The population so ascer-
tained was divided up among the various
constituent areas, — towns, counties, and other
administrative areas.

The rate, it is said, is the lowest on record.
The record goes back to 1836. But it is
enough to consider the facts of the last fifty
years. For the five years from 1861 to 1865,
the death-rate was equal to 21*4 per 1000
persons living. From that date, the Regis-
trar-General reports, the death-rate fell

DEATH-RATES— INTERPRETATION 43

steadily, declining in the whole period under
review by nearly one-third. When, there-
fore, the rate is called " the lowest on record,"
it means that, for every thousand living,
only some fourteen die in each year as against
twenty-one fifty years ago. There is thus a
saving of nearly seven lives for every thousand
of the population, and, as the population
numbered over 35 millions, the numbers saved
are enormous, being at least 245,000. For
the ends of administration, the calculated
figure of 14-683 per 1000 symbolised aU
this vast saving of life. But it is well,
occasionally, to translate back the rate into
the concrete facts and so make an effort to
realise in imagination the amount of life and
happiness the figures body forth for us.

But this death-rate of 14-6 per 1000 living
is not so simple as it seems. It is a death-
rate of persons living " at all ages." It,
therefore, in some way contains within
it the death-rates at each particular age.
If the population is analysed, it is found to
be made up of so many persons under five
years of age ; so many, from five to ten ;
so many, from ten to fifteen ; from fifteen

tto twenty ; from twenty to twenty-five ;
from twenty-five to thirty-five ; from thirty-
five to forty-five ; from forty-five to fifty-
five ; from fifty-five to sixty-five ; from

44 HEALTH AND DISEASE

^

sixty-five upwards. These are the ages
selected by the Registrar-General to parcel
out the population into convenient sections.
Each section has its predominant diseases,
its predominant causes of death, its own
current of sectional life. Children under
five, for example, tender, rapid-growing,
unstable, just entering the world of life's
stresses, infections, and injuries, naturally
have a higher death-rate than children of five
to ten, who have reached a relatively smooth
plane of life. At the other end of the scale
are the men and women over sixty-five.
They are past maturity ; they are living on
the remnants of their physiological capital ;
they are already " within the fore-shadows
of the tomb."

Imagine that, in the beginning of 1908, a
thousand children under five were placed in
the order of age from birth upwards and
certified living. If, at the end of 1908, the
same children were once more to be placed
in the same order, there would be forty
places unfilled. For, in that year, the death-
rate of children under five was 40 per 1000.
If, in the same year, a thousand persons over
sixty-five had been placed in their order,
the unfilled places at the end of the year
would have numbered eighty-seven. The
death-rate of persons over sixty-five was

DEATH-RATES— INTERPRETATION 45

87 per 1000. Between these extremes there
are many variations. The death-rate for the
children living between five and ten was 3
per 1000 ; for children living between ten
and fifteen, it was nearly 2 per 1000 ; and
for youths of both sexes living between
fifteen and twenty, nearly 3 per 1000 ; for
those of twenty to twenty-five, over 3 per
1000 ; for those of twenty-five to thirty-five,
nearly 5 per 1000 ; for those of thirty-five
to forty-five, over 8 per 1000 ; for those of
forty-five to fifty-five, over 14 per 1000 ;
for those of fifty-five to sixty-five, over 28
per 1000.

Has such an analysis any special value ?
It has immense value for many purposes.
It guides the student of health in his investi-
gation of the conditions that foster disease.
It shows him what the feeble ages are, and
stimulates him to find the causes of enfeeble-
ment. It suggests many complicated ques-
tions for biology and sociology. If our
population was formed solely of children aged
ten to fifteen, the death-rate would be less
than 2 per 1000. If it were formed of men
and women over sixty-five, it would be nearly
90 per 1000. In the urban counties it actually
was 94 per 1000 for those ages. These death-
rates, therefore, suggest further analysis. Ob-
viously, if any community has a very large

46 HEALTH AND DISEASE

proportion of children from ten to fifteen
years old, its death-rate will be low. If it
has a very large proportion of people over
sixty-five, its death-rate will be high. The
low death-rate of one locality, therefore,
does not by itself prove that the locality is
healthy, nor does the high death-rate of
the other locality prove that it is unhealthy.
It is clear that, if we are to compare the health
of localities, the proportion of young and old
in the population must be carefully esti-
mated and allowed for. This is what is
meant by " correction for age." There is a
similar correction for the local differences
in the relative numbers of males and females.

It would be possible to pass on from one
fertile suggestion to another, until our minds
were possessed with nothing but figures and
the extraordinary revelations they bring.
Figures are fascinating ; they are necessary ;
they will never fail to attract the mathe-
maticians and statisticians. But here we
are concerned with other questions of practice.
To us the death-rate is not an end in itself ;
it is merely an index to what happens among
our fellow-men, a guide to what can be done
to remove the causes of death, an illuminating
comment on the possibilities of preventing
disease.

^

DEATH-RATES— INTERPRETATION 47

Look, then, for a moment at another aspect
of the same facts. What are the most deadly
diseases ? It is still the year 1908 that we
study. The deaths from all causes were,
as we saw, 520,426. If we took any thousand
deaths, we should find that certain diseases
contributed many more deaths than others.
Thus, tuberculosis in all its forms contributed
over 107 to every 1000 deaths — rather more
than a tenth of the whole. Tuberculosis of
the lungs alone contributed 76 to the 1000
deaths. In the list of contributors, tuber-
culosis is an easy first. Next come diseases
of the heart, which contributed 96 to the
1000 deaths. Then follow diseases of the
respiratory system, with a contribution of
89 per 1000 deaths. If pneumonia, which is
now classified as an infection, were added,
the total contribution of respiratory diseases
would be nearly 170. Diseases of the nervous
system contributed 64 ; cancer and other
malignant diseases, 63 ; old age, 63 ; diseases
of the blood-vessels, 60 ; diseases of the
digestive system, 55. The most fatal infec-
tions of that year were measles, contributing
15 ; influenza, contributing 19 ; whooping-
cough, contributing 19 ; diphtheria, con-
tributing 11 ; diarrhoea, contributing 35, — to
I every 1000 deaths.

48 HEALTH AND DISEASE

m

death-dealing diseases are tuberculosis, dis-
eases of the heart and blood-vessels, and
diseases of the respiratory system. The
others all are important, but no single group
can rival these. It is now clear why, in our
visits to the hospitals, these great diseases
were found in the ascendant. Wherever we
went, we encountered them. At that stage,
they were diseases of the living, claiming
sympathy and skill ; at this stage, they are
causes of death, recorded in the cold
quantities of administrative science.

But this analysis of a thousand deaths
concerns only a single year, and a total
death-rate of 14-6 per 1000 living. It is the
progress of the death-rate year by year that
tells us where we are going. Let us look
backwards. This time our illustration may
come from Scotland. The diseases on record
there are just the same and tell the same
story.

Of two diseases, the history is marvellous —
typhus fever and smallpox. It was not till
the year 1865 that typhus fever and typhoid
(enteric) fever were separately recorded.
Indeed, only a short time before then were
they definitely known to be distinct. They
are still occasionally confused ; but, in the
typical cases, no confusion is possible. It

DEATH-RATES— INTERPRETATION 49

may be assumed, however, that of the two,
typhus contributed more than typhoid to
the enormous total of deaths. In 1855 the
Scottish deaths from these two diseases
numbered 2419, representing a death-rate of
90 for every 100,000 of the population. The
deaths fell a little and rose a little in the ten
years ; but in 1864 the two diseases together
killed 4804 people, corresponding to a death-
rate of 116 for every 100,000 of the popula-
tion. In 1865 the deaths from each disease
were separately recorded. In that year
typhus alone killed 3272 — a death-rate of
108 per 100,000.

Mark now the change. In 1880 typhus
killed only 170 people — a death-rate of 5 per
100,000. In 1890 it killed only 77— a death-
rate of 2 per 100,000. In 1900 it killed only
35 people — a death-rate of 1 per 100,000.
In 1908 it killed eight persons — a fractional
rate per 100,000. Consider the average rates
for the ten -yearly periods — 91 (the two
diseases), 65, 15, 3, 1, less than 1, per
100,000. A disease that alone numbered tens
of thousands of sick and its thousands of
dead has practically vanished in fifty years.
It is so rare that, when it comes, it is usually
taken for something else. But it is so
virulent that it always compels attention.
The extirpation of this disease is a triumph

50 HEALTH AND DISEASE

of administration. It is a supreme example
of what can be done by isolation, uncrowding,
drainage, cleansing, and the systematic re-
moval of waste. The germ that causes the
disease is still undiscovered ; but the natural
history of the disease is well understood.
The tale told of Scotland is true of England
and Ireland. Once, typhus was a scourge in
Europe ; to-day, it is hardly to be found
among the causes of death.

The history of smallpox is little less striking.
If, again, ten-yearly periods are taken, the
smallpox death-rates are these — 35, 18, 19, 1,
per 100,000.

For scarlet fever the corresponding figures
are 98, 96, 79, 29, 19, per 100,000. There
is here a steady fall in the death-rate. After
typhus and smallpox, scarlet fever has
received the lion's share of administrative
attention. The death-rate from it everywhere
has gone down ; but the disease still comes
back in frequent epidemics ; it always rises in
the autumn and tails off in the spring ; but
it is universally allowed to be a less serious and
more manageable disease than it was thirty
or forty years ago. But measles, which from
the average of the five years after 1855
killed 43 per 100,000, still continues its ravages
almost unchecked ; for, on the average of the
ten years after 1891, it killed 47 per 100,000.

DEATH-RATES— INTERPRETATION 51

With one depressing fact, this chapter must
end. The death-rate from cancer and other
malignant diseases was, on the average of the
ten years following 1861, 42 per 100,000.
The average of the ten years following 1891
was 74 per 100,000. Allow for improved
diagnosis — which is the fact ; allow for the
great saving of life up to the cancer ages —
which is also the fact ; allow, too, that the
increase has not occurred in the easily
accessible and readily recognisable cancers,
as of the lip, the tongue, the face, but rather
in the hidden cancers of the internal organs.
It matters little. The dreary, depressing
fact remains, Up till now cancer must be
labelled " incurable." But the scientific
passion of the world is centred on it in a
hundred laboratories. Already, hints of
discovery are everywhere ; for all we know,
perhaps the discovery is already made. The
history of other diseases allows us to hope ;
for scientific pathology is not a century old.
Possibly within the lifetime of the middle-
aged, cancer will pass into the class of
preventable diseases^

52 HEALTH AND DISEASE

m

CHAPTER IV

FEVER, INFECTIOUS DISEASE, AND EPIDEMICS

In 1844, the Commissioners appointed to
inquire into the administration and practical
operation of the Poor Law in Scotland issued
their report. Among other things, they
reported on the problems of medical relief
to the poor. In particular, they reported on
" fever " and epidemics, which, in those days,
were recorded as inevitable incidents of indi-
vidual and social life. Typhus was every-
where. Smallpox was everywhere. In one
town of Western Scotland a careful school-
master and session-clerk divided the people
into two classes — those that had taken
smallpox and those still to take it I Of the
infections now most common — scarlet fever,
measles, and whooping-cough — less is heard.
They were probably masked by typhus,
smallpox, and enteric fever. They were all
well known ; but they were of less account
than the great death-dealers.

It is in such a social atmosphere that the
Commissioners of 1844 write in reference to
fever and epidemics : "It is, however, very
questionable whether the periodical prevalence
of fever in these places — that is, in Edinburgh

FEVER AND EPIDEMICS 53

and Glasgow — can justly be ascribed to any
specific cause. There may be said to be
three distinct opinions on the subject. The
first is stated in the Sanitary Report, it attri-
butes the spread of fever to filth and defective
sewerage ; the second would ascribe the evil
to an overcrowded population ; the third,
to destitution. We believe it to be true that
wherever fever prevails, one or more of these
concomitants will be found to exist. But as
to the amount of influence which all or any
of such causes may have on the diffusion or
origin of disease, we feel that it would be
presumptuous in us to offer any opinions,
where medical men of the greatest experience
are not agreed."

In those days it was not possible to be more
exact. The infectivity of certain fevers was
well known ; but the germ theory had not
yet come to light. There was no science of
bacteriology. Not for some years after 1844
did it enter the mind of any investigator to
suggest a bacillus or any other microbe as the
cause of enteric fever, or diphtheria, or small-
pox, or typhus, or measles. Indeed, for
several of these diseases no germ has yet
been isolated ; but analogy leaves us in little
doubt that for them all a specific germ will
be found. In those days, too, there was
little effort at sanitation. The reports of

54 HEALTH AND DISEASE

Chadwick and Neil Arnot on the state of
Glasgow are sad reading. Except in the
more remote and most neglected hamlets or
villages of to-day, the lower animals are
housed in better conditions than in those days
the human beings were. The fevers were
lumped together under the vague name of
" fever." In medicine, the word is now the
name of a symptom — the rise of temperature
above the normal. But, used of an un-
differentiated mass of virulent sicknesses, it
acquired a terrible meaning, whose traditions
you find still living in the popular mind.

It is difficult to understand why, even at
that date, the distinction of infectious types
was so little advanced. The great physicians
knew them well ; for their descriptions are
extant. Perhaps the lesser medical men hacl
little chance of attaining to even such science;
as existed. It is certain that the study o:'
infection had not advanced far ; for, at the
beginning of the century, a distinguishecl
physician is still proving the infectivity of
whooping-cough. The want of scientific
methods of research accounts for much, and
seventy years ago the physician had not
grasped the conception of prevention. He
looked on " fevers " much as more recently
he looked on " tropical diseases," — that is, as
a chaos without a clue. It is probable that

FEVER AND EPIDEMICS 55

" fever " included diseases as diverse as
these — typhus fever, typhoid fever, pneu-
monia, eerebro - spinal fever, tubercular
meningitis (inflammation of the brain
membranes), appendicitis, septicaemia (blood-
poisoning), and some others. But, in spite
of their inadequate knowledge, the Com-
missioners of 1844 made many recommenda-
tions of a fruitful kind and prepared the way
for the public health services we now enjoy.

To point the differences between then and
now, let us visit a modern Public Health
Hospital of one hundred beds. It is built in
six separate pavilions. It has an administra-
tion block standing apart. Between each
two pavilions there is a clear space, forty feet
wide. There are a laundry and disinfecting
block, a discharging block, and all the other
offices needed for the management. The
whole is spread over some five or six acres.
It is really a group of separate hospitals ; for
each pavilion houses but a single disease, and,
at the moment, there are perhaps four or five
or six diseases, and the whole six pavilions
are in full occupation. Each patient has
2000 cubic feet of room. It will, therefore,
be easy to see how the " fever " of the old
days is now split up in order that it may be
conquered.

66 HEALTH AND DISEASE

^

In the first block, where scarlet fever is
housed, there are a score of children, varying
in age from two upwards ; possibly one or
two adults. It is a fair index of the pro-
portional incidence of the disease. Here is
a school child of ten, just admitted. His face
is flushed, but there is no " rash " on it. His
hands, arms, chest, body, and lower limbs,
however, all show a bright red eruption, —
the rash of scarlet fever. He has some
difficulty with his breathing ; for his throat
is much inflamed and his tonsils swollen.
His eyes, too, are congested. He is excited,
but feeble. His pulse runs at a high rate.
His temperature has gone up to 103° F. or
104° F. It will remain near that figure for
a day or two. The rash will fade away in
forty-eight hours. The throat will grow less
painful. Any discharge from the nose wi'l
diminish. The pulse will slow down. Ii
perhaps four days he will be back, apparentl}',
to his normal state. A new process, howevei',
begins. The skin, formerly so bright red, is
now pale and dry. Within a week, some-
times much earlier, sometimes later, it begins
to be shed. The shedding goes on until the
face, neck, body, arms, legs, and even the
hands and feet are completely cleared of the
old skin. The process may take weeks.
Through all this period the patient is ex-

FEVER AND EPIDEMICS 57

tremely susceptible to cold. He may develop
complications ; the kidneys may become
inflamed, and death from dropsy may result.
But, if all goes well, he is out of bed, out ol
ward, and out of hospital well within six, seven,
or eight weeks.

Every year tens of thousands of British
children run through this history. They die
at the rate of some 3 per cent, of all those
affected. In the old days, the death-rate was
higher ; but we are not certain whether the
disease was quite the same. Possibly it was
" a mixed infection " ; as typhus and typhoid
were rolled into one, so possibly scarlet fever
and some other virulent infection went
together. In modern days, severe cases
frequently occur; but, for the most part, the
cases are mild.

You ask how this child was infected.
Possibly, he drank infected milk. Possibly,
he caught directly the infective discharge
of some other patient ; but whatever the
immediate origin, there is always " the one
before." From thirty-six hours to three, four,
or five days after he " catches " the infec-
tion, he shows the symptoms in the sequence
described.

We pass now to the typhoid pavilion.
Three weeks ago this woman was niu-sing a

68 HEALTH AND DISEASE

1

case of known typhoid fever. A week ago
she began to suffer from bad headache ; her
temperature began to rise ; in three days it
had reached 104° F. She is now at the end of
the first week after the onset of the disease,
the invasion. The temperature remains high,
falhng a httle in the morning, rising again at
night. For three weeks it will continue so.
Gradually, while maintaining the same vibra-
tions night and morning, it will on the whole
slowly subside, until in the fourth week it will
be once more normal. Meanwhile, the patient
suffers little pain, but great prostration. She
has to be kept on a rigidly limited diet ;
because the bowels are ulcerated and much
food might be dangerous.

The disease is due to a specific germ, which
may be swallowed with milk, or water, or food,
and must have come from a previous case.
Within six weeks of the onset of the illness,
this woman will be well, but profoundly
feeble. Mentally, she may suffer for a time ;
for delirium is a common symptom of the
disease, and it may be followed by temporary
feebleness of mind. In France, typhoid fever
is looked upon with much alarm ; for it is a
common starting-point of functional nervous
diseases. Any shock, or fright, in the period
of feebleness may, without the after knowledge
of the patient, result in serious nervous

FEVER AND EPIDEMICS 59

disturbances that may affect the whole after
life. These results are not common in this
country ; but they indicate the need for
careful nursing and the greatest attainable
quietness and peace.

But there may be another result. The
patient herself may recover ; but she may
continue to be infectious. In her excretions
the bacillus of typhoid fever may remain active
for weeks, for months, for years. In a word,
she may become " a carrier case." Immune
to the disease herself, she will remain
capable of infecting others. She will harbour
in the liver (in the gall-bladder) an innumer-
able host of typhoid germs. From time to
time these will pass into the blood or the
bowel and afterwards be diffused just as if
she still suffered from the disease.

It is only some five years ago since this
condition was thorouglily understood. At a
certain Continental restaurant every new
servant that came took typhoid fever. There
was nothing in the water, in the milk, in the
food, in the sanitation of the house to account
for the occurrences ; but the head of the
establishment had some years before suffered
from typhoid. She was still infectious. The
case was carefully studied, and scores upon
scores of such cases are now on record.

The carrier case accounts for many ap-

60 HEALTH AND DISEASE

parently unaccountable outbreaks of typhoid
fever. Murchison, the greatest English
authority on typhoid and typhus, held a
theory that typhoid fever could originate
from uninfected filth. In the days before
bacteriology, such a theory was justifiable
provisionally ; now that the germ and the
carrier case are known, the hypothesis is
superfluous. The carrier case presents very
difficult administrative problems ; but the
experts are busy at research, and the prospects
of a radical cure are already promising.

Incidentally, let it be said that the carrier
case is not confined to typhoid fever. It
may occur in scarlet fever, in diphtheria, in
cerebro-spinal fever, in tuberculosis, and
possibly in several other infections. In all
those named, such cases have been demon-
strated. Patients that recover from those
diseases may carry germs with them and
hand them on to infect others. But it is
not even necessary that the carrier should
himself have had the disease. He may have
caught the germ from another ; he may
carry it about with him, growing in his nose
or throat, harmlessly ; he may hand it on to
a third person, and so maintain the continuity
of the disease. This gives a new significance
to the " contacts " — the persons exposed to
infection. Of these, some are perhaps immune

FEVER AND EPIDEMICS 61

to the given infection, but they are capable
of cultivating the germ on their tissues.
Others may catch the disease and remain
infectious. Yet others are incapable either
of catching the disease or maintaining the
germ of it alive. But all three classes must
be dealt with if the radiations of the disease
are to be stopped.

From these we might pass to the measles
cases, or the chickenpox cases, or the cerebro-
spinal cases, or the mixed infections like
scarlet fever and diphtheria, or scarlet fever
and chickenpox, or measles and scarlet
fever. But we have already seen sufficient
to give us the type of an infectious fever.

It so happens, however, that there is
typhus in hospital to-day. Typhus now
comes only in little outbreaks. It is an infec-
tion easily killed. It never goes far. Here is a
group of severe cases, of whom the forerunner
was a supposed case of pneumonia. The
two diseases are totally distinct, but they
resemble each other in some symptoms.
Sometimes they are concurrent. In this
outbreak the supposed pneumonia must have
been typhus. The patients lie on their back ;
muttering to themselves ; picking at the
bedclothes ; faces flushed ; eyes closed ; heed-
less ; helpless. There is an eruption of very

62 HEALTH AND DISEASE

characteristic type. There is, too, an offensive
odour. The patients will lie in the same
attitude for days on end.

Here is one on the fourth day of her illness.
Some twelve or thirteen days before the inva-
sion began, her brother had died of supposed
pneumonia. Her temperature ran rapidly
up to 104° F. or 105° F., and has kept near
that level for the four days. If she lives, the
temperature will continue high until the
thirteenth or fourteenth day, when it will drop
in a few hours to normal. Every symptom
will have disappeared, and the delirious,
oblivious patient will come to herself, clear-
minded and smiling.

This sudden transformation I have seen
many times. The whole violent invasion
ends as rapidly as it began. It is a raid oi'
microbes. Too often it destroys the life.
Children sleep through it peacefully ; the
middle-aged and the old mostly die. With
the exception of smallpox, the disease is
probably the most infectious of all infections
known to the West. Repeatedly, it has been
suggested that it is transferred by fleas. It
will strike through the air at as great a
distance as a flea jumps. It is certain that,
whatever the virus be, it does not live long
in the air. The flea hypothesis needs proving ;
but it has much in its favour.

FEVER AND EPIDEMICS 63

Typhus, I have said, is often mistaken for
some other disease. I have seen it mistaken
for the following : influenza, meningitis,
pneumonia, typhoid fever, bronchitis. No
disease vanishes more rapidly under preventive
measures ; but the swiftness of its spread,
the difficulty of recognising it, its origin in
filth, squalor, overcrowding, and destitution
all make it somewhat difficult to handle ad-
ministratively. And the danger to life is
great. Unlike smallpox, it cannot be warded
off by vaccination. Unlike typhoid, it spreads
swiftly by the air, whether carried by fleas
or not. Unlike diphtheria, it is not located
in any special part of the body ; it is a diffused
infection. But, as we have seen, it has
vanished from its place at the head of fatal
epidemic diseases, and now recurs here and
there, to remind us that there are slums in
town and county still to be destroyed.

Fevers, it is now seen, have been parcelled
out into perfectly definite classes. From
these classes some inferences are possible.
The infectious fevers are no longer a shapeless
mass of unexplained signs and symptoms ;
they are a group of specific diseases. Each
of them has a natural history of its own. Each
of them can be tracked separately along its
whole course. Each of them is treated in

64 HEALTH AND DISEASE

1

the ways adapted to its habits. But, separate
and specific though they are, these diseases
have certain common features. These it is
important to know ; for they are the general
guide both to theory and to administration.

The infective agent always comes from
without. It may be a minute rod-shaped
plant (bacillus), as in diphtheria ; or an
organism of higher grade, as in malaria ; or
a form unknown, as in smallpox, typhus,
scarlet fever, measles, chickenpox, and many
others. That in every case it is an organism
with a life-history of its own, there is no
reasonable doubt. The science of bacteriology
is still young ; but it has discovered hundreds
of unsuspected germs, — unveiling their life-
histories by observation and experiment, and
proving whether they are disease-producers or
not. Though but partially verified, the germ
theory may be accepted at least provision-
ally. The diseases, like smallpox, whosa
germ is yet unrevealed, behave precisely
like those whose germ is known. But, germ
or no germ, the general features of infection
are always the same.

The infective agent, then, always comes from
without. It may be breathed in with the
dust, as probably in smallpox. It may be
swallowed with water, as often in enteric
fever. It may be swallowed with milk, as

FEVER AND EPIDEMICS 65

often in enteric fever, scarlet fever, diphtheria,
and tuberculosis. It may enter the blood
through a scratch in the skin, as in anthrax,
or in blood-poisoning from a pricked finger.
It may be injected by a flea, as probably in
plague. It may be injected by a mosquito,
as certainly in malaria and yellow fever. It
may be growing for months or years in the
mouth, as probably the pneumococcus does ;
for Professor Osier, in a vast number of
examinations, found the pneumococcus
present in practically every mouth examined
except the mouths of the tobacco-chewing
negroes. Or again, the infective agent may lie
harmless for a period in the nose, as probably
in cerebro-spinal fever and possibly in ery-
sipelas. Sometimes the infective agent enters
by one channel, sometimes by another, even
in the same disease.

The channels of infection are a profoundly
difficult problem in pathology. No subject
excites more interest at medical conferences ;
none creates a more acute division of opinion.
Is the germ of tuberculosis breathed into the
lungs, and does it start its nefarious course
there ? Or is it swallowed with the dust,
entering the blood - stream through the
bowels ? The practical consequences are far
from unimportant. If it enters directly
into the lungs, the time of its reappearance
c

66 HEALTH AND DISEASE

in the material coughed up has one mean-
ing,— the presence of the germ would be
an early symptom. If it enters indirectly
through the bowel, passing by the lymphatic
channels into the blood-stream and ending in
the lungs, its reappearance in the material
coughed up would have another meaning, —
the presence of the germ would be a late
symptom. And so with endless variations
for each of the infections. For years to
come, the precise channel of entrance for
many diseases will remain a problem. In
plague, for instance, one of the most difficult
parts of the late Royal Commission's work was
the determination of the channel of entry.
It is fascinatingly simple to assume that,
as millions of Indian natives go bare-footed,
the rat fleas would most readily attack the
lower limbs, and the buboes of plague would
most frequently appear in the groin. But
this solution is almost too easy. How
complex the problem is any one may learii
from the pages of the Commission's Report..
Sir Thomas Eraser's analysis of the anatomy
of the lymphatic glands or lymphatic vessels
is a classic piece of applied science. It shows
how many factors enter into a problem
apparently simple. The general drift of
recent information is that the rat flea does
convey plague from the rat to man ; that it

FEVER AND EPIDEMICS 67

does inoculate the lymphatics, and that a
proportion of the innumerable cases is
due to this cause. We leave the question
open ; it will soon be closed by the
evidence now accumulating. Already, the
evidence is enough to require that every
precaution shall be taken against rat fleas
and rats.

Volumes have been written on the channels
of infection. Here we are concerned only
with illustrations. But it is definitely proved
that malaria is spread by a particular species
of mosquito and by no other means ; that
yellow fever is spread by another form of
mosquito, and by no other means ; that
flies, on their feet, may convey typhoid and
other germs for long distances ; that rat
fleas can convey plague from rat to rat, and
almost certainly from rat to man ; that
many species of tropical insects can inoculate
the human body with deadly diseases. The
massed details of the splendid researches
that justify these conclusions have opened
up for us an illimitable field for further
investigation. To biology preventive medi-
cine owes as much as to the study of disease
at the bedside.

The infective agent, once it enters the
body, seems for a time to lie dormant. This
c 2

68 HEALTH AND DISEASE

is its incubation period. The incubation
may last only a few hours, as occasionally in
scarlet fever. It may last for twelve or
thirteen days, as in typhus fever, or measles,
or smallpox. It may last for twenty-one
days, as in mumps, and, occasionally, in
typhoid fever. It may last for four, five,
or six weeks, as in syphilis. It may last
for a period unknown, as in hydrophobia.
Even in the same disease, it varies from a few
hours to several days, as in scarlet fever,
where, however, it practically never exceeds
five days.

In diseases like pneumonia, or diphtheria,
it is difficult to give a precise meaning
to the term incubation. For, in those
infections, the germ may grow in the
mouth or in the tonsils for weeks or
months without producing a single per-
ceptible symptom. In tuberculosis, too, the
germ may go on growing in the tissues of
the body for years without producing one
sign discoverable by naked-eye observation.
And the term incubation does not seem to
fit well to the history of a recurrent fever
like malaria. There, the infective agent at
once enters the blood-stream, affects the
blood corpuscles, running through a series of
changes that end in fever, and then again in
a period of quiescence. The process comes

FEVER AND EPIDEMICS 69

and goes in ascertainable periods. But for
none of the periods does the term incubation
seem suitable.

The infective agent, I have said, seems to
lie dormant. But it is only " seems."
Perhaps it is growing, as in a laboratory-
incubator, until it has amassed numbers
sufficient to make an attack in force. Pos-
sibly this occurs in diphtheria, where the
germ may often be found in masses on the
surface of the tonsil. Or, perhaps, it is
actively breaking down the natural defences
offered by the blood cells, the blood liquids,
the tissue cells and the tissue liquids. These
all probably contain or produce antidotes
to those living poisons. Once the antidotes
are all exhausted, then the germ may ad-
vance freely, conquering and to conquer.
It may increase in numbers until the dose of
its poison overwhelms millions of the body
cells. Then, indeed, the incubation is over ;
but is incubation the best name for this war
between two species ?

Or, once more, the infective germ, having
lost its virulence in passing through another
body, may need nursing and nourishment
before it can deal a blow at a new enemy.
Or, yet again, it may enter a body where
it is biologically welcome, or not ex-
ceptionally unwelcome. In a group of

70 HEALTH AND DISEASE

smallpox cases, all in one family, I have
seen every grade of infection from a single
doubtful spot on the skin of the youngest
child, to a well-marked eruption on an
older sister. Between the two extremes
lay other cases that showed what the ex-
tremes meant. In one case appeared an
eruption that seemed to be the forerunner
of a violent confluent smallpox ; but in
forty-eight hours this eruption disappeared.
In another, some thirty trifling pocks formed
and slowly disappeared, — a modified small-
pox. Is incubation the name for the pro-
cess that had an issue in each case so different ?
Surely not. Probably the incubation period
covers a various multitude of active processes,
each peculiar to the given disease. It may
even be that the germ is actively immunising
against itself the whole tissues of the body,
and that the final outburst that we name " the
disease," the " fever," is only a too rapid, too
violent process of immunisation.

These are some of the puzzles that cluster
round the incubation period. They are a
type of innumerable problems that have
sprung up since the germ theory appeared.
They complicate the study of medicine ; but
they show how intricate the adaptations of
the body are to the infinitely various environ-
ment. But the increasing application of

FEVER AND EPIDEMICS 71

theories does on the whole result in an in-
creasing simplification of practice.

Let us pass on. When the incubation is
over, the invasion begins. The temperature
rises, there is shivering, distress, perhaps
vomiting, perhaps even convulsions. In a
time that varies from an hour or two to three
days or more, the invasion is complete. The
temperature remains at a certain level ; the
pulse and the respiration keep company
with it.

Perhaps the invasion means, as I have
said, the beginning of the last stage of the
war. It is different in each disease. In
typhoid fever, it is shown perhaps only by
a headache. In smallpox, it often begins
with pain in the back. In diphtheria, it
often starts with sudden prostration. In
scarlet fever of infants, it may produce con-
vulsions. In practically every disease, it is
something violent and striking, even to the
most casual observer. With the invasion,
too, begins, as a rule, the period of active
infectivity. Before the invasion the infected
person is not himself infectious. You can
eat with him, and drink with him ; but you
will not catch infection from him. After
the invasion, it is entirely different ; he is a
danger to his fellows. It is then that he

72 HEALTH AND DISEASE

m

invokes the public health service. In ignor-
ance, he may have caught the infection ;
but after the invasion, he remains in ignorance
no more ; he is sick physically and mentally.
Like a man intoxicated, he finds his ideas in
confusion, his will overpowered, his feelings
beyond his control. He is glad to have done
with action and thinking ; he is content to
leave himself to the care of his friends.

Once the invasion is over, the patient runs
a more or less level course for times that
vary with each disease. If he has lost con-
sciousness, he occasionally, for short periods,
recovers it. If he has not lost consciousness,
he establishes a sort of relative health on the
new plane. If the disease goes favourably,
he gradually regains the mastery of himself.
Sometimes he suddenly drops to normal ;
sometimes he glides into it imperceptibly, like
an alighting bird. The fight between the
infective agents and the tissues is done, and
the victory is with the greater organism.
The danger to himself is over ; but the
danger to his fellows is not. If the disease has
been smallpox, the infective agent reappears
in the gross, palpable eruption, which forms
large scabs on the skin. The scabs dry and
crumble into dust. The dust passes into the
air, or is scattered over the room, or is caught

FEVER AND EPIDEMICS 73

in the clothing, or adheres to utensils. In a
hundred ways, it is spread abroad once more.
Every grain contains fresh infective material.
So long as a scab remains on the skin the
patient remains a danger. But the day
comes when all the scab drops off, when the
skin can be finally disinfected, when the
patient may with safety resume his place in
the ranks of society. And so it is with nearly
every infection. Through all the time of
its activity there is danger. But each disease,
as it had a definite beginning, has a definite
end. The infective agent comes in, fights
with the forces against it, and at the end
passes out — perhaps in greater multitudes,
but almost always for ever.

And that leads to an important truth, — some
infections infect only once and never again.
This knowledge is as ancient as history. The
explanation of it is still to find. Of the fact,
however, there is no doubt. Take smallpox
once and you will not take it again — or almost
certainly not ; for there are known excep-
tions. Take scarlet fever and you will prob-
ably not take it again. Take measles and
you will probably not take it again. Take
chickenpox and you will almost certainly not
take it again. Is this true also of diphtheria,
or enteric fever, or typhus, or malaria, or

74 HEALTH AND DISEASE

^

plague ? It is not true absolutely, but it is
partly true. In most of those diseases, one
attack absolutely protects against another
for a varying time. The conditions of pro-
tection are not yet completely investigated.
The problem is among the most difficult in
the whole range of biology.

The theories of protection or immunity
are not merely fascinating ; they are of great
practical importance. They deserve our
attention. For, if one thing marks more
distinctively than another the research of the
present generation, it is the effort to discover
the conditions of immunity. The fact is
old ; the methods of investigating it are
young. Inoculation with mild smallpox to
forestall severe smallpox is a custom cen-
turies old. Vaccination is more recent, bui:
the fundamental idea is the same. To thes(j
theories we return later.

In one of the Acts of Parliament, diseases
are divided into epidemic, endemic, or in-
fectious diseases. The division is not logical ;
but it is convenient. When a disease foreign
to the country, or non-existent at the time
in any community, enters and spreads among
the people, it is called epidemic. The word
is also loosely used to describe any large out-
break of disease, infectious or other. When

FEVER AND EPIDEMICS 75

a disease propagates itself within an area,
persisting there indefinitely, affecting person
after person, it is called endemic. Up till
late in the nineteenth century, malaria was
endemic in England ; tuberculosis is endemic
now. These terms are in common use ; and
the legal application of them has had great
practical consequences.

Under certain powers the Local Govern-
ment Board can impose certain far-reaching
obligations upon the local health authorities —
notification of disease, house to house visita-
tion, rapid burial of the dead, provision for
hospital accommodation, supply of medicines
and treatment, and any other duties necessary
to prevent the spread of the disease. These
powers are of immense value internationally ;
for, as will be shown later, they constitute
our chief protection against the importation
of plague, cholera, and yellow fever. Nation-
ally, to judge by the recent Tuberculosis
Orders of the English Local Government
Board, they promise to become a potent
factor in the prevention of our great
endemics.

To illustrate compactly an epidemic of
infection is difficult ; for the conditions of its
actual occurrence are so complex that the
details are apt to interest only the individual
officer. But the general course of an epidemic

76 HEALTH AND DISEASE

^

may be represented by a curve. Assume
that a scarlet fever patient moves about
uncontrolled. He meets in every relation
of society some people susceptible to the
disease. He thus infects several, who in turn
infect others. As time goes on, the numbers
infected increase ; the curve rapidly or
slowly rises. A time — weeks, months, years
— comes when all the susceptible people in a
community have contracted the infection.
Gradually, the curve declines, and at last
again reaches the level. If the death-rate
alone, not the disease-rate, be taken as the
index, the curve will also, periodically, rise
into similar epidemic peaks. When the
epidemic is over, another crop of susceptible
people begins to grow. When their number
reaches a certain ratio to the whole population,
there is apt to be another explosion.

In a milk epidemic, the course is some-
what different. Instead of spreading from
person to person, the disease spreads suddenly
in the milk. Twenties and thirties may be
infected in a single day. These tend to start
sub-epidemics among their contacts, and so
we have a compound epidemic. In water
epidemics, it is the same ; the outbreak is
sudden, and it ends rapidly when the water
is withdrawn or sterilised. Milk and water
epidemics resemble wholesale poisonings of

FEVER AND EPIDEMICS 77

the susceptibles rather than infection from
person to person.

But, generally, an epidemic follows one
type, — sudden appearance of infection from
beyond the borders of the community ; a
series of severe illnesses linked one to the
other or to a common source ; a sudden
cessation of the epidemic when the source is
discovered and countered by appropriate
measures ; some deaths ; many survivals,
protected for years or for life.

Endemic infectious diseases tend to rise,
from time to time, into epidemics. Scarlet
fever, at its lowest in April, rises steadily to
November and then declines. Enteric fever,
at its lowest from May to July, rises to
November and similarly declines. Measles, at
its lowest in February, rises above its normal
in June, falls to its lowest in September,
and reaches its climax in December, declining
again in February. Whooping-cough rises
in January, to a climax in March and April,
falls to a minimum in September and October,
and then rises again. The course of smallpox
is somewhat the same. Diarrhoea reaches its
maximum in July.

These seasonal variations may be com-
plicated by the conditions of industry, aggre-
gation in schools, the activity of the preventive
authorities, and other incidental factors.

78 HEALTH AND DISEASE

^

But the rises and falls with the seasons show
how each disease follows its own natural
history.

If you wish to study epidemics in detail,
as they are managed by the sanitary authori-
ties of England, procure the reports of the
medical inspectors of the Local Government
Board. These, in a series extending over
many years, illustrate, in endless variety, the
methods of preventive medicine in dealing
with disease and its causes. Studies on a
larger scale are to be found in the reports by
the medical officer of the Board. Unfortun-
ately, there is no difficulty in obtaining
accounts of actual epidemics ; for the reports
by the medical officers of health of town and
county have still to record scores upon scores
of outbreaks every year. And reports by the
medical inspectors of schools add to our
materials, already too great.

Biologically, it fascinates the observer to
study the fight between the minor organism
and the major ; administratively, it often
exhausts the medical officer of health to
dissociate the combatants. But, as time goes
on, the biologist becomes more of a medical
officer and the medical officer more of a
biologist.

A TOXIN AND ITS ANTITOXIN 79

CHAPTER V

STUDY OF A TOXIC INFECTION AND ITS
ANTITOXIN

What is diphtheria ?

For Biology, it is an incident in the hfe-
history of a micro-organism — the Klebs-Loffler
bacillus — during its residence in a human or
other animal body.

For Chemistry, it is a means of generating
two, if not three, kinds of poison — one kind
a ferment, another an albumose (allied to
albumen or white of egg), and the third an
organic acid.

For Pathology, it is a sequence of tissue-
changes, beginning usually in the throat
and ending in the muscles, nerves, or
other structures ; so causing nerve-degenera-
tions, muscle-degenerations, local and general
paralyses ; these conditions being the result
of the poisons manufactured by the Klebs-
Loffler bacillus.

For the Practice of Medicine, diphtheria is
a disease of the throat, very frequently fatal,
most frequently fatal in children under five,
running an indefinite course, liable to recur,
frequently attended by complications ; affect-
ing both the local organs and the general

80 HEALTH AND DISEASE

constitution, sudden in onset, treacherous in
results, sometimes as easy to treat as a bleed-
ing finger, at other times baffling every resource
of the most skilful.

For Hygienics or Public Health, diphtheria
is a highly infectious disease, liable to spread
chiefly by personal contact ; varying with the
yearly rainfall ; apt to become epidemic after
a series of dry seasons ; not demonstrably
connected with bad drains or bad water, but
frequently with low-lying and damp houses ;
capable of being carried by milk, by clothing,
by dust, by cats, by cows ; sometimes associ-
ated with crowding in schools ; always capable
of being confined by isolation.

The precise scientific knowledge of diph-
theria is essential to an intelligent campaign
for its prevention. I propose, therefore, to
order my remarks according to the sciences
I have named. Our study will thus be at
once theoretical and practical, a synthesis of
science and administration. But first I shall
steady our minds by a short account of a
concrete case. It occurred sixteen years
ago, when antitoxin was still a new drug on
its trial, not the seasoned friend it has since
become.

One morning a medical practitioner, as
required by the Infectious Disease Notifica-
tion Act, intimated at my office a case of

A TOXIN AND ITS ANTITOXIN 81

diphtheria. He had that morning, at seven
o'clock, been summoned to a girl of eight.
He found her suffering from great difficulty
of breathing (croupy symptoms), pallor of the
face, blueness of the lips, subnormal tempera-
ture, feeble pulse. She had been ill for a
day or two at least. Emergency remedies
rallied her somewhat. There was a large
membrane covering the whole of one tonsil
and extending over part of the soft palate.
This was at 9.30 a.m. The case was forthwith
removed to hospital. By 11 o'clock she was
washed, warmed, and in bed, enjoying the
comfort of hot bottles and the soothing in-
fluence of a steam-kettle and tent. By this
time her pulse had somewhat improved,
the croupy symptoms were lessened, and the
medical attendant, who wished to see the
injection of antitoxic serum, declared her con-
dition somewhat improved. The membrane
on the throat was one of the worst I
have seen, coming away in large pieces and
renewing very rapidly.

The next step was to verify the diagnosis,
of which, however, there was no real doubt.
Accordingly, I did not delay treatment.
But a piece of membrane was detached, with
the usual precautions, and put in a test-tube
for examination by a bacteriologist.

Then, with every care against accidental

82 HEALTH AND DISEASE

contamination, a dose of antitoxin was ad-
ministered. Next day the membrane was
not visibly altered. A second dose was given.
On the third day the membrane was more
easily detached. All croupy symptoms had
gone. A third dose was given. The mem-
brane completely disappeared. By the fourth
day of treatment the throat was free of any
sign of the disease. Local treatment was
continued until there were no diphtheria
bacilli left. The patient was, in due course,
discharged. She showed no signs of paralysis.

Meanwhile, the hygienic forces had not
been idle. The house, bed, bedclothes, body-
clothes, and other articles exposed to the
infection had all been disinfected in the usual
way.

This case shows how the public health
organisation combines the various sciences
to extirpate the disease and to preserve life.
I shall now present, in more detail, the rational
basis of the procedure.

That the Klebs-Lofiler bacillus — a minute,
rod-shaped organism — is a factor in diphtheria
no one seriously disputes ; whether it is the
whole cause, whether the chemical condition
of the tissues is equally important, what
precise part the glandular tissues of the
throat play, and many other problems, are

A TOXIN AND ITS ANTITOXIN 83

still matters open to argument. The Klebs-
Loffler bacillus is at least a good diagnostic
sign ; in doubtful cases it is the only early
definite sign, and any physician who finds
the micro-organism in a suspicious sore-throat
is incurring a very grave responsibility if he
fails to use the recognised methods of destroy-
ing it and its poisonous products. In matters
of doubtful theory, it is well to give one's
patient — not one's own prejudice — the benefit
of the doubt

This micro-organism can be isolated from
the diphtheritic membrane ; it grows readily
in blood serum, or other suitable medium,
at 95° Fahr. to 98-6° Fahr., — that is, at about
the temperature of the body, — and with the
products of its activity diphtheria can be
produced. In milk at this temperature the
bacillus grows luxuriantly. " The diphtheria
bacilli," says Klein, " are killed by heating
to 60° Centigrade (i.e. 140° Fahr.) for five
minutes." This bacillus affects rabbits,
pigeons, cats, dogs, horses, calves, and milk
cows. In the last — Klein holds it as proven
— a form of pure cow diphtheria can be
produced, and frequently is produced ; the
eruption so caused on the teats may infect
the milk, and thus may arise an epidemic
of true human diphtheria. When the micro-
organism alights on the human throat in an

84 HEALTH AND DISEASE

inflamed, or irritated, or raw, or ill-guarded
conditiovX, human diphtheria is the result.

Dr. Sidney Martin has determined the
nature of the diphtheria poisons. The
bacillus of diphtheria produces two orders of
poisons — one found in the throat membrane,
the other in the tissues, blood, and spleen
of patients dead of diphtheria. The poison
of the membrane acts probably as a ferment ;
at least, a single dose produces progressive
paralysis, wasting, diarrhoea, and death.
Examination after death shows nerve-de-
generation, fatty degeneration of the skeletal
muscles, and fatty degeneration of the heart.
These results Dr. Martin has proved on
warm-blooded animals such as rabbits. The
other poisons — those found in the tissues —
are similar to the substances produced by
digestion in the stomach and small intestine.
Being peculiar derivatives of albumen, these
poisons are named " albumoses " — a. class
of physiological substances whose nature
has been studied only within the last twenty-
five years or so. The albumoses of diph-
theria cause a rise of temperature (fever),
increasing paralysis, difficulty of breathing,
wasting, diarrhoea, nerve-degenerations, fatty
degeneration of the heart, and fluidity of
the blood after death. Some of these results

A TOXIN AND ITS ANTITOXIN 85

follow the injection of other than diphtheritic
albumoses. The ferment present in the
membrane, on entering the body, acts on
certain substances, and converts them into
the albumoses mentioned. All the poisons
are, therefore, directly or indirectly the
result of the bacillus acting on special sub-
stances. The third poison — organic acid —
produces certain nerve - degenerations, but
not progressive paralysis.

Now, by the cultivation of the bacillus in
appropriate media, all these poisons can be
produced outside the body altogether ; they
can be injected into the veins or tissues,
and the results produced are the same as
in true diphtheria. With these results
before him. Dr. Martin concludes : " For
these reasons, therefore, the bacillus diph-
therise is the cause of diphtheria. . . . When
the membrane is formed, the bacilli grow
in it, especially near the surface, secrete
a ferment which, when absorbed into the
body, produces, by acting on the proteids
of the body, digestive products, the chief
of which belong to the albumose class. It
is not that the body is poisoned by a single
large dose, and then the action stopped
(although this may occur in certain cases),
but it is that numerous small doses are,
in the course of the disease, absorbed into

86 HEALTH AND DISEASE

the system, and are gradually producing
their effects." The action of these poisons,
or toxins, it is that the antitoxin has to
counteract. Dr. Martin's experiments on its
power of counteraction are, so far as they
go, equally decisive. His general conclusion
is : " These experiments . . . tend to show
that the antitoxic serum is capable of
counteracting the poisons which are found
in the tissues of patients dead of diphtheria.
It has only a slight effect on the febrile rise
of temperature produced by the albumose,
but it completely counteracts the fatty
degeneration of the heart produced by those
substances, and to a great extent also the
nerve-degeneration." Fifteen years of re-
search have confirmed and extended these
conclusions.

The case I have already described shows
what part falls to the practical physician.
The treatment of diphtheria all over the;
world is now based on the biological,
chemical, and pathological results I have
summarised. The physician's aim is two-
fold— first, to destroy the bacillus in the
throat, and so to arrest the formation of
the three orders of poisons ; second, to
counteract the effects of the poisons (or
toxins) already absorbed. The longer the

A TOXIN AND ITS ANTITOXIN 87

disease has been allowed to go on the less
chance there is of a cure, because the poisons
act rapidly and may produce organic changes
that are beyond cure.

For local treatment — that is, the destruc-
tion of the bacillus — a whole multitude of
germicides have been recommended ; cures
have been claimed for them all, doubtless
with more or less justice ; but there is hardly
one that, in other hands, has not resulted in
keen disappointment. Much depends on the
competence of the nurse. One solution was
devised by Loffler himself. He experimented
until he discovered a combination of drugs
that could, without injuring the mucous
membranes of the throat, destroy the Loffler
bacillus in five seconds. Many reliable
drugs could destroy it in twenty seconds
or more. But this length of time made a
proper application to the throat difficult.
Loffler's solution has been in common use for
many years. Loffler himself, when he intro-
duced it, recorded that in ninety-six cases so
treated there was not a single death. This
is a good record, and he refers to cases in the
early stage and markedly local. But even in
these, one may fail from incompetent handling.
But all such local treatment is immeasurably
more satisfactory than sixteen years ago ;
for the patient is first made safe with anti-

88 HEALTH AND DISEASE

toxin, and local treatment is no longer needed
for cure, but simply for the preventing of
fresh infection.

In the sixteen years that have passed since
this case occurred, the use of antitoxic serum
has spread all over the world. Cases in
hundreds of thousands have been treated.
The technique of dosage and injection have
been improved. Thus in a severe and late
case one very large dose is usually better than
several small doses. The serum is also
coming more and more into use as an immunis-
ing agent in advance. The death-rate from
diphtheria has continued to fall. Diphtheria
has lost much of its terror and all its hope-
lessness. To take but a single figure from
the Statistical Reports of the Metropolitan
Asylums Board. In 1894, the non-anti-
toxin days, of all the cases brought to all the
hospitals for treatment on the first day of the
disease, 22-5 per cent, died (133 cases, with
80 deaths). In the years 1895-96, the days
of antitoxin, of all the cases brought on the
first day for treatment, 3-8 per cent, died
(209 cases, with 8 deaths). The difference
between the methods when treatment is
delayed is less striking, but it is well on the
side of antitoxin. For instance, of 539 cases
treated on the second day, 27 per cent, died
under non-antitoxin treatment ; of 1126

A TOXIN AND ITS ANTITOXIN 89

cases, under antitoxin treatment, 12 per cent,
died. In Chicago, in 1895, antitoxin began
to be freely administered to the poor in their
homes. The death-rate fell from 35 per cent,
to 6 per cent. And the low death-rate has
been on the whole maintained. Both in
England and in Scotland, the Local Authori-
ties for public health, with the consent and
active approval of the Local Government
Boards, have power to provide antitoxin
free to every person suffering from the
infection or requiring a protective dose.

The antitoxin of diphtheria has thus stood
the most rigid tests both of laboratory experi-
ment and of practical use. It has done more.
It has led to the production of other anti-
toxins, whose use is only less known because,
in this country, the diseases are less common.

Environmental factors always play a part
in outbreaks of infection. In diphtheria,
personal infection is, no doubt, the chief
cause of spread. The bacillus is easily con-
veyed from the patient to any persons in his
immediate neighbourhood. Indeed, it is
probable that the chief reason why the num-
ber of cases occurring still remains so high is
that " contacts " are not yet as thoroughly
examined as in the great infections like
smallpox and typhus. As the medical in-

90 HEALTH AND DISEASE

1

spection of school children comes to closer
grips with personal infection, the contacts of
diphtheria will be as radically examined
as those of smallpox, and diphtheria will
receive another check.

But there are other factors, not least the
type of season. It has been shown by Dr.
Newsholme that " an epidemic of diphtheria
never originates when there has been a series
of years in which each year's rainfall is above
the average amount. An epidemic of diph-
theria never originates or continues in a wet
year . . . unless this wet year follows on two
or more dry years immediately preceding it.
The epidemics of diphtheria for which accurate
data are available, have all originated in dry
years."

The practical deduction from these con-
clusions is that diphtheria spreads more easilj;
and more harmlessly in dry years, possiblj
because the conditions of the throats are
then less fitted to give it a start within the
body. Let the wet and cold season come,
or let local conditions favour the occurrence
of sore-throats and then we have a wide-
spread and apparently sudden epidemic.
The bacilli are lying on hundreds of tonsils,
ready to grow dangerous when the throat
inflames.

HOW ANTITOXINS ARE PRODUCED 91

CHAPTER VI

HOW ANTITOXINS ARE PRODUCED AND
PREPARED

Fifteen years ago circumstances found
me in London.

" Have you been to The Poplars ? " in-
quired a medical friend.

"No," I answered. "Where is The
Poplars ? "

" The Poplars," he said, " is the name of
the farm at Sudbury in Middlesex where the
anti-diphtheritic serum is prepared for the
Lister Institute. Dr. Blank, from India,
and I intend to drive out there to-morrow.
Will you come ? "

" I should, with pleasure," I said, " but 1
fear my duties will prevent me."

And they did.

But on another day I took the train at
Euston Station. Sudbury lies in Middlesex,
to the north-west of London. From Euston
it is only some eight miles by rail. The
train sweeps you rapidly out of the new-laid
north of London into a purely agricultural
landscape. You pass Willesden, Harrow-on -
the-Hill, and Wembley, until you come to a

92 HEALTH AND DISEASE

1

little country station that seems as far from
London as the Glenkens of Galloway.

When I arrived at Sudbury I asked my
way to The Poplars. The Poplars ? The
first person was not certain ; he bade me
inquire of a carrier, whose horse stood at a
public-house door. Of him, then, I inquired ;
but his knowledge was vague. " I think,
sir, it is about a mile farther on, to the left-
hand side." I walked onwards, over a dusty
road, among rows of tall trees, and I was
saluted everywhere with the charming and
inimitable greenery of southern English
landscapes. At last, guided by the map as
much as by personal inquiry, I came to a
farm — a dairy farm. " No, sir ; The Poplars
is farther on." Every one that answered
spoke of The Poplars in the most common
tone of voice, as if one dairy farm were like
another, and one green field not more than
another green field. They showed no sign
that within stone-throw of their door a
miracle was going forward. The resources
of science and the resources of nature were
here coming to deadly grips, and the victory
was less likely to be with nature than with
science. Here the intellect of an inventive
century was busy among the warp and woof
of life, if haply one patch or pattern might
yield up its secret. The tall trees near me,

HOW ANTITOXINS ARE PRODUCED 93

the green grass farther away ; the farmyard
living things here, the silent farmer there ;
the silent, still life made more silent and more
still by the oppressive contrast with the
tangled noises of London, — all came together
in my imagination as I approached this farm
of mystery, where the man of science, the
Faust of our era, was busy with his alembics
and his books of magic and wealth of learn-
ing that should save man from his sorrow.
And I was reminded of the Spirit's reply to
Faust when he was beginning to handle the
instruments of mystery :

** In the currents of Life, in action's storm,
I wander and I wave;
Everywhere I be.
Birth and the grave,
An infinite sea,
A web ever growing,
A life ever flowing:

Thus I weave at the loom of the years
The garment of life that the Godhead wears."

At last I came on some roadside houses,
which the Time Spirit seemed to treat kindly.
There was The Poplars. I rang, and was
admitted. In the room I recognised books
and photographs and interests that belonged
to my friend when we were at college to-
gether ; and when the first doctor appeared
I found him the same clear-eyed scientific

94 HEALTH AND DISEASE

idealist that I have known and admired for so
many years — a gentleman from South Carolina,
who came to learn the science of medicine
at a Scottish University, and who now, after
years of practical study, was still filling his
mind with more mysteries of bacteriology.
The doctor-in-chief — the director of this
farm — came in about half an hour afterwards.
He also was a fellow-graduate, and a con-
temporary of my own. It did not lessen
the feeling of romance that two of the same
University should have come — one from the
North of Scotland, the other from the
Southern States — to work out together and
help to make the life-saving fluids that then
raised our hopes so high. And more than
ever I felt that here is your true man of
practice : he labours night and day in th(5
light of the pure intellect, adding fact to
theory and developing theory from fact ;
heeding neither day nor night, neither wealth
nor poverty, neither comfort nor pain ; caring
only for the truth and the good it may do.
So long as life can offer us those free minds,
ready to give themselves up to truth and the
service of man, the world is going forward.

The afternoon was a lucky one. A tele-
gram had been received the night before
from Egypt for a supply of serum. Im-

HOW ANTITOXINS ARE PRODUCED 95

mediately on receipt of the telegram, the
horse was bled and the blood subjected to
all the operations necessary to separate off
the serum and maintain it pure. These
operations are very simple, and they apply
to all the serums prepared — to the anti-
diphtheritic serum among the rest. The
horse is bled from the neck in the way familiar
to the veterinary surgeon. The blood is
received into a large flask, perfectly sterilised.
In this flask it is allowed to sit until the
clot separates from the serum. The serum
is then decanted off and filtered through
a Chamberland-Pasteur or a Berkefeld filter,
under pressure of a small air-pump. This
process is very slow ; the serum is more or
less viscid, and, unlike water, it filters very
slowly through the minute pores of the clay
or porcelain. At every stage every pre-
caution is taken against contamination, and
the purpose of the filtration is to free the
serum of any chance micro-organisms caught
in the passage from the horse to the
flask.

The next stage is the bottling, and it was
my privilege to see the bottling of the first
anti-choleraic serum ever drawn from a horse
in Britain, possibly in the world. The pro-
cess is very rapid and very precise. The
two doctors and the laboratory boy take up

96 HEALTH AND DISEASE

their places at a bench, the American on
the left, the director in the middle, the
laboratory boy on the right. Ready to the
hand of the American is a heap of small phials,
perfectly sterilised, and plugged with cotton-
wool. In front of him is the flask of filtered
serum. The flask has a hooded pipette.
Attached to this flask is a blow-pipe bellows
which he works by foot, so forcing the serum
through the pipette. To his right is a bunsen
burner. In front of the director lies a vessel
with indiarubber corks, also sterilised. In
front of the laboratory boy is a vessel of
melted paraffin, kept at boiling point. At a
signal from the director the work begins.
The American snatches a phial ; with a
forceps, which he passes through the bunsen
flame, he removes over the flame the plug
of cotton- wool, instantly places the phial
under the hooded pipette, forces into it the
proper amount of serum, and hands it to the
director. He in turn has already taken up
a sterilised cork with a sterilised forceps ;
instantly he fits the cork into the phial over
the flame, and hands the corked phial to
the laboratory boy. He in turn dips the
corked end into the boiling paraffin and
sets the phial down. These operations are
carried out so rapidly that some 600 phials
may be filled in an hour.

HOW ANTITOXINS ARE PRODUCED 97

After the bottling, the phials are kept in
an incubator for twenty-four hours, and, if
possible, longer. If, at the end of the time,
any one of a set shows the slightest sign
of impurity or microbic life, the whole set
is destroyed. Such is the care taken in
the preparation of these delicate antidotes
to those delicate and remorseless poisons.

Afterwards, I was taken round the farm,
which had twenty-two horses, many rabbits,
and guinea-pigs by the score. Among the
horses the director pointed out the first
pony that had ever yielded anti-diphtheritic
serum in Britain. He had now ceased to
yield any ; but he was kept as an interesting
old friend, and he was quietly enjoying the
life he had so well earned by his blood.

Diphtheria has here a perfectly definite
meaning ; it yields its poison ; it produces
its definite sequences of morbid phenomena ;
it produces its antidote. At every stage
it is under control ; its actions and reactions
can be predicted ; its precise strength can
be measured ; it can be neutralised to a
perfect nicety. I was shown about a pint
and a half of diphtheria fluid, which, so I
was informed, was the most concentrated
and strongest diphtheria poison hitherto
produced in the world. Yet it was in use
there to produce definite, predictable results.

98 HEALTH AND DISEASE

How is antitoxin produced ? It is pro-
duced by slowly immunising a horse against
diphtheria. The process of immunisation
takes five or six months to accomplish.
The dose of diphtheria toxin is increased
slowly, but never so as to put the animal in
danger. At a certain stage the blood and
tissues acquire complete immunity to diph-
theria, and the largest dose of virulent diph-
theria that can be conveniently injected into
the blood will fail to produce the slightest
evidence of disease. It is then that the horse's
blood-serum is ready to be used as an anti-
toxin. The process of preparing it, I have
already described.

If the same course of graduated doses of
toxin could be carried out in the human being,
the same process of immunisation would
result Indeed, such a process of partial im-
munisation probably does result in " carrier
eases " of diphtheria. Diphtheria, it hes
been conclusively shown, spreads from person
to person in the dry seasons ; it grows mildly
in the throat without producing symptoms,
and in the course of its growth probably
confers a certain immunity. Unfortunately,
it is not practically possible so to inoculate
the throat as to graduate the doses and the
partial immunity otherwise occurring cannot
be relied upon. When the child has only

HOW ANTITOXINS ARE PRODUCED 99

hours to live, he must have the benefit of
the most rapid remedy, which is the flooding
of the body with an antidote.

Antitoxins of some other diseases have
been prepared in a similar way. Thus a
horse can be immunised against lockjaw, and
the resulting antitoxin, though it has not
had the striking success of diphtheria anti-
toxin, has shown great curative power.
Lockjaw (tetanus) is probably the most
deadly of diseases, and it is usually well
established before antitoxin can be applied.
An antitoxin, too, has been prepared from
cholera ; but hitherto its success as a cure
has not been established.

The immunity produced by antitoxin is
not permanent. In diphtheria, it passes
away in a few months. A person may have
a second and a third and a fourth attack.
Further, the antitoxin does not itself kill
the bacillus of diphtheria. It is not a micro-
bicide. To inject antitoxin, therefore, is
never by itself an adequate treatment of
diphtheria ; the throat and nose must also
be sterilised ; for, although the patient
himself is made immune, the bacilli can grow
on his tissues and retain all their former
virulence

D 2

^

100 HEALTH AND DISEASE

CHAPTER VII

IMMUNITY — NATURAL AND ACQUIRED

A DIRTY pin-prick may produce an in-
flammation of the finger. What is inflamma-
tion ? Its cardinal marks, recorded from the
most ancient days of surgery, are — redness,
swefling, heat, pain. The pain comes from the
irritation of the nerve-endings. The heat
comes from the increased circulation of hot
blood at the surface. The swelling comes
from the distention of the blood-vessels, the
concentration of blood-cells and exudation
of fluid from the vessels. The redness also
comes from the local increase of the blood
supply. These are familiar facts ; but they
contain some of the most difficult problems
in the biology of disease.

Assume that the dirt on the pin-point has
been a minute round germ, — a micrococcus.
Assume, too, that on the given pin-point
there were some thousands of micrococci.
Their minute size allows us to make the
assumption. For the moment, neglect the
mechanical effect of the pin itself. Let
us attend only to the micrococcus. The
moment it is through the skin^ it begins its
work. Its numbers are soon doubled and

IMMUNITY 101

quadrupled, and rapidly become millions.
To this the blood and blood-vessels reply-
by a series of changes. The minute arteries
dilate ; the minute veins dilate ; the blood-
stream is quickened. After a time, the
blood-stream slows down, and the white
blood-cells, separating from the red, glide
along the walls of the most minute vessels.
At last the stream stops ; the minute vessels
are filled with red and white blood-cells —
the white adhering in many places to the
side of the vessels. Then there is an exuda-
tion of fluid through the vessels into the
tissue. Following this, white blood-cells
squeeze through the vessel-walls and, in their
thousands and millions, gather round the
point of disturbance.

Then the battle between the white cells
and the micrococci begins. Rapidly the
jelly-like cell alters its shape, steadily sur-
rounds one microbe after another, until
its body contains ten, fifty, one hundred or
more. If the conditions are favourable to
the white cells, the battle goes on until every
microbe is absorbed by a cell, until the
exudation, solid or liquid, is all reabsorbed,
and until the circulation of the blood in the
part again becomes normal.

But, if the conditions are favourable to
the micrococci, the issue is very different.

102 HEALTH AND DISEASE

Their numbers may be too great ; then
millions of white cells die in the struggle,
their bodies perhaps breaking up and liber-
ating small quantities of antitoxin. The
micrococci, too, die in their millions; but
their rate of increase is enormous, and they
continue to advance. To meet them come
millions more of the white cells, absorbing
their enemies, digesting them, and producing
the antidote to the microbic poison. If,
at last, the white cell conquers, the process
of repair goes on as before ; but now the
process takes longer, for an abscess, contain-
ing the dead white cells, has been formed, and
some of the fixed tissues have been destroyed.
If the white cells on the outskirts of the
abscess could be examined, they would be
found gorged with micrococci. The rapid
mobilisation of the white cells in response
to the violent stimulus has been enough to
stop the invasion.

If, however, the conditions continue to be
less favourable to the white cells, and more
favourable to the micrococci, the cells may be
killed in millions more, their cordon may be
broken through, and the microbes may pass
into the larger vessels of the body, so caus-
ing a general infection. Even then, the work
of the white cells continues ; in the blood,
it may meet the microbe and absorb it as

IMMUNITY 103

before. In the glands, it does the same ;
everywhere, it goes on devouring the microbes
and producing its antitoxin, until, at last,
the microbe meets its antidote everywhere,
and its warfare fails. If, however, the condi-
tions are still unfavourable to the white cells,
the microbe, dying in millions, produces
more millions to continue the invasion. The
war goes on until every defence is broken
down ; then the slight inflammation of the
pricked finger ends in a fatal blood-poisoning.

What are the conditions favourable to the
white cells ? The conditions are many, but
some are cardinal

The blood has in it some substances that
make it easier for the white cell (or leucocyte)
to take in the microbe. These substances
are the opsonins — the discovery of Sir Alm-
roth Wright. The name opsonin is formed
from the Greek word opson, which means
a sauce, or seasoning, anything that makes
the morsel more tempting. If the blood is
rich in opsonins, the leucocytes, when a
germ whose opsonin is present enters, win
the fight ; for they find the germs, thus
prepared, easy to absorb and digest. And
the opsonins are, possibly, of as many kinds
as the germs that enter. But here there
IS much dispute among experts. Probably

104 HEALTH AND DISEASE

there is a common opsonin, which may, in
some degree, act as a sauce to every microbe ;
but there are certainly special opsonins, and
on these depends the readiness of the special
microbe to be eaten by the leucocyte. To the
eating leucocyte let us also give its technical
name — phagocyte (eating cell).

What are the special opsonins ? They are
probably the opsonins produced by the
action of the special microbe itself. They
are regarded as substances distinct from
toxins.

In diphtheria we saw that the toxin in
the blood results in the production of an
antitoxin. In many other cases, there is a
parallel result. If the lockjaw (tetanus)
toxin is introduced, the result is a specific?
antitoxin. If the tubercle bacillus is intro-
duced, the result is an antidote to tubercle.
If the typhoid bacillus is introduced, th(i
result is an antidote to typhoid. »The times
and quantities vary, but the general reaction
is the same. And it is not confined to
microbes. If cells from a kidney are intro-
duced into the blood, the result is an anti-
toxic substance that destroys the tube-lining
of the normal kidney. If liver cells are
introduced, there is a similar result for the
cells of the liver. And there are many other
substances that once introduced into the blood

IMMUNITY 105

produce similar anti-substances. In every
case, whether the agent be a microbe or
other substance, the dose, if it is to produce
the result, has to be carefully adjusted ;
but the result always occurs. It is, then,
possible to make a wide general proposition,
— certain substances produce anti-substances.
But the substances that produce these extra-
ordinary effects have one thing in common :
they all have a somewhat similar chemical
composition.

To return now to the opsonins. Every
infectious fever probably leaves behind more
or less of its particular opsonin. When,
therefore, the microbe of the fever re-enters
the blood, it is more easily absorbed and
digested by the phagocyte. It may re-enter
a hundred times, but it never breaks down
the first line of defence. So long as this
condition remains, the patient is safe against
a second attack. When the condition dis-
appears, he may become as liable to an attack
as ever. But one attack confers a passing
or permanent immunity against another.

Let us add another technical point. Assume
two persons — one a person in normal health,
the other infected with the tubercle bacillus.
Take from the body of each some of their
leucocytes. Prepare, also, a culture of the
tubercle bacillus, which can now, thanks to

106 HEALTH AND DISEASE

the methods made familiar by Koch in 1881,
be easily cultivated. Let us now make
two experiments. Mix the leucocytes of the
normal person with a certain quantity of the
tubercle bacilli. Mix the leucocytes of the
tubercular person with a certain other quantity
of the bacilli. Keep both the mixtures at the
proper temperature for a quarter of an hour
or so. Then make two microscopic prepara-
tions, one from the normal person's mixture,
the other from the infected person's mixture.
Examine each under the microscope and note
the difference. Select, say, fifty leucocytes,
and count the number of bacilli they have
eaten in the time. The counting is difficult,
but it can be done by a skilled eye. Add up
the numbers found in each of the fifty cells,
and divide the total by fifty. This gives the
average for each cell. Do the same with
the infected person's cells. Let us suppoj;e
that in each cell of the normal person we
have found on the average 125 bacilli ; in
each cell of the infected person we hsLve
found on the average 75. Make these two
numbers into a fraction — 75 as numerator,
125 as denominator — which is three-fifths, or
in decimals 0-6. This is the " opsonic index."
Here I have omitted the delicate and com-
plicated technique, which is one of the mar-
vels of modern insight and invention. It is

IMMUNITY 107

enough that we get a general understanding
of the opsonic index. And it is important
that the term opsonic index should become
familiar to everybody ; for, like the term
phagocyte, it is part of a system of marvellous
discoveries, a world by itself, a kingdom where
only the skilled have entry, and they only
after years of laborious toil.

The opsonic index, then, is an index of
relative powers of resistance. If, in our
particular case, the resistance of the healthy
person be counted as one, the resistance of the
infected person would be only three-fifths.
A healthy person's resistance to tubercle is,
therefore, greater than the infected person's
resistance. If, therefore, they were both
equally exposed to a fresh dose of the tubercle
infection, the healthy person would throw off
the attack much more effectively than the
person already infected. When the opsonic
index is high, the leucocytes can absorb and
destroy germs in much greater quantity than
when the opsonic index is low. When,
therefore, the index is high, the resistance is
great ; when the index is low, the resistance
is feeble.

If this be so, the question at once is sug-
gested : Is it possible to heighten the opsonic
index when it is low ? It is possible to answer
" yes." And this answer has a claim to be

108 HEALTH AND DISEASE

called the greatest departure in modern
medicine. Here, at last, it seems, prevention
and cure pass into a perfect synthesis.

This is a broad outline of Metchnikoff's
theory of phagocytosis — ^the theory that the
white blood cells, by absorbing microbes
and other foreign invaders, defend the body
from infection and probably from some
other poisons too. The theory is not uni-
versally accepted ; but it has a vast mass of
experimental research to rest upon. The
action of the white cell is not an isolated fact.
It has many parallels among the lower
animals. The white cell is itself a living
organism. In the blood, it acts as if it were
a free animal. It searches for food, it meets
aggressors, it adapts itself to dangers, it hi
attracted by some chemical conditions, it
is repelled by others. Some microbes, there-
fore, it will absorb and digest ; some it will
permit to pass into the circulation. In the
one case, it prevents infection ; in the other
case, it permits infection. Why it takes to
one and leaves the other, is not easy to
explain. Possibly some microbes produce a
substance that attracts a leucocyte ; some,
a substance that repels. There are facts in
favour of this idea. There are, however,
cases that the phagocyte (eater-cell) theory

IMMUNITY 109

does not directly cover. In diphtheria, the
poisonous agent is not a microbe, but a soluble
toxin. Does the antitoxin come from the
phagocyte ? Possibly it does ; possibly the
phagocyte secretes the antitoxin and sets it
free in the blood.

These disputable details need not be pur-
sued. The theory is fascinating, even
romantic, but full of difficulties. Yet it
correlates an immense range of facts in the
animal world. It brings protection against
infectious diseases into line with many
other natural processes. It puts before us
a protective material mechanism, visible,
definite, capable of experimental test. And
it is not incompatible with other theories of
immunity.

For the present, no one theory holds the
field. But the chief accepted fact is — that
when microbes, blood-cells, tissue-cells, and
other substances chemically allied to them,
are injected into the blood, they stimulate
the blood, its cells, and the cells of the fixed
tissues to produce anti-substances, which are
antidotes to the substances injected. Let
this be granted. It in no way conflicts with
the theory of phagocytosis. It is, too,
enough for the ends of immediate practice ;
because, relying on this general truth, we can
prevent or stay the progress of certain

110 HEALTH AND DISEASE

diseases by injecting " vaccines " prepared
from the microbes that produce the disease.
The preparation of such vaccines is a highly
technical process, but it is entirely practicable,
and is now very widely practised. The
essential principle of the method is that the
microbe of the given disease is carefully
cultivated, until it is a pure culture It is
then by sterilisation rendered incapable of
reproducing itself in the blood, but it is not
robbed of its power to produce immunity.
There is in the substance of the microbe's
own body a substance that induces the
formation of an anti-substance. The aim of
the treatment is to produce this anti-substance
for the given disease. When the anti-sub-
stance is produced in the blood and tissues,
the disease is cured and immunity against
it is established.

Many diseases are treated on these lines.
For instance, acne or " pimples," boils,
common colds.

Of the greater diseases so treated, the
greatest is tuberculosis. Early in his re-
searches, Koch discovered that the tubercle
bacilli contained a special substance in their
bodies This he named tuberculin. It is
now known as Koch's " old tuberculin,"
because of its method of preparation. It is
used all over the world, mainly for the pur-

IMMUNITY 111

poses of diagnosis. Wherever tuberculosis
of any kind is present in a patient's body,
tuberculin, injected in a minute and harmless
dose, produces a slight fever. This reaction
is a proof that tuberculosis is present.

Recently the method of applying tuberculin
has been simplified. Calmette applied it to
the conjunctiva, the external membrane of
the eye. It produces there a local and
evanescent inflammation, but only if the
patient is tubercular. To von Pirquet we
owe a further improvement. He applies it
to the skin. This results in a definite local
reaction, wherever there is or has been
tubercular disease. It is, indeed, almost too
delicate a test for practice. Among the
inmates of one asylum in Scotland it indicated
that some 70 per cent, of patients had all,
at some time in their lives, suffered from
tuberculosis. Dr. Herford, Altona, with the
consent of the parents, applied the test to
2594 school children. Of these, 63 per cent,
reacted. Of the five-year-old groups, 50
per cent, reacted. Of those about to leave
school, that is, the thirteen- and fourteen-year-
old groups, 94 per cent, reacted.

These facts are confirmed by other re-
searches. They prove the extreme delicacy
of the test and the practical universality of
some degree of tuberculosis.

112 HEALTH AND DISEASE

For treatment, too, tuberculin has been
used in several forms. One of the commonest
forms is Koch's TR or new tuberculin. Some
form of tuberculin has been in more or less
constant use for treatment ever since Koch
first discovered it. But recently the " old
tuberculin " has been confined to diagnosis.
The " new tuberculin " and preparations
based on it are alone used for treatment.

Sir Almroth Wright, in working out his
opsonic index theory, found that, when a
small quantity of tuberculin is injected
into a tubercular patient, the first and im-
mediate result is that the capacity of the
phagocytes goes down. There is a " negative
phase." The susceptibility to the spread
of the infection within the body is, for the
time, increased. In a few days, the negative
phase passes away and, in the end, ths
opsonic index reaches a higher level than
before the injection. The capacity of the
phagocytes is increased. Thus, by watching
the rise and fall of the opsonic index, the
physician can determine when it is most
profitable to give a second and a third and
a fourth injection.

This, incidentally, bears out what is said
below of unborn children of tubercular fathers
and mothers (p. 128). The disease will take
no accoimt of the " negative phase," though

IMMUNITY 118

occasionally it may pass into the child when
his negative phase is ending and then the
infection will be curative. But, often as
not, it will reduce the capacity of the em-
bryonic phagocytes, so increasing the sus-
ceptibility of the child to tuberculosis. But
this is all a matter of chance for the unborn
child. It is a matter of precise science for
the patient under treatment.

After long and laborious trials, the experts
are now able to gauge the correct dose of
tuberculin. It may be as small as the
10,000th part of a milligramme of the solid
tuberculin, that is about the 650,000th part
of a grain. The dose can be slowly increased,
the opsonic index being taken from time
to time, or some similar test being applied,
to ensure that the patient's immunity is
not being reduced instead of increased.

Now that the way is made clear, the use
of tuberculin is increasing steadily every-
where for all forms of tuberculosis, — glands,
bones, etc. In a short time the injection of
tuberculin will be as familiar as vaccination
for smallpox. The stupid haste of twenty
years ago in working without first ascertaining
the correct dose did harm, but the reaction
due to it has now passed away. The secrets
of the method are now revealing themselves
outside the laboratories. The administrative

114 HEALTH AND DISEASE

bodies thus obtain a new instrument of
immense value. If the hopes now stirred
by tuberculin are even in small part realised,
the drop in the death-rate from tuberculosis
will soon astonish the world. The fight
between the greater and the lesser organism,
the human body and this remorseless parasite,
will be changed into a friendly and con-
tinuous process of immunisation. And so
the terrors of heredity will be once more
put to confusion ; for to be born of mildly
tubercular stock may yet become the best
certificate of physical and ethical fitness.
The stone that the builders rejected may
become the head of the corner.

CHAPTER VIII

A DISCUSSION OF THE TUBEKCULAR
DIATHESIS

It is now profitable to ask the question :
Is immunity to a particular disease ever
inherited ? Is a predisposition to a particular
disease ever inherited ? What is meant by
diathesis, or predisposition to a particular
disease ?

THE TUBERCULAR DIATHESIS 115

These questions it is well to ask ; for
they are questions of the hour and affect
fundamentally the practice of life. In
particular, it is well to discuss the meaning
of diathesis ; for it is frequently flung at
the administrator to prove the futility of
his administration. If I had taken at face
value half of what I had been taught about
heredity and diathesis, I should probably
not have thought it worth while to enter
the public health service. Further, as the
tubercular diathesis is at present the focus
of violent disputes, I prefer to investigate its
meaning before passing on to discuss the
control of tuberculosis.

Opium produces sleep because it has a
virtus dormitiva — a dormitive virtue. This
is the classical gibe at the metaphysics of
the Middle Ages — the metaphysics that
Comte's Positivism is supposed to have
superseded. But the dormitive- virtue theory
of opium was at least in line with the science
of its own day. It was as good as the concept
of material substance to " explain " matter,
or mental substance to " explain " mind.
But somehow men are slow to give up this
way of satisfying their intellectual desires.
They love to repeat to themselves in their
answer precisely what they put to themselves

116 HEALTH AND DISEASE

in their question. Does not pharmacy with
its " essences " keep alive for us the names
of no end of mediaeval ghosts ? And can
we say that anywhere our language has
shaken itself free of them ? But I am not
now thinking of differentiations of language,
which, of course, do not always keep pace
with the realities of thought. If the doctor
accidentally uses ancient terms, he is not
often misled by them either in his diagnosis
or in his treatment. But there are some
terms that are still doing as much harm
to clear thinking as the worst that can be
selected from mediaeval medicine.

Take, for instance, the term " diathesis."
How often we heard the word when we were
students ! What a thrill of pleasure we had
when we were first able to write down of our
own motion that our patient was an illus-
tration of the " Tubercular Diathesis " !
We looked for every feature — the transparent
skin, the long eyelash, the fragile frame ; or
again, the coarse skin, the thick lip, and all
the correlated items of the classical descrip-
tions. It was with a sense of intellectual
finality that we heard scrofula defined as a
" vulnerability " of the tissues, particularly
of the skin and mucous membranes.^ The
words did more than satisfy our intellectual
emotions. They positively stopped the im-

THE TUBERCULAR DIATHESIS 117

pulse to question the teacher. They remained
for years in our minds as a solvent of new
difficulties, an obstruction to new mental
growths, blessed words of perfected science.
They were like Spencer's Evolution formula
— a thing first to learn by heart and then to
fit on to everything that happened, not
minding much whether a finger of the glove
was only half on, or, indeed, whether there
was anything particular for the glove to fit
on to.

Then there was our first case of rheumatism
— the " rheumatic diathesis." We searched
the text-books for the exact characterisation
of this typical state of human flesh. It was
not merely a disease we were contemplating ;
it was a history, a whole theory of the organ-
ism, a metaphysic of all the symptoms.

Then there was the " gouty diathesis."
How much it counted for ! Gout was the
name for the possessing spirit, the demon
that proceeded to the toe or retroceded to the
stomach, producing wherever he went fresh
evil and pain. Sometimes, perhaps, he was
called " gout " because the patient could not
spell " rheumatism." But gouty or rheu-
matic, it was always " diathesis," and there
our minds rested, blocked with a beautiful
Greek word, silenced by the genius of the
-^gean Sea.

118 HEALTH AND DISEASE

I have often wondered who introduced
the term " diathesis." He is one of the
benefactors of the race. His word is an indis-
pensable term in the htany of the medical
religion — the Religio Medici. What should
we do without its emotional suggestion, its
capacity for satisfying intellectual desire ?
No plain Saxon word like " set " or " through-
set " could give us the touch of mystery that
" diathesis " gives. It will hold its ground
in the litany for many generations ; because
it comes trippingly on the tongue and not
offends the ear. There is, of course, the word
temperament — ^the melancholic, lymphatic,
etc. But " temperament " is Latin, " dia-
thesis " is Greek, and there is a subtle differ-
ence between them that only spiritual ex-
perience enables us to discern.

Shall we leave this beautiful word to con-
tinue its gentle ministrations to our intel-
lectual life ? Or dare we ask whether the
time has not come for testing its credentials ?

This question I should never have thought
of asking but that recently I have had to
read a good deal about tuberculosis. On
every hand I have been silenced by the " tuber-
cular diathesis." When I expressed the
belief that the tubercle bacillus was the chief
cause of tuberculosis, the body being for the
time a medium of infinite complexity and

THE TUBERCULAR DIATHESIS 119

offering a thousand varieties of food for
the parasite, I was always met with — " Yes,
but there is the diathesis. You must take
that into account." And it was explained
to me that there was something that made
some people " predisposed " to phthisis and
left others " unpredisposed." When I
pressed to know what " predisposed " meant,
I found it was another name for the "dia-
thesis," and, indeed, it is pretty much the
Latin of which diathesis is the Greek. Some-
times I had thrown at me the whole word
" predisposition," as if, being longer, it might
produce more psychological effect than
" diathesis." And it did ; just because it
was longer, but for no other reason. When
I pressed the further question, what evidence
there is of a tubercular diathesis or predis-
position, I was answered : " The fact that
the person takes tuberculosis." Thus my
education was advancing ; for now I had got
into a circle — a vicious circle. The tuber-
cular diathesis makes it easy for a person
to contract tuberculosis ; that he contracts
tuberculosis proves that he has the tuber-
cular diathesis. When I pointed this out
to my tutor, he said : " Yes, yes, that may
be logical ; but we are not dealing with logic,
we are dealing with facts."

And then he proceeded to detail to me.

120 • HEALTH AND DISEASE

with instance upon instance, how the " fairy
type " falls a victim to the bacillus in spite of
every conceivable precaution ; how the coarse-
skinned type equally falls a victim, and
nothing will either prevent his fall or slow
down the progress of the disease. He ex-
plained to me by what tests I should know
the various types, and that I need never
mistake them. These had survived in the
course of selection as the " vulnerable "
types, clothed with a skin of extreme vulner-
ability, the victim being non-resistant in
tissue, keen in brain, precocious, restless,
fragile, near to genius. I am not sure that
he did not also tell me about Wright's dis-
covery of the opsonic index, by which you
can invariably tell the true " tubercular
diathesis."

These " facts " were very persuasive. It
did seem as if we could, after all, determine
by objective marks whether a tubercular
diathesis existed, and could from it predict
the probability of subsequent infection. But
I was still puzzled as to why, in the course
of racial evolution, such types should have
survived at all. It is a truism that all men
are different, some being born with one
susceptibility in the ascendant, others with
another ; some to honour, some to dishonour.
This I could accept. The man of six feet

THE TUBERCULAR DIATHESIS 121

will usually have a longer stroke at golf than
a man of four feet, and if the race of life were
a game of golf we could predict that the
longer arm would have the shorter score.
But the " tubercular diathesis " seemed to
me a little more complicated. It is so
Protean in its embodiments. At one time
it is clothed in fat ; at another time it is
thin and pale. At one time it is coarse,
sallow, dark-haired, thick-lipped ; at another
time it is fine, pink-skinned, blue-veined,
long-eyelashed, fair-haired, with a delicate
woolly hair on the body. Its forms have a
variety suspiciously resembling the forms of
real tuberculosis. And as I thought of this,
the suspicion flashed upon me — " Can the
diathesis after all be an undiagnosed case
of real tuberculosis ? Is the thick-lipped,
scrofulous child not already suffering from
the actual infection of tuberculosis ? Is the
fair-haired, thin-skinned, pink-cheeked fairy
not already also suffering from the toxic
effects of the bacillus ? "

Then, looking backward, I remembered
just such a beautiful fairy, nine years old.
She came of a highly tubercular family,
father and mother being alike affected. One
day swellings came on in the cheeks, and
the doctor diagnosed mumps, which was
then going the round. But ultimately he

122 HEALTH AND DISEASE

found that the swellings were due to diph-
theria. She then came into my hands ;
but too late for antitoxin to save her. She
died of cardiac collapse at the end of three
days. All her tissues were eminently
" vulnerable." The needle of the syringe
caused a considerable haemorrhage under
the skin. Her " tissue-resonance," as it
were, was very high. After she died I
found diseased glands in the chest and in
the abdomen ; some of them were well on
the way to considerable abscesses. Yet the
child had been at school until the day her
cheeks began to swell, and had shown practic-
ally no symptom of serious ill-health. She
had always been " delicate." One would
have called her a typical instance of the
" fairy type " of the tubercular " diathesis."
She was, in fact, a perfect type of actual
tuberculosis.

Then I began to look for our positive
evidence of the existence of a special tuber-
cular diathesis. Have we, after all, been
accepting this term too uncritically ? What
tests have we applied to the " fairy " or the
" coarse " types of the diathesis ? Have
we done anything whatever to show that,
by the time they exhibit signs of the diathesis,
they have not already been for months or

THE TUBERCULAR DIATHESIS 123

years infected with tuberculosis ? In fact,
I now put the question — May not the so-
called diathesis be itself the product of the
tubercle bacillus ? Do we not simply assume
that the diathesis is a fact without making
any effort to prove that it is a fiction ?

Consider the chances that the child of one
year has of acquiring tuberculosis. At birth,
it is impossible to say by simple observation
whether the child illustrates the tubercular
diathesis or not. He must be at least several
months, more probably years, old before we
can say with certainty. There is the " fairy
type." He must have the thick scrofulous
lip before we can say. There is the " scrofulous
type.'* But the infant has to be fed at least
six or eight times a day for a year. Roughly,
he will receive three thousand diets in his
fu-st year. That is, he may have three thou-
sand prolonged opportunities of swallowing
tubercle germs. And he has fifty thousand
shorter opportunities of absorbing them from
his fingers, from the floor, from clothing, from
sucking-bottles, from his mother's fingers, and
from all the other paraphernalia that con-
stitute the environment of the infant. With
this enormous potentiality of infection, who
shall say that, by the time he exhibits the
signs oi the " fairy type," he is not already
well advanced in tuberculosis ?

124 HEALTH AND DISEASE

1

The signs of the so-called tubercular
diathesis, therefore, may be themselves signs
of infantile tuberculosis, and as yet we have
no proof that they are not. If it should turn
out that the " fairy types " are really tuber-
cular patients, we shall have helped to
exorcise one more ghost from our heritage
of mediaevalism.

If there is a tubercular diathesis, there
must also be the following : the smallpox
diathesis, the cow-pox diathesis, the chicken-
pox diathesis, the measles diathesis, the
scarlet fever diathesis, the typhus diathesis,
the typhoid diathesis, the plague diathesis,
the diphtheria diathesis, the cerebro-spinal
fever diathesis, the cholera diathesis, the
whooping-cough diathesis, the influenza dia-
thesis, the mumps diathesis, the erysipelas
diathesis, the septicaemia diathesis, the;
tetanus diathesis, and as many more as there;
are specific infectious diseases now known
or yet to be discovered. We might go even
further. We might add a diathesis for each
peculiarity that adapts the human body as
a soil for any special germ or any parasite,
whether it produces disease or not. For
instance, there would be the ringworm
diathesis, the favus diathesis, the scabies
diathesis, and so on.

If we understand clearly that the term

THE TUBERCULAR DIATHESIS 125

diathesis means only the fact that the human
body is adapted to the growth of the micro-
organism, if it is only a short way of saying
that the micro-organism can grow in the
body, no one can object to that use of the
word. But for the term tubercular diathesis
there is a further claim made. It is main-
tained that we have definite signs of its
existence before the individual under ex-
amination actually contracts the infection or
could have been subject to tubercular toxins.
This is a very large assumption when we
reflect that any person might be exposed to
tubercular toxins even before birth.

Doubtless, if we had methods of the re-
quisite delicacy, we could, in every instance,
find out precisely what conditions of the
body make it possible for each individual
germ to grow. We should know why the
human being takes smallpox, and diathesis
would be a name for our discovery. But,
for the present, to call it so adds nothing
to our knowledge, and does not help us
in the least to understand the conditions.
The word serves only as a convenient label of
an unexplained fact. The same would be true
of scarlet fever diathesis and all the others.
But once the term diathesis is thus reduced to
its legitimate meaning, as simply a name for
the fact that if you take scarlet fever, you

126 HEALTH AND DISEASE

must first have been capable of taking it,
all the emotional value evaporates, and
we turn to other gods. The term is then
an " honest ghost," but it unravels no
mysteries. Is it not time that medicine
gave up the virtus dormitiva method of de-
scribing its problems ? Would it not better
serve the ends of science if the terminology
were kept scientific ? Why load the student's
mind with those myths, those superstitions
of the pre-scientific days ? Or, to put it
lower down still, why cannot we describe
our qualities by adjectives, and not by
abstract nouns, which always tend to " go
off on their own," and afterwards return
to dominate our intelligence instead of
serving it ?

That the question is not unimportani;
practically is proved by the recent discussion
at the International Anti -Tuberculosis Asso-
ciation. Experts from every country tools
part in the discussion. The old view has
its adherents ; but the new view seems to
gain ground. That some people take tuber-
culosis more easily than others goes without
saying. They are, it may be, born with the
disposition. That is not the question in
dispute. The question is, — how is the dis-
position produced ? Is it an inherited varia-

THE TUBERCULAR DIATHESIS 127

tion of the germ-plasm, or a condition acquired
by the child before birth, because the father,
or mother, or both, are themselves infected
and have communicated to their child the
microbe or some of its toxins ?

On the answer to the question largely
depends the method of prevention. If the
condition commonly described as tubercular
diathesis be itself a condition of actual
tuberculosis, it offers no explanation of
predisposition. Do the human tissues
have any property that enables the tubercle
bacillus to grow on them ? Undoubtedly.
It is this property that has to be accounted
for. Does the property vary in different
individuals ? Most probably it does. Lines
of possible explanation are indicated in the
theory of phagocytosis and other theories
of natural or acquired immunity. The
phagocytes have a general capacity for
capturing and destroying all intruding
microbes. This would be, for the human
being, a general " diathesis " against in-
fectious diseases. The phagocytes may also
have a special capacity for capturing and
destroying particular microbes, like the
tubercle bacillus. This, if inherited, would
be a special " diathesis " against tubercle.
This special capacity may depend on the
presence of certain opsonins or other condi-

128 HEALTH AND DISEASE

■

tions. The point in dispute is this : Is this
special capacity for capturing and destroying
the tubercle bacillus genuinely inherited as
a physical peculiarity of healthy stock, or
is it acquired by the individual either through
infection from the parents or from some other
outside source ?

It is admitted that the advance of tuber-
culosis in the body depends on the dose of
tubercle administered. If the dose is large,
the advance is rapid. If the dose is care-
fully graduated, not only does the disease
not advance, it slows down and stops. And
it is possible to inoculate any healthy person
with tubercle bacilli. It is probable that
any person whatsoever may be so reduced in
resistance to disease in general, or so grossly
dosed with virulent preparations of the
tubercle bacillus, that he will develop the
disease in its full strength. The predisposi-
tion, or special capacity, can, therefore, te
produced if the trouble is taken to produce i g.
Measles probably increases the predisposition
or susceptibility of children to tuberculosis.

The mere fact, therefore, that children
born of tubercular fathers and mothers do,
in exceptional numbers, contract tuberculosis,
does not prove that, in the healthy state,
their tissues are exceptionally susceptible ;
for there is, by hypothesis, no obtainable

■

THE TUBERCULAR DIATHESIS 129

evidence that their tissues were ever in a
healthy state. Before conception they may
have been poisoned on the father's side or on
the mother's side, as is known to occur in
syphilis ; after conception they may have
been continually poisoned during the whole
period from conception to birth. If, after
birth, they show signs of exceptional pre-
disposition, this is precisely what, by hypo-
thesis, we should expect. If any human
body has been subjected to persistent doses
of a poison, we are entitled to look for either
of two results — greater susceptibility to the
poison or partial immunisation. It is possible
that those born with the so-called tubercular
diathesis are those in whom the ante-natal
doses have broken down the natural resistance,
and that those born without the so-called
diathesis are those in whom the doses have
been such as to produce partial immunity.

The infinite variety of the disease in fathers
and mothers makes these suppositions per-
fectly legitimate. We know that, in tuber-
culosis, it is possible, by careful graduation
of the dose of tuberculin, to confer immunity
on the patient ; but the graduation of the
dose is difficult, and, in unskilled hands, the
immunity might be lessened instead of
increased. It may be so in the unborn
infant, — sometimes its resistance (natural im-

130 HEALTH AND DISEASE

munity) may be lessened, sometimes increased.
If it be possible, in perfectly healthy tissue,
to increase the susceptibility to tuberculosis
— and there is much evidence to show that
this is possible — there is no need to assume
any special variation of the human germ-
plasm. Any germ-plasm exposed to the
disease in the father's or mother's body may
have its natural capacity to grow the bacillus
increased. The original natural capacity to
grow the bacillus, like the capacity to grow
the bacillus of smallpox, or typhoid, or scar-
let fever, is legitimately named "diathesis."
But the special predisposition produced by
the paternal or maternal infection or poisoning
is not in the strict sense a " diathesis," a
fundamental quality of the healthy tissue that
will develop whether the body is ever exposed
to the infection or not Such a special pre-
disposition is not " inherited." It is an
*' acquired character." It is made up of two
elements — an original capacity to grow the
bacillus on the tissue, and a specially developed
capacity induced by the actual presence of
the bacillus or its poisons, a prolonged and
predominant " negative phase." The original
capacity to grow the bacillus is, of course,
inherited like any other physical peculiarity.
That is only another way of saying that we
can take the disease. But, if the bacillus

THE TUBERCULAR DIATHESIS 131

were a flea or a bug, we should not think of
inventing a flea-diathesis or a bug-diathesis
to account for the fact that the insects can
live on our body juices. But if an attack of
bugs could increase our body's attraction for
bugs, we should then possess both an original
capacity for feeding bugs and a special pre-
disposition (acquired) for being fed on by
them.

In the discussion of immunity we saw that
the conditions of natural, or apparently
natural, immunity alter by very fine shades.
If Metchnikoff's view that animals are immune
to cholera because their intestines contain
a special microbe that kills the microbe of
cholera be correct, the immunity of animals
to cholera is not, in our sense, a diathesis ;
it is possibly an accident of the food environ-
ment. Change the food, and the animal's
immunity may disappear. Or change the
food of the human being, and he may become
immune. The extraordinary facts revealed
by the " soured milk " treatment — treatment
with lactic-acid-producing bacilli — make such
a suggestion reasonable. Probably many of
the states we are all too ready to regard as
inherited are after all only acquired characters
subtly masked.

The more the causes of immunity are
found to belong to the environment, the
£2

132 HEALTH AND DISEASE

more manageable will they become, and we
shall not always be met with the insuper-
ability of the "intensity of inheritance."
That the environment counts even in the
very stable immunities is certain. It is
known that disturbances of digestion may
predispose to cholera. Immunity, says Dr.
Tanner Hewlett, is perhaps never absolute.
It may alter with trifling alterations in the
chemical composition of the blood. It may
disappear when there is a change in the
animal's temperature or in the external
temperature. It may be complete for a
specific germ acting alone, but incomplete
for the same germ acting with another. It
may rise or fall with fatigue. And there are
many other special conditions that cause it
to vary.

To take another illustration, — ^no one sug-
gests that, when a child is born with syphilis,
the reason is because it inherited from its
syphilitic parent or parents the " syphilitic
diathesis." It is known that the child shows
symptoms of syphilis because it has contracted
syphilis directly from the father or mother.
It is also known that "the syphilitic diathesis,"
the capacity to contract the infection of
syphilis, is universal among mankind. It is
not so among the animals ; only a few of the
higher animals are capable of contracting the

I

THE TUBERCULAR DIATHESIS 133

infection. They have not the " syphilitic
diathesis." On the contrary, they have " the
anti-syphiUtic diathesis." Not to load a
discussion with needless refinements, let it,
then, be said that if " tubercular diathesis "
is to run on all-fours with the syphilitic
diathesis, if it is to be regarded as universal
among mankind, no one need object to the
term ; but the inferences based on the hypo-
thesis that it is not universal among mankind
fall to the ground.

But a more serious point remains. The
tuberculin test as now applied on the skin
(von Pirquet's test) indicates that probably
fifty, sixty, seventy, or even ninety per cent,
of the general population suffer or have, at
some period of their lives, suffered from some
degree of tuberculosis. It is also known that
tuberculosis contracted in infancy may lie
latent for many years. It is also reasonably
conjectured that, in later life, the apparent
infection from an outside source is not really
a new infection, but a flaming-up of the old
infection into activity. If these facts be so,
and the evidence in their favour steadily
accumulates, our conclusions on " the intensity
of inheritance " need re-interpretation. How
much of apparent tuberculosis is due to a
truly inherited variation, how much to con-

134 HEALTH AND DISEASE

ditions of evil nurture, how much to the
assaults of other diseases, how much to
accidental intoxications by other organisms,
how much to the absence of protecting organ-
isms in the bowel, how much to wrong habits
of food, — these and many other problems must
then be subjected to a new analysis.

Meanwhile, as administrative activity in-
creases, the death-rate from tuberculosis
diminishes ; but the few thousands of lives
that will be saved in the years coming need
not terrify the Eugenists or seriously hamper
the man of science in his search for a more
complete theory. The King's government
must be carried on I

CHAPTER IX

THE ADMINISTRATIVE ASPECTS OF
TUBERCULOSIS

■i

How does the problem of tuberculosis
present itself to the administrative mind ?
To that question I shall try to give some
answer.

For the modern administrator, the history

ASPECTS OF TUBERCULOSIS 135

of tuberculosis began when Koch isolated
his bacillus. That the disease was an in-
fection, communicable from man to man, is
a fact as old at least as the days of Isocrates,
and older. Through the ages, the belief
in its infectivity can be traced in literary
and scientific records. The nineteenth cen-
tury cannot claim to have discovered the
fact, nor can the twentieth century yet claim
to have exhausted the pathology of the
disorder. But it remains true that, for the
ends of administration, the whole history
of the disease before Koch may be blotted out
of our books. Even with the isolation of
the bacillus, the administrative problem was
weighted by a thousand irrelevancies. The
pre-Koch pathology is far from dead. It
still perverts the bedside mind. It is still
repeated in the text-books. It still crowds
the lectures with antiquarian rubbish. It
clouds the mind of the student with use-
less knowledge. It blocks the way to frank-
ness of outlook and precision of practice
Curiously, it has faded most rapidly where
the lay mind has had to be convinced. For,
to teach the farmer, or the salesman, or the
butcher, or the dairyman, or the mother of
children, or any of the other innumerable
units that constitute an organised society,
all the delicacies contained in the ancient

136 HEALTH AND DISEASE

theories of a " wasting disease " would have
been a hopeless and futile task. Even the
youngest medical officer of health — fresh,
enthusiastic, full of Virchow and not ignorant
of Darwin — would have been beating his
head against the rocks had he tried to rouse
in the lay mind any interest answering to his
own. Until Koch, the disease was too diffi-
cult, too complex, too little understood, to
be taught to any but technically trained
people. But when Koch came, a note of
hope rang round the world. He passed
through the fire of criticism, not scathless,
but carrying with him his cardinal fact —
that where his bacillus was, there also was
tuberculosis. The word tuberculosis passed
from the vagueness of speculative pathology
into the circle of positive science. It was
henceforth to mean something as definite
as gunpowder, or oxygen, or steam. Forth-
with, tuberculosis became a doctrine that
the lay mind could grasp. It could be
taught as easily as the multiplication tabic,
and it could be shown to be as practical. |

So far, well. But this alone, though it |
excited the hopes of the world and simplified
the duty of the administrator, would not
have secured the growing interest of the
layman. To him a new germ may be an
interesting curiosity ; he will listen to tales

ASPECTS OF TUBERCULOSIS 137

about it ; he will take pride in repeating its
name. But he is nothing if not practical.
If you cannot do him some definite good,
you will tire his interest and you will provoke
him to reaction. Fast on the heels of the
new bacillus came the suggestion that the
disease due to it was no longer hopeless and
incurable. Then the whole world began to
ask for a miracle. It seemed for a time as if
the miracle had happened and the diseased
were to be made whole. The heart sank
when the signs failed. But the miracle had
indeed happened, although the revelation
of it was looked for too soon. Science on the
one hand, and on the other hand Nature, came
once more together, and the open-air treat-
ment became a fact. Meanwhile, science
pushed forward more and more intensively,
until new facts, new methods, new habits of
the organism revealed themselves, and now,
after all, the tuberculin cure of tuberculosis
is no longer a dream of possibilities, but a
definitely established doctrine. The condi-
tions are not so simple as the natural feelings
led us to imagine ; but they are not so com-
plex as to have baffled the patience of re-
search. The day is here when, not as a vague
belief resting on unsolved mysteries, but as a
permissible deduction from ascertained fact,
the forecast of the near future may be —

138 HEALTH AND DISEASE

n

tuberculosis will be extirpated, or reduced,
or, by a simple biological bargain, converted
from an enemy to a friend.

So far, again, well. But in the popular
mind there was another obstacle. Biology,
on the authority of great names, had left us
with a crude theory of inheritance. What
could it profit that we isolated the bacillus
if the personal pedigree were bad ? Did
we not hear tales of families swept away,
member after member, each when his day
came ? Were we not filled with horror at the
inherited taint ? Did not the insurance
companies, do they not still, base their cal-
culations on the belief that a phthisical
inheritance ought to mean a loaded premium ?
And in some sense, they are perhaps justified.
But the countenance began to lighten and the
action to grow athletic when it was, again
after long research, made clear that tuber-
culosis is not inherited — that it is mainly a
thing of the environment. It is, in fact, a
struggle between two organisms, a lower and
a higher. The lower is the invader, the
parasite ; but the higher has now in theory
become the master. The vague hopes of the
earlier days are now planted firmly on a basis
of definite inductions. The bacillus can be
isolated ; it can be killed ; it can be traced
into a thousand by-paths ; it can be stopped

ASPECTS OF TUBERCULOSIS 139

at a thousand points of its path from one
mouth to another ; it does not pass from
generation to generation.

To the administrator, the isolation of the
bacillus made the problem simple. To the
reformer, the growing belief in the non-
inheritance of the disease has offered a new
basis of action. The reformer is justified
in taking as his objective a possible society
of persons immune or immunisable to
tuberculosis. The administrator has now to
devise the methods of attaining that end.

Ever since Koch's discovery, conviction
has been gaining ground that the spread of
tuberculosis can be limited by administrative
methods. In many parts of Europe and
America it has been so limited. There is a
good deal of evidence for the proposition that
the isolation of phthisical cases has materially
reduced the total number of cases. It is
true that, for fifty years, the death-rate from
phthisis in Britain has fallen year by year
until to-day it is only about 50 per cent, of
what it was. It has been assumed, without
much effort at analysis, that this steady
decrease has been the result of improved
" general sanitation." Doubtless, general
sanitation has contributed much, if under
'• general sanitation " we include the draining

140 HEALTH AND DISEASE

of soils, the sewering of towns, the improve-
ment in houses, the increase in cleanliness of
habit, and most of all the steady, remorseless,
systematic campaign against infection of
every form What destroys one infection
destroys another. Incidentally, in our efforts
to limit typhus, typhoid, puerperal fever,
scarlet fever, diphtheria, septicaemia, pyaemia,
and many other infections, we have been
dealing, intimately and in detail, with the
same conditions as the tubercle bacillus
thrives in In killing typhus and typhoid,
we have, doubtless, without intending it,
killed also tuberculosis, but the tubercle
bacillus is a slowly invading and most per-
sistent parasite. It gets to places that few
other parasites can invade. Everywhere it
finds a nest so easily that it is naturally the
last to be expelled Precisely because it
kills slowly, it kills most. That is probably
why, when most of the other parasites steadil y
fall back before isolation, disinfection, ard
protective injections, phthisis needs more
determined and subtle dealing. But, with
every allowance for the insidiousness of this
slow parasite, we are now justified in our
conclusion that by direct attack, as in typhus,
typhoid, scarlet fever, and the others, we shall
be able to reduce the spread of the disease
by securing that the patient shall confine

ASPECTS OF TUBERCULOSIS 141

his infection to himself. To this we are now
able to add direct methods of cure. When
cure and prevention can, as they ultimately
will, work perfectly together, tuberculosis
will fall back to the social status of plague and
cholera in the western world.

Is tuberculosis of the lungs an infectious
disease ? It is. The proofs of its infectivity
are overwhelming ; but the methods of its
transfer from person to person are infinitely
various and difficult to determine. That it is
infectious, however, even in the popular
sense, is not open to question. The bacillus
can be cultivated outside the body ; it can be
inoculated into animals, and produces in them
the same sequence of signs and symptoms as
in human beings. In hundreds of cases,
collected by Koch and others, it has been
accidentally inoculated into human beings,
giving rise to local infection of the glands
precisely as in the common untraced in-
fections of glands in children or adults. It
has been dried, powdered, and given to
guinea-pigs as a dust-inhalation. The result
was lung tuberculosis. In 1899, Fliigge, by a
™^ series of experimental tests, showed " that
'■jm^ speaking, coughing, and sneezing produce a
^ftthin spray of minute drops which, in the
^B^case of tuberculous persons, have been shown

I

142 HEALTH AND DISEASE

^

to contain bacilli." Heymann showed that
such drops may be projected to the distance
of a foot and a half from the patient's mouth.
*' Out of thirty-five patients experimented
on, fourteen were found to have tubercle-
bacilli - laden drops." Laschtschenko en-
closed a patient in " a glass case for an hour
and a half ; he coughed spontaneously and
also intentionally at intervals, but the amount
of coughing was not extraordinary. In the
glass case were cups containing a weak saline
solution. The contents of these cups were
injected intra-peritoneally (into the abdomen)
into guinea-pigs. Out of nine tests, four gave
positive results. It is thus shown that a
tuberculous patient can spray the surround-
ing area with minute drops containing viru-
lent tubercle bacilli." Fliigge showed that
guinea-pigs can be infected by exposing them
to be " coughed at " by tuberculous patients..
All the experiments go to demonstrate that
the moist sputum sprayed from the moutli
of patients in the advanced stages c»f
the disease are much the most virulently
infectious.

These experimental results are confirmed by
masses of other observations. It matters
nothing whether the material is breathed in
and then swallowed, as Professor St. Clair
Symmers strongly maintains, or inhaled by the

ASPECTS OF TUBERCULOSIS 143

lungs. The practical result is the same. No
person capable of estimating the evidence
will now withhold assent to the proposition
that tuberculosis of the lungs is infectious
from person to person. This, on the large
scale, is confirmed by the figures so carefully
analysed by Dr. Newsholme to exhibit the
part that segregation in institutions (work-
houses, infirmaries, hospitals, asylums) has
played as one of the factors in the decreasing
death-rate.

The administrative control of pulmonary
phthisis, or tuberculosis of the lungs, is
increasing rapidly all over the world. In
Scotland, it was provided for, in words, if
not by intention, in the Public Health
(Scotland) Act, 1897. As that Act contains
no definition of infectious disease, the denota-
tion of that term is to be settled by the
scientific opinion of the day. What applies
to one infection applies to another. By a
later Act, certain too stringent clauses of the
earlier Act were modified. It can now with
truth be said that, without unnecessary
hardship to individuals, the full resources of
the Public Health Law in Scotland can be
brought to bear on every variety of pulmonary
tuberculosis. But the administrative value
of the statutory provisions was not actively

144 HEALTH AND DISEASE

developed until 1906, when the Local Govern-
ment Board for Scotland issued a circular on
the administrative control of pulmonary
phthisis. This circular concentrated the mind
of the health authorities on their statutory-
obligations, which, hitherto, had been left,
to a great extent, unacknowledged and un-
discharged. Among other things, the Board
recommended that pulmonary tuberculosis
should be added to the list of diseases com-
pulsorily notifiable. There were recom-
mendations, too, on hospitals, on sanatoria,
on disinfection, on dispensaries, and, generally,
on the whole question of pulmonary tuber-
culosis as affecting the administrative organisa-
tions. The response of the localities through
these five years has been extraordinary.

In England, the course of administrative?
evolution has been great, but on somewhat
different lines In 1908, the Local Government
Board of England issued an Order requiring th 3
notification of all cases of pulmonary tubercu-
losis that occur in the workhouses, in infirm-
aries, and among the poor on outdoor relief.
This Order was issued under the same powers
as enable the Local Government Boards of
England, Scotland, and Ireland to deal with
any" epidemic, endemic, or infectious disease,"
including the great international epidemic
diseases — plague, cholera, and yellow fever.

ASPECTS OF TUBERCULOSIS 145

Tuberculosis is to be regarded as an endemic
disease. Later, the English Board has issued
a second Order requiring notification of
pulmonary tuberculosis by all public dis-
pensaries and hospitals in England ; requir-
ing, too, the sanitary authorities to follow
up the notifications on certain lines of pre-
ventive administration.

Ireland has also taken great strides forward.
At the instance of the Irish Local Govern-
ment Board, an Act was passed enabling the
Board to require notification of pulmonary
phthisis and to make further provision by
hospital and dispensary.

Officially, therefore, the three kingdoms
have effectively entered on an administrative
campaign against pulmonary tuberculosis.
There is, however, nothing to limit adminis-
tration to tuberculosis of the lungs alone.
Every form of tuberculosis will ultimately
benefit, and the demand is already heard for
more direct dealing with tuberculosis of the
bones, of the joints, of the skin ; in a word,
" surgical tuberculosis."

The administrative activity shown in Great
Britain and Ireland is only part of a world-
wide movement. All the nations come to-
gether every three years at the International
Congress of Tuberculosis, where all the great
questions of diagnosis, cure, and adminis-

146 HEALTH AND DISEASE

trative control are discussed and re-discussed.
The policy of the governing bodies, therefore,
cannot any longer be regarded as the hasty
and indiscreet application of abstract ideas
to a practical problem ; it is a well-considered
policy of skilled statesmen, moving slowly
and deliberately in response to ascertained
social demands.

In many localities of Scotland voluntary
notification systems have been tried, and in
some localities they still continue. But ex-
perience has shown that voluntary notifica-
tion is, on the whole, a failure. Now that
the Public Health Act has been adapted to
phthisis, local authorities are much more
ready to add phthisis to the list of the com-
pulsorily notifiable diseases. The following
figures will indicate the rapid rate of progres:?
now established.

In 1906, not a single health authority of
the whole 313 had adopted compulsor/
notification In 1907, compulsory notifica-
tion was adopted by 8 health authorities —

4 towns, 4 county districts — representing a
population of 589,698, or 13*2 per cent, of the
population of Scotland In 1908, the number
of adopting local authorities rose to 10 —

5 towns, 5 county districts — representing a
total population of 634,467, or 14-2 per cent.

ASPECTS OF TUBERCULOSIS 147

of the population of Scotland. In 1909, the
number of adopting local authorities rose to
53 — 30 towns, 23 county districts — repre-
senting a total population of 1,150,344, or
26 per cent, of Scotland. In 1910, 82 health
authorities applied the Act — 47 towns and
35 county districts — representing a total
population of 2,281,388, or approximately

51 per cent, of the whole population of Scot-
land. In 1911, up to the end of March, 89
health authorities have applied the Act —

52 towns and 37 county districts — repre-
senting a total population of 2,359,154, or

53 per cent, of the whole population of Scot-
land. The Board's first circular was issued
in 1906. The phenomenal spread of noti-
fication has taken place within five years.
In several places the Act has been only tem-
porarily adopted, but it has always been
renewed when the period expired.

These are the facts about notification in
Scotland. In the days before notification
became popular, we heard a great deal about
the probable hardships to individuals, social
ostracism, boycotting, and similar difficulties.
The same has always been said at some stage
about notification of the ordinary infections
Yet no Act works more smoothly than the
Notification Act. Up till now we have
rarely heard of anything but friendly services

148 HEALTH AND DISEASE

to the sick. The stricken people are too
eager to find ways of recovering their health
to be worried about any sort of social con-
sequences. The experience everywhere is
that when treatment, whether much or little,
is provided, the claimants never fail to come
forward spontaneously. To use words like
ostracise, boycotting, and similar terms of the
inexperienced amateur is now a practice
long out of date in Scotland. We know
better. These are, I am afraid, only the
prejudiced phantasies of the unilluminated.
They are, however, balanced by the opposite
strain of difficulties, namely, the exaggerated
fear that the resources of any health authority
will be overwhelmed by the claimants for
treatment. This, too, is contradicted by
experience. As numbers come forward, ways
for their reasonable treatment continue to
open up. Here a little and there a little,
something is being done, and, as time grows
older, the administrative pace grows quicker :
for, on the one hand, the public authorities
are more and more realising their public duty.,
and, on the other hand, the private patients
are animated more and more by well-founded
hopes of recovery. These two tendencies
are now in full play, and already, thanks to
long and persistent educational efforts, health
authorities and patients alike are swept

I

ASPECTS OF TUBERCULOSIS 149

forward by a social momentum that nothing
will arrest or divert.

Hitherto men have rested the significance
of the notification of phthisis on the fact
that it is an infectious disease. This is
important, but it does not explain the real
significance of notification. This significance
lies rather in the fact that, when a disease is
once notified, the patients must be dealt
with, not in the mass, but as individual
cases. In the days when we knew only of
the existence of masses of disease — crowds of
cases of typhus, of typhoid, of smallpox, of
scarlet fever — naturally preventive measures
took the form of improving the general
environment, the drains, the water-supply,
the sites of houses, and the like. But as soon
as individual cases came to be notified, each
case had to be dealt with on its own special
merits, isolated, and treated according to its
needs. That is what notification has done for
the infectious diseases. That is what it is
now doing for phthisis. We are long past the
stage when we stop at general improvement
of the environment. We are now well into
the stage when we must deal with the in-
dividual case and his individual environment
That is why notification is important. It
enables the health authority to bring the full

150 HEALTH AND DISEASE

force of an improved environment to bear
on the specific needs of the individual patient.

What has somewhat amazed, if not amused,
me in this whole movement is the curious
paradox that, in all other infectious diseases,
such as typhoid, scarlet fever, etc., it is con-
sidered right and necessary for the Health
Authority to deal with the individual patient ;
but, in pulmonary phthisis, many maintain
that we should leave the individual patient
alone, and deal only with the environment.
The death-rate, it is alleged, is going down
" of itself." Improve housing, improve food,
improve the environment generally, but leave
the private patient to the private doctor.
Apparently some men are more or less
satisfied with the way the death-rate is going
down. I am not. It is going down, but not
fast enough.

And it is not going down of its own accord,
or from any mysterious influence of th<3
Time Spirit. It is going down because we are
putting it down. It has been going down
ever since the serious work of sanitation in
Scotland began, say, seventy years ago. It
continues to go down because the medical
men are getting to understand phthisis
better, because they are diagnosing it earlier,
because they are helping forward the im-

I

ASPECTS OF TUBERCULOSIS 151

provement of the surroundings, because they
are letting fresh air into the houses, because
they are reducing the consumption of alcohol,
because they are beginning to understand
dietetics better. It is going down, too, because
the Medical Officers of Health are, day in,
day out, pushing forward the operation of
every variety of health machinery, — the
cleansing of houses, the disinfection of houses
and persons and clothing, the steadily in-
creasing isolation of as many varieties of
acute infection as are likely to benefit by that
measure, and, in a word, every proceeding
that places the individual patient in a better
environment, permanent or temporary, — so
increasing the personal resistance and reducing
the complications of the acute infections.

It is going down, too, because the Sanitary
Inspectors and Borough Engineers maintain
a ruthless attack on damp houses, defective
drains, defective ventilation, dirty rooms,
dirty people, dirty clothing, over-crowding, —
so reducing on every hand the chances of
contracting any infection, tuberculosis among
the rest.

It is going down, too, because the Inspectors
of Poor and the Parish Councils are steadily
strengthening their grip of this primary
cause of pauperism.

But the pace of the down-going of the death-

152 HEALTH AND DISEASE

rate is still very slow. So long as we can say
that in Scotland alone nearly six thousand
people die every year of phthisis, this one
form of tuberculosis, the pressure of adminis-
trative measures should never slack. And, so
long as I have an administrative breath to
draw, it never shall slack. The belief that the
death-rate is going down of itself and rapidly
enough, looks like the special pleading of the
interested or the fatuity of the fatalist. The
belief is an erroneous belief.

Before I end this chapter, I cannot resist
the temptation to make a remark on certain
" red herrings " that are persistently drawn
across the administrative scent. I call them
" red herrings " somewhat disrespectfully.,
because I have repeatedly found that the>'
are offered, not as a reason for doing some-
thing positive on the special line suggested,
but to prevent any one from doing anything:
positive on any line whatever.

For instance, it is said, phthisis is a Hous-
ing question. Undoubtedly it is a Housing
question. So is typhoid fever. But the
quickest way to get at the house is to deal
with the patient in the house That is what
our Housing Acts, and our Public Health
Acts, and, above all, our Town Planning
Acts are there for. For my part, I should

ASPECTS OF TUBERCULOSIS 153

like to see every health authority in Britain
rise to the great height of the opportunities
it now has to make every house, every hamlet,
every village, every small town, every great
town, serve to the full the ends of business,
health, and beauty. But the direct attack
on phthisis will still have to go on. For
phthisis is much more than a Housing question.
It is an Infantile question. To meet that, we
have our Notification of Births Act and the
Children Act. These contain immense powers,
and all the powers are powers of dealing with
the individual. The crop of health visitors,
voluntary and official, is the answer to the
children question. It is also a School Child
question. The answer to that is the system
of medical inspection, now happily estab-
lished over the length and breadth of the
kingdom. If it should finally appear that the
great period of personal infection is, as von
Behring maintains, the period of infancy,
the shortest way to bring assistance to mother
and child is to deal individually with both.
If it should be established, as is probable,
that practically every child is, in one degree
or another, at some time or another, infected
with tuberculosis, and if it be true that a
limited dose acts in some measure as an
immunising agency, it is all the more impera-
tive that we should deal with the individual

154 HEALTH AND DISEASE

^

child and his personal environment, and so,
by clearing away all sources of major in-
fection, keep down the dose to the relatively
harmless minimum. Phthisis is also a Food
question. The answer to that is our elaborate
Food Acts, our power of dealing with meat and
milk. If milk is the chief factor of infection,
the shortest way to the guilty dairy is to start
from the infected child. All our dairy
regulations and milk acts have arisen out of
the clinical physician's demand for an ex-
planation of this or that infectious disease.
But phthisis is also a Factory question. The
answer to that is the unremitting enforcement
of the Factory and Workshop Acts. And so,
through every other one of the many relations
of administrative control, we must work the
administrative machinery we have or devise
machinery more suitable. The whole cam-
paign must go forward at once. For all these
special questions are strung on a single thread
— the thread of the individual life. We have
talked long enough about the big things. We
are now in the full tide of the little duties
that make the big things possible. In
Scotland we need no more legislation for
the moment. We need first to work for all it
is worth the legislation we have In Scotland
we have taken our own line, and we intend to
keep it. We have shown that the powers of

INTERNATIONAL INFECTIONS 155

our statutes are simple and effective. All
we require is the wish and the will to work
them. The facts I have given are proof
that neither the wish nor the will is wanting.
To every man that wants to live, we would
offer the chance to live

CHAPTER X

THE INTERNATIONAL INFECTIONS — PLAGUE,
CHOLERA, AND YELLOW FEVER

When plague came to Glasgow eleven
years ago, there were sceptics to question
the identity of the disease. True, the first
cases emerged under a curious guise. A child
and its * grandmother, living in the same
house, had sickened suddenly. Four days
later the child died of " zymotic enteritis "
(a form of diarrhoea). Two days later the
grandmother died of " acute gastro-enteritis."
In both cases a " wake " was held. The
grandmother was buried on the third day
after death. Her husband sickened the day
after the burial ; but it was not until fifteen
days later that he was admitted to hospital

156 HEALTH AND DISEASE

as " enteric fever." Other sicknesses, not
at first known to be related to the same
focus, rapidly appeared. Three cases were
provisionally diagnosed as " enteric fever."
The medical attendants, however, were not
satisfied ; but they knew the cases were
infectious and wished to bring them to the
knowledge of the health authority. On
admission to the hospital, these cases were
carefully examined. The physician concluded
that "the patients were suffering from Bubonic
Plague, although they were inhabitants of
Glasgow and there was no known case of
Bubonic Plague in Britain."

So the long record of two centuries and a
half was broken. The identity of the ancient
plague of London and the modern plague in
Glasgow was proved. And the proof came
of the insight of a skilled physician, who,
though he had never seen plague, kept an
" open sense." His first conjecture was
confirmed within a few minutes. Within ;i
few days, it was absolutely established by an
independent expert. The instantaneous con-
jecture was thus verified; but it was the interest
of a million people to discredit it. To those
familiar with the hundreds of thousands,
even the millions of deaths, that every year
take place in India, such an attitude must
seem curious. But I remember as if it were

m

INTERNATIONAL INFECTIONS 157

yesterday how the excitement of the event
spread everywhere and evoked everywhere
the same comments. The diagnosis was a
triumph of medicine and bacteriology. The
physician quite understood that on the view
he took of this microscopic germ would
depend the closing of the port, the interrup-
tion of the shipping, the establishing of the
strictest scrutiny at every continental port,
the institution of a laborious survey of the
infected area of the city, the searching out
of contacts, the cleansing of houses and
stores, the hunting of rats, and a thousand
other administrative activities in Glasgow and
the other cities of Britain. Yet the diagnosis
was made and announced. It stood the test.
And every fresh case confirmed it. Experts
from East and West confirmed it. The subse-
quent history of Glasgow itself confkmed it,
for plague appeared again a year or two later
in rats and in men.

The discovery of an identity in circumstances
so different as those of London in 1665 and
those of Glasgow in 1899 has an intellectual
interest all its own. But to Glasgow, directly
and indirectly, the discovery meant the loss of
thousands upon thousands of pounds. Plague
was still a terror, though it was a terror under
control. But the attitude of the official
organisation towards it was the attitude of

158 HEALTH AND DISEASE

^

a master. The city, by the persistent applica-
tion of her vast resources and her elaborate
sanitary police, did, with the general mind
all alert and open, succeed in keeping the
treacherous disease within narrow limits. By
good fortune wakes were not obsolete ; there-
fore the quick succession of cases revealed
the seriousness of the situation. But for
this fortunate bad social habit, the city might
have had to reckon its cases, not by groups
of one and two, but by groups of tens and
hundreds. The original case was never, I
believe, discovered. This is not strange to
those that know how casual life is among the
people affected. Care sits lightly on them
when they are sober, and when they are
drunk memory is the memory of dreams, and
experiences vanish like morning gossamer on
the hillsides.

This and other outbreaks in Europe le<i
to the revision of the Venice Convention,
which then regulated the international health
relations of nearly all the European states.
The part that rats played in the spread of
plague had been made familiar by the Report
of the Royal Commission on Indian Plague.
In the Agreement of Paris, 1903, the modern
knowledge of plague was incorporated. By
this agreement plague, cholera, and yellow

INTERNATIONAL INFECTIONS 159

fever are to-day regulated all over the
world.

Of these three not one is endemic in Britain.
They normally enter this country by a
large seaport. As all the leading seaports
are customs ports, the customs officers form
the first line of defence. Any vessel from
any foreign port that is infected with plague,
cholera, or yellow fever, is challenged by
the boarding officer, who asks certain definite
questions from the master, who, in turn, must,
under heavy penalties, answer correctly.
If any case of plague, or suspected plague,
or any case of illness exists on board, the
customs officer stops the vessel. He reports
the facts to the Medical Officer of Health
for the port. He, in turn, must visit and
examine within twelve hours. From the
time he boards the vessel until he completes
his examination, he has full control of the
ship and every person on it. If he finds a
case of plague on board, he has full powers
to order the ship to anchor in the place pro-
vided, to remove the case to hospital, to
remove suspected cases, to disinfect, to re-
tain suspected cases until the nature of the
disease is ascertained. He also takes the
name, address, and destination of every
person that wishes to leave the ship, forwards
the information to the officials at the destina-

160 HEALTH AND DISEASE

1

tion named, and thus secures that all along
the course a certain amount of supervision is
exercised. Sailors, as a rule, are ready enough
to go to hospital rather than leave the port ;
but the freedom of movement now accorded
to passengers and crews has been evolved
out of a long experience of the tendency to
concealment and evasion. Concealment and
evasion, however, are much commoner among
passengers than among crews. In six years
of pretty active port life, I never found a
master or officer that was not quite ready
to reveal every important fact of the voyage.
The shipping companies are only too anxious
to keep themselves right with the law. If,
however, an infected ship enters harbour
without suspicion, the Medical Officer of
Health still has a reserve power. If he sus-
pects that the ship is infected, or comes from
an infected port, he may examine the vesssl
and take all measures necessary to make it
safe. The number of ships, however, that
escape the lynx eyes of the customs officers is
small.

In British ports, quarantine, as formerly
understood, is not legally required and is not
practised. Every object of quarantine is
obtained by the method I have sketched.
Such quarantine as is practised at all, is carried
out on shore ; the ship is set free at the

INTERNATIONAL INFECTIONS 161

earliest possible moment, and thus the
interests of the commercial community are
little injured. For the carrying out of the
Agreement of Paris, each country has its
own special regulations ; but these, in nearly
all the signatory countries, are now much
the same as in Britain. Everywhere, pro-
vision is now made for dealing with rats.
These are a greater danger than human beings.
How great the danger is the appearance of
plague among rats in the east of England
last year has made manifest. It is known
that in India rat plague precedes human
plague. As rat plague now exists in Britain,
the precautions against human plague, no
less than against rat plague, have to be all
the more stringent.

The Agreement of Paris, based as it is on
actual experience of plague in the West, is
more adaptable to western conditions than
any previous agreement. Five days after the
death or isolation of the last known case of
plague, a commercial port may once more be
declared free. Usually, cases are under isola-
tion as suspects for some days before plague
can be demonstrated. The result is that
commerce is not now liable to be seriously
interrupted. How much this means to the
comity of nations only those can under-
stand that have had to stop, even for an hour,

F

162 HEALTH AND DISEASE

one small tributary of the great stream of
international commerce.

Plague, in spite of every precaution,
scientific and administrative, continues to
kill its millions in India, to spread steadily
over East and West, and to-day it leaves no
continent unaffected. It is in the strictest
sense an international epidemic. Any hour
may bring fresh cases to our shores, but the
probability of a widespread epidemic in
Britain is not great ; the scouting is too
alert, the administrative machinery too
mobile, the general interest too informed, the
general fear too intense. Imported cases,
outbreaks, little epidemics there may be,
but an epidemic on the scale of the great
plague of London is not likely to occur in
^ny of the western or northern countries
of Europe.

In the last fifteen years plague has beea
well " worked over " scientifically. Preven-
tive serums and vaccines have been devised.
Their success more than justifies their use ;
but the problem of prevention in Eastern
countries needs more than curative serums.
The sanitary conditions of the hot countries
present difficulties unknown to the West.
The rat population of Calcutta is said to be
greater than the very great human population.

INTERNATIONAL INFECTIONS 163

The rat is among the most prolific of the
rodents. He goes everywhere and lives.
Up till now, he has defied every civilisation.
He is the menace of empires. Malaria, it is
suggested, came from Egypt to Greece
with the slaves. Plague goes all over the
world with the rat. He has his defenders,
who count him a good scavenger. He has
his detractors, who count him an expensive
luxury. Perhaps he has a beneficent place
in nature ; but, for the moment, he is an
enemy of mankind.

Plague is spread by the rat. Cholera is
spread by water.

Briefly, cholera is a form of diarrhoea —
violent, contagious, and rapidly fatal ; at-
tended with agonising pains in the digestive
organs, cramps all over the body, and great
depression. The disease lies dormant for
about two days after it is first caught ; it
then strikes suddenly, and often in the night,
and then, within a limited number of hours,
it runs towards death or recovery. Cholera,
thus marked in its main features, is due to a
specific poison. Koch maintained that the
poison is from a specific microbe, viz., the
Comma Bacillus. This he discovered in
several places, viz., in the discharges of
cholera patients, in the bowels after death,
f2

164 HEALTH AND DISEASE

and in cisterns of drinking-water that he
knew to be infected. He isolated the bacillus
and cultivated it. The bacillus is an un-
questionable fact ; it may be seen in any
pathologist's laboratory. But Koch cannot
be held to have demonstrated its causative
action in cholera, though recent research
tends to confirm his view. But, whatever
the germ be, the poison is a specific poison ;
it produces a distinct and invariable train
of symptoms ; it is carried by water, by
clothing, by food, by every variety of human
intercourse. It had its original home prob-
ably in India. It became fully recognised
at the beginning of last century ; time and
again it has spread westward, and towards
the end of the nineteenth century it was once
more in force within two or three dayis'
journey of our shores. Occasional cases ha\e
come across the Continent since 1892 ; but
there has been no serious outbreak in Gre^.t
Britain.

" In the nineteenth - century annals of
pestilence," writes Hirsch, " the year 1817
stands as one charged with fatality to the
human race. It was in that year there began
the epidemic extension over India of a disease
which had previously been known only as
an endemic in a few districts of the country ;
in that and the following year it overran

I

INTERNATIONAL INFECTIONS 165

the whole peninsula ; in a short time it
crossed the borders of its native territory
in all directions, penetrated in its farther
progress to almost every part of the habitable
globe, and thus acquired the character of a
world-wide pestilence, which has repeatedly
since then entered on its devastating cam-
paigns, and has claimed its many millions of
victims." Cholera, thus breaking its primi-
tive bounds, has come westward and spread
over the world tour times during the nine-
teenth century. The first time was from
1817 to 1823, when it all but crossed the
frontiers of the European Continent. The
second time was in 1826. In this year it
broke out in India ; before the end of 1830
" the pestilence had obtained an extensive
footing on Russian soil " ; from Russia it
came to Germany, and from Germany in
1831 it came to Great Britain. The places
first affected were Sunderland, Newcastle,
Gateshead, Haddington (1832), Musselburgh,
Edinburgh, Glasgow, Belfast, Cork. " Thus
in the course of the year it spread over a great
part of Britain, following the commercial
highways chiefly, and the coast routes and
rivers ; while the mountainous parts of
the country were little visited by it, and the
Scottish Highlands not at all." — (Hirsch.)
This great epidemic ended in 1838, and for

166 HEALTH AND DISEASE

ten years Europe was free from cholera.
The third great epidemic began in 1846.
In 1847 it was in Russia, Astrakhan, along the
Volga, and round the shores of the Sea of
Azov. In 1848, it appeared in England and
Scotland. Among the Scotch towns visited
were Edinburgh, Glasgow, and Dumfries.
The fourth great epidemic began in 1863.
As in the other epidemics, the European
countries were nearly all visited In Scotland,
during 1865, there were 1170 cholera deaths.
In 1873, cholera was still common in many
parts of the Continent, and at many seaports
in Britain cases were landed ; but in Britain
itself the disease did not spread inland.

All through the history of these epidemics
one tracks the disease to the great seaports
everywhere. These are the natural landing-
places of such an enemy.

The last epidemic of cholera in Scotland
undoubtedly hastened the passing of the
Public Health Act of 1867,— an Act full of
sagacious and advanced provisions. Tlie
scare resulted in a small crop of separate
cholera hospitals, which have almost entirely
stood empty ever since they were built.
But the impulse so generated has been bene-
ficial in every direction. It taught the
people the need of pure water. It prepared
the way for the great reform of 1889, when

INTERNATIONAL INFECTIONS 167

public health was transferred bodily from the
rural Poor Law Authorities to a special
Health Authority with a larger area. The
continued menace of cholera, assisted by
outbreaks of typhoid fever, has worked a
marvellous reform in water supplies all over
Britain. The preventive health service has
been going on for these twenty years un-
relentingly. It has been steadily removing
from every corner of the country the condi-
tions that would favour a widespread out-
break of cholera. The danger of such an
outbreak, though less to-day than even
twenty years ago, is far from small. It can
be met only by active administration.

Of the three international epidemic diseases,
yellow fever remains. But in the colder
climates yellow fever is not a danger. It
may be imported, but it cannot live ; for the
mosquito that spreads it is not a native of
the cold climates. But the disease is still a
great danger to many countries of the world.
As the problems of malaria centre round
one mosquito, the problems of yellow fever
centre round another. Either this mosquito
must be destroyed, or a remedy found to
make its specific injection harmless. Of
this there seems to be no doubt. Experiments
such as this have been carried out : — ^Mos-

168 HEALTH AND DISEASE

qui toes were " fed on the blood of yellow
fever patients not less than twelve days
previously." They were then permitted to
bite ten persons that had never had the
disease and were in no way protected against
it. Of the ten bitten, eight developed the
disease. Apparently the mosquito needs some
twelve days to become infectious. If he bites
to-day, taking with him the germ from the
blood of the patient, he is harmless until the
germ develops within him. This takes twelve
days. If he then bites a healthy person, he
conveys the disease.

Here once more we are on the borderland
of biology. The plague germ has the rat
and the rat flea ; the cholera germ has the
water ; the yellow fever germ has its own
mosquito. To save the afflicted peoples pre-
ventive medicine must upset those " balances
of nature." Man must fit his environment;
to himself. It is curious that, when those:
great diseases are in question, nothing is heard,
about heredity, or the danger of preserving,'
the unfit, or the sacrilege of not permitting
the socially rejected to work out their own
salvation by natural selection. Why do we
hear so little in this strain ? Because plague,
cholera, yellow fever, malaria, are none of
them respecters of persons. They attack the
strong and robust as readily as they attack

INTERNATIONAL INFECTIONS 169

the feeble. They kill without discrimination.
If they were left to roam the world unre-
stricted, the remnants that would survive
would be, indeed, more " fit " to continue in
a world flooded with those four diseases, but
they would not thereby be the " fittest " for
the work of great civilisations. When strong
men have to fight against foreign enemies
like these, they have no time to concern
themselves with fears about heredity. It is
only when faced with familiar destroyers like
tuberculosis, or measles, or poisonous trades,
that they lend an easy ear to proposals for
letting the " unfit " die. They yield less to
logic, perhaps, than to psychology. It is this
that makes the health service scrutinise with
the most active scepticism everything that
touches the theory of heredity, when that
theory is used to foster an attitude of impotence
in the face of preventable disease. And this
attitude, I regret to think, seems to attract
only too readily the non - administrative
speculators in heredity.

170 HEALTH AND DISEASE

CHAPTER XI

OTHER PREVENTABLE DISEASES

The infections, though not all equally pre-
ventable, are pre-eminently preventable dis-
eases. But there are others. How great the
mass of them is could be learned only from a
careful scrutiny of the whole list of diseases.
Here I offer only a few gross indications.

Long ago, in his book on The Hygiene,
Diseases, and Mortality of Occupations, Dr.
J T. Arlidge gave a carefully elaborated
analysis of the occupational diseases. He
first classified occupations, following the lead
of Dr. Ogle and Dr. Farr. He then set him-
self to a systematic study of the correlative
diseases. Not an important trade escaped
his observation. But he laid special stress
on the dust diseases, — the diseases arising
out of the dusty occupations. Many manu-
factures generate dust. There are mineral
dusts, — metallic, as in file-making, or razor-
grinding ; non-metallic, as in coal-mining,
tin-mining, flint-working, slate-quarrying,
china-painting, and a number of others. Then
there are dusts of organic origin, — some of
them vegetable, such as the dust of cotton-
manufacturing, cotton-cloth sizing, flax-work,

OTHER PREVENTABLE DISEASES 171

linen-manufacturing, seed-crushing, tobacco-
manufacturing. And there are organic dusts
of animal origin, as in cloth and shoddy
manufacture, hosiery manufacture, wool-
sorting. Then there is the large range of
occupations where poisonous materials are
dealt with. There are others where noxious
vapours are constantly encountered. There
are others where the temperature is excessive ;
others where the strain, pressure, and friction
are too prolonged. In a book of nearly six
hundred large crowded pages. Dr. Arlidge
professed to give only a condensed sketch
of the occupational diseases.

This volume had much to do with improve-
ments both in legislation and in adminis-
tration. Commissions on the dangerous trades
have gone into great detail in examining the
precise processes of manufacture, the prob-
able and actual effects on health, and the
amount of illness due to the particular trades.
On the basis of such inquiries, the Home
Office, which is the central authority for the
administration of the Factory Acts, has for
years set itself systematically to reduce the
occupational diseases. Not a month passes
but some fresh or revised regulation is issued
to meet some hitherto unregulated cause of
disease or death. The mass of these regula-
tions is very great ; but not one is enacted

172 HEALTH AND DISEASE

without an elaborate inquiry into the whole
conditions of the given trade and the given
process. If one would know the vast area
covered by the Medical Department of the
Home Office, he has only to glance at the
yearly and occasional reports of the Chief
Factory Inspector, Dr. Arthur Whitelegge,
C.B. There is not a dangerous or unwhole-
some trade that he and his Department do
not know. There is no department of central
administration more vitally in touch with
the environment of labour.

The rapid expansion of industry, the con-
tinued improvement in methods, the increased
demand for more healthy conditions, all
combine to make the occupational diseases
more and more a subject for special study.
In a book on Dangerous Trades, edited by
Professor Thomas Oliver, will be found nearly
a thousand pages of standard information in
sixty chapters, not only on the hygiene of
the special trades, but on the special diseases
and general questions arising out of them.
The work includes among its experts, factory
inspectors, medical officers of health, sta-
tisticians, and others familiar with special
processes or diseases.

To take but one or two illustrations. Of
all the poisonous metals, lead, because it is
so widely used, is probably the most destrue-

1

OTHER PREVENTABLE DISEASES 173

tive. Lead-mining, lead-smelting, the manu-
facture of red-lead, of white-lead, and
manufactures where these substances
are used, may all lead to lead-poison-
ing. " Lead is a subtle poison," writes
Professor Oliver. " Most of its salts have in
small doses no unpleasant taste or odour,
they are very soluble, and they produce their
baneful effects sometimes in such an insidious
manner that the health of the operative
becomes so gradually undermined that he is
often precipitated into a serious illness without
any warning. In most instances, however,
there are prodromata (preliminary symptoms),
for lead causes colic or severe pain in the
abdomen." The effect of lead on women is in
the highest degree evil. It seriously inter-
feres with the maternal powers. " Children
of female lead-workers almost invariably die
of convulsions shortly after birth or during the
first twelve months. If a child is the off-
spring of parents both of whom are lead-
workers, it is puny and ill-nourished, and is
either born dead, or dies a few hours after
birth." Lead is even more dangerous. It
not only kills the offspring ; it destroys " for
the time being the child-bearing powers of
women." But why continue ? To describe
fully the effects of lead alone would take much
more than the present volume. Let one

174 HEALTH AND DISEASE

further quotation be enough. "It is upon
pregnant women that the metal exercises its
worst effects. . . . When a white-lead worker
becomes pregnant it is almost impossible for
her to go to the end of term if she continues
to follow her employment. ... In the liver
and kidneys of still-born children of female
lead-workers . . . there were found minute
quantities of lead. . . . Mrs. H., age thirty-
five, worked in a white-lead factory for six
years, before which she had four children born
at full time. Since going to the lead-works
she has had nine miscarriages in succession
and no living child." These facts can be
added to indefinitely. If, as some social
critics assert, the effect of preventive medicine
is to preserve the unfit, here is a fair case for
testing the view. But if the high infant
mortality in certain industries is to be a test
of the unfitness, let the infants at least star:
fair. Let them come into the world at th(i
instance of healthy nature, not under the
expulsive power of lead.

But though lead-working is the most strik-
ing, it is not the only poisonous industry. The
manufacture of arsenic contributes its share
to the disabled. So does the manufacture
of rubber. " Girls have told me that on
leaving the factory at night they have simply
staggered home. . . Prolonged exposure

OTHER PREVENTABLE DISEASES 175

to the vapour of bisulphide induces an en-
feeblement of the intelHgence that recalls
the mental weakness of chronic alcoholic
inebriety."

Or take this of mercurial poisoning : " The
worker becomes pale and loses his appetite.
He frequently has headache, giddiness, and
transitory pains in the limbs. The muscles
of the face twitch, the fingers tremble when
spread out, and the tongue is also tremulous
when protruded. The mental condition under-
goes change. Workers assured of their skill
become shy and nervous, especially when
watched." The teeth are affected. "Chronic
mercurial poisoning does not frequently lead
directly to death. It appears to lower the
vitality of the tissues markedly, and Kussmaul
calls attention to the frequency with which
mercurial workers die of phthisis."

Of dust as a cause of occupation disease,
Professor Oliver says : " Were it not for dust,
fume, or gas, there would be little or no
disease of occupation except such as might
be caused by infection, the breathing of air
poisoned by the emanations of fellow-work-
men, and exposure to cold after working in
over-heated rooms.** He considers that dust
plays such a prominent part in the causation
of disease that it needs a discussion by itself.
The coal miner's lung is familiar at an early

176 HEALTH AND DISEASE

stage to every medical student. The steel
grinder's lung is common knowledge. But
there are also skin diseases arising from
certain kinds of dust. These may vary from
simple irritation to inflammation, pustules,
and ulcers. In some dust trades, the nails
suffer. In others, the irritating dust affects
the bowel.

These illustrations are enough to point the
lesson. The prevention of all these diseases
is not only theoretically possible ; it is en-
tirely practicable. Partly, it may be secured
by improving the conditions of the manufac-
tures, and this is the object of the stringent
regulations everywhere obtaining. Partly, it
must assume the co-operation of the worker,
and for this also the regulations provide.
But familiarity breeds indifference. The
result is that, in spite of every precaution
and enforcement, the occupational diseases
of the dangerous trades will for years to come
constitute an appreciable item in the disease
roll. *

Let us leave this and look to another set
of facts. If the diseases named in an earlier
chapter are carefuly followed out into their
individual conditions, many of them will
be found entirely preventable. In a volume
on the Prevention of Disease, translated from

OTHER PREVENTABLE DISEASES 177

the German some years ago, and containing
a pointed introduction by Dr. Timbrell
Bulstrode, the whole field of medical and
surgical diseases has been carefully studied
specifically from the standpoint of prevention.
" With the rapid growth and diffusion of
knowledge as to the prevention of disease,"
writes Dr. Bulstrode, " the physician will
be asked in an ever-increasing degree how
the onset of certain pathological conditions
may be prevented ; and although he may
not, at present, always be in a position to
indicate the lines which may be followed,
there may, I think, be little doubt that the
subject of individual prophylaxis (protective
prevention) will occupy an important place
in medicine in the near future." With this
opinion every member of the preventive
medical service will agree. Not until one
works carefully through the groups of diseases
here studied can he even partially realise how
much of current disease can either by early
direction or by early treatment be either
postponed or prevented. And we do not refer
to prevention of the infectious diseases, but
to the prevention of heart disease, by judicious
nurture in youth and moderate living as life
advances ; prevention of digestive diseases,
by the careful study of foods and modera-
tion in their use ; prevention of children's

178 HEALTH AND DISEASE

diseases, by careful nurture in infancy,
systematic inspection and supervision in
childhood, attention to teeth, food, and sleep ;
prevention of nervous and mental diseases,
by the regulation of life and the avoidance
of excesses.

Of the special senses there needs only
a word — the eye, the ear, the throat, the
nose, the teeth, the skin, have all been so
fully studied, they are all so important
economically, that the great majority of our
population realise the need for care in the
prevention of their diseases and for immediate
cure if disease supervenes. The Medical
Inspection of School Children secures the
necessary administrative acceleration.

It is, therefore, fully established that
out of the many classes of disease many are
preventable, partly by improving the general
conditions of life, partly by bringing to bear
on the individual case the resources of
knowledge. The mass of preventable disease
is so great that it more than justifies the
preventive service evoked by its existence.
It does more. "^ It justifies in every person the
mental attitude that, in any individual case
of sickness or disablement, leads the observer
always to ask fu-st — ^is it preventable ?

There is, of course, the necessary residuum

OTHER PREVENTABLE DISEASES 179

that no knowledge has yet enabled us to
prevent. These are problems of the future.
But, meanwhile, every medical service,
official and voluntary, is grossly overloaded
in the effort to provide even for the coarser
diseases that spring from the evil environ-
ments of industry. Of the efforts to prevent
fatigue and to develop personal resources
by an adapted personal hygiene, I say
nothing ; they are swamped, except among
the leisured. If you would judge how the
" pressure of life " tells in the heavier trades,
procure and study Dr. Arthur Newsholme's
recent report on Infant and Child Mortality.
It is said by one writer that " the conse-
quences of that pressure are prevented from
producing effects that are of selection value."
Dr. Newsholme shows that the " selection
value " in the indiscriminate death-dealing
of the heavy industries is mostly, if not
entirely, mythical. In the counties where
the deaths of infants under one year are
greatest, there also the deaths of children from
one to five and five to ten years are greatest.
Any " selection value " that the correlation
method reveals is practically nothing, except,
doubtfully, for children of the second year. The
facts about lead are eloquent of the reason why.
Surely it is our first duty to provide an environ-
ment that is not certain to kill. We can then

180 HEALTH AND DISEASE

take up at leisure those interesting speculations
on " selection value." The number of men,
women and children incidentally saved for
a few years more from death or disablement
will not, even if labelled " unfit," seriously
affect our social resources.

CHAPTER XII

THE HYGIENICS OF A STAPLE FOOD — MILK

Shall I, with Mr. Upton Sinclair, fast for
ten days and recover on milk and oranges ?
Shall I, with Professor Chittenden of Yale,
keep my nutrition down to the limits of phy-
siological economy ? Or shall I, with Sir
James Crichton-Browne, keep a big excess-
margin for contingencies ? Shall I, with
Mr. Bernard Shaw, cease eating my fellow-
creatures ? Shall I, with Dr. Haig, displace
the meat and tea poisons by milk and cheese ?
Shall I, with Sydney Smith and his Edin-
burgh Reviewers, cultivate learning on a little
oatmeal ? Or, not to omit a great name
from the ever-lengthening chain of dietetic
specialists, shall I, under Metchnikoff, the

THE HYGIENICS OF MILK 181

director of the New Hygiene, stop the disease
of old age by a diet of soured milk ?

These are questions the modern man puts
to himself. Whomsoever he selects from the
multitude of skilled counsellors, he will not
find one that forbids him milk or the products
of milk. Milk, too, is the staple food of
infants. Whatever happens to meat, milk
will maintain its place ; for the children must
be fed. For adults, too, it is practically as
indispensable and, as time proceeds, will
become increasingly a necessity. In every
country in the world, milk has risen in
dietetic importance. This is why I select it
as a type of the food environment.

The problem of the milk-supply is : To bring
to the consumer clean, harmless, palatable
cow's milk. By clean, I mean free from
adventitious impurities, such as sand, dust,
cobwebs, cow-dung, hairs, epithelial scales,
and the like. By harmless, I mean not
capable of producing any disease, infectious
or other. By palatable, I mean not so altered
from the natural flavour of wholesome milk as
to disgust. Other qualities of milk are equally
important, from other points of view. For
example, the percentage of butter-fat may be
more important than the absolute freedom from
dirt ; or, again, fat may be of less importance

182 HEALTH AND DISEASE

than the readiness to decompose. But those
qualities are only indirectly, not directly,
questions for hygienics ; because hygienics,
which here practically means the scientific
care of the human environment, concerns
itself with the reduction in number of abnor-
mal factors. Dirt, disease, and the conse-
quent decompositions of milk may destroy
it as a possible human food, so throwing it out
of relation to the physiological needs. These
three, therefore, it is the first duty of hygienics
to eliminate. Practically, therefore, the prob-
lem is how to eliminate dirt and disease, how
to prevent unintended decompositions, and
how, thus, to preserve in its full physiological
relations, a food of immense value. I assume
that milk is a highly important factor in the
food environment of our present highly
complicated society ; that our present methods
of providing the consumer with milk are full
of defects ; that the rectification of thestj
defects is an entirely practical enterprise.

Under dirt, I include all the non-pathogenic
germs ; for these, though they do indirectly
encourage specific diseases, are not individu-
ally associated with any particular disease.
They affect seriously the " keeping " qualities
of milk. They have, therefore, pre-eminently
a bearing on commercial, and, by consequence.

THE HYGIENICS OF MILK 183

on practical management. They are the
pest of the small or the town dairy and the
minor shopkeeper. They are the quint-
essence of uncleanness. They are, however,
in part useful in the production of milk pro-
ducts ; but in " market " milk, as it goes
forth for consumption as milk, they are
nothing less than destructive ferments. The
germs, or micro-organisms, I mean, are mainly
these : the lactic ferments (including special
bacilli, micrococci, and streptococci, in many
varieties), bacillus coli communis (in some of
its " races "), the casein ferments, the blue
milk bacilli, the red milk bacilli, yellow
milk bacilli, bitter milk bacilli, the organisms
that produce slimy milk, or stringy, or soapy
milk. Besides these, there are the yeasts
and other moulds.

To protect milk from most of these is not
very difficult ; but the care necessary is more
than will ever be systematically taken by any
but the most scrupulous dairyman. In the
cleanest cowsheds I have ever seen, where,
too, the cows were well-groomed and looked
it, the chances of germ pollution were more
than could be readily calculated. There are
always at least the following germ-yielding
conditions : Dry hay or other fodder, dust
from roofs, dust from floors, moulds, dried
excreta, decomposing urine, the micro-

184 HEALTH AND DISEASE

organisms of the cow's hide, the innumerable
germs of ordinary water, the repeated con-
tacts with human hands and clothing. The
cows lie down clean ; they rise up dirty

To watch the milking of cows is to watch a
process of unscientific inoculation of a pure
(or almost pure) medium with unknown
quantities of unspecified germs. Perhaps
feeding is just over, or the cows are in fresh
from the field ; or, as in town cowsheds, they
were in some fields six months ago, and have
never seen clear skylight again. In comes
the milker, man or woman, slaps the cow's
buttock to make her rise. The milkstool is
placed, taken from some dirty corner of the
cowshed. A few squirts of the teat, or of two
teats, are given as a preliminary encourage-
ment to the cow and a convenient lubrication
for the fingers. Incidentally, the first squirts
may help to clear out any micro-organisEis
that lodge in the ducts. The hands may 1)6
clean — or not. The clothes may be newly
washed — or not. The nose, the mouth, the
eyes, the ears, the face generally, the hair,
may all have been specially cleaned just
before — or not. Whoever knows the meaning
of aseptic surgery must feel his blood run cold
when he watches, even in imagination, the
thousand chances of germ inoculation. From
cow to cow the milker goes, taking with

THE HYGIENICS OF MILK 185

her (or him) the stale epithelium of the last
cow, the particles of dirt caught from the
floor, the hairs, the dust, and the germs that
adhere to them. Meanwhile, what with
switching of cows' tails, what with stamping
of feet, the cowshed is in a state of persistent
agitation. The cows are feeding. The im-
prisoned dust of the dry fodder is scattered
to the air currents. Meanwhile, too, the
other milkers are collecting the milk. They
perspire. They transfer the milk from pail
to can. They leave the total to gather more
germs and dust. Perhaps, the moderately
careful dairyman sieves the milk roughly
from the pail ; but the sieve is not such as to
enmesh any but the major particles. Every-
where, throughout the whole process of milk-
ing, the perishable, superbly nutrient liquid
receives its repeated sowings of germinal and
non-germinal dirt. In an hour or two, its
population of triumphant lives is a thing
imagination boggles at.

And this in good dairies. What must it be
where the cows are never groomed, where
udders are never washed, where teats are never
rubbed, where the cowsheds are never even
approximately cleaned, where ventilators are
never open, where the dung is a stale heap at
the cowshed door, where the pigs are a few
feet away, where cobwebs are ancient and

186 HEALTH AND DISEASE

heavy, where the ammoniaeal emanations of
decomposing urine nip the eyes, where hands
are only by accident all washed, where heads
are only occasionally cleaned, where spittings
(tobacco or other) are not infrequent, where
the milker may be a chance-comer from some
filthy slum, — where, in a word, the various
dirts of the civilised human are, at every
hand, reinforced by the inevitable dirts of the
domesticated cow ?

Are these exaggerations ? They are not.
1 could name, for town and county, many
admirable cowsheds where these conditions
are, in greater or less degree, normal. But
a general statement of germ-yielding con-
ditions were incomplete without some quanti-
tative confirmation. Here are a few figures
from reliable sources : —

Dr. Edward von Freudenreich says : " In
Berne I have found on an average 160,000 to
320,000 bacteria per cubic inch in fresh milk ;
while Cnopf in Munich estimates the numbc]:
at 960,000 to 1,600,000 per cubic inch, i.e.
thirty-three to fifty-six millions per pint."
Again, he found that a " sample of milk
containing 153,000 bacteria per cubic inch,"
on being kept at a temperature of 59° F.,
had, after an hour, 539,750 per cubic inch ;
after four hours, 680,000 ; after nine hours,
2,040,000 ; after twenty-five hours, 85,000,000.

THE HYGIENICS OF MILK 187

In other instances, the increase was even
more striking, the temperature being higher.
By the time milk usually reaches the con-
sumer in this country, it is certain to contain
some millions of germs in each cubic centi-
metre. Mr. H. L. Russell, of the University
of Wisconsin Agricultural Experiment Station,
found that " a gelatine plate exposure made in
the stalls during the feeding showed that over
160,000 organisms were deposited in a minute
on an area covered by an ordinary milk pail."

So much for germinal dirt. Non-germinal
dirt has less significance in itself ; for its
principal effects are essentially those of the
adhering germs, and these effects have
already been generally indicated. Yet the
dirt, apart from the germs, is not unim-
portant either in amount or in kind. The
consumer wishes to consume milk approxi-
mately as it comes from the cow. What I
have already stated demonstrates how diffi-
cult it is, by current methods, to obtain such
milk ; but to realise how much the dirt,
germinal and non-germinal, amounts to, one
must examine actual specimens.

Let one spend half a day or so at a creamery
where, say, 6000 to 10,000 gallons of milk
are dealt with between 7 a.m. and 4 p.m.
Let him watch the milk as it is poured,
apparently pure, into the mixing vat Let

188 HEALTH AND DISEASE

him then watch the scraping of the separators
(centrifugal machines) at the end of theMay.
To strip off the tough, elastic layer from the
metal, it is necessary to use a strong scraper.
This layer, which is driven on to the wall of
the separator by the centrifugal force due to
about 6000 revolutions a minute, is made up of
hairs, dust, cobwebs, pieces of straw, particles
of cow-dung — scraps, in fact, of every sort
possible in a cowshed. These varieties of dirt
are bound in a matrix of mucus, epithelial
scales, and such other slimy matter as may
be separated from the milk. Experiment
has shown that milk bacteria are perceptibly
reduced in number, but not entirely elimin-
ated, by the process of centrifugalisation,
and probably the germ population of the in-
spissated debris described is proportionally
greater than in corresponding volumes of milk .
But even if the germ-population of the
milk is not very seriously reduced, the milli
is made more limpid, and consequently more
palatable. At the very least, the consumer
does not want to consume either cow-dung
or cobwebs ; hairs might be, if they are not,
filtered out by the ordinary sieves ; epithelial
scales and minute amounts of mucus are
neither here nor there. But, for my own
part, ever since I first saw and realised the
amount of this lining deposit, which not in-

THE HYGIENICS OF MILK 189

frequently is nearly a hard half-inch thick, I
have never been able quite to feel that non-
centrifugalised milk is as clean as centri-
fugalised milk. Partly this is, no doubt, a
prejudice, or rather a revulsion, due to seeing
facts out of relation to the whole they belonged
to. For, in a drinkable quantity of milk, the
few epithelial scales, broken hairs, straw par-
ticles, or particles of organic dirt, would not,
for the moment, appreciably alter its physical
qualities. But, as I have shown, germinal
dirt affects the " keeping " qualities of the
milk, and the germinal is not in fact separable
from the non-germinal. The milk is heated
before, and cooled after, separation ; and
it is true that, with no further treatment,
separated milk " keeps " longer than non-
separated. Whether it be that the removal
of the non-germinal dirt removes mechanically
a large percentage of bacteria, or that the
dirt removed reduces the nutrient quality
of the medium, I am unable to say. Perhaps,
independently of either alternative, the
flavours of the milk are improved by the
removal of foul organic substances that would
normally form excellent material for bacterial
putrefaction. One fact the " separation "
demonstrates, namely, that the ordinary
cowshed or dairy sieve (or filter) does not
remove any but the major varieties of dust

190 HEALTH AND DISEASE

particles. But there are many more efficient
sieves in the market. (Separation and centri-
fugalisation may be taken here as meaning
the same. The milk and cream can be, and
often are, re-mixed after separation.)

In thus painting, with a broad pencil, the
dirt conditions, I have omitted the aggrava-
tions due to ulcerated teats, inflamed udders,
pustular conditions, and the like. To realise
what these amount to, one must examine a
few large dairies. For curiosity, I have some-
times gone round a cowshed of a hundred cows
or more. The percentage of abraded teats
would astonish any but a practised milker
or inspector. This is easy to explain. To
begin with, the conditions of the milk cow
are largely pathological. The appropriation
of her by the human milker compels certain
modifications and adaptations. The ever-
renewed dragging at the teats leads to hyper-
trophy, congestion, and increased vascularity,
Normally, the teat is tender, easily abraded,
easily inflamed. If the cow is on pasture, sh(j
itiay have the teats scratched or pricked b}^
thorns, whins, brambles, or the like. If she
is, as commonly in towns, entirely confined
to the cowshed, coarse bedding, bad floors,
or the innumerable accidents of movement,
may irritate or injure. Obviously, want of
protection exposes the teat to many injuries.

THE HYGIENICS OF MILK 191

Twice or three times a day these injuries are
aggravated by rough, mechanical handling.
The gentlest human hand hardly matches
the " toothless gums " of the calf. And the
hand of the milker is, as a rule, far from
gentle. I speak from observation of many
scores of town and county dairies. At least
half of the milkers, if not more, are men,
who, in their ordinary labour, develop the
normal " horny hand," and cannot divest
themselves of it at the moment of milking.
And the hands of the women-milkers are not
softer and not often cleaner.

Then, in calving time, the puerperal cows
occupy the same cowsheds as the non-puer-
peral. In such a time, the increase of organic
putridity must be enormous. But the milk
market is unaffected, — except for the in-
creased quantity of milk.

One could add to these facts indefinitely.
I mention only things visible in ordinary
dairies. Then who shall enumerate the
passing ailments of the milker ? Head colds,
sore throats, ranging from evanescent redness
to complicated diphtheria, inflamed fingers,
inflamed eye-lids, conjunctivitis, acne, ring-
worm, eczemas in their varieties, and the
large range of minor diseases that are more
or less septic in their effects. Bronchitis
and the like, I may leave alone.

192 HEALTH AND DISEASE

When these commonplace facts are clearly
grasped, and set coherently in the imagina-
tion, they teach one to estimate how much
the " lime-washing in April and October "
has to accomplish ; how ridiculously futile
are the efforts at enforcing cleanliness, when
every movement means more dirt ; how
miserably on the outside of the disgusting
facts are the provisions for lighting, ventila-
tion, and cleansing. These provisions, how-
ever, are not without value ; for they are
forcing into prominence the minimal con-
ditions of wholesome managements of cow-
sheds.

Turn now to the dirt incidental to the dis-
tribution of milk. The distribution of milk
is as difficult a problem as the preparation
of it before distribution. Our current methods
are of the crudest. Recently the structure
of the carts and of the cans has shown some
regard to the cleanly handling of a delicate
liquid ; but there is yet a vast amount to
improve. Then, consider for a moment the
ordinary town milkshop. Exceptions, hand-
some exceptions, there are, doubtless ; I
speak of the ordinary shop. It is placed
in a busy thoroughfare. It is every hour
of the day frequented by the people of the
locality. They come from every grade, and

THE HYGIENICS OF MILK 193

in every variety of dress. The door opens
and shuts every five minutes — now to receive
supphes, now to serve an urchin. " A
penny'sworth o' skum milk," he says. " We
have no skim milk," replies the shop-maid.
" Weel, then, gie's sweet." He comes from
a poor home ; his hands, not long ago, have
been assisting at the cleansing of a street
gully ; but he takes the milk home in an
open jug, placing it, perhaps, on the ground
in order to have another turn at the gully.
As he left the shop a gust of wind blew in
some dust. The milk-vessels on the counter
were open to receive it. In some cases, it
is true, the vessels are covered ; in a few
cases, they are kept in a glass cupboard ;
but any milk-seller of experience will tell
you that milk shut off from the air is less
pleasant to drink. He is, of course, thinking
of raw milk, as it comes to him from the byre
— half-cool and but roughly sieved. Prob-
ably he is right. As milk absorbs odours
very readily, so it may part with them
sooner on exposure. It is certain that in
butter-making free exposure to the air during
the churning dissipates certain disagreeable
odours. Anyhow, a glass case would pro-
tect from dust without preventing aeration.
But to return to the shop's environment.
Once a day the cleaning cart comes round

6

194 HEALTH AND DISEASE

Like as not, the ash-bucket is tilted into the
cart and pitched down just opposite the door.
The dust is naturally borne where its chance
of alighting on the milk is greatest. Mean-
while, look further in. That door goes, by
a short passage, to a living-room behind — a
kitchen, bedroom, scullery, and workroom
all in one. That is the inviolable freeman's
house, which is his castle. The short passage
is sometimes reduced to two doors, separated
by three or four feet. That is " indirect " as
opposed to " direct " communication. The
*' short passage " is, in fact, a legal subterfuge
to evade the Dairies Order. From and to
the shop the children run all day. Perhaps
groceries are sold ; perhaps only eggs and
butter ; much more frequently, confections ;
rarely is the shop devoted exclusively to milk,
milk products, and accessories like eggs.
Then the shop goods must be dusted ; they
must be arranged from time to time ; thev
may, in many shops, stand until the dust
covers them ; and then every swing of skirt
or cloak or shawl, every current of aii',
sets something more floating milkwards.
Perhaps, again, mangling and milk-selling go
together. Perhaps the means of scalding
the plates and pails are inadequate. To
describe every variety of combination legally
permitted is impossible. What I have said

THE HYGIENICS OF MILK 195

is enough to demonstrate that, if the dirt
of the cow-shed is enormous, the possible dirt
of the milk-shop is little less.

And if, to the inevitable dirt of the cleanest
town environment, one adds the dirt of
infrequently washed hands, uncut nails, shed
skin, fouled sleeves, and the innumerable
abominations of pent-up life in single rooms of
town houses, one cannot but stand amazed
at the capacity of the civilised palate to feed
on polluted supplies. It is necessary to add
— clothes that go for months unwashed ;
beds unaired ; blankets washed once a year ;
adults and children that have never had a
bath of the whole body. In places like these,
a surgeon would exercise the most stringent
care in his endeavour to secure asepsis, even
for a minor operation ; a major operation he
would not tackle. But the same surgeon, if
bacteriology has not cured him of his milk,
often as not permits his kitchen staff to supply
his children with milk from the very shop
where he would not operate.

Here, then, is a serious proble3^. The
hygienic solution is simple enough. Let
milk-shops be constructed on the same lines
as an aseptic operating theatre ; let the
principles of the laboratory be applied to the
protection of the milk ; let the shops be
g2

196 HEALTH AND DISEASE

devoted exclusively to the sale of milk and
milk products ; let there be no communica-
tion with living-rooms ; let there be air ;
let there be light. To fit up a shop with
impervious walls, shelves, counters, etc., is
an affair of every day. To provide protect-
ing cases for the milk, to separate old milk
from new, to reduce the need for manipula-
tion to a minimum — these are easy problems
hygienically, and, now and again, they are
solved. But for the most part they are
blocked by the " economic " incidents of the
vast trade in milk.

Did space allow, it would be profitable to
consider how the consequences of all these
pollutions can be, at least partially, averted, —
by mechanical cleaning, by complete sterilisa-
tion, by partial sterilisation (pasteurisation),
and other methods. Milk, too, is often the
means of spreading enteric fever, scarle:
fever, and diphtheria in large and sudden
epidemics. It is probably a leading cause in
the spread of tuberculosis. There are legal
means of countering these effects, — dairy
regulations, cleansing of persons, inspection,
construction of buildings, etc. But the hygi-
enic difficulties are complicated by economic
difficulties; for the milk trade is a very
great trade, and the need for milk induces

THE HOUSE AS HOME 197

the consumer to take risks. But legislation
steadily grows more exacting ; opinion, more
informed ; organisation, better adjusted. Yet
we are far off even from ideals immediately
possible. But the " soured milk " treatment
continues to spread. The needs of infants
and children more and more impress the
public mind. The values of milk, butter, and
cheese are more appreciated in the dietaries.
Everything points to an enormous demand for
milk. The day may come when, as a distin-
guished student of reform suggests, pure milk
may be " laid on " like water, gas, or elec-
tricity. If that day should come, the present
dirty methods of producing milk will dis-
appear like the polluted water supplies and
the unlit streets — only more rapidly.

CHAPTER XIII

THE HOUSE AS IMMEDIATE FAMILY
ENVIRONMENT OR HOME

The family is an incipient city. The city
is an organisation of services to express, to
develop, and to protect the growth and

198 HEALTH AND DISEASE

functions of the family. The rural cottage,
the farm-house and its cot-houses, the estate
mansion-house and its group of service
houses, the village, the small town, the town,
the great city, all, in their degrees, embody
the services necessary to let father, mother
and child grow to their full social functions.
The needs of the family determine the evolu-
tion of the city. The limit of civilised sub-
sistence in the city is the one-roomed house
for the minimum family of father, mother, and
infant. But, at the sacrifice of health, decency,
and, therefore, morals, the limit is usually
overstepped. The result is the slum and its
population of de-civilised families. This is
the primary problem of town-planning.

Consider the functions of the home. They
are, primarily, to shelter parents and children.
As to parents, the home must provide housing
adequate to the occupation of the bread-
winner ; it must provide means of storing
and cooking food ; it must provide facihties
for washing clothes and body, for clearing
away waste, for maintaining cleanliness ;
it must leave space for the occupations of
leisure, for the treatment of disease, for the
growth and education of families. As to
children, the home must provide nursing,
feeding, cleansing, education. All these the
house must make possible ; for to be a home

THE HOUSE AS HOME 199

is the highest function of a house. The home
is the focus of social activities, the head-
quarters of the functional social unit. The
home is the home of the family, and the
family needs shelter, food, clothing, education,
and medical care.

But the home is not alone the stone walls
where our father and mother and brothers
and sisters live. Hoine is there only where a
man will wish to turn when his day's work is
done : it may be the shelter for wife or child ;
it may be the birthplace of sister or brother ;
or again, it may be the hermit's hut on the
mountain-side, where solitude is the one
companionship ; or yet again, it may be the
open moorland, where freedom is and where
" the wind blows on the heath." And they
that live in the ideal may be " citizens of the
world " ; to them the whole earth is their
domain, and one place like any other place
fulfils the purpose of humanity.

How does the house of the town worker
answer our description ? How shall this
suite of mean rooms — undecorated, uncleaned,
unaired, odorous, crowded, unhandsomely
domestic, and dull — how shall this focus of
broken interests, and starved ideals, and petty
disappointments, and spiritless resignations
— how shall this temple of broken gods be a
home, a haven to run for in a storm, an altar

200 HEALTH AND DISEASE

to weep on in sorrow, a pillar of fire to guide
him in the tangle of living ? How shall he
enter into his chamber in silence for com-
munion with holy things when he cannot get
beyond the common noises of the day, the
squalling of children not his own, the offence
of cooking food, or the greater offence of
spilled alcohol ?

Compare the rural worker and the town
worker. The rural worker has his open door ;
he can walk miles without meeting another
like himself ; he has fields to roam in, hills to
climb, trees to shade himself under, streams
that croon to him when he is weary and guide
his imagination when he is glad. Compared
with the invasive dust and din of the town, his
day is a perpetual Sabbath of cleanliness and
quiet. But he, too, has his life of the slums ;:
no more than the town-dweller has he learned
the uses of a house ; he oftener keeps it
clean, because there is less dirt to invade it ;
but he as often keeps his windows shut and
sleeps in space too little for his dog. With,
all his advantages of open sky and clean air.,
the rural worker is not so far in front of the
town artisan as the mere living in the country
seems to indicate. Often, he is far behind
He suffers from damp houses, badly built, in
bad situations. He has difficulty in keeping
the soil clean, in removing refuse, in providing

THE HOUSE AS HOME 201

for the elementary decencies. All over, given
equal physique, he is more vigorous ; for he
has freer access to the greater goods of light
and air, and, which is equally important,
he is less exhausted by the routine of his
labour and the multitudinous attacks that the
town life makes on the senses of eye and
ear. He is slow in his actions, for he has to
keep pace only with the seasons and the
cows ; not with cars, cabs, and trains.

Consider, too, the worker's wife. She
is compelled to be industrious ; she has the
children for her daily burden. Usually, she
makes the children's clothing ; she keeps
them constant in their school attendance ;
she assists them at lessons ; she reports their
illnesses ; she trains their characters. I
know of no better ethical teacher than a good
artisan's wife. She is always in touch with
reality. She has manners ; she has intelli-
gence ; she has foresight ; she has ambition.
But often she runs under a heavy handicap.
She interviews the factor when the drains
are choked ; she abuses him when he fails
to repair them ; she pays the rent, she pays
the rates, she banks the wages in the friendly
society. " I paid his society money for
sixteen years, but he was aye ill and over-
wrocht. I fell back wi' the instalments,
and now Fii no* get a penny.'* She was the

202 HEALTH AND DISEASE

widow of a hard-worked riveter, who had
given himself a sacrifice for children and wife,
dying of overwork at forty, and leaving his
wife to continue the battle.

How shall we relieve the pressure of this
domestic drudgery ?

To begin with, there are the children. The
problem of the children has been in part solved
already. The older of them go to school ;
they remain there for a fair proportion of the
day ; they come home again, or remain for
a time on the street, and on the whole they
are not too much of a burden to the weary
and heavy-laden mother. But the children
of less than school age ? One is six months
old, and demands constant nursing. Another
is eighteen months or two years old, and
demands constant supervision. A third is
three and a half or four years old, and is just
capable of getting constantly into mischief.
There may be others, but we shall rest at
three. To do full justice to the life of one
infant would require more than all the
mother's energies, and she has to divide
herself among three. Nor that only ; she
must prepare her husband's meals — at least
three in the day. She may have a lodger,
and she must prepare his meals — at least
three in the day. She must feed the school
children — ^three times a day. She must wash,

THE HOUSE AS HOME 203

she must scrub, she must mend, she must
buy, she must cook, she must bake, she
must suckle the one baby and keep the other
moderately clean and the third moderately
safe, she must all day and most of the night
give of her soul and body to the needs of
others ; but one thing she must never do,
she must never fall out of temper, and she
must never feel tired. Is it a wonder if
now and again the brave heart begins to
weary, and the eyes to water, and the lips
to pale, and the limbs to tremble, and the
breath to come fitfully, and the stairs to
grow heavy, and the body to grow thin, and
the interests to grow narrow, and the desire
of life to run low, and the world to be too much
for her, and the very flesh at last to cry out
for rest — " Give us long rest or death, dark
death or dreamful ease " ? Is it any wonder
if she gives the biggest contribution to the
consumption death-total — she that cannot
venture into the air because she cannot carry
the baby, and rarely sees the sun ? Do we
need any more to explain why the friendly
societies are there ? why the doctor is kept
busy ? why infection multiplies ? and why
even a slum grows tolerable to its inmate ?
It is not that they prefer darkness, and bad
air, and perpetual labour ; it is that the life
they grow into is beyond their individual

204 HEALTH AND DISEASE

strength. They must go under ; they do go
under.

Take a walk with me down to Newhaven,
This young woman has lost her husband.
He was a young fellow of good character —
capable, steady, reliable. One night, on his
way home from his night-work on the railway,
he dropped down ill. His companion ran to
the nearest hospital ; he was taken there and,
on examination, he was found to be suffering
from severe bleeding of the lungs. He was
kept until he had recovered sufficiently to be
sent home. A week later he took a sudden
bad turn and died. On hearing of his death,
I called at the house. There I found some
sympathetic neighbours, who had shown
the young widow her duty. She was calm ;
she belonged to good people ; she rested on
human sympathy. She took me to the room
where her husband lay, telling me how hs
had died. There, in a room as clean and tidy
as if it were in a palace, lay the dead man,
covered over with sheets of spotless white —
the last sacrifice on the altar of personal
devotion. The baby smiled and kept to its
mother, and all was peace and quietness and
brave character.

Later, I saw the young woman again ;
but this time her dream had long gone
by and she was once more the Newhaven

THE HOUSE AS HOME 205

fisherwoman — clean, powerful, foresighted,
equal to the fate imposed upon her. It is
with regret that one watches the covering
over of that ancient and powerful people ;
the very houses are vanishing under our
eyes : the individuality of race is invincible,
but the individuals of it are becoming less
and less numerous.

Surely it is not hopeless to think that
something of the fine energy of these peoples
of the sea-border might find a parallel in the
streets farther inland ; or must we, after all,
accept the depressing conclusion that, as
the freedom and risks of the sea made that
great race of fishermen — strong, independ-
ent, competent, fatalistic — so the grinding
monotony of the ordinary industrial life
of the towns makes a race of feeble body,
unsatisfied mind — hopeless, heedless, un-
stirred by any excess of " the will to live " ?
One cannot think of this as a permanent
consequence of industrialism, even if it be
for the time inevitable. In a town of varied
occupations, all types are to be found — from
the dejection of the dirtiest slum-labourer to
the buoyancy of the full-blooded carrier from
the country. The continued infusion of fresh
country blood is the salvation of the towns ;
and usually, though the incomers are deeply
grieved at the town dust and dirt, they do.

206 HEALTH AND DISEASE

on the whole, maintain a higher standard
of management in their houses than the
older generations of town-dwellers. But
even among the less vigorous of our people,
the environment plays an enormous part ;
and I am satisfied that the energies of life
can be organised to far greater purpose if
only the fearful waste of a bad environment
could be eliminated.

When this is thoroughly understood, some
consequences grow clear. The school is a
necessity ; the hospital is a necessity ; the
industrial school is a necessity ; the day-
nursery is a necessity ; the nursery-school is
a necessity ; everything that increases the
energy of the home by reducing the friction
to be overcome is, from the standpoint of
social progress, a necessity. As things are,
the home ceases to be a home because it is
overweighted with the squalid and the un-
worthy. Remove these by better external
organisation, and the home at once has a
chance of rising into the most intimate of
social clubs.

One morning, about five o'clock, it was my
painful duty to visit a workman's house to
inform his wife that he was dying in hospital.
The door was opened by a child of five. She
had risen from her temporary bed on the

THE HOUSE AS HOME 207

floor ; she had been suffering from measles.
In the other bed lay the mother and four
other children, arranged as the accidents of
coverings would permit : the oldest child
was, perhaps, twelve ; the youngest, a few
weeks. Six people slept in the one room,
and this is hardly to be called overcrowding
compared with some cases I could give. This
house, however, was the home of a respect-
able workman, who would have earned some
30s. or £2 a week steadily. Trouble had come
upon him ; health failed ; the spirit had gone
out of him ; poverty began to take possession ;
then he died, and the mother with her five
had to face the pitiless world. In cases like
these, where shall we begin with a remedy ?
And they are to be counted by the hundred.
Yet this brave woman has faced the desert,
and she has not fainted by the way. The
oldest girl has gone to some occupation. The
others go to school. The baby is in hospital.
The mother will, by the help of one institu-
tion and another, climb up again into the
circle of efficient citizens ; adversity has tried
her and tempered her ; it has not subdued
her. If one could help her by the impersonal
service of some institution to nurse her weakest
from time to time, she would gain in energy
without losing in effort ; society would be a
true providence, seeking no reward but the

208 HEALTH AND DISEASE

reward of renewed endeavour after new
life.

Even overcrowding has its good side. The
family of the working man is thrown so much
together that the children instinctively cling
to one another. Here, for instance, is a
mother with five children. The oldest is
about fourteen, the youngest is five months.
One of them has German measles and a cough.
Another has a sore throat. The mother is
herself suffering from the bad weather. It
is about ten in the morning. They have
just risen — those of them that are able. The
baby and the two patients are yet in bed
with the mother. The father has gone early,
but he will be home again in the evening.
Squalor, do you say ? Unhappiness ? Not a
bit of it ! The baby is eyeing us all placidly ;
" she hath but wondered up at the white
clouds." The three-year-old at the bed-foot
is gazing with newly opened eyes at the
intruders. The oldest boy, half -dressed, is
kissing his hand and snapping his fingers to
the baby. The oldest " girlie " is exploding
every second with laughter at this little
wondering wonder. Even the mother, anae-
mic, depressed, smiles with them. The house
is not yet cleaned ; it may not be to-day ;
it is not tidy ; the breakfast dishes are not
cleared away ; a stocking is lying here, a

THE HOUSE AS HOME 209

petticoat there ; kitchen and bedroom are
one and the same. Yet have we not here
for the moment, could we but keep it, the
very essence of the ideal family — the romance
of innocence, fresh love untouched with
worldliness, spontaneous service, self-sacrifice,
the will to live, the joy of life ? In every
family those moments come ; perhaps among
the poor they are more frequent than among
the comfortable, where personal service be-
comes often too conscious of itself and passes
into sentiment ; but they come only to pass
again, and the very problem we are seeking
to understand is how to convert those sparks
from heaven into the steady light of our every-
days.

Now, further, as to this overcrowding.
Let us analyse a little. What amount of
space does a healthy adult need to breathe
in ? To this no one answer is possible.
But assume that we are thinking of a dwelling-
house where a man may have to sit or move
about for an average of three or four hours of
an evening. To keep the carbonic acid of the
fouled air down to 6 parts per 10,000, he will
require about 3000 cubic feet of air per hour ;
in three hours he will need 9000 cubic feet.
That is, if the room is 10 feet wide, 10 feet
long, and 10 feet high, the air in it must be

2ia HEALTH AND DISEASE

completely changed three times every hour.
Most working men's kitchens are rather
larger than this ; but furniture reduces the
available space. We may assume a room of
1000 cubic feet as a fair standard.

But the man is rarely alone. There is his
wife ; there are the children ; say, six persons
in all. Often as not there is a stranger
Suppose we say that the room's average
population will be, at a low figure, equivalent
to five adults. As each adult requires 3000
cubic feet of air per hour, five will require
15,000 cubic feet. But we have omitted
something very important. The house is
lit with gas, and the gas burner consumes,
say, five cubic feet of coal gas (mixed, I
believe, with some so-called " water gas,"
or hydrogen and carbonic oxide) per hour.
The gas pollutes the air as the human indi-
vidual does. Each cubic foot of coal gas
burnt per hour is, roughly, equivalent in
polluting effect to half an adult ; five cubic
feet will be equivalent to two and a half
adults, or, say, in round numbers, three
adults. We thus have, in our 1000 cubic
feet, eight adults, each requiring 3000 cubic
feet of air per hour, that is, 24,000 cubic feet
in all. Air costs absolutely nothing ; it is
absolutely essential to life ; yet where are
these eight adults (five of them alive and three

THE HOUSE AS HOME 211

of them simply a gas burner) to get it Y Not
by the kitchen window, for it was shut as
soon as the light went in and the blind went
down ; not through the door, which is kept
shut to keep the neighbours and the cats and
other children and thieves out ; not by the
parlour window, for that is open only once a
week or so, for fear the rain might get in or
the light spoil the carpet. If you stand up
on a chair, after two hours of this " home
life," you soon come down again, for the upper
levels of the air are reeking with burnt gas
and hot vapour. The baby falls asleep ;
the mother says it is because he has been out
so much, and perhaps he was out an hour in
the morning. The school children grow hot
in the cheeks and dull in attention. They
gradually grow drowsy and go to bed. The
father and mother soon follow — weary and
yawning.

Next morning the room is colder ; the fire
has gone out ; they have breathed some of
the air for the hundredth time ; the father
brushes himself up, gets out into the open air,
lights his pipe, and by the time he reaches
his work he is positively fresh. The mother
never gets out all day, and never gets fresh.
The children soon knock off the depression.
But the baby gets the worst of it ; he must
wait until he is taken out. The windows at

212 HEALTH AND DISEASE

last are opened, and there is a temporary
return to nature and sanity.

So far I have spoken only of the functions
of the house. Functionally, as we see, the
two- or three-roomed house is really a one-
roomed house. If this be the result with
two rooms or more, what shall we say of the
real one-roomed house ? Its condemnation
was written in words of fire by Dr. J. Burn
Russell of Glasgow. I have read no more
terrible indictment of a social system. And
it was written out of a wealth of detailed
knowledge probably unsurpassed in the
world.

The need of a good home is the driving
power behind all the movements for the better
Housing of the Working Classes and for the
better Planning of Towns. This is not the
place to discuss remedies. But one general
danger I may emphasise.

There is a tendency to separate the Town
Planning movement from the movement for
improving individual houses. This tendency
is natural, and the influences that create it are
easily analysed. There is the Building interest,
which looks for more possibilities of renewing
its activity as soon as one area is built up.
There is the Land interest, both owning and
speculative, which naturally wants to sell or

THE HOUSE AS HOME 218

use land to the best financial purpose. There is
the Architectural interest, which sees in every
new scheme of an extended town fresh oppor-
tunities of artistic development. There is
the Hygienic interest, which welcomes at all
hands the spreading of the town over a wider
area, if thereby the congestion of the centre is
relieved. But, with the exception of the
Hygienic interest, none of these pays special
regard to the improving of individual houses.
That is not for the moment their point of
view. It is, however, the ultimately necessary
point of view if the Town Planning movement
is to result in improved dwellings. The value
of the Garden City movement lies mainly
in this, that it steadily combines the two
standpoints — first, the provision of better
houses for the individual dweller, and, second,
the planning of the town to secure good
aesthetic effects.

Between the two standpoints there is, or
should be, no fundamental antagonism ; yet
it is unquestionable that the tendency of the
town-planner, as such, is to forget that the
final test of town planning is not the produc-
tion of artistic towns, but the improvement
of individual housing. Professor Rudolph
Eberstadt, of Berlin, who has given twenty
years to the study of towns, maintains that the
town-planning movement and the housing

214 HEALTH AND DISEASE

movement tend everywhere to conflict On
general grounds this is probable, and the
proof of it is the city of Berlin itself. But
the conflict is not necessary. If we watch
the wave of building as it proceeds, decade
by decade, we do, indeed, note that improve-
ment of the margin goes hand in hand with
deterioration of the centre ; but we also note
that the new houses are individually rising
to a higher standard, and that the demand for
a higher standard continually asserts itself in
the old houses too.

CHAPTER XIV

DISEASE AND DESTITUTION

Disease produces destitution ; destitution
produces disease. Both propositions are true ;
the evidence for both is overwhelming.

How does disease produce destitution ?
Let us follow a case. Here is a workman
earning £2 a week. He has a wife and five
or six children, and keeps them in comfort.
His wife develops tuberculosis of the lungs.
She was, perhaps, infected early in youth, and

DISEASE AND DESTITUTION 215

now, overworked and underfed, rapidly be-
comes unfit for her duty. What is the husband
to do ? He goes to his private doctor, who
advises sanatorium treatment. But he finds
sanatorium treatment beyond his means. He
goes to a voluntary hospital in the locality,
seeking admission for his wife ; but he finds
either that they do not admit cases of the kind
or that no beds are available. For a time, he
keeps his wife at home, procuring the best
treatment that his means afford. But, with
no extra food, no fresh air, no constant medical
direction, she grows no better and tends to
grow worse. She may, at the same time,
infect the children. The husband occupies
the same room with her, possibly the same
bed. He, too, may take the infection. At
last he comes to the end of his resources. He
cannot procure treatment for his wife and at
the same time afford maintenance for his
children. He has exhausted every source of
voluntary assistance. He can no longer pay
his doctor's bill. He applies to the Inspector
of Poor. In Scotland, he would not be
entitled to relief for his wife, because, by law,
he is able-bodied, and no able-bodied person
is entitled to relief. Legally, therefore, he
cannot have his wife removed to the sick
wards of the poorhouse ; but, if the Poor
Inspector and the Parish Council are generous,

216 HEALTH AND DISEASE

they may, as they sometimes do, admit such
a case to the poorhouse, and take the risk.
The Pubhc Health Authority is under legal
obligation to take charge of the case ; but,
in many localities, the transfer from poor law
to public health has hardly begun, and the
poorhouse may be the most convenient
destination, even if the Health Authority
pay.

His wife is now provided for, and the house-
hold for a time thrives. But, driven by the
cares of a sick consort and himself over-
worked, he gradually loses condition and
ultimately shows signs of tuberculosis himself.
The infection of a husband by a tubercular
wife is said not to be common — statistically ;
but the infrequency of the occurrence does
not help the individual case, and, whether
infected by the wife or not, this man suffers
from the disease. For a time he fights on ;
he asks for easier work ; he has frequent
periods off work, coming on his friendly
society for sick pay. At last he is thrown
out of his skilled occupation and falls into the
ranks of unskilled labour. Here he finds that
his children begin seriously to suffer. His
wages are now inadequate for their full main-
tenance. The disease advances until he is
entirely disabled. Then he goes through the
same weary round as his wife, and ultimately

DISEASE AND DESTITUTION 217

joins her in the poorhouse, or in the Health
Authority's hospital. The children are
boarded out.

Pulmonary tuberculosis alone accounts for
hundreds of cases like these. Any one that
knows anything of the lives of an industrial
town can add other illustrations from his
own experience.

When tuberculosis of the lungs goes hand
in hand with destitution, they move round
in a vicious circle. The disease causes the
destitution ; the destitution aggravates the
disease. This is above all true of tuberculosis ;
for an essential condition of recovery is the
provision of excess nourishment. If you
would have more evidence, go to the work-
house infirmaries of England, or the sick
wards of the great Scottish poorhouses.
There you will find cases in hundreds, not of
phthisis alone, but of many other preventable
diseases ; and, if you track out their histories,
you will, in many a case, find it difficult to
determine whether the disease came first or
the destitution came first. It is certain that
they are bed-fellows now.

A poor person, suffering from non-infectious
illness, has no claim on public funds unless
he is destitute. He is, therefore, deterred
by the conditions attached to the relief. It
is, I think, accepted by all that destitution

218 HEALTH AND DISEASE

as a condition of medical service does, in a
considerable degree, deter the really sick
from invoking public assistance.

But this condition has a further conse-
quence. It prevents the medical service of
a destitution authority from ever becoming
effectively preventive. Of the many pre-
ventable diseases already mentioned, some
may, on occasion, lead straight to destitution
and disablement. But the patient will not
come to the Poor Law for treatment until
no other treatment is to be had. A disease,
therefore, that, in its acute state, might be
easily cured and possibly prevented, tends by
the delay to become chronic and incurable.
This type of fact is accepted both by the
Majority and the Minority of the recent
Royal Commission on the Poor Laws. A
deduction so obvious from premises so easily
verifiable could scarcely be disputed. Bui:
if a medical service cannot be preventive,
its maintenance must be in some proportion
a waste of money. It is certainly true that
masses of preventable disease are, at th(3
present moment, untouched by any preventive
medical service.

Look now at the Public Health service.
It is grounded in the idea of prevention. Its
administrative evolution has steadily followed
preventive lines. It has shown in practice

DISEASE AND DESTITUTION 219

that masses of the infectious diseases are
entirely preventable, that others are capable
of control, that others are capable of ameliora-
tion. Everywhere, it goes on both improv-
ing the environment and providing for the
individual.

But the movement has revealed another fact.
It has shown that, between the infectious
diseases proper and general diseases due to
environment, there is no steady line of
separation. The more the individual person
is studied, the more his disease-conditions
get allocated to environmental agencies. But
this means that the concept of prevention
must be extended. It cannot be any longer
confined to the infectious diseases, great
though that group is. Already the adminis-
trative organisations deal with the poisonings
incident to certain trades, and do what pre-
ventive regulation can do to prevent their
occurrence. But the preventive service can
hardly stop at regulation. It will, in the
course of events, pass on to the provision of
treatment.

If this be so, the tendency to place disease
on a footing independent of destitution will
gather momentum. Every development of
medical service within the last twenty years
has followed preventive lines — notification of
births, milk-dep6ts. health- visiting, medical

220 HEALTH AND DISEASE

inspection of schools. Any new developments,
it is practically certain, must do the same.
Fifty years of public health administration
have educated the general mind in the ad-
vantages of early diagnosis by skilled people
and early treatment in suitable institutions.
The general opinion thus generated is not
likely to stand still.

There are, I am aware, economic difficulties
no less than administrative difficulties. But
the economic difficulties will be at least in
part surmounted by the next great step in
the prevention of sickness, namely, obligatory
Insurance of Workmen. To this let us now
turn for a moment.

CHAPTER XV

INSURANCE METHODS OF PREVENTING
SICKNESS

Insurance against sickness is not itself a
preventive remedy, but it leads to prevention.
This is the experience of every country that
has organised compulsory insurance of work-

INSURANCE AND SICKNESS 221

men. Over twenty years ago, Germany
established a system of compulsory insurance
of wage-earners. The system did not begin
with the open intention of preventing disease,
but it has everywhere had that result. The
best illustration is tuberculosis.

Recently, at an International Congress,
Herr Bielefeldt, President of the Imperial
Insurance Office, gave an account both of the
insurance system and of the preventive
methods developed under it. The benefits
conferred by the insurance against sickness
are chiefly these — first, sick benefit during
disablement caused by a disease. Here the
benefit runs for at least twenty-six weeks.
In different localities, different amounts may
be allowed, but the amount allowed must be
at least half of the average earnings accord-
ing to local usage. Second, assistance to
the workman's family while he is treated in
hospital. This money assistance amounts to
half of the sick allowance. Third, money
assistance for six weeks to women during
confinement. The amount is equal to the
sick pay. Fourth, in the event of death, an
allowance to the parent of the deceased —
this allowance amounting to twenty times
the average daily earnings. So much for
sickness insurance.

There are also certain allowances tor

222 HEALTH AND DISEASE

disablement extending beyond twenty-six
weeks, and allowances for old age.

Here the wage-earner is under obligation
to insure. The money so accumulated must
be expended in his service. Insurance
organisations have found that, in certain
diseases, it is more profitable to treat early
with a view to prevention than to wait till the
patient is a permanent invalid. Tuberculosis
is a striking example. In the early stages of
insurance, all that was guaranteed was medical
treatment and the necessary medicines. But
the insurance associations were under obli-
gation themselves to provide the medical
attention and medicines. This led to a
closer study of the problems of treatment.
At first, no doubt, the associations tended to
save money on the price of drugs. But,
gradually, the conviction grew that the
common interest of the association and its
members lay in the rapid, efficacious and
continuous provision of medical assistance.
The number of doctors was increased. Speci-
alists were engaged. Among others there
were specialists for tuberculosis. It is to
these considerations that the immense activity
of the sickness insurance societies is due.
Year by year they have expanded their scheme
of treatment, always along the line of pre-
vention. To-day it is possible for their

I

INSURANCE AND SICKNESS 223

members to have full advantage of the
methods of modern medicine — the resources
of bacteriology, of radiography, of hydro-
therapeutics, electric treatment, massage, etc.
In some cases, the associations allow to
their members tonics in the form of
milk, wine, various drugs, and mineral waters.
In a serious case of tuberculosis, they offer
gratuitously the service of nurses, or treat-
ment at a watering-place, the open-air cure,
and the like. There is also available treat-
ment in a hospital or a clinic. Everywhere
over Germany, as the result of experience,
the sickness insurance associations have de-
veloped hospitals, clinics, and sanatoriums,
all on preventive lines.

In whatever way, therefore, insurance
against sickness may start, it necessarily ends
in the development of preventive methods.
The economic difficulties are thus partially
solved. But many administrative diffi-
culties remain. In Germany, when the
system of insurance began, the public health
movement, though it reckoned great names,
was administratively not so fully developed
as it is in Great Britain to-day. Doubtless,
had the health organisations of town and
county been fully organised, they would
have been worked directly into the service.
To some extent, indeed, they were. For,

224 HEALTH AND DISEASE

^

in the leading German towns, hospitals for
the treatment both of infectious and of
non-infectious diseases are part of the muni-
cipal system. There are, of course, many
voluntary hospitals ; but, unlike our customs
in Britain, the treatment of general sickness
on the Continent has largely fallen to muni-
cipal hospitals. These institutions, there-
fore, are available as a working part of the
insurance system. To that extent, the
insurance societies have the advantage of
hospitals under public management.

In Britain, the course of administrative
evolution has been somewhat different. It
is only now, but with the advantage of con-
tinental experience, that insurance against
sickness is to be instituted. It proceeds
frankly from the beginning on preventive
lines. It will cover a large part of the field
of sickness and disablement. It therefore
necessarily takes with it the health authorities
everywhere established in England, Scotland,
and Ireland. These authorities, directly or
indirectly, will therefore have their bounds
enormously widened. They will be no longer
authorities merely for securing the sanitation
of the environment and the prevention of
infectious diseases. They will be animated
by a broader outlook They will scan the
whole environment as it is m relation to the

INSURANCE AND SICKNESS 225

individual. They will push their analysis
of the causes of disease until every producer
of disablement is revealed, whether the
disablement come from infection, or from
poisoning, or from the dust diseases, or any
other of the occupational diseases. The
line between public health and individual
health, always merely provisional, will at
last disappear. The individual will no longer
be in abstract antagonism to the community
he lives in ; he will, even by his cash nexus,
find himself an organic unit of the greater
organisation.

And so a system of individual insurance
reveals new social relationships. The system
shows itself as, after all, only a specialisation
of the public health movement. That move-
ment began with an inspection of the grosser
defects of the environment ; it ends with a
minute scrutiny of the individual. Yet the
line of evolution is perfectly continuous. At
no stage can it be said, here is a definite end.
There can be no end until the individual, in
his passionate desire for health, finds that
the common health service is the only instru-
ment that can achieve his individual aims.

It was this high purpose that created the
scheme of National Health Insurance pre-
sented to the House of Commons by Mr. Lloyd

H

226 HEALTH AND DISEASE

George, Chancellor of the Exchequer, on the
4th of May 1911, a red-letter day in the his-
tory of industrial democracy. The scheme
is, perhaps, the most comprehensive scheme
of Health Service that has yet emerged in
any civilisation. It has in it the beginnings
of a vast revolution in medical organisation.
It concerns the daily lives of some fifteen
millions of people. It brings the enormous
individual energies of the great Friendly
Societies into relation with the social energies
of the public organisations. It is a new corre-
lation of social forces to prevent disease and
to establish health. And, politically, it has
caught the imagination of all sections of
society It has stilled the criticism of the
political partisan. It has evoked the cool
consideration of the expert. It has persuaded
the mind of the man of business. It has
opened before the eye of the worker new ways
in the wilderness of living. It has devised
new services for the health authorities. It
provides them with resources for the extension
of their beneficent activities. The Chancel-
lor's exposition of his scheme showed that the
measure was a great one. The impression is
but deepened by the detailed study of the
Bill.

The State arranges for the collection of the
funds. By Mr. Lloyd George's original pro-

INSURANCE AND SICKNESS 227

posals a workman would contribute 4d. a
week, a workwoman 3d. a week, the employer
3d. a week. The State would contribute two-
ninths of the benefit in the case of men and
one-fourth in the case of women. Certain
classes of worker are excluded. But certain
classes may be admitted as voluntary con-
tributors.

The funds are distributed by the State
through two channels — first, the Friendly
Societies; second, a special organisation named
the "Local Health Committee." The Friendly
Societies must be approved by the State, and
must undertake to provide for their members
certain minimum benefits. For those not in
Friendly Societies, the State distributes the
collected money through a Local Health Com-
mittee, representing four main interests —
the local authorities for public health, the
Friendly Societies, the insured persons not in
Friendly Societies, and the State itself. This
Committee is the principal new creation of
the Bill.

What form shall the distributed money
take ? Look first at the minimum benefits
made possible by the contributions of work-
man, employer, and State. For all those
insured in Friendly Societies, there must be
the following : The insured person will re-
ceive medical attendance throughout life.
h2

228 HEALTH AND DISEASE

The allowance in sickness according to the
original Bill would be at the rate of 10s. a
week for men and 7s. 6d. a week for women
for thirteen weeks from the fourth day of
sickness, and 5s. for the next thirteen weeks.
For the remainder of sickness, however long
it lasts, the insured person would receive 5s.
a week. A provision of immense value is the
provision for maternity benefit, to be received
if the mother is either herself insured, or is
the wife of an insured person. As the Old
Age Pension system already in force pro-
vides for persons over seventy, the benefits
under the present scheme cease at that
age.

Out of the whole contributions a proportion
per person insured must be set aside for a
Sanatorium Fund. This fund will be con-
trolled by the Local Health Committee. I1:
will be used for the provision and manage-
ment of sanatoria of all kinds — sanatoria fo:?
tuberculosis being at the moment the most
prominent. But other diseases may also be
provided for. Further, a substantial vote
would enable local authorities and others
to provide sanatoria and other institutions
for the treatment of tuberculosis and such
other diseases as the Local Government
Board may appoint, this sum being dis-
tributed by the Local Government Board,

INSURANCE AND SICKNESS 229

which, as the central authority for health,
controls the whole health policy of the local
authorities.

There is another major provision. If, in
any locality, there is any excess of sickness
among the insured, the Local Health Com-
mittee or a Friendly Society may demand an
inquiry by the State Department concerned —
the Home Office, for instance, or the Local
Government Board. If the excess of sickness
can be shown to be due to the conditions or
nature of the employment, or to bad housing,
or to insanitary conditions in any locality, or
to defective or contaminated water-supply,
or to the neglect on the part of any person or
authority to observe or enforce the provisions
of any Act relating to the health of the workers
in factories, workshops, mines, quarries, or
other industries, or relating to public health,
or the housing of the working classes, or any
regulations made under any such Act, or to
observe or enforce any public health precau-
tions,— then the various persons or bodies
concerned may have to make good the differ-
ence of expense due to the excess of sickness
so caused. These provisions are of immense
range, and place the prevention of disease on
the bed-rock of personal money interest.

The Bill also contains a scheme for insur-
ance against unemployment. But this eon-

230 HEALTH AND DISEASE

cerns health only indirectly, and may here be
disregarded.

The details fox'the realisation of these great
ends occupy in the original Bill nearly eighty
large pages of foolscap. The experience of
other countries has been taken as a guide, not
as a model. The special conditions of British
society have led to the great proportional part
played by voluntary organisations. And the
contributing persons control the destination
of their contributions. But the official health
authorities receive not only new powers, but
new stimulus to use them. As time goes
on, the movement towards prevention will
steadily increase in volume. The health of
the person and the health of the community
will be once more revealed as but two phases
of a single problem.

And this leads to our last chapter, whero
all the threads are woven into a flowing
pattern, which is the progressive synthesis
of prevention and cure.

THE HEALTH MOVEMENT 231
CHAPTER XVI

THE EVOLUTION OF THE HEALTH MOVEMENT

Dr. J. Burn Russell struck a high ethical
note in his Evolution of the Function of
Public Health Administration.

He spoke not as an administrator only.
He was a stern pleader for social righteous-
ness. The burden of his twenty-six years
of administration was — " Comfort ye, com-
fort ye my people." How much Scotland
and the world owe to his personal devotion
none can conjecture except those that knew
him. But the city of Glasgow published a
Memorial Volume of his writings. And there
the record of a great and patient adminis-
trator can be read. He could clothe statistical
dry bones with the flesh and blood of an in-
formed social doctrine. His diagrams have
passed into the text-books ; his intensive
studies of housing are classics in their kind ;
but the science of them was informed by a
singular righteousness and potency of con-
viction.

The story his writings tell is a marvellous
one. It reveals the progress of a community
more convincingly than any mere history of
institutions. It lays bare the nerve of social

232 HEALTH AND DISEASE

health, the minimum conditions of individual
growth, the contrast between the listless
neglect of fifty years ago and the skilled
services of to-day. Surely the Service of Man
owns no higher, no more honourable minister
than him whose mission it is to cleanse, to
purify, to sweeten the bright air, to shine
the light into dark places, to fill with the joy
of living the highways and byways, the alleys
and the lanes, the courts and the wynds and
the reeking cloisters of the social under-world.
For in that dim land the primary ritual of
nature has passed from the memory ; misery
and filth clog the spontaneity of life and
overload the will ; there is nothing but torpor
and hunger and the melancholy vices of
personal degeneracy.

Fifty years ago, Glasgow stood first among
the cities of the kingdom for wretchedness.,
for filth, for the multifarious hordes of disease
that follow them. But the fifty years sslw
the birth of a new movement, which is no^'
sweeping round the world. In every great
city the same problems have to be faced ;
but the science of administration has gone
steadily forward. Glasgow is but a type.
How she shook herself free from the night-
mare of typhus and all it meant ; how,
through panic and error, she passed from one
bad method to another less bad, and how at

THE HEALTH MOVEMENT 233

last, like all city organisations, she came to
follow a policy designed and defined by a
genuine social insight, form one of the finest
illustrations of the transit from a vaguely
felt social need to the scientific elaboration
of an administrative system.

What one city in a hundred years of her
history shows, every city in the world shows
in its own degree and kind. For the move-
ment towards health is world-wide. And
it is not limited to the cities alone. There
are the rural areas, more thinly peopled,
it is true, but feeling their needs as warmly
and developing their systems of administra-
tion as scientifically.

It was in 1889 that the great departure
in rural administration took place in Scotland.
It was then that the Parish as an adminis-
trative unit for public health was superseded
by the County Council and the District
Committees. For twenty years, the Public
Health Acts in the counties had lain quietly
on the parochial tables, — Acts that, in many
of their provisions, were far in advance of the
general opinions of their day. But I remem-
ber well how, as young medical officers of
health, we were stirred by the new movement
towards better social organisation. The field
was wide. There were no guides to help us
in our duty. Some of us had had experience

234 HEALTH AND DISEASE

n

in the towns ; some of us had to invent our
experience in the counties. The irrespon-
sible studies of the University had here to
meet the hard necessities of administration
in a world where individual houses were
separated by miles, where the farms were
incipient communities, where villages pre-
sented the problems of budding cities without
the city resources, where, in a word, the
whole common organisation was difficult to
discover and more difficult to make effective.
It was then that one felt how little the laws
can do until the common heart is moving.
But it did not take long to unlock the feelings
of men in the counties. They were only
waiting for a lead. The newly created county
medical officers became the points of contact
between the world of scientific ideas and the
world of social needs. The hygienic con-
science was awakening.

What was the material we had to work
upon ? The whole range of rural life in farm,
in village, and in small town. The farm hi
a simple social unit, which, on the whole,
understands well the hygiene of animals,
not so well the hygiene of men. Pigs must
pay; men are free. Pigs for pigs, therefore,
are often better off than men for men. It is
not one or an occasional farm, but many, I
have seen, where absolutely the animals had

THE HEALTH MOVEMENT 235

more space, more air, altogether a healthier
home, than the men that tended them.

It is natural ; for, unlike animals, men are
held fit to house themselves. And, on the
other side, the plain dispositions of farm life
are not so easily offended ; a daily familiarity
with dirt lets the sense for handsomeness
drop, and nothing more astonishes a cowherd
than to indicate how much cleaner his cow-
shed might be, or a long-lived crofter how
much better aired his stables might be.
If, thus, with animals, where good hygiene
is so much in hard cash, the attention is not
all it should be, how much worse is it with
human beings, whose health is a secondary
thing to their passing and seasonal efficiency
It was the work of the medical officer to
disturb this quiescence, to place the ideal
higher, to generate a social sensitiveness
that should regard filth as an indecency,
defective ventilation as a breach of fashion,
and more sleeping space as, at least, a legiti-
mate ambition. In a lower middle -class
house with what certainty may you find
" oils " in the dining-room, engravings or
etchings in the drawing-room, and not for
worlds an ornamental tea-table in the break-
fast parlour \ The poor man's menage is
less elaborate ; but there is much in it that
he knows not how to use, or that he has

236 HEALTH AND DISEASE

^

caught a bad fashion of using. At least,
he may be taught that windows should always
open ; that chimneys should never be closed ;
that if the kitchen is warmer in the winter,
his spare room is fresher to feed in for the
summer ; and that in illness " under the bed "
is not a good place for odds and ends, least of
all for use as a wardrobe. These defects of
living the medical officer of health could
bring to a clear consciousness ; he could
initiate a " fashion " of healthiness ; and
thus he could, as it were, sensitise the major
decencies.

In our smaller villages the material was
not much different. For what are our vil-
lages ? Here is one stuck down, a few
houses at the meeting-point of two roads.
The inhabitants are labouring people, farm
hands, and the like ; shopkeepers, to supply
the mixed group with food ; a carpenter's
shop, a smithy, and not infrequently a
common lodging-house. Sixty years or more
ago, the mail coach passed this way ; that
accounts for the inn, which now suppliers
alcohol to the group. The horses rested or
changed there. By and by, another house
got stuck down near the inn ; yet later the
gregarious instinct, and perhaps the cheap-
ness of useless land, produced another and
another ; till now you see it — inn, school-

THE HEALTH MOVEMENT 237

house, church, and village congregation.
The houses are not ungainly ; the walls are
kept white, the windows black-bordered, the
doorsteps clean ; but what of sanitation ?
What of the water, for instance ? There
is the original well, enough for one, enough
for two, for three ; but too little for the
group of families now constituting a com-
munity. New wells must be made ; they
are made. But in this haphazard, unguided
growth, the assumptions of heedless farm
life are slowly causing degeneration in the
incipient town. For refuse accumulates ;
drains are not made ; pigsties are not
cleaned ; ash-heaps are not changed ; and
the houses become unhealthy, damp, hardly
habitable. And, a worse result, the wells
are defiled. In our pastoral and agricultural
counties this is the history of village on
village. It is much to abate the major
nuisances ; it is more to teach their future
avoidance ; it is most, and most to aim at,
to generate, in the affairs of health, the
social feeling that keeps the walls white and
the doorsteps clean. And this, it seems to
me, was not beyond the scope of a medical
officer's legitimate efforts.

What methods were devised to stir up
the rural mind, I need not indicate ; but
to-day there is not a district of these com-

238 HEALTH AND DISEASE

I

munities that has not better water, better
houses, better drainage, better hospital ac-
commodation, than twenty years ago. The
organisation of pubHc health in Scotland has
everywhere advanced with an ever-increasing
acceleration. To those that knew the
counties and some towns twenty years ago
and that know them now, the total difference
is barely credible. Perhaps to the men
engaged in effecting the evolution, the pro-
gress has not always been the thing most
visible ; but the progress has been vast.
Health authorities have become a reality.
Even the economic value of health has
become an impelling force. District Com-
mittees, Burgh Councils, and County Councils
spend much time, energy, and money in giving
concrete form to the prescriptions of the
public health laws. And these changes
followed on two main changes, — the areas
mere made large enough to let administration
become effective, and medical officers were
appointed to prevent disease.

But these are only local manifestations c>f
the Public Health movement. In England,
it started consciously in the early years of the
nineteenth century, when Edwin Chadwick
was still young. Chadwick's father, it is
worth mentioning, had seen Napoleon drilling
troops in the Champ de Mars, and it is not

THE HEALTH MOVEMENT 239

far-fetched to believe that the younger Chad-
wick inherited some elements of the Revolu-
tion spirit. Anyhow, Chadwick is the great
name in several beginnings, and certainly in
the beginning of the modern Public Health
movement.

His " Report on the Sanitary Condition of
the Labouring Classes of Great Britain "
was the result of Lord John Russell's com-
mission in 1839, and remains to this day a
classic in its kind. There is hardly a subject
of interest to modern society that, at some
stage, he did not handle and illuminate.
The value of life, life as a commercial prob-
lem, life in prisons, days of sickness among
the masses, dietaries, registration of births,
marriages, and deaths, taxes on knowledge,
the economics of intemperance, education,
the physiological and psychological limits of
mental labour, the half-time system, physical
training for trade unionists, the construction
of schools, pensions to school teachers, cheap
railways, employers' liabilities, sewerage,
cremation, over-crowding, ventilation, un-
healthy trades, epidemics, war, poor-law,
police, and the multitude of phenomena
indicated by them, — these were the occupa-
tion of Chadwick's immense and unremitting
energy. The organisations that flowed from
the revolution achieved by the political

240 HEALTH AND DISEASE

reform of 1832 — ^reforms largely inspired and
guided by men like Chadwick and James Mill
and George Grote — gave scope for the develop-
ment of a public health service in towns. If
we had time, we might trace step by step
from these great initiations the modern
growth in local government, the organisation
of rural and village life, the vast expansions
of public health activities in county and
town.

Curiously, the Assistant, that is the active,
Secretary of the first Board of Health, which
Chadwick was the means of establishing, was
Alexander Bain, psychologist, afterwards
Professor of English and Logic and, later,
Lord Rector in the University of Aberdeen.
Chadwick was a friend of Bent ham, and had
acted as his secretary. He was an ardent
Benthamite. These names are always
associated with the two Mills and George
Grote Not one of them was a medical man,
although Bain had studied in some of the
medical classes ; yet out of the social move-
ments in which they were, in one degree or
another, leaders, grew the movement towards
Public Health. It is not often that we can
associate a great movement so definitely
with the initiative of individual men ; but,
without straining the facts, we may really
regard the Public Health movement as a

THE HEALTH MOVEMENT 241

specific application of Benthamite principles
to the improvement of society.

In the marvellously specialised organisa-
tion of our present-day health authorities,
with their skilled medical officers, medical
inspectors of schools, health visitors, nurses,
nuisance inspectors, fever hospitals, their
drainage districts, their water districts, their
housing, and their whole machinery for
administration of elaborate Public Health
Acts, it is difficult to discover any trace of
the social philosophy from which they have
all taken their immediate inspiration. But,
whatever be the particular origin, the Public
Health movement in Britain is one of the
finest examples of social growth known to us.
It is the name for a vast organisation that
has grown out of definite social needs ; it has
a perfectly defined objective ; it has methods
that can be analysed down to detail ; it is
steadily showing itself in new differentiations
and integrations. There is no section of society
unaffected by the movement; there is no section
that can disregard it ; there is no meanness of
finance that can escape it ; there is no inertia
that it will not ultimately overcome. Over
and over again, we see the bitter lesson driven
home on the reactionary mind ; over and
over again, the densest imagination must
waken up to a local need that disease, dis-

242 HEALTH AND DISEASE

^

ablement, and death have revealed ; over
and over again, the unhealthy locality,
the unhealthy house, the death-dealing in-
dustry, and other innumerable varieties of
insanitation have vanished under the tide of
hygienic ideas.

If we turn from history, and look directly
at the movement of the moment, we can
detect at least one steady drift, — the drift
from curative medicine to preventive medicine.
The expert of the movement is the Medical
Officer of Health. The evolution of this
term would itself be an interesting study.
Probably its first legal embodiment is to be
found in the Public Health (Scotland) Act,
1897, where "Medical Officer of Health"
is among the definitions. The phrase is now
so common that over all England and Scot-
land it has shrunk to three capitals — M.O.H,
That it should be only a few years old indicates;
the velocity of the movement. The term
" Officer of Health " is an old one, and is not
peculiar to England. Possibly also, " Medical
Officer of Health " is older than I imagine ;
but certainly it is only within the last twenty
years that it has passed into social currency.
The phrase is a crystallisation of the Public
Health movement. It is " health " the move-
ment aims at, — the establishing of every

THE HEALTH MOVEMENT 243

individual in his physiological normal. It
is by " medicine " that this aim should be
achieved, — the practical science of cure for
the sick individual and prevention for him
and his social group. And it is through an
" officer " that the aim and the method come
into synthesis, — the officer presupposing the
organisation that determines his functions.
The phrase, "Medical Officer of Health,"
therefore, is the embodiment of a new syn-
thetic idea, which, on analysis, is no other
than the transformation of cure into pre-
vention, or rather the absorption of cure as
a factor in prevention. The " doctor of
medicine " thus reverts to his true place
among other " doctors." He ceases to be
the " leech " of old days, and becomes once
more the teacher of health, the expounder
of remedies. But the remedies are no longer
applied to individuals alone ; they include
the whole sweep of the environment as it
affects the individual, and the individual as
he is to be fitted to make his environment.

At first, naturally, the unspeakable abom-
inations of the environment drew the fire of
the Public Health services, and continue to
draw it. But the effect has been, to some
extent, a false abstraction. In elevating
the environment, the Medical Officer of
Health has tended to forget the individual

244 HEALTH AND DISEASE

organism. This he has left largely to his
correlative, the " general practitioner." The
Medical Officer tends to think of an abstract
environment adapted to an average organism.
He has developed great tables of birth-rates,
of death-rates, and of disease-rates He
speculates on their rise and fall, as the stock-
broker speculates on 'change, and he not
infrequently forgets that his curves of averages,
real though they be for their purpose, are
only the symbol of actualities, not the
actualities themselves. The more intensive
has been his study of the environment and
the more intense his efforts to improve it,
the more he has tended to become dissociated
from the care of the individual organism and
absorbed in the preparation of abstract
environments. Yet, ever and again, hour by
hour, week by week, year by year, he is
violently brought back to the needs of the
individual. However much he may devote
himself to the perfecting of water-supplies,
the sites of new houses, the clearance of slum
areas, the teaching of hygienic physiology,
he can never get far away from the infected
individual, who needs his definite assistance,
and who, by his disease, reflects new light
on the imperfections of the environment.

Meanwhile, however, other differentiations
have been in progress. The medical inspection

THE HEALTH MOVEMENT 245

of school children has become a reality in
England and in Scotland. The immediate
point of departure for this new specialisation
of duties was the Royal Commission on
Physical Training (Scotland), whose report
appeared in 1903. Few movements have
developed so rapidly. New organisations
have been created, or new developments of
old organisations have been made. New
officers have been appointed. In England,
there are in the School Medical Service now
approximately 1000 medical men, 73 medical
women, and some 300 nurses. Large sums
of money have been voted. Endless disputes
have arisen. But the primary objective of
the new specialisation is coming nearer and
nearer, namely, the direct personal examina-
tion of the school child. It is no longer the
environment ; it is at last the individual.
And it is not the individual alone, but the
individual as he, by his defects and diseases,
reveals all the relations he bears to the en-
vironment. Curative medicine and preven-
tive medicine have come to a fresh synthesis
in the medical inspection of the school child.
The skill of the physician and the science of
the Medical Officer of Health unite in the
Medical Inspector of Schools.

And the Public Health movement cannot
stop there ; for the school child, on his coming

246 HEALTH AND DISEASE

to school, brings with him the long history of
his nurture and, on his leaving school, will
bear with him into life the bias of his educa-
tion. It follows that medical inspection of
the school child must look backward into
infancy and forward into adolescence and
maturity. At every step the Medical In-
spector watches the interaction of the indi-
vidual and the environment, anxiously jealous
that the environment shall meet the highest
needs of the individual, and that the indi-
vidual shall be strengthened to respond to
the highest purposes of the environment.

There is now to follow a further specialisa-
tion of all the medical services This will
come as the result of the National Insurance
for the prevention of sickness. Individual
health and common health are at last seen
to be one and the same. What re-organisation
of administrative functions this third new
departure may involve, no one can foresee.
The last twenty years cover a record of great
changes ; but these are nothing to what the
next twenty years will bring. Let us, how-
ever, for a moment shift the point of view.
It is natural, in these rapidly appearing
developments, to look for fundamental prin-
ciples. They are not easy to put into words.
Perhaps, the postulates of the Public Health
movement, the movement towards individual

I

THE HEALTH MOVEMENT 247

health, individual efficiency, are something
like these : —

The movement has its root in the ethical
effort after a richer, cleaner, intenser life in
a highly organised society. Society or the
social group is itself essentially organic. But
the social organism is an organism loosely
knit. It is capable of easy and rapid modifi-
cation. When the modification is the ex-
pression of a real social need, it will survive ;
it will generate for itself the necessary ad-
ministrative form. Disease, as we have seen
at the beginning, is a name for certain mal-
adaptations of the social organism or of the
organic units that compose it. These dis-
eases, as has been abundantly shown, are in
greater and lesser degrees preventable. Their
prevention promotes social evolution. But
their prevention needs definitely organised
agencies. These are the administrative
bodies, — County Councils, Town Councils,
District Councils, Parish Councils, School
Boards, Imperial Government Boards, Inter-
national Executive Committees. Through
these it is possible to control disease-producing
conditions, to prevent the onset of disease in
the individual, to permit society as a whole
and its individual citizens to benefit by all
the preventive methods from time to time
discovered or invented. Natural selection

248 HEALTH AND DISEASE

may thus be definitely aided by artificial
selection. Constitutional inheritance of dis-
ease may be, in some degree, compensated
by more efficient social environment. By
the continued modification of the social organ-
ism and its flowing environment, it is possible
to further the production of better citizens, —
more energetic, more alert, more versatile,
more individuated.

The majority of the diseases that afflict
the human body do not come from the body
itself ; they come in the conflict between the
human body and its environment. The
environment includes all the organisms and
conditions that operate as causes of death.
These have been fully illustrated. Infectious
disease, now a conflict between a higher
organism and a lower, may be converted into
a friendly co-operative life. The fatal an<i
disabling trades may all have their fatality
and disabling power reduced. The food
environment is capable of indefinite improve-
ment. And so on, through all the relations
of men to each other and of all to the physicfJ
conditions of life. In its first stage, public
health is the application of scientific ideas
to the extirpation of environmental disease.
In its second stage, it is the application of
scientific ideas to the production of personal
immunity. Everywhere, it is the synthesis

d

THE HEALTH MOVEMENT 249

of prevention and cure. It is an organised
effort of the collective social energy to heighten
the physiological normal of civilised living
beings.

And so the circle is completed. The healthy
individual man with whom we began needs
a healthy community in order that he may
maintain his physiological normals at their
highest efficiency.

To these propositions many objections may
be made. Of these objections, I name two, —
first, the charge that the Public Health move-
ment exalts the environment at the expense
of the individual heredity ; second, that
thus it evolves into a systematic method of
reducing the pressure of life and thereby pre-
serving the unfit.

As to heredity, the charge sits lightly upon
us. Any one that reads what has here been
written must allow that the obstructions to
healthy development are a vast and confused
mass. Until this gross environment is dis-
entangled, split up, and reduced to its least
potential, no one can know what the human
organism can do. If you give children more
light, more air, more food, they will grow
into healthier, stronger, more resistant adults
than if you keep them in the dark, poison
their air, and restrict their food. To any one

250 HEALTH AND DISEASE

that doubts this, I merely say : Try the
experiment of transplanting an infant from a
slum to a hospital. To go from the lightless,
airless, foodless home to the well-lit, well-
aired, well-provided hospital, is to go from
physiological poverty to physiological wealth.
Among the middle classes one never fails to
note the change from pinching to prosperity.
The thin, pale man with restless eye, anxious,
always thinking backwards, alters into the
rosy-cheeked, full-bodied citizen, with head
erect and a smile for all comers. In the less
favoured proletariat, the change is no less
striking. After a few weeks of light and air
and regular food, the human weakling sprouts
out and grows both in muscle and in nerve,
both in energy and in co-ordination, both in
body and in mind. It is not that new
faculties are created ; it is that old faculties
cease to be clogged up. And the sole change
has been a change in environment.

Until, therefore, the environment is first
made healthy, the question of physiological
inheritance does not concern the health
movement. It is an absurd waste to evolve
by natural selection an inheritable " fitness "
against an environment that can itself be
swept out ot existence, in this country we
do not build houses in the tree-tops to escape
the wolves ; there are no wolves ! Neither

THE HEALTH MOVEMENT 251

do we kill thousands in order to evolve a
type fitted by heredity to resist plague ; we
simply keep plague out !

But a more fundamental answer may be
made.

It is our duty to prevent death. Out of
the effort to keep alive those that would
die of preventable diseases, the vast Health
Service has grown. Of what diseases do
we die ? Of what diseases must we die ?
These it is our duty to answer. Until the
secret of physical persistence is revealed, it
is ours to reduce the agencies of death to
those few that men must face and accept ;
to create, if it but be possible, new channels
for human energy, that the waste of living
may fall to its least and the wealth of living
— in breadth, in depth, in intensity — may
increase to the uttermost Our service
meets heroic obligations. In despair, it is
not desperate. As the physician never
abandons the bedside until the breath ceases
and the pulse fades into rest and the limbs
lie without will and the eyes change their
lustre and there is no more man, so the
service of health watches the birth, the
adolescence, the full tide, and the ebb of
the social life. Never at any period is the
task abated. From the simplicities of the
primitive life on the hills, in the woods, in

252 HEALTH AND DISEASE

I

the fields, along the rivers, and by the sea-
shore, to the infinite involutions of life in
the cities, — in the dust, in the noise, in the
dark, — our service is unremitting day and
night ; it has its orders to administer, its
care to offer, its word for consolation. And
as men grow more from living to thinking,
as labour grows into knowledge, as the
nerves begin to dominate the muscles, and
as education, the arts, the sciences, the
crafts, catch the imagination of men and
intensify their interest for the invisible and
immaterial, the Health Service must grow
in subtlety to meet the keener diseases of
civilisation.

And, if it is given to any of us to watch
the decline and fall of any people, when trade
passes and hunger enters and famine glides
hither and thither telling who are the con-
demned, our service has yet its duty, — w(3
must be the last to go. If the phoenix may
not rise, we must yet prepare the funeral
pile and watch the fiames die down.

So, through all the stages of the growth
of men in societies, the Health Service may
never be wanting. It is the form the Service
of Man takes equally in the day of his strength
and in the last phases of his decrepitude.

I

NOTE ON BOOKS

PoR a general conception of health, the reader may
study one of the many elementary physiological hand-
books, e.gr., Sir Michael Foster's Primer of Physiology^
or Foster and Shore's Physiology for Beginners (both
Macmillan & Co.). For death-rates, disease-rates,
figures about epidemics, occupational diseases, etc., he
may study the statistical section of any good manual or
textbook of Public Health, e.g., Whitelegge's Hygiene
and Public Health (Cassell & Co.), or Lewis and Balfour's
Public Health and Preventive Medicine (Green & Sons,
Edinburgh), or Notter and Firth's Theory and Practice
of Hygiene (J. & A. Churchill). These are all technical
books, but contain much general information. For
special details, Newsholme's Vital Statistics (Swan Sonnen-
schein), which is a standard handbook, may be con-
sulted. On the problems of immunity, the most com-
prehensive book is MetchnikofE's Immunity in Infective
Disease, translated by Binnie (Cambridge University

Metchnikoff's book on The Nature of Man, translated
with introduction by Dr. Chalmers Mitchell, F.R.S., and
his small book on The New Hygiene, with preface by
Sir E. Ray Lankester, contain much that is of immense
importance for the study of diet and disease regarded
from the higher standpoint of evolutional efl&ciency.
Here is found the scientific basis of the " soured milk "
treatment. As to diet .two of the most important works

853

254 HEALTH AND DISEASE

are Professor Chittenden's Physiological Economy in
Nutrition and The Nvirition of Man (Heinemann). There
are many good recent works on diet, e.gr.. Dr. Chalmers
Watson's Food and Dieting, Dr. Robert Hutchison's Food
and Dietetics (Edward Arnold), Dr. Bumey Yeo's Food in
Health and Disease (Cassell & Co.). Books on vegetarian
and special diets are without number. For food as a factor
in the evolution of races, see Dr. Marion I. Newbigin's
Modern Geography (Home University Library).

On general questions, the following will be found
eminently interesting: Hygiene of Nerves and Mind in
Health and Disease, by Dr. August Forel, translated by
Aikins (John Murray) ; Dr. Clouston's Hygiene of the
Mind ; also his Unsoundness of Mind (Methuen) ; Dr. Arthur
Newsholme's Prevention of Tuberculosis (Methuen),
U Hygiene moderne, by Dr. J. Hdricourt (Ernest Flam-
marion, Paris) ; Manual of Natural Therapy, by Dr. T. D.
Luke (Wright & Sons, Bristol). The Therapeutics of the
Circulation (]Murray), by Sir Lauder Brunton, though
technical, is well adapted for general study Professor
Arthur Thomson's Heredity (Murray) gives a perfect
orientation on every question concerning diathesis,
inheritance of disease, Weismannism, Mendelism, etc.
Such a work makes an admirable biological disciplino
prehminary to the study of the whole field of disease..
Other works are mentioned in the text.

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40. PROBLEMS OF PHILOSOPHY

Hon. Bertrand Russell, f.r.s.
54. ETHICS Prof. G. E. Moore, m.a., litt.d.

Science

32. AN INTRODUCTION TO SCIENCE. Revised 1928

Prof. J. Arthur Thomson, m.a., ll.i
46. MATTER AND ENERGY Prof. F. Soddy, f.r.s."

62. THE ORIGIN AND NATURE OF LIFE Prof. Benjamin Moore
20. EVOLUTION Profs. J. Arthur Thomson and P. Geddes

I38.^THE LIFE OF THE CELL

David Landsborough Thomson, m.a., b.sc, ph.d.
145. THE ATOM G. P. Thomson, m.a.

115. BIOLOGY (lUus.) Profs. J. Arthur Thomson and P. Geddes
no. HEREDITY (Illus.) E. W. Macbride, m.a., d.sc.

44. PRINCIPLES OF PHYSIOLOGY Prof.. J. G. McKendrick

Revised 1928 by Prof. J. A. MacWilliam, m.d., f.r.s.

86. SEX Profs. J. Arthur Thomson and P. Geddes

41. ANTHROPOLOGY R. R. Marett, d.sc, f.r.a.i.

57. THE HUMAN BODY Prof. Sir Arthur Keith, f.r.s., f.r.c.s.
120. EUGENICS Prof. A, M. Carr Saunders, m.a.

I?. HEALTH AND DISEASE

Sir Leslie Mackenzie, m.d., f.r.c.p., f.r.s.e.
128. SUNSHINE AND HEALTH

R. Campbell Macfie, m.a., m.b.c.m., ll.d.

116. BACTERIOLOGY (IIlus.) Prof. Carl H. Browning, f.r.s.
119. MICROSCOPY (Illustrated) Robert M. Neill

79. NERVES. Revised ig28 Prof. D. Eraser Harris, m.d., f.r.s. e.

49. PSYCHOLOGY Prof. W. McDougall, f.f :.s.

28. PSYCHICAL RESEARCH, 1882-191 1 Sir W. F. Barrett, f.b .s.

22. CRIME AND INSANITY Dr. C. A. Mercier

19. THE ANIMAL WORLD (Illustrated) Prof. F. W. Gamele
130. BIRDS D. Lansborough Thomson, m.a., b.sc, ph.d.

133. INSECTS F. Balfour Browne, m.a., f.r.s. e.

126. TREES Dr. MacGregor SKE^^E
9. THE EVOLUTION OF PLANTS Dr. D. H. Scctt

72. PLANT LIFE (Illustrated) Prof. Sir J. B. Farmer, d.sc, f.f .s.
132. THE EVOLUTION OF A GARDEN E. H. M. Cox

18. AN INTRODUCTION TO MATHEMATICS

Prof. A. N. Whitehead, d.sc, f.f.s.
31. ASTRONOMY, circa 1860-1911 A. R. Hinks, m.a., f.r.s.

58. ELECTRICITY Prof. Gisbert Kapp
67. CHEMISTRY Prof. Raphael Meldola, d.5c.

Revised 1928 by Prof. Alexander Findlav, d.sc, f.i.c.
122. GAS AND GASES (Illustrated) Prof. R. M. Caven, d.sc.

78. THE OCEAN Sir John Murray, k.c.b.

53. THE MAKING OF THE EARTH (Illustrated)

Prof. J. W. Gregory, f.r.s., ll.d.
88. THE GEOLOGICAL GROWTH OF EUROPE (Illustrated)

Prof. Grenville A. J. Cole
36. CLIMATE AND WEATHER (Diagrams) Prof. H. N. Dickson

127. MOTORS AND MOTORING (Illus.) E. T. Brown

Complete List up to January ist, 1930. New titles will be added yearly.

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