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MEDICAL REVOLUTION 
 
MEDICAL 
 REVOLUTION 
 
 A PLEA FOR NATIONAL PRESERVATION 
 
 OF HEALTH BASED UPON THE 
 
 NATURAL INTERPRETATION 
 
 OF DISEASE 
 
 BY 
 
 SYDNEY W. MACILWAINE 
 ft 
 
 M.R.C.S., L.R.C.P. (Retired) 
 
 NEW YORK 
 
 HAROLD OBER 
 
 1911 
 

 Copyright, 1911, By 
 SYDNEY W. MACILWAINE 
 
 ©CLA292670 
 
TO 
 
 THE INTELLIGENT, AND PUZZLED, LAYMAN 
 
 TO 
 
 MEDICAL OFFICERS OF HEALTH, AND 
 GENERAL PRACTITIONERS 
 
 AND TO 
 
 MEDICAL STUDENTS, TO WHOM BELONGS 
 THE FUTURE OF OUR PROFESSION 
 
PREFACE 
 
 Even in such a short and imperfect sketch of medi- 
 cal reform as this is, many details must be introduced 
 that may well seem at first sight somewhat bewilder- 
 ing to the layman. The adjustment of details will 
 occupy much time, and this adjustment belongs ex- 
 clusively to the profession; but the question whether 
 reform is needed or no, turns on a broad and simple 
 issue that is as comprehensible to the laymen as to 
 the professional man. 
 
 When Darwin had finished his marvellous scientific 
 work, he affirmed the natural origin of species ; we ac- 
 cept this conclusion without possessing any knowl- 
 edge of natural history whatever, and why? Be- 
 cause once our eyes are opened we can see for our- 
 selves that his interpretation is in accordance with 
 facts. 
 
 The natural interpretation of disease is a corollary 
 of Darwinism; no one denies that occurrences of 
 tuberculosis, plague, scurvy, heat-stroke, are natural 
 processes, that they arise in accordance with the un- 
 varying sequence of cause and effect. The funda- 
 mental question at issue between the medical au- 
 thorities and myself is, whether there is any longer 
 any justification for interpreting some of the' processes 
 of disease on an artificial system, now that the nat- 
 ural method based on causation has been recognised. 
 All that has been written here is intended simply to 
 illustrate this central dispute, and to show how prac- 
 
Xlll i PREFACE 
 
 tical results in medicine follow inevitably the theoreti- 
 cal views that dictate them. 
 
 There are two reasons, generally quite sufficient, 
 why the regular practitioner should not address the 
 public on professional matters. In the first place, 
 it may lead consciously or unconsciously to advertis- 
 ing; in the second place, it may lure the layman on 
 to morbid self-examination. The first reason does 
 not apply to the retired practitioner. As regards the 
 second, nothing could be further from my intention 
 than to give the layman any encouragement, or even 
 excuse, to enter the slough of despond that belongs 
 to the quack and the self doctor er; I have a firm and 
 conscientious belief that the desertion of the regular 
 profession leads always and inevitably in the wrong 
 direction. 
 
 I have felt bound, nevertheless, severely to criticise 
 some of the scientific and practical methods of the 
 regular profession, and to suggest drastic changes. 
 These criticisms and suggestions have been put as 
 shortly and pointedly as possible, so that any one of 
 average intelligence, inside or outside the profession, 
 may follow and judge for himself. Whatever tech- 
 nical matter is introduced is only intended by way of 
 necessary illustration; it is hoped it may prove suf- 
 ficient, and yet not copious nor obscure enough to 
 bewilder the layman. 
 
 It is now nearly forty years since observation from 
 without convinced me that medicine had lagged be- 
 hind the other sciences in the advance of the Dar- 
 winian epoch, and stood therefore in urgent need of 
 revision. So definite was this impression that it was 
 formulated, in speaking to a friend, by saying that 
 the time had come for a physician to put medicine in 
 
PREFACE IX 
 
 order as Darwin had revised natural history. More 
 than thirty-five years of observation and reflection 
 from within have given this impression definite shape. 
 It is now quite clear to me that medicine is ham- 
 pered with a false interpretation of the processes of 
 disease, just as natural history was confused, before 
 Darwin's time, by a false interpretation of the origin 
 of species ; our undefined diseases seem to me to offer 
 a strict parallel to the specially created species of pre- 
 Darwinian natural history. l But there is a difference 
 between medicine and natural history that I was not 
 then in a position to realise : natural history belongs 
 entirely to pure science; the end and object of medi- 
 cine is practical. Darwin studied for the sake of 
 pure knowledge, however usefully this may be ap- 
 plied by others; the physician's business, although 
 primarily scientific, is to take charge of patients. 
 
 When Darwin had overcome professional and 
 theological prejudices, the science books were put in 
 order, and there the matter ended; the mass of hu- 
 manity remained unconcerned and passive, because 
 Darwinianism did not touch their life directly. Medi- 
 cine contains a huge personal element that makes the 
 physician's task utterly different. One man put nat- 
 ural history in order in the course of a few years; the 
 work of one man, or of a whole generation of men, 
 will not do so much for medicine; the individual 
 physician can indeed do no more than set up a finger- 
 post to guide those who come after him. 
 
 My object, therefore, is to lay bare a false inter- 
 pretation of Nature that still vitiates the scientific 
 method of medicine; and, further, to show how the 
 adoption of the natural interpretation of disease 
 
X PREFACE 
 
 would introduce order and uniformity into all our 
 methods, both scientific and practical. 
 
 My thanks, in connection with the production of 
 this book, are due first and foremost to my brother 
 Herbert. But for his comprehension, sympathy, and 
 help — extending over many years — it would probably 
 never have been written. Mr. G. Montagu Harris 
 has also, for several years, given most valuable aid. 
 He has read my work, and has pointed out, as only 
 one of clear and cultivated intelligence could, the diffi- 
 culties of the layman in face of medical matters. Mr. 
 and Mrs. Sidney Webb have taken a most friendly 
 and active interest in the production of the book. 
 Their help, owing to their unique position in the field 
 of social reform, has been invaluable. When the 
 time came for the final reading of manuscript, and 
 other essential steps towards production, Mr. F. 
 James Matheson, representing Messrs. P. S. King & 
 Son, brought both capacity and enthusiasm to my 
 help. His suggestion, tending towards better Eng- 
 lish and greater clarity, are scattered all through the 
 book. 
 
CONTENTS 
 
 PAGE 
 
 Preface vii 
 
 I. Introductory i 
 
 II. The Evolution of Medicine ... 7 
 
 III. The Pure Science of Medicine . . 14 
 
 IV. Diagnosis 24 
 
 V. The True Relation of Theory and 
 
 Practice . 28 
 
 VI. Pathology 31 
 
 VII. Spurious Diseases 39 
 
 VIII. Illusory Diagnosis 58 
 
 IX. The False Relation of Theory and 
 
 Practice 62 
 
 X. Medicine 74 
 
 XI. Surgery jy 
 
 XII. Specialism 81 
 
 XIII. General Practice 86 
 
 XIV. The Hospital 89 
 
 XV. A Suggestion 96 
 
 XVI. Medical Education 100 
 
 XVII. Organisation 108 
 
 XVIII. The State and the Medical Profes- 
 sion 117 
 
 XIX. Death Certification 122 
 
 XX. Quack Medicine 126 
 
 XXI. Summary 129 
 
MEDICAL REVOLUTION 
 
 i 
 
 INTRODUCTORY 
 
 These introductory remarks are intended to put be- 
 fore the reader the scope and object of this book. 
 
 I address myself primarily to the " intelligent lay- 
 man." Through him, it is my intention to reach the 
 profession. But the profession will not listen, volun- 
 tarily, to any one who suggests changes, drastic 
 changes, in professional methods. The failure of at- 
 tempts to arouse interest inside the profession in 
 medical reform has convinced me of this. That the 
 suggested changes would be disturbing, temporarily, 
 there is no denying; they amount, indeed, to a revolu- 
 tion, but it is a counter-revolution; an attempt to re- 
 turn to the Hippocratic method. 
 
 We are concerned with the future of medicine ; but 
 our steps must be guided by the light of the past. 
 He who does not know whence we come cannot possi- 
 bly tell whether our present course be true. It is, 
 therefore, essential in the first place to give a sketch 
 of the history of medicine; the layman must begin 
 by realising the nature of medicine and its mode of 
 development. Having done this, he will be in a posi- 
 tion to understand what is said of the pure science 
 of medicine, and the method and aims of those who 
 cultivate it. With a firm grasp of the meaning of 
 the science of medicine, the layman will be able to 
 
2 MEDICAL REVOLUTION 
 
 realise, as he has certainly never done before, the 
 true relation of theory and practice. 
 
 It will be noticed that the constructive part of my 
 work is put first, whereas, in my own progress, de- 
 structive criticism naturally came first. The order 
 adopted seems to me more appropriate for the en- 
 lightenment of others. 
 
 When the reader has obtained a firm hold of the 
 true relation of theory and practice, he will be able to 
 appreciate intelligently the criticisms of the present 
 methods that follow. No one denies that my scheme 
 of medicine is an ideal, the ideal one, that must ulti- 
 mately be adopted ; but the orthodox of to-day main- 
 tain that our science must remain amorphous for an 
 indefinite time, before it will be profitable to act fear- 
 lessly and found it wholly — as it is already partially 
 founded — on the natural, scientific basis of causation. 
 
 But an attack on the orthodox ideas of to-day, and 
 on the relation of theory and practice in vogue, implies 
 an attack on the present system of medical education. 
 This I shall also try to make comprehensible. Finally, 
 destructive criticism reaches the hospital, where the 
 leaders of the profession cultivate their science and 
 their art, untrammelled, to the highest pitch of perfec- 
 tion. Even at the risk of being accused of descending 
 to personalities, it is essential to mention the unpalata- 
 ble subject of vested interests. Our present system — 
 quite apart from its merits or demerits — produces men 
 who are " highly successful " ; they gain honours and 
 rewards just as do the men produced by the great uni- 
 versities, the navy, the army, and so on. Now as 
 long as human nature remains the imperfect thing that 
 we know, so long will these men defend the system 
 that produced them, as it stands. 
 
INTRODUCTORY 3 
 
 I can justify myself, with regard to my own pro- 
 fession, by giving a single example that is still sus- 
 ceptible of full substantiation. Lord Lister an- 
 nounced and demonstrated his antiseptic method in 
 1868; very nearly twenty years later we were still 
 taught in London that " there was nothing in it " ; 
 it was also called " a Scotch fad." These opinions 
 were expressed by some of the most eminent surgeons 
 in London. It does not matter a rush whether these 
 men spoke from stupidity or from prejudice, we are 
 only concerned with the historical fact. Antiseptic 
 surgery was an extremely simple matter compared 
 with the medical revolution that it is my duty to 
 preach; it caused no professional upheaval whatever; 
 it had practical results that were obviously and im- 
 mediately beneficial to patient and surgeon ; yet, from 
 professional conservatism, let us say, it was derided 
 and bitterly opposed for many years. 
 
 The medical revolution that is coming will be a 
 veritable earthquake amongst vested interests; the 
 masses of the profession will rise enormously in use- 
 fulness, in public esteem, in security of livelihood ; and 
 many of our rich will be sent empty away. My pro- 
 posals have been before the profession, at intervals, 
 for twenty years; they have been received in stony 
 silence. If they now gain a hearing I would beg the 
 layman to weigh professional criticism on its merits, 
 not on its professional weight or vehemence. 
 
 Up to that point, in my case, where the criticism 
 of the hospital methods ends, the debate is concerning 
 medical affairs as seen from within. When we go 
 beyond the precincts of the hospital, and reach the 
 suggestion for bringing the family physician to the 
 home of those living in the hospital area, we come 
 
4 MEDICAL REVOLUTION 
 
 upon ground that is common to the medical profes- 
 sion and the social reformer. The ultimate problem 
 for the civilised nation is the preservation of the health 
 of all its component citizens; in other words, the cul- 
 tivation of the vigour of the muscular system of the 
 national body. Here, therefore, the social reformer 
 and the physician are working for, and under the di- 
 rection of, the State; for the preservation of the life 
 and health of the people is a recognised duty of the 
 State. 
 
 Many people, may, therefore, be tempted to read 
 somewhat cursorily the earlier part of my work, or 
 even think that it might have been omitted. But re- 
 flection will, I think, show that it would be useless to 
 suggest great social changes, even on the most tenta- 
 tive scale, without detailing the scientific grounds on 
 which these changes are urged, and the medical re- 
 forms without which they cannot be carried out. 
 
 The steps through which I have tried to lead the 
 reader's mind towards the adoption of the practical 
 social reforms which are my ultimate objective, are 
 these : the nature and evolution of medicine, the nat- 
 ural interpretation of disease, and the scientific method 
 based thereon; the true relation of theory and prac- 
 tice that goes with genuine diagnosis; the false rela- 
 tion of theory and practice that goes with illusory 
 diagnosis; the bearing of these antagonistic proposi- 
 tions on hospital practice. 
 
 Beyond this point, the problem becomes purely prac- 
 tical ; the State, the Social Reformer, and the Hospital 
 Physician meet on common ground to fulfil their com- 
 mon duty. But before they get to work they are 
 faced with the question : Is the present hospital method 
 right or wrong? This leads to another question: If 
 
INTRODUCTORY 5 
 
 the hospital method is wrong, can it be modified so 
 as to meet the situation ? 
 
 The nation has become, almost suddenly, alive to 
 the fact that health can only be preserved by the pre- 
 vention of disease. The efforts that are being made 
 in this direction are splendid; they were represented 
 in the Conference of Health-Promoting Institutions 
 recently held in London. The Lord Mayor, in open- 
 ing the proceedings, stated admirably the reason of the 
 creation of all these societies. He said : " It is a 
 striking feature of the development of modern medi- 
 cal science that it has divided itself into two great 
 branches of study and practice, which severally relate 
 to the curative and the preventive sides of the sub- 
 ject." The hospitals and the schools with physicians, 
 surgeons, specialists, and general practitioners, the 
 Poor Law infirmaries, and the Poor Law medical offi- 
 cers are concerned with cure, and solely with cure; 
 while the medical officer of health, aided by lay helpers, 
 is concerned with prevention. 
 
 This is the crux of the whole problem; the over- 
 whelming majority of the profession do not concern 
 themselves with prevention, while the intelligent pub- 
 lic has grasped the fact that without prevention medi- 
 cine is robbed of more than half of its rightful in- 
 heritance. My task is, on the one hand, to persuade 
 the profession to make the whole science and art of 
 medicine primarily preventive ; and, on the other hand, 
 to convince the public that the study and management 
 of disease belong exclusively to the trained physician 
 and the trained nurse, however large and beneficent 
 a part the laity may play in social service amongst the 
 sick and destitute. 
 
 Finally, what I advocate is, first of all an exhaus- 
 
6 MEDICAL REVOLUTION 
 
 tive inquiry, by Royal Commission, into our present 
 hospital method as applied to the preservation of the 
 health of the people. This inquiry should embrace 
 every subject touched on in this book. If such an in- 
 quiry were to result as I anticipate, it would be fol- 
 lowed by medical reform, beginning at and radiating 
 from the hospital. 
 
II 
 
 THE EVOLUTION OF MEDICINE 
 
 At the very outset, the reader must be reminded that 
 medicine consists of two wholly distinct parts; it in- 
 cludes a pure science and an applied science, or scien- 
 tific art. The fact that the physician * is scientist and 
 practitioner in one has led to much confusion, even 
 inside the profession; it is well, therefore, to draw a 
 parallel. Navigation is an art, a scientific art; it is 
 founded on pure science, on astronomy. The sailor 
 who guides his ship to the Antipodes uses astronomical 
 knowledge in just the same way as the physician uses 
 pure science when he vaccinates against smallpox or 
 typhoid fever. Science has been well described as 
 organised knowledge of Nature, and of this great 
 whole, medical science is a branch ; it is our organised 
 knowledge of human disease. One of the leaders of 
 English medicine has described my work as, " a bold 
 attempt to make of medicine an exact science," and 
 has condemned it accordingly ; because medical science 
 is not supposed to have any claim to rank among the 
 exact sciences. 
 
 With all due deference, I must protest that this 
 statement represents a certain confusion of mind, a 
 tendency to confound natural phenomena with our at- 
 tempts to interpret and record them. There is, ac- 
 
 1 As a distinguished physician has said : " It is time to discard 
 that mongrel word ' doctor ' and to restore the good old English 
 word ' physician.' " 
 
 7 
 
8 MEDICAL REVOLUTION 
 
 cording to the theory on which I work, no more inex- 
 actness or uncertainty in the occurrence of the pro- 
 cesses of disease than there is in the genesis of those 
 other processes that go to make up the province of 
 the astronomer, the chemist, or the engineer. But 
 our observation and records of any of these processes 
 can never be free from inexactness; medical science, 
 a record of natural processes, is just as exact as we 
 can make it, so is the science of astronomy or of 
 chemistry. 
 
 The territory of Nature has been more or less 
 arbitrarily divided into provinces, and each province 
 has been allotted to a body of scientists for special 
 study; the processes, of disease form one of these; the 
 same limitations hold for the physician as for his 
 brother scientists, but he is not separated from them 
 by any natural division ; we all reach broad truths, but 
 the details of astronomy and of chemistry are no more 
 exact than are the details of medical science. Not 
 unless Nature became her own recorder should we 
 reach exact science, and then it would be compre- 
 hensive as well as exact. 
 
 The question whether the supernatural enters into 
 the causation of disease is not for argument; it is part 
 of the greater question that was, for scientific pur- 
 poses, settled in the last century. When Darwin af- 
 firmed the natural origin of species and the evolution- 
 ary descent of man, he said that the truth or false- 
 hood of his theory could not be settled by argument, 
 that the decision must rest on observation of Nature. 
 The natural origin of disease processes is the axiom 
 on which rests all that is here to be said, and this 
 is claimed as a plain corollary of the Darwinian theory. 
 If man is subject as to his origin and condition to 
 
THE EVOLUTION OF MEDICINE 9 
 
 the same- invariable sequence of cause and effect as 
 rules elsewhere in Nature, then so also are all those 
 phenomena that go to make up human disease. There 
 is no room for argument on the subject, nor for com- 
 promise; some minds postulate supernatural interfer- 
 ence, some do not; I proceed on the theory that the 
 processes of human disease occur in accordance with 
 the natural, invariable sequence of cause and effect. 
 
 Its two component parts must thus be borne sepa- 
 rately in mind while glancing at the evolution of 
 medicine. It is at once evident that the art is much 
 the older of the two ; the beginning of the art of medi- 
 cine, indeed, takes us back far beyond the origin of the 
 human race; for there is no difficulty in discovering 
 attempt amongst the lower animals to escape the pains 
 and penalties of disease. And amongst primitive men, 
 medicine is represented by efforts to escape disease 
 that are almost unreasoning. Pure science, organised 
 knowledge of disease, cannot be said to exist as a 
 foundation of primitive medicine. Just as there is 
 no line to be drawn between the nebular state of 
 our system and the highly differentiated condition 
 of matter as we now know it, so is there no dif- 
 ference, but one of degree, between the nest-building 
 art of the earthworm and our highly elaborated art of 
 medicine; " art is but a part of Nature." The worm 
 knows, when the autumn comes and the leaves fall, 
 that he must build his nest at a certain depth and in a 
 certain way to escape the winter cold; he also knows 
 that he must grasp the leaf by a certain part in order 
 that it may be easily pulled into the earth. There is 
 much knowledge at the back of this art of building; 
 it is not organised, it is not science, but such are the 
 
IO MEDICAL REVOLUTION 
 
 beginnings from which our wonderful science has been 
 evolved. 
 
 As the higher reason that belongs to man developed, 
 his primitive medical art was gradually fortified by 
 observation; these observations were slowly systema- 
 tised, and then recorded ; our organised knowledge of 
 human disease began to grow; the pure science of 
 medicine was born of the older art. The evolution of 
 medicine has not advanced with an even front, as 
 the tide mounts the level beach, far from it; and so, 
 in some backwaters we can still see for ourselves to- 
 day what the medicine must have been like that ante- 
 dated the science and art of Hippocrates, in the direct 
 line, by ages. Any one wishing to read the history of 
 medicine nowadays must begin with the lucid accounts 
 that have recently appeared of its practice amongst the 
 Australian aborigines, in Tibet, and elsewhere. 
 
 Those who, like myself, have listened to the Aus- 
 tralian describing, with palpable sincerity, the descent 
 of his deity, more than half -demon, to snatch up to a 
 giddy height in mid-air the candidate who is to be 
 admitted D.D. and M.D. in one, cannot fail to realise 
 the meaning of primitive medicine. Its science is a 
 branch of theology; its art consists, essentially, in at- 
 tempts to control the cause of disease through pro- 
 pitiation of the deity. All the essentials of both our 
 science and our art are there represented. The ulti- 
 mate desire of all men is the preservation of health, 
 the prevention of disease ; the only possible way to ac- 
 complish this is by controlling the cause; the abo- 
 riginal ascribes disease, just as he ascribes drought, 
 hurricane, eclipse and flood, to the interference of a 
 supernatural power which he seeks to propitiate, be- 
 cause in his ignorance he cannot hope to control it. 
 
THE EVOLUTION OF MEDICINE II 
 
 Man has been eloquently described as " Nature com- 
 prehending herself"; the medical man, at least, has 
 had to pass through a stage when he could be only 
 truthfully described as Nature misunderstanding her- 
 self. 
 
 The only great epoch in the history of medicine 
 occurred when it was clearly asserted that the pro- 
 cesses of disease were of natural, and not of super- 
 natural, origin; it is connected with the name of 
 Hippocrates ; it marks the beginning of the end of 
 the domination of the theological school in medicine. 
 When Hippocrates said that the physician is but the 
 servant of Nature, he looked, as only men of genius 
 can, from the mountain top, he discerned an ultimate 
 truth. We are taught in this masterly phrase that 
 only in the light of a full knowledge of their causa- 
 tion can we hope to guide and control the processes 
 of disease, and for the reason that they are natural 
 processes. Thus was the natural interpretation of 
 disease established once for all as the true ideal of 
 medical science, as the true foundation of all medicine. 
 
 How far the science and art of Hippocrates fell 
 short of this ideal we do not know; for although the 
 fantastic Humoral Pathology, that served so long as 
 the orthodox science of medicine, is ascribed to him, 
 there can be no doubt that it gathered many incrusta- 
 tions for which he was never responsible. What- 
 ever the intervening details may be, the fact remains 
 that Hippocrates spoke from the inspiration of genius ; 
 but the common mind will not, cannot accept the dic- 
 tates of genius ; common belief must rest on common 
 experience ; and so, the profession has been toiling ever 
 since through the flat of detailed observation, until 
 at last we are face to face with facts, now fully sub- 
 
12 MEDICAL REVOLUTION 
 
 stantiated, that Hippocrates realised nearly two thou- 
 sand five hundred years ago. 
 
 Medicine reached very nearly its high-water mark 
 for the period of the older civilisation in ancient 
 Greece; and then, with the destruction of order and 
 stability, came the great gap of the Dark Ages. 
 When security began to reappear in Western Europe, 
 and men could turn their thoughts again to science, 
 the Humoral Pathology was adopted in medicine and 
 kept the field, at least nominally, until nearly the mid- 
 dle of the last century. W r hen the time was ripe for 
 its destruction, the task was undertaken and com- 
 pletely accomplished by the great German anatomist 
 Virchow. When Virchow had destroyed the Humoral 
 Pathology, he set up his Cellular Pathology in its 
 place and described it as the true science of medicine. 
 This brings us down to our own time, for " Path- 
 ology " is still authoritatively held to be the scientific 
 basis of medicine. 
 
 What it is intended to impress on the reader by this 
 reference to the evolution of medicine is this': the 
 art of medicine has its origin in Nature, even before 
 the appearance of man on the earth, in the instinctive, 
 unreasoning efforts of the lower animals to escape 
 the inconveniences of disease. With the evolution of 
 the higher reason that belongs to man, and the con- 
 sequent development of the habit of intelligent obser- 
 vation, the science of medicine was grafted upon, 
 sprang from this primeval art. At a much later date 
 came the dawn of our own time, when disease was 
 ascribed to natural causes, and when the study of Na- 
 ture was pointed out as the only basis on which the 
 art of medicine could be securely founded. The 
 greatest scientific advance of all time occurred in the 
 
THE EVOLUTION OF MEDICINE 13 
 
 last century, when Darwin threw natural history into 
 the crucible ; but medicine was then still too completely 
 under the domination of an artificial system to share 
 in the purification that followed. As far as Virchow 
 and his " Pathology " are concerned, Darwin might 
 as well have been silent; medicine was not then truly 
 recognised as a branch of natural history. 
 
Ill 
 
 THE PURE SCIENCE OF MEDICINE 
 
 The structure that we call medicine consists of two 
 parts; the foundation is, a branch of pure science, part 
 of our organised knowledge of Nature; the super- 
 structure is a scientific art. For the moment, we are 
 concerned only with pure science. It is essential to 
 grasp clearly at the outset how the word " disease " 
 is used in medical science. This word is used in two 
 wholly different senses, and much confusion arises 
 from a very general failure to understand this. 
 
 When we say: Disease is a calamity; the first use 
 of the word is illustrated. Here " disease " stands 
 simply for the negation of health; when health is de- 
 ficient disease arises. Health may be taken to mean 
 the condition associated with a normal, or wholly de- 
 sirable state of existence. Our conception of " dis- 
 ease " in this general, negative sense, corresponds pre- 
 cisely with our conception of cold as the negation of 
 heat. Health and heat are positive conceptions, dis- 
 ease and cold are their negations. 
 
 When, on the other hand, we say: The disease 
 from which these people are suffering is microbic in 
 origin, the particular, positive use of the word is ex- 
 emplified. When an immense number of cases have 
 been investigated, and it has been found that a cer- 
 tain microbe is actively parasitic in every case, these 
 patients are said to be all suffering from the same 
 
 14 
 
THE PURE SCIENCE OF MEDICINE 1 5 
 
 " disease." From a number of cases in which we 
 observe a series of symptom-groups of determinate 
 and similar causation, we are enabled to draw a men- 
 tal conception that stands for " a disease." 
 
 A caution must be given here. When it is said, 
 for instance, that a patient is suffering from typhoid 
 fever, it is meant, literally, that he is suffering from 
 an attack of typhoid fever. There is a great tend- 
 ency, even inside the profession, to overlook the ob- 
 vious distinction between the actual attack and the 
 mental conception — " the disease " — that is derived 
 from the observation of a series of attacks. It must 
 also be pointed out that when the specific cause of the 
 symptoms present has been determined, the whole 
 problem of causation is not thereby solved. 
 
 When, for instance, it was discovered that the 
 symptoms called malarial were caused by the para- 
 sitism of a certain protozoon, it became possible for 
 the first time to define accurately " the disease ma- 
 laria." But the observers recognised at once that un- 
 til they had discovered all the conditions immediately 
 antecedent and leading to each particular attack, their 
 scientific task was not completed. This rule applies 
 universally; no symptom-group has been fully inter- 
 preted until both the specific cause and the conditions 
 leading to the attack have been laid bare. But, be 
 it noted, in framing our conception of the specific dis- 
 ease, account is taken only of the specific cause; the 
 conditions leading to the attack are neglected. These 
 two factors in causation are the " exciting and pre- 
 disposing causes " of medical writers. This misuse 
 of the word " cause " still leads to much misunder- 
 standing. 
 
 The specific causes that lie at the basis of the 
 
1 6 MEDICAL REVOLUTION 
 
 scientific — the natural — definition and classification of 
 diseases fall into two primary divisions; those of one 
 division arise in the environment of the patient, those 
 of the other originate in his constitution. The causes 
 of extrinsic origin fall again into three main groups, 
 under the headings of parasitism, poisoning, and trau- 
 matism. Typhoid fever, lead-poisoning, and heat- 
 stroke are respectively examples from each of these 
 groups. The diseases of extrinsic causation are so 
 universally recognised that they need not be more par- 
 ticularly referred to. 
 
 But the diseases of intrinsic causation, in attacks of 
 which the cause arises in the patient's constitution, 
 are not officially recognised and must be described. 
 The individual begins his separate existence with a 
 number of inherited characters, and these characters 
 carry with them certain tendencies. Both characters 
 and tendencies become modified through contact with 
 environment. It is, therefore, evident that we have 
 to deal with a variable quantity. But the constitution 
 may be roughly described as the intrinsic tendencies 
 of the individual at the time of observation. 
 
 The diseases of intrinsic causation fall into five 
 main groups, thus — 
 
 I. Certain children are born in whom the develops 
 ment of the heart is incomplete; the observation of a 
 long series of such cases clearly leads to the concep- 
 tion of " a disease.'' We have a series of cases pre- 
 senting symptom-groups of determinate and similar 
 causation. But the cause is not to be found in the 
 child's environment, therefore it must be sought in 
 the constitution; it is intrinsic in origin. The cause 
 in all these cases is, in fact, incomplete development. 
 
 As in the case of diseases of extrinsic causation, so 
 
THE PURE SCIENCE OF MEDICINE 17 
 
 here, it must be recognised that the determination of 
 the cause of the symptom-group does not complete the 
 solution of the whole problem of causation. The con- 
 ditions leading to the individual attack clearly go back 
 beyond the child's separate existence; they must be 
 sought in heredity. Heredity is the channel through 
 which this cause of disease has reached the child, and 
 our study of the child, and of its disease, is not com- 
 plete until we understand its family history. 
 
 II. Other children are born, apparently, quite 
 healthy, but despite the best possible hygienic sur- 
 roundings, they sicken and die, perhaps at at the age 
 of three, with symptoms called diabetic. Again, the 
 cause of these symptoms does not arise in the environ- 
 ment, it is intrinsic in origin, it is a constitutional de- 
 feet; received again through the channel of heredity. 
 There are many other diseases of a similar nature. 
 
 III. What is and what is not overwork must ulti- 
 mately be decided in accordance with an arbitrary 
 standard, and the standard will vary for different indi- 
 viduals. But it is quite clear that overwork is a pro- 
 lific cause of disease. It is also true that the symp- 
 toms are definitely recognisable, they are susceptible 
 of systematic record. This is all that it is necessary 
 to insist on here. 
 
 'IV. On the other hand, health cannot be main- 
 tained in idleness; in other words, deficient work is 
 a cause of disease. Again, of course, the amount of 
 work, and the proportion of mental and bodily work, 
 that conduces to health must be fixed arbitrarily for 
 each individual. But the urgent necessity of ascrib- 
 ing the symptoms that arise in idle people to deficient 
 work, and the duty of systematising our knowledge 
 
1 8 MEDICAL REVOLUTION 
 
 of the subject, are obvious and need not be insisted 
 on further. 
 
 V. Finally, a man may enjoy good health for many 
 years, and although continuing to live under ideal con- 
 ditions, there will come a time when simple wear and 
 tear bring his life to a close. We may hesitate to 
 call the natural degenerations of old age symptoms of 
 disease, but the fact remains that arteries grow hard, 
 muscles waste, even bones, sight and hearing fail, 
 health disappears, and its negation is disease. All 
 that I wish to insist on now is that the symptoms of 
 wear and tear must be systematised and set down for 
 the guidance of the profession. 
 
 There is, in fact, no generic difference between at- 
 tacks of disease due to intrinsic and those due to ex- 
 trinsic causes ; in both cases we find series of cases that 
 exhibit symptom-groups of determinate and similar 
 causation ; therefore, the conception of " a disease " 
 of intrinsic causation is no whit less definite and use- 
 ful than the conception of " a disease " of extrinsic 
 causation. Before the causation of an attack clue to 
 an intrinsic cause can be said to be fully elucidated, 
 it is essential that the conditions leading to the attack 
 be cleared up ; the determination of the specific causes 
 is not sufficient. 
 
 This is not the place, nor am I competent, to dis- 
 cuss the relation that heredity bears to the constitu- 
 tion, but it is nothing less than a scandal that the 
 student passes through his whole course without ever 
 having his attention specially drawn to the part played 
 by heredity in the causation of disease. The medical 
 profession has no right to stand idly by and to accept 
 theories, and even dogmas, from students of heredity; 
 we are concerned with the effects of heredity as they 
 
THE PURE SCIENCE OF MEDICINE IQ 
 
 are presented to us clinically, that is, at the bedside, 
 in practice ; no one, statistician, biometrician, nor Men- 
 delian, can solve our problems for us. 
 
 It must be pointed out that, not only do the causes 
 of a vast number of attacks of disease originate in the 
 constitution, but it profoundly modifies in each patient 
 the character of attacks of which the cause is extrinsic. 
 It is no exaggeration to say that the recognition of 
 the constitution as a factor in the causation of dis- 
 ease will necessitate an entire rearrangement of our 
 science, the rewriting of medical text-books. 
 
 The reader cannot yet fully appreciate the signifi- 
 cance of the statement, but it must be emphasised here 
 that, while the intrinsic causes of disease remain un- 
 recognised more than half of the pure science of medi* 
 cine must remain unsystematised. The layman can 
 hardly realise, but he may surmise how far-reaching is 
 the paralysing effect of this lack of scientific method. 
 But I would beg him to bear the point in mind while 
 reading subsequent chapters. 
 
 My only object at present is to give the reader, 
 especially the layman, a definite idea of what is aimed 
 at by those who cultivate the pure science of medicine, 
 and of the methods they use; probably this end has 
 now been attained. What has been written may be 
 very briefly summed up. " Disease " — lack of health 
 — arises in consequence of the occurrence of certain 
 natural processes; to observe and record these pro- 
 cesses is the scientific duty of the physician. Experi- 
 ence has shown that this vast array of natural pro- 
 cesses falls into divisions, groups, and sub-groups, un- 
 til we reach ultimate sub-divisions in each of which all 
 the processes are of determinate and similar causation. 
 From each of these ultimate subdivisions — represent- 
 
20 MEDICAL REVOLUTION 
 
 ing a series of attacks — we draw a mental conception 
 and call it " a disease." This bird's-eye view of the 
 results obtained in the pure science of medicine may- 
 be put diagrammatically in the form of a chart. 
 
 The definition of the meaning of " a disease " given 
 above, although implied in the recognition of, for 
 instance, typhoid fever as a true disease, has never, 
 so far as I know, been previously formulated. And 
 the recognition of the causes of disease of intrinsic 
 origin — with the consequent recognition of diseases 
 of intrinsic causation — is a new departure. These 
 are the two points on which the validity of both my 
 constructive work and my destructive criticism ulti- 
 mately depend. I shall, therefore, state and answer 
 the only criticism to which these ideas have been sub- 
 jected in the profession. 
 
 I have often been told, more especially by teachers 
 of medicine, that the demand for the defining of the 
 meaning of " a disease " represents an unpractical 
 fad. Again, I am told that to determine, in any par- 
 ticular case, that the cause of symptoms arises in the 
 constitution is of no practical value. I shall illustrate 
 the fallacy of these two orthodox contentions by re- 
 ferring to a problem that is much in the public eye at 
 present, the cancer problem. 
 
 In the first place, it is quite evident to the onlooker 
 that those who are investigating this problem have 
 not any clear idea of what they are seeking. They 
 have set out to track down " the disease " cancer, with- 
 out first attaching a definite meaning to " the disease." 
 They do not realise that " the disease " is not lurking 
 in every case, but that it is a clear mental conception 
 that can be framed only when a series of symptom- 
 
THE PURE SCIENCE OF MEDICINE 21 
 
 groups of determinate and similar causation has been 
 observed. 
 
 In the second place, using the word " cancer " in its 
 proper, comprehensive sense, all cases' have one funda- 
 mental character in common ; that is, certain cells take 
 on an abnormal manner of multiplication, leading to 
 overgrowth, recurrence, malignancy. This abnormal 
 activity can only be accounted for by the action of 
 some intrinsic cause, some dislocation, temporary or 
 permanent, of the normal tendencies of the patient. 
 Various antecedent conditions may lead up to the con- 
 stitutional dislocation, as for instance, chronic irrita- 
 tion ; but the " cause " of the abnormal cell-growth 
 must be sought in the constitution. Cancer, being of 
 intrinsic causation, will prove ultimately to be " a 
 disease " that is not sharply or definitely bounded ; it 
 will be indefinitely and arbitrarily divided from other 
 conceptions. 
 
 I venture, therefore, to state dogmatically that un- 
 til two essential conditions are complied with, the can- 
 cer problem cannot be finally solved. These two con- 
 ditions are, the defining of the meaning of " the dis- 
 ease," and the recognition of the reality of constitu- 
 tional causes of disease. I would only add that — in 
 medicine at least — we cannot be practical, usefully, 
 until we have first been truly scientific. 
 
 It must be explained what the chart appended to 
 this chapter is and is not intended to be. In the first 
 place, it is an outline only, but as an outline I venture 
 to claim that it is permanent. It is put in, in order 
 to bring graphically to the reader's mind the fact that 
 the science of medicine has now entered on its final 
 phase. When Hippocrates said " follow Nature " he 
 meant that we should adopt, wholly and candidly, the 
 
22 
 
 MEDICAL REVOLUTION 
 
 natural interpretation of disease. Now, the natural 
 interpretation of disease consists simply in systema- 
 tising all our experiences of the processes of disease 
 on the basis of natural causation. I have shown how 
 this may be done, in this chapter ; I shall have to show 
 in some detail in subsequent chapters that it is not 
 done, not uniformly or completely at present. Should 
 the reader become somewhat bewildered amongst my 
 " spurious diseases," I would ask him to turn back to 
 this chart so as to realise that in knowing what is " a 
 disease " he must know also, if he will take the trouble, 
 what is not " a disease." 
 
 On the other hand, it need hardly be said that this 
 chart is to a certain extent diagrammatic; that it is 
 incomplete and tentative in detail; it is only an out- 
 line, but as an outline it is permanent; it is founded 
 upon a principle which I hold to be immutable. There 
 is no attempt whatever made to represent the com- 
 plexities that will arise when the task of definition and 
 classification is seriously undertaken by an organised 
 and scientifically led profession. 
 
 INTRINSIC CAUSES 
 
 Incomplete 
 Development. 
 
 Constitutional Defects. 
 
 Overwork. 
 
 Hare-lip, cleft-palate, 
 spina bifida, con- 
 genital heart defects, 
 idiocy. 
 
 Diabetes, asthma, chorea, 
 gout, hysteria, insanity. 
 
 Various forms 
 of breakdown, 
 mental and 
 bodily. 
 
 Deficient Work. 
 
 Wear and Tear. 
 
 Obesity, hysterical attacks, 
 general debility. 
 
 Hard arteries, wasted bones and 
 muscles, defective sight, hear- 
 ing, etc. 
 
THE PURE SCIENCE OF MEDICINE 
 EXTRINSIC CAUSES 
 
 23 
 
 Parasitism. 
 
 Poisoning. 
 
 Traumatism. 
 
 Tuberculosis, typhoid 
 fever, plague, cholera, 
 malaria, sleeping sick- 
 ness, hydatid disease, 
 ringworm, itch. 
 
 Lead-poisoning,opium- 
 poisoning, arsenical 
 poisoning, rickets, 
 scurvy. 
 
 Wounds, fractures, dis- 
 locations, heat stroke, 
 frostbite, electrical in- 
 juries, miner's phthisis, 
 housemaid's knee, coal- 
 trimmer' s elbow. 
 
IV 
 
 DIAGNOSIS 
 
 To diagnose a case means, in general terms, to find 
 out what is the matter, and no more definite meaning 
 than this is at present attached to the word in medi- 
 cine. This follows necessarily from the failure to 
 attach a definite meaning to " a disease " ; because to 
 diagnose means, strictly speaking, to specify " the 
 disease" from (an attack of) which the patient is 
 suffering. Here it is palpable that the profession is 
 halting between two opinions, for, in the case of 
 tuberculosis or typhoid fever, lead-poisoning or ar- 
 senical poisoning, this strict meaning is attached to 
 diagnosis, while in the vast majority of cases it is 
 not. 
 
 It is evident that as soon as a definite meaning is 
 attached to " a disease," a fixed value has also been 
 attached to the solution of the problem of diagnosis. 
 " A disease " has been defined as a conception, drawn 
 from the observation of a series of symptom-groups 
 of determinate and similar causation. The " diag- 
 nosis " of such " a disease " can only mean the cor- 
 relation of cause and effect in the individual patient. 
 So much is tacitly acknowledged by the medical au- 
 thorities in the case of all diseases of extrinsic origin ; 
 it is therefore unnecessary to insist further on this 
 part of the subject. 
 
 It is beyond serious dispute that exactly the same 
 standard holds good for diagnosis in the case of 
 
 24 
 
DIAGNOSIS 25 
 
 diseases of intrinsic causation. To make a diagnosis, 
 we must correlate the symptoms shown with their 
 cause. When a child dies with diabetic symptoms, 
 and these are demonstrably not due to the action of 
 any intrinsic cause, the cause is a constitutional de- 
 fect; to determine this means to make a diagnosis. 
 And so it is with symptoms resulting from other con- 
 stitutional defects, from incomplete development, 
 from overwork, from deficient work, or from wear 
 and tear. It is surely palpably ridiculous, to say the 
 least, to pretend that because symptoms arise from a 
 cause of intrinsic origin we are, therefore, absolved 
 from discovering the cause. As a matter of fact, no 
 one candidly denies that diagnosis means the correla- 
 tion of cause and effect in the individual patient; but 
 this position is not openly taken up by the authorities 
 because it is not always convenient. 
 
 The differentiation of the conditions leading to, or 
 predisposing to, the individual attack from the 
 specific cause of the symptoms must again be insisted 
 on. When the physician is called to see a patient 
 acutely ill, his first business is to make a diagnosis, 
 and this he does by specifying the " cause " of the 
 symptoms shown. If it is a case, for instance, of 
 tuberculosis, the demonstration of the active para- 
 sitism of the specific microbe settles the diagnosis; 
 cause and effect have been correlated. To elucidate 
 all the conditions that led up to the attack is a very 
 different, and quite a distinct problem. We want to 
 know how and why the microbes reached the patient, 
 and we want to know why they found suitable con- 
 ditions for propagation in the patient. It is quite 
 clear that, practically, the elucidation of antecedent 
 conditions may often be vastly more important than 
 
26 MEDICAL REVOLUTION 
 
 the immediate and individual problem of diagnosis; 
 but in the absence of a plain understanding as to the 
 meaning of diagnosis (the correlation of cause and 
 effect), it is impossible to elucidate antecedent con- 
 ditions intelligently. 
 
 This applies with equal force in the case of diseases 
 of intrinsic causation; if we do not candidly 
 acknowledge the primary obligation of diagnosis, the 
 whole problem of causation cannot possibly be clearly 
 grasped, still less solved. For instance, when a 
 young woman shows hysterical symptoms it is not 
 warrantable to conclude that she is therefore truly 
 hysterical; inquiry sometimes proves that the 
 " cause " of the symptoms is to be found in bad 
 hygienic conditions and overwork that have led to a 
 deterioration of health. The breakdown of constitu- 
 tion resulting in hysterical symptoms, is then a con- 
 dition precedent to the particular attack; the young 
 woman has no intrinsic defect tending to loss of self- 
 control, she would not have broken down under nor- 
 mal health conditions. 
 
 Apart from the fact that lines of demarcation must- 
 be broad and ultimately arbitrary, amongst consti- 
 tutional diseases, and that there will therefore be 
 borderland cases, there is evidently no real difference 
 between diseases of intrinsic and extrinsic causation 
 in the matter of diagnosis. A diagnosis has not in 
 any case been made until effect has been traced to 
 cause, and the whole problem of causation has not 
 been cleared up until the conditions leading to the 
 particular attack have also been ascertained. 
 
 It must not be imagniecl from this plain exposition 
 of the meaning of diagnosis that it is contended that 
 the problem may be always reduced to simplicity; 
 
DIAGNOSIS 2J 
 
 that, for instance, symptoms however complex may 
 always be traced to a single cause. The tracing of 
 causation in disease is one of the most complex 
 problems in science, it is often impossible to complete 
 it. The same cause produces the most widely dif- 
 ferent symptom-groups in different cases; different 
 causes produce symptom-groups that are often in 
 parts quite identical ; these two facts account for 
 much complexity. Then again, while every cause of 
 disease is single, it does not always act singly. For 
 instance, a man who has a gouty constitution may in- 
 dulge in gluttony, alcoholic excesses, and idleness; 
 his attack of gout will evidently not be due entirely 
 to one cause. People sometimes suffer from attacks 
 of more than one disease at the same time. Much 
 more might be said on the subject, but this will be 
 sufficient. The more complex the problem the more 
 essential is it that its true nature should be grasped 
 and candidly recognised. 
 
 The view here taken of diagnosis may be summed 
 up thus: all the processes that make up human dis- 
 ease are of a similar nature, they are natural proc- 
 esses, and consist invariably of cause and effect; in 
 other words, symptoms of disease are in Nature in- 
 variably grouped round their causes. The physician, 
 as diagnostician, is a pure scientist, and must, there- 
 fore, interpret these processes uniformly on the 
 natural basis of cause and effect. Beyond the im- 
 mediate problem of diagnosis lies the elucidation of 
 the conditions leading to the occurrence of each par- 
 ticular attack. When both these problems have been 
 solved, the whole channel of causation has been 
 charted, the physician's scientific task is finished. 
 
V 
 
 THE TRUE RELATION OF THEORY AND 
 PRACTICE IN MEDICINE RESULTING 
 FOM GENUINE DIAGNOSIS 
 
 The pure science of medicine has been described 
 above as the outcome of an organised attempt to 
 discover the whole causation of d.S ease; this knowl- 
 edge of causation, taken as a whole, forms the theory 
 on which the regular practice of medicine is founded. 
 The more we go into detail the more apparent be- 
 comes the entire dependence of practice on theory. 
 Take, for instance, the case of malaria ; it was known 
 for a long time that the bark of a certain tree was 
 useful in the treatment of an attack. When the 
 parasite which caused the attack was discovered, it 
 appeared that the quinine in the bark acted as a 
 poison to the parasites, and the old empirical method 
 was justified, as far as it went. But the tracing of 
 the entire life-history of the parasite, that is, the 
 elucidation of the conditions leading to the individual 
 attack, put us in a position to rid whole districts, and 
 even countries, of the scourge. 
 
 Thus we see that cure may be occasionally hit on 
 empirically, that a knowledge of the specific cause 
 puts this empirical treatment on a scientific basis, and 
 that a complete knowledge of causation puts the art 
 of medicine on its ultimate and true foundation when 
 it makes prevention possible. 
 
 28 
 
RELATION OF THEORY AND PRACTICE 29 
 
 Another instance is furnished by the treatment 
 of surgical wounds. The manual dexterity of the 
 surgeon was no less fifty years ago than it is now, 
 but the results of his operations were startlingly dif- 
 ferent. Encouraged by Pasteur's discoveries, Lord 
 Lister set himself the hitherto neglected task and 
 succeeded in clearing up the whole causation of septic 
 infections ; complete prevention was then for the first 
 time possible. Instances might be multiplied indefi- 
 nitely, but these are sufficient to illustrate the dif- 
 ference between ancient and modern methods. 
 
 Ancient art was not founded on knowledge of caus- 
 ation; in the instances given, modern art is; with the 
 difference that the ancients dealt blindfold with 
 effects while the moderns deal intelligently with 
 causes. The relation of theory and practice in med- 
 icine will have to be examined in much detail pres- 
 ently; for the moment, only broad principles are 
 dealt with. But it must be insisted that these prin- 
 ciples are of universal applicability in medicine, and 
 that the word " medicine " is here used in its original 
 sense, that is, to include the whole science of human 
 disease and the whole art of its management. 
 
 The end and object of all medicine is purely prac- 
 tical, it should consist in the preservation of health 
 instead of merely in its restoration; the ultimate 
 achievements of medicine are therefore directly due 
 to practice. There are still some rare instances in 
 which these practical results are reached by the em- 
 pirical method, survivals of the time when almost the 
 whole art of medicine was empirical. But with these 
 exceptions the practice of the regular profession is 
 now professedly based on pure science, on knowledge 
 of causation. 
 
30 MEDICAL REVOLUTION 
 
 The case of malaria indicates that though random 
 cure is possible by the empirical method this does not 
 bring prevention within reach; prevention is possible 
 only in the light of a full knowledge of causation. 
 But the preservation of health is impossible unless 
 prevention be added to cure; therefore we say that 
 the whole art of medicine is completely and abso- 
 lutely dependent on science. Nowhere is it truer 
 than in medicine that knowledge is power, that 
 ignorance is impotence; and the only knowledge that 
 can give power in the practice of medicine is knowl- 
 edge of the causation of disease. 
 
VI 
 
 PATHOLOGY 
 
 It is now necessary to begin the destructive part of 
 my criticism; but before doing so I shall summarise 
 the constructive part of my work on the science of 
 medicine, so as to provide the reader with the stand- 
 ard on which this criticism is founded. 
 
 The processes of which human disease consists 
 are assumed to arise exclusively from the action of 
 natural, and therefore discoverable causes. From 
 this it follows that our interpretation of these pro- 
 cesses must be based on causation, and on this only. 
 Experience proves that all the processes of disease 
 fall into two primary divisions, according as the cause 
 arises in the constitution or the environment of the 
 sufferer, and that each of these divisions falls again 
 into groups and sub-groups, until we reach ultimate 
 subdivisions in each of which all the processes are 
 of determinate and similar causation. From each of 
 these subdivisions we derive the conception of " a 
 disease," such as typhoid fever, lead-poisoning, heat- 
 stroke, hair-lip, diabetes, hysteria. It follows as a 
 corollary from this, that the specific term " a disease " 
 or " the disease " cannot be applied to any conception 
 not derived from a series of symptom-groups of 
 determinate and similar causation without misinter- 
 preting the processes of disease referred to; on this 
 my criticism is based. 
 
 3* 
 
32 MEDICAL REVOLUTION 
 
 While no one would attempt to cut off human 
 disease sharply from the rest of Nature, it is con- 
 venient roughly to draw an arbitrary line round it, 
 so as to indicate the part of science in which the 
 physician specialises his study: "pathology" is an- 
 other name for this science of human disease. From 
 the time of Hippocrates until within the memory of 
 people still living, " pathology " was practically syn- 
 onymous with " Humoral Pathology." The Humo- 
 ral Pathology appears to us now as a mass of fan- 
 tastic speculations; but it stood with our immediate 
 predecessors as a satisfying " explanation " of the 
 origin of disease; it was the "science of medicine" 
 on which practitioners professed to base their art 
 even within my own memory. 
 
 In the first half of the nineteenth century a young 
 German anatomist, Rudolph Virchow, not only dis- 
 covered but boldly declared, what no doubt many had 
 suspected, that this so-called science of medicine had 
 no foundation in fact. After a fair show of re- 
 sistance by the strictly orthodox, the profession was 
 only too glad to be rid of the Humoral Pathology, 
 and the " anti-phlogistic method " was discarded with 
 great benefit to all concerned. Unfortunately, Vir- 
 chow not only destroyed the Humoral Pathology but 
 he devised the Cellular Pathology to take its place, 
 and his constructive work was accepted with the same 
 unanimity as his destructive criticism. This accept- 
 ance was inevitable; because, when the Humoral 
 Pathology had been destroyed, the practice of med- 
 icine had no longer even a nominal scientific basis. 
 So that at the present time " Pathology " means Vir- 
 chow's Pathology, and this means that Virchow has 
 supplied medicine with a scientific basis for its art. 
 
PATHOLOGY 33 
 
 When Virchow originally assembled a number of 
 German medical men to announce his discovery, he 
 told them that the practitioner, being so much en- 
 grossed in practice, had neither time nor opportunity 
 for the study of medical science, and that he must 
 therefore resort to the " pathologist " for scientific 
 guidance. 1 am well aware that the profession, out- 
 side the narrow circle of orthodox " pure physicians," 
 now ignores Virchow's pathology, as a basis of prac- 
 tice, quite as completely as our fathers ignored the 
 Humoral Pathology; but it is none the less still the 
 nominal basis of orthodox medicine. 
 
 It is only three years since the senior physician of 
 one of the great hospital schools of London, in ad- 
 dressing the annual meeting of the British Medical 
 Association, declared that " all medicine is based on 
 pathology." Lesti there should be any misunderstand- 
 ing about what was meant by " pathology," he added 
 that the " physician " could not therefore spend too 
 much time in the post-mortem room. This declara- 
 tion, considering the circumstances in which it was 
 delivered, represent the very acme of authority, and 
 it would be unhesitatingly endorsed by every pure 
 physician. So that modern orthodoxy is still ex- 
 pressed in words that are an exact paraphrase of 
 Virchow's own declaration to the practitioners of his 
 day. 
 
 Virchow set himself to devise a strictly scientific 
 method in accordance with which the physician might 
 seek the origin of disease, so as to have something 
 solid on which to base his practice instead of the 
 sandy foundation of the humoralists. He summed 
 up the essence of his teaching in the memorable 
 
34 MEDICAL REVOLUTION 
 
 phrase : " Every chronic disease is rooted in an 
 organ." 
 
 It must be clearly understood that the " localisa- 
 tion of disease " was nothing new, it goes back at 
 least to the days of demonology; specialists flourished 
 in ancient Egypt just as they do in London; but Vir- 
 chow gave a new, a " scientific " basis to an old su- 
 perstition. In Virchow's time, the microscope was a 
 new weapon in the physician's hands; the cellular 
 structure of plants was a recent discovery, and when 
 Virchow saw the physiological meaning of the cellular 
 structure of man, and the pathological changes in 
 these cells, he thought he had indeed reached the very 
 origin of disease. 
 
 One single example will suffice to show the nature 
 and scope of " scientific pathology," as it is sometimes 
 tautologically called. A certain symptom-group had 
 been familiar to physicians, clinically, for ages, of 
 which dropsy was a leading feature. Bright found, 
 on post-mortem examination, that these clinically 
 observed symptoms were always associated with 
 certain pathological changes in the kidneys, and so 
 he connected the two as cause and effect. Virchow 
 declared that Bright had succeeded in tracing " the 
 disease " to the organ in which it was " rooted," and 
 that therefore the demands of medical science were 
 satisfied; " Bright's disease" became "a disease of 
 the kidneys." 
 
 It is only necessary to compare Bright's disease 
 with a true disease, such as lead-poisoning, to expose 
 the fallacy underlying the whole " pathological " 
 theory of disease. " The disease lead-poisoning " is 
 a conception drawn from the observation of a series 
 of symptom-groups of determinate and similar 
 
PATHOLOGY 35 
 
 causation ; it stands for definitely correlated cause and 
 effect. " Bright's disease " is also a mental concep- 
 tion, it represents a summing-up of a long series of 
 observations; but the symptom-groups, from the ob- 
 servation of which it is derived, are neither uniformly 
 of determinate nor of similar causation. It is quite 
 evident, it is in fact beyond dispute, that when the 
 pathologist demonstrates the kidney-changes, post- 
 mortem, and decides therefrom that the patient 
 suffered from " Bright's disease," not only does he 
 not assign a cause for the symptoms shown, he does 
 noe even pretend to do so. 
 
 What Bright really discovered was cirrhosis of the 
 kidneys; that is, a certain morbid change in the 
 structure of the kidneys that interferes with their 
 physiological action; but it is perfectly evident that 
 this cirrhosis is a symptom, just as dropsy is a symp- 
 tom. When Virchow declared that the lesion dis- 
 covered in the kidneys was the " cause " of the other 
 symptoms included in an attack of " Bright's disease " 
 he established the fallacy that lies at the foundation 
 of his " pathology " ; in calling one symptom the cause 
 of others he created for himself and his disciples an 
 artificial horizon that effectually shout out the true 
 cause from their view. Every one knows this now- 
 adays just as well as I do, but it is not convenient to 
 acknowledge it. 
 
 Every physician who describes lead-poisoning puts 
 down cirrhosis of the kidneys as one of the symp- 
 toms often present; yet in other cases when he finds 
 this same cirrhosis, on post-mortem examination, he 
 declares that the patient died of " Bright's disease," 
 a disease of the kidneys. Scarlatina, influenza, alco- 
 holic poisoning, gout, are amongst the other true 
 
36 MEDICAL REVOLUTION 
 
 diseases where cirrhosis of the kidneys is known to 
 occur as a symptom; so that in drawing a conception 
 from a number of cases of cirrhosis of the kidneys 
 and calling it " a disease " the conception is clearly 
 drawn from a series of symptom-groups known to 
 be of dissimilar causation. 
 
 It may be, it often is, urged that as these facts are 
 well known inside the profession it does no harm to 
 make a loose use of the specific word disease, and 
 that it is convenient to retain Bright's disease as " a 
 disease." The answer to this is, that the licence thus 
 taken is constantly used for the purpose of concealing 
 ignorance of causation in individual cases. When 
 the pathologist finds cirrhosis of the kidneys, post- 
 mortem, he knows perfectly well that there was a 
 cause at the back of it during life, and his duty as 
 pure scientist is obvious; he ought to say, Here is a 
 symptom of disease for which I am unable to account 
 with the evidence before me. Instead of this, he 
 falls back on " scientific pathology " and declares that 
 the man died of " Bright's disease," thus distinctly 
 implying that he has found the cause of death. The 
 pathologist of to-day uses Virchow's dogma to cloak 
 his ignorance of causation in precisely the same way 
 as his predecessor used the old Humoral Pathology. 
 
 There could not be a more complete misuse of 
 terms than to say that " a disease " is rooted in an 
 organ : every attack of disease consists of a cause and 
 a resulting symptom-group; even if all of these symp- 
 toms were concentrated in one organ — as they never 
 are — the cause cannot possibly be localised; therefore 
 the attack is not " rooted in an organ." " The 
 disease " is a mere abstraction, to say that this is 
 " rooted in an organ " is clearly absurd. Therefore 
 
PATHOLOGY 37 
 
 Virchow's one great dogma, " every chronic disease 
 is rooted in an organ," has no foundation whatever 
 in fact. The origin of such a belief goes back really 
 to the dark ages of medicine, when the word " dis- 
 ease " was used quite indiscriminately. Such an 
 expression as this: if your kidneys are diseased, you 
 must have a disease of your kidneys, represents pretty 
 faithfully the nebulous state of the medical mind only 
 a few years ago; the resulting amorphous condition 
 of our science is still with us, as is seen in the case of 
 Bright's disease. 
 
 It is impossible to read Virchow's great work Die 
 Cellular Pathologic, without seeing that he was an 
 anatomist, pure and simple ; his " science " began and 
 ended in the post-mortem room ; there is not a breath 
 of true, of clinical, medicine in the book. With Vir- 
 chow, " the science of medicine " and " morbid an- 
 atomy " are synonymous terms; the clinical correla- 
 tion of cause and effect are beyond his ken; he was 
 not a physician. 
 
 In 1868 Lord Lister had completed his immortal 
 scientific work on the septic infections, had put it 
 into practice and had announced the successful results 
 to the world; in 1870 the German army surgeons 
 practised " antiseptic surgery " in the war. In 1871 
 Virchow published a new edition of his work, and 
 it contained no mention of these events; neither does 
 it contain any reference to " the diseases " of poison- 
 ing nor to those of constitutional origin. 
 
 So that it is literally true to say that Virchow's 
 science of medicine rests entirely on his " organic 
 diseases," and of these " Bright's disease " is a class- 
 ical example. After exposing the artificiality of the 
 ancient " Humoral Pathology " Virchow devised and 
 
38 MEDICAL REVOLUTION 
 
 set up in its place another system that is not one whit 
 less artificial ; the man who calls Bright's disease " a 
 disease " is in the same boat with the man who used 
 to call dropsy " a disease." But as soon as it is 
 recognised that all " diseases " must be defined and 
 classified on the natural basis of cause and effect — 
 clinically correlated — there is an end of all artificial 
 systems, humoral or cellular. 
 
VII 
 
 SPURIOUS DISEASES 
 
 The determination to take a comprehensive view of 
 " disease " leads inevitably to the definition and class- 
 ification of " diseases " on the natural basis of cause 
 and effect. According to this ideal, all symptoms of 
 disease must be included in the survey of the phys- 
 ician; in other words, those who pursue the science 
 of medicine must have for their ultimate object the 
 compilation of a complete record of the processes that 
 make up human disease; and in order to serve as a 
 reliable basis for practice, this record must be kept 
 in terms of causation. It follows from this, that 
 there must be only one scientific method in medicine; 
 if all symptoms must be recorded on the basis of 
 causation there will be none left to be dealt with other- 
 wise. But, as a matter of fact, no scientific method 
 is recognised by the profession as holding the field 
 to the exclusion of all others ; hence it occurs that 
 medicine is hampered by a vast number of spurious 
 diseases. 
 
 The whole creation of spurious diseases rests ulti- 
 mately on a misunderstanding, but this misunder- 
 standing is rooted in superstition and has been much 
 fortified by modern pathology. It is essential in dis- 
 cussing spurious diseases to bear in mind the differ- 
 ence between the actual attack and " the disease," 
 which represents a summing-up of our experience of 
 many similar attacks. 
 
 39 
 
40 MEDICAL REVOLUTION 
 
 The so-called diseases of the mind may be dealt 
 with first. It has been stated by no less an authority 
 than Dr. Charles Mercier that in an attack of insanity 
 symptoms are never confined to disturbance of the 
 mind, that the bodily functions are invariably dis- 
 turbed as well. Therefore, to begin with, an attack 
 of insanity is only called so because the mental symp- 
 toms are the most prominent. It is clearly conven- 
 ient to speak so, but it is important to realise that 
 there is no such occurrence as " pure insanity " ; pure 
 insanity is connected in the popular mind with the old 
 superstition of possession. 
 
 In the next place, when we speak of insanity we 
 are speaking only of symptoms, and of symptoms 
 that are caused by many different agencies in different 
 cases. Some people show symptoms of insanity be- 
 cause they have inherited a faulty constitution that 
 leads inevitably to this particular form of disease; 
 others show similar symptoms under the influence of 
 drugs, others when they suffer from severe infections, 
 others under stress of war, or of the terror attached 
 to earthquake, fire, or other calamity. 
 
 At present, our conception of " the disease in- 
 sanity " is derived from the observation of such cases 
 as those just mentioned, and others; it is derived in 
 fact from the observation of all cases where mental 
 symptoms are prominent, regardless of causation. 
 This differentiates absolutely " the disease insanity " 
 as at present described, from " the diseases " typhoid 
 fever, lead-poisoning, heat-stroke; for, our concep- 
 tions of these diseases are based on the correlation of 
 cause and effect; each one of them represents a series 
 of cases that are all of determinate and similar caus- 
 ation. 
 
SPURIOUS DISEASES 4 1 
 
 It is possible to frame a conception of " the disease 
 insanity " that shall correspond with the other true 
 diseases; by taking that series of cases in which the 
 cause of mental symptoms is invariably a constitu- 
 tional defect we may draw therefrom a conception 
 based on the clinical correlation of cause and effect, 
 this will be a true disease. But as long as cases of 
 dissimilar causation are forced into one series, " in- 
 sanity " must remain a spurious disease. Until the 
 profession can be persuaded to recognise the intrinsic 
 causes of disease the present state of confusion is in- 
 evitable. The subdivisions of insanity do not con- 
 cern us at the moment, j 
 
 The so-called diseases of the nervous system are 
 nearly allied to insanity, they often overlap. The 
 neurologist is simply a specialised " pathologist," he 
 is a true disciple of Virchow. The work called 
 Diseases of the Nervous System, by Sir William 
 Gowers, is one of the most complete tasks ever ac- 
 complished by one man; it is truely a monumental 
 work. But it was written under the masterful in- 
 fluence of Virchow; it is specialised " pathology," and 
 its proper title would be " The Morbid Anatomy and 
 Physiology of the Nervous System." At the basis 
 of the work lies the dogma : Every chronic disease is 
 rooted in an organ. The morbid anatomy of an 
 organ is accepted as the " cause " of " a disease." 
 
 Locomotor ataxy is one of the most cherished 
 " diseases of the nervous system." A certain symp- 
 tom-group, observed clinically, is traced post-mortem 
 to certain " lesions " in the spinal cord, and then a 
 case of " the disease " has been demonstrated ; the 
 neurologist sometimes calls it a " complete patho- 
 logical entity " ; why " entity " it would be hard to 
 
42 MEDICAL REVOLUTION 
 
 say. No one knows better than Sir William Gowers 
 that several different " causes," properly so-called — 
 different toxic agents — are capable of giving rise to 
 this symptom-group; it arises also in cases of in- 
 trinsic causation, not merely, be it noted, the clinical 
 symptoms, but the symptom-group characteristic of 
 locomotor ataxy, post-mortem lesion and all. 
 
 Therefore, the conception that is called " the 
 disease locomotor ataxy " is knowingly drawn from 
 a series of cases admittedly of dissimilar causation; 
 it is therefore a spurious disease. Locomotor ataxy 
 is thus just as much and just as little a true disease 
 as is Bright's disease; if it is legitimate to confine 
 attention to symptoms, to the exclusion of their cause, 
 it is true that symptoms demonstrated post-mortem 
 are indeed the " cause " of other symptoms observed 
 clinically, then these are true diseases; if this is not 
 true, they are spurious diseases, misleading concep- 
 tions. 
 
 Infantile paralysis is another so-called disease of 
 the nervous system; a certain lesion of the spinal 
 cord is the basis of the neurologist's conception. In 
 cases of locomotor ata^xy the true cause of the dam- 
 age to the cord is often quite obvious, the case of 
 infantile paralysis is just the reverse. There is no 
 pretence whatever made in defining " the disease " in- 
 fantile paralysis to reach the cause of the symptoms 
 described. The neurologist is here quite candidly a 
 " pathologist " ; he observes a whole symptom-group, 
 partly clinical and partly post-mortem, and then, in- 
 stead of looking for the cause of the entire group, he 
 divides it arbitrarily into a clinical part and a post- 
 mortem part, and calls the latter the cause of the 
 former. So obsessed is the neurologist by his faith 
 
SPURIOUS DISEASES 43 
 
 in " pathology," that if pushed' on the subject of caus- 
 ation he asserts that he is quite justified in calling the 
 " lesion " in the cord " the proximate cause of the 
 clinical symptoms." 
 
 But he goes much further than this, for the neur- 
 ologist so implicitly accepts infantile paralysis as " a 
 disease " that he is honestly convinced " the cause " 
 will be discovered some day; and no doubt by a 
 " laboratory man." This, as any practitioner could 
 tell him, is a mere delusion ; this sacred " lesion " is 
 not always the result of the same toxic agent; the 
 tracing of causation is a clinical problem and it will 
 never be solved in the laboratory, nor fully solved in 
 cases of infantile paralysis, until the constitution, his- 
 tory, and environment of the patients are taken into 
 account. " The disease infantile paralysis " is there- 
 fore a conception drawn from the observation of a 
 series of cases of dissimilar and unknown causation; 
 it is a spurious disease. It is unnecessary to mention 
 in detail any more of the " organic diseases " of the 
 neurologist; they all rest on the same pseudo-scien- 
 tific basis; general paralysis, spastic paraplegia, in- 
 sular sclerosis, Landry's paralysis, are other ex- 
 amples. 
 
 In contradistinction to these " organic diseases," 
 the neurologist describes others as " functional 
 diseases of the nervous system " ; hysteria is an ex- 
 ample. The neurologist does not mean that symp- 
 toms of hysteria are confined to functional dis- 
 turbance, for hysterical patients suffer sometimes 
 from muscular atrophy and contracture, with possibly 
 fatal results. I shall give the neurologist's meaning 
 in language of the highest official authority; he means 
 that he " has been unable to find the anatomical seat 
 
44 MEDICAL REVOLUTION 
 
 of the disease." This is merely a fresh profession of 
 faith in " pathology " ; he cannot determine in what 
 organ " the disease is rooted." Here, again, the neur- 
 ologist, as pathologist, is debarred from seeking the 
 cause of the symptoms clinically; he must not 
 acknowledge that the patient has a " constitution." 
 And accordingly, in the orthodox definition of hys- 
 teria, there is no mention whatever of causation. 
 
 We all know that hysterical symptoms follow dif- 
 ferent causes in various cases, therefore our concep- 
 tion of " the disease " is at present drawn from a 
 series of cases of dissimilar causation. The situation 
 would be easily rectified by recognising that a con- 
 stitutional defect is the invariable cause of hysterical 
 symptoms in all cases of true hysteria, and that in 
 other cases where these symptoms occur, the cause is 
 extrinsic in origin. 
 
 It is perfectly obvious that in all cases of so-called 
 diseases of the nervous system we have to do with 
 cases where the most prominent symptoms are 
 nervous; these symptoms are named — quite irres- 
 pective of causation — and then made to masquerade 
 as " diseases " ; but they are spurious diseases. 
 
 If the so-called diseases of the heart are looked at 
 closely, it is again evident that we have to do with 
 symptoms, falsely called diseases. Fatty degeneration 
 of the heart is confidently called by the specialist " a 
 disease of the heart " ; but, in some cases, fatty heart 
 is part of the symptom-group characteristic of phos- 
 phorus poisoning, and here it clearly becomes a 
 symptom of phosphorus poisoning. In many cases, 
 in most, in fact, fatty heart is only discovered after 
 death; it is then too late to determine the cause of 
 
SPURIOUS DISEASES 45 
 
 the degeneration. But such a degeneration never 
 occurs without cause, and whether we discover the 
 cause or not, fatty heart remains a symptom. 
 
 It is evident, then, that if we draw our conception 
 of " a disease " from the whole series of cases in 
 which fatty heart occurs, we shall create a spurious 
 disease; some will be cases of phosphorus poisoning, 
 some will not; the majority will be of unknown caus- 
 ation. " The disease " fatty heart is, therefore, not 
 derived from the observation of a series of cases of 
 determinate and similar causation; it is a misleading 
 conception. All attempts to localise " a disease " in 
 the heart are doomed to similar failure; symptoms 
 are localised, but symptoms only, the cause must be 
 sought elsewhere before there is ground for the fram- 
 ing of reliable conception. 
 
 " The diseases of the lungs " are in no better case, 
 they are of necessity spurious. No more universally 
 recognised " disease of the lungs " could be chosen 
 than! " bronchitis." Bronchitis means an inflammation 
 of certain parts of the lungs, with various accompani- 
 ments that need not be specified. Now, the symptom- 
 group bronchitis occurs in cases of tuberculosis, of 
 typhoid fever, of measles, and in attacks of various 
 other true diseases; it is when all recognised diseases 
 have been excluded, and the symptom-group bronchi- 
 tis still occurs, that the patient is said to be suffering 
 from (an attack of) " the disease bronchitis." It is 
 therefore beyond dispute that " the disease bronchi- 
 tis " is a conception, drawn from the observation of 
 a series of cases of unknown causation. The ortho- 
 dox definition of bronchitis is confined to an enumer- 
 ation of symptoms ; all mention of causation is delib- 
 erately excluded. If typhoid fever, lead-poisoning, 
 
46 MEDICAL REVOLUTION 
 
 and heat-stroke are true diseases, then bronchitis is 
 certainly a spurious disease. 
 
 The definition of bronchitis is in strict accord with 
 the doctrines of " pathology " ; it is instructive, as 
 showing how the " localisation of diseases " rests now 
 on so-called science, where formerly it rested on 
 superstition. The pathologist says that " every 
 chronic disease is rooted in an organ " ; there is here 
 not only no mention of causation, it is deliberately 
 excluded; the pathologist's mind moves in an abso- 
 lutely closed circle of symptoms, he has made an 
 artificial horizon beyond which he will not look, and 
 it shuts out the cause of the symptoms; the lung 
 specialist is a pathologist. When the chief weight of 
 an attack of tuberculosis falls on the lungs, the 
 specialist again recognises " a disease of the lungs." 
 This is obviously wrong; tuberculosis is a disease of 
 parasitism; symptoms are in no case confined to the 
 lungs, neither is the cause; such nomenclature is not 
 in correspondence with acknowledged facts and ought 
 to be discarded. 
 
 Much has been heard of late years of myxoedema, 
 " a disease of the thyroid gland." Certain symp- 
 toms develop during life, and after death the path- 
 ologist demonstrates the " lesion " in the thyroid 
 gland that " caused " the clinical symptoms ; a series 
 of such cases is the basis of the conception of " the 
 disease myxoedema." The position is exactly anal- 
 ogous with Bright's disease; the thyroid is cirrhosed 
 just as are the kidneys. But the cirrhosis of the 
 thyroid is the result' of the action of some toxic agent ; 
 it is a symptom of which the toxic agent is the cause. 
 
 Practitioners, who have the opportunity of seeing 
 
SPURIOUS DISEASES 47 
 
 cases in their entirety, could tell the pathologist of 
 some of these causes — properly so-called — of the en- 
 tire symptom-group, but he would not listen, he has 
 traced " the disease " to the organ in which it is 
 rooted, and there the matter must end. If the caus- 
 ation of every case that shows myxedematous symp- 
 toms were fully traced, it would be evident that these 
 symptoms form part of attacks of many different true 
 diseases ; but as long as causation is not inquired into, 
 and our conception is drawn from a series of symp- 
 tom-groups of indeterminate and varying causation, 
 myxcedema must remain spurious disease. 
 
 The so-called diseases of liver, pancreas, spleen, 
 suprarenals, and so on, are all of exactly the same 
 nature, and need not be particularly dealt with; they 
 all rest on the " pathological " theory of the origin 
 of disease. 
 
 There is a large class of spurious diseases that may 
 be described as the " itises," that are much in evidence 
 at the present time; appendicitis and neuritis are 
 familiar examples. An inflammation, real or suppo- 
 sititious, is located in some organ or region, and then, 
 under the name of some particular " itis," it figures 
 as " a disease." If the physician were to say to the 
 patient : " I think, perhaps, one of the nerves of your 
 arm is inflamed," it would not be convincing; yet this 
 is all that " neuritis " means ; no pretence is made of 
 tracing causation. When a patient suffers from 
 " sciatic neuritis," it is quite true that the sciatic nerve 
 may possibly be inflamed by some unexplained 
 reason; but it also possible that the pain may arise 
 from the pressure of a spinal abscess near the origin 
 of the sciatic nerve; not all' cases of " sciatic neuritis " 
 are of similar causation, therefore " sciatic neuritis " 
 
48 MEDICAL REVOLUTION 
 
 is a spurious disease, a misleading conception; and so 
 is every other variety of " neuritis." 
 
 " Appendicitis " is equally misleading, as " a 
 disease." Even if the appendix were inflamed in 
 every case of so-called appendicitis — which it is not — 
 it is clearly absurd to delude ourselves with the notion 
 that in saying " itis " we have traced the causation of 
 the inflammation. The present conception of " ap- 
 pendicitis " is drawn from a series of cases that are 
 of causal antecedents far too numerous to mention 
 here; it is a spurious disease of the most misleading 
 character. Arthritis, iritis, gastritis, enteritis, colitis, 
 synovitis, laryngitis, tonsilitis, and many others, 
 might be cited, but it is unnecessary; no one would 
 maintain nowadays that to say " inflammation " is 
 to specify the cause of the attack; to call the in- 
 flammation " itis " does not improve matters. 
 
 People have become so accustomed to hear of " the 
 diseases of the skin " that their genuineness is taken 
 quite for granted; they are nevertheless spurious. 
 When the dermatologist says that urticaria (nettle 
 rash) is a disease of the skin, he draws his conception 
 from the observation of a series of cases in all of 
 which this rash has been present; but he draws his 
 conception from the rash, not from the whole case, 
 the cause of the rash is not included in his survey. 
 In some cases this rash is caused by unwholesome 
 food, in others by sewer-gas poisoning, in others by 
 some traumatic agency, such as parts of the nettle, 
 and in many the cause is not discovered. So that 
 " the disease urticaria " represents a series of cases 
 that are of varying and often of wholly unknown 
 causation; it is a spurious disease. 
 
 The case of "psoriasis" is different; I have never 
 
SPURIOUS DISEASES 49 
 
 known the dermatologist, or any one else, inquire for, 
 still less discover, the cause of this rash in any case; 
 therefore " the disease psoriasis " represents simply 
 a rash 1 that is known to occur frequently ; it is another 
 spurious disease. The subject is too paltry to pursue 
 further; nothing could be more arbitrary and arti- 
 ficial than the method of dermatology, neither can it 
 by any possibility be made consistent. The derma- 
 tologist does not venture to call the rashes of small- 
 pox, scarlatina, measles, typhoid fever or typhus, 
 " diseases of the skin," simply because the corre- 
 lation of cause and effect in these cases is so obviously 
 important; but eczema, psoriasis, Hebra's prurigo, 
 urticaria, purpura, and all other rashes are also 
 always due to some natural, discoverable cause; to 
 call them " diseases of the skin " is simply to cloak 
 ignorance of causation; every so-called disease of the 
 skin is of necessity a spurious disease. 
 
 Glaucoma is called " a disease of the eye " because 
 in the cases from which the conception is derived 
 symptoms are very prominent in the eye. But the 
 ophthalmologist does not carry his examination of a 
 case of glaucoma beyond the investigation of symp- 
 toms, causation is not mentioned. Here, again, we 
 find a specific disease erected on the observation of 
 symptoms without any reference to their causation. 
 It is part of a method that has survived from the time 
 of ancient Greece: " the disease " is in your eye; the 
 symptoms are so and so ; " the disease " is glaucoma. 
 Such an expression was quite excusable two thousand 
 years ago ; but to set up " the disease glaucoma " be- 
 side typhoid fever, lead-poisoning, and heat-stroke, 
 and to pretend that we do not know which is true and 
 which spurious, is not excusable. 
 
50 MEDICAL REVOLUTION 
 
 The discovery of " adenoids " was undoubtedly an 
 important one ;' but to call this local glandular increase 
 " a disease of the throat " was not scientific. If the 
 throat were not the private preserve of the laryngolo- 
 gist, it would have been impossible for the profession 
 to overlook the duty of tracing the causation of every 
 case of " adenoids" before attempting to frame a 
 specific disease. No one would dream of maintaining 
 that all those who show enlargement of the glands in 
 the axilla are suffering from the same " disease," and 
 yet this would be precisely analogous with the posi- 
 tion of the laryngologist with regard to adenoids. 
 The profession is dominated by specialism, and spe- 
 cialism is founded on error; to call local symptoms 
 "diseases" is wilfully to deceive ourselves; all true 
 diseases are based on the correlation of cause and 
 effect. 
 
 Chronic atrophic rhinitis is called " a disease of 
 the nose," and this is a very instructive instance of the 
 spurious disease. A case comes before the rhinologist 
 in which certain parts of the nose and surrounding 
 region are inflamed, and this inflammation is followed 
 by wasting. If the custom of interpreting symp- 
 toms on the basis of causation were established, the 
 rhinologist's first duty would, be to look for the cause 
 of the inflammation ; but he, being a specialist, is look- 
 ing for "local diseases," and so he gives the local 
 symptoms a more or less classical name and leaves the 
 causation alone; such is " a disease of the nose." 
 
 Deafness is so palpably a symptom that one won- 
 ders at the audacity of the specialist in calling it a 
 disease of the ear; but we have seen that unless mere 
 symptoms are called specific diseases, the whole house 
 of cards that the specialists have built would fall, 
 
SPURIOUS DISEASES 5 1 
 
 therefore the whole profession recognises deafness as 
 " a disease." 
 
 There is at least more plausibility about the expres- 
 sion " the diseases peculiar to women " than can be 
 claimed for " the diseases of the nose," but the " dis- 
 eases of women " are just as spurious as all other 
 special diseases. The differences in the anatomy and 
 physiology of the sexes give rise to differences in the 
 symptoms through which the processes of disease 
 show themselves in men and women ; but the causes of 
 disease, both intrinsic and extrinsic, are identical in 
 the case of both sexes. There is no true disease the 
 conception of which does not rest on its cause, there- 
 fore it is only symptoms and not " diseases " that are 
 peculiar to the sexes. 
 
 The number of " general diseases " is steadily 
 diminishing; the term is becoming too obviously ab- 
 surd to keep company, for instance, with " diseases of 
 parasitism." It is so painfully apparent that the one 
 set of conceptions is based on a definite knowledge of 
 causation, while this is excluded in the case of " gen- 
 eral diseases." It has been shown that, having due re- 
 gard to causation, we can frame a conception of " the 
 disease diabetes " from the observation of a series of 
 cases in which the cause of diabetic symptoms is in- 
 variably a constitutional defect. But Virchow's sys- 
 tem excludes all recognition of the fact that the 
 patient has a " constitution," and the modern " phy- 
 sician " is a " pathologist," therefore he must base his 
 conception of " the disease diabetes " on symptoms 
 only; the consequence is that " diabetes " is a spurious 
 disease. 
 
 Diabetic symptoms are often the result of the ac- 
 tion of an extrinsic cause, dietetic or traumatic, for 
 
52 MEDICAL REVOLUTION 
 
 instance; such cases do not belong to the same series 
 as the case of aj child whose symptoms are of intrinsic 
 causation. When diabetic symptoms are not due to a 
 constitutional defect, they belong to a case of some 
 disease of extrinsic causation; when this cause has 
 been discovered, the nature of " the disease " from an 
 attack of which the patient is suffering is decided, but 
 not otherwise. When the physician says that several 
 people who show diabetic symptoms, in each of whom 
 the cause is different, are suffering from the same 
 specific disease, " diabetes," he deliberately conceals 
 the fact that he has not discovered the cause of the 
 symptoms in any of the cases; this is the inevitable 
 result of creating spurious diseases. 
 
 Until the definition of all diseases is candidly made 
 to rest on causation, gout must also remain a spurious 
 disease. Some people suffer from gout because of an 
 inherited constitutional defect; this series of cases 
 forms the natural basis of the conception of a true dis- 
 ease ; all such cases present symptom-groups of deter- 
 minate and similar causation. But the symptom- 
 group from which gout takes its name arises also in 
 many cases as the result of extrinsic causes — lead- 
 poisoning, alcoholic poisoning, and so on. Therefore, 
 while our conception of " the disease gout " is drawn 
 — as at present — from all cases that show gouty symp- 
 toms, without any regard to their causation, it is 
 clearly a spurious disease. 
 
 Many new growths are classed together as repre- 
 senting a group of " diseases " ; but it is quite evident 
 that such a conception of the nature of " a disease " is 
 purely " pathological," and therefore utterly mislead- 
 ing. It was perfectly satisfying to Virchow to give 
 the anatomical and morphological characters of can- 
 
SPURIOUS DISEASES 53 
 
 cer; the idea of tracing its causation never dawned on 
 him; he was an anatomist not a physician. So firm 
 was Virchow's belief in his own system, that he in- 
 sisted with vehemence on classing cancer and tubercle 
 together. The futility, and worse than futility, of 
 calling a symptom-group of unknown causation, such 
 as cancer, " a disease," is only slowly dawning on 
 people even now. But as long as people were content 
 with " pathological diagnosis " and went on treating 
 cancer as " a disease," so long was our fatal ignorance 
 of causation completely cloaked and absolutely stereo- 
 typed. " A frank confession of ignorance is the first 
 step towards enlightenment." It is to be hoped that 
 the adoption of a rational attitude towards the cancer 
 problem may act as the thin end of the wedge in medi- 
 cal science; that before long we may be as candid in 
 the case, not only of all other new growths, but also 
 of myxcedema, infantile paralysis, lumbago, sciatica, 
 and even " liver," whatever that may mean. 
 
 Enough examples of spurious diseases have now 
 been cited to illustrate every possible phase of the 
 question as to the differentiation of true from spurious 
 diseases; the whole subject may therefore now be 
 summed up. i If it be granted that disease arises only 
 in response to the action of natural, and therefore dis- 
 coverable, causes, it follows that the scientific interpre- 
 tation of the processes of disease must be based on 
 causation. Following this method, we found that " a 
 disease " is a conception, drawn from the observation 
 of a series of cases presenting symptom-groups of 
 determinate and similar causation. It follows from 
 this, that any conceptional disease that is not drawn 
 from a series of symptom-groups of determinate and 
 similar causation must be a spurious disease. 
 
54 MEDICAL REVOLUTION 
 
 The attitude of the medical profession towards 
 this problem is summed up in a little book called The 
 Nomenclature of Diseases, and I shall make this book 
 the basis of my criticism. It is written under the au- 
 thority of the Royal College of Physicians of London 
 by a Committee appointed for the purpose. The most 
 striking feature of this work is, that no attempt is 
 made at the outset to make it clear what is or what is 
 not " a disease " ; this means that permission was 
 given by the College to use the specific word " dis- 
 ease " as it might appear convenient to the members 
 of the Committee in compiling the index; no limita- 
 tion was imposed on them. 
 
 This must mean one of two things : either that the 
 meaning of " a disease " is so well defined and so gen- 
 erally understood as not to require mention; or, that 
 it has no fixed meaning; we shall see that the latter 
 alternative represents the actual state of the question. 
 But although it is undeniably " convenient " to use 
 the specific word " disease " indiscriminately; it is not 
 satisfying either to the Committee or to those who 
 rely on their index for guidance. ! 
 
 For instance, " infantile convulsions " is set down 
 as " a disease of the nervous system " ; but it is 
 marked with an asterisk. At the foot of the page is 
 the note : " This term, being the name of a symptom, 
 should only be used when more precise information is 
 wanting. When the cause is known, the return should 
 be made under the head of that cause." So that the 
 Royal College of Physicians of London lays down in 
 the body of this work what it lacks the audacity to 
 lay down in front of it; that it is permissible to call 
 " a symptom " by the name of " a disease " when we 
 cannot, or will not, find the cause. This is an im- 
 
SPURIOUS DISEASES ' 55 
 
 portant declaration; it justifies, for instance, a custom 
 that is said to have prevailed at the beginning of the 
 South African war, according to which cases of 
 typhoid fever (of which the cause was not known) 
 were returned as " simple continued fever " ; it was 
 convenient to call " the symptom " " a disease." But 
 if the authorities acknowledged that what our fore- 
 father called " the disease convulsions " must now- 
 adays be recognised as being merely a symptom, why 
 is " elipepsy " not also marked with ari asterisk? 
 
 Epilepsy is another name for convulsions; the con- 
 ception " epilepsy " does not rest any more than the 
 conception " convulsions " on the correlation of cause 
 and effect; they are both spurious diseases; they are 
 derived, both of them, from the observation of series 
 of symptom-groups that are not of determinate and 
 similar causation. It is an example of the supersti- 
 tious reverence for imposing words that still hangs 
 about medicine ; " epilepsy " carries more conviction 
 than " convulsions " ; " chronic rheumatism " is more 
 imposing than " a pain in the knee " ; " acute neuritis " 
 is more readily accepted than " a pain in the arm." 
 But in no case does one word or phrase contain more 
 information about causation than the other. 
 
 All through this remarkable book the same admis- 
 sion is made occasionally with regard to symptoms 
 uncorrelated with a cause ; but the obvious conclusion, 
 that true and spurious diseases may always be differ- 
 entiated, is not drawn. The result is, that in the No- 
 menclature we are given a list of true and spurious 
 diseases under the common description of " diseases " ; 
 typhoid fever, lead-poisoning, and heat-stroke are offi- 
 cially held to be scientifically on a par with Bright's 
 disease, infantile paralysis, and psoriasis. This part 
 
56 MEDICAL REVOLUTION 
 
 of the subject may be dismissed with the assertion 
 that to place these two sets of conceptions on an 
 equality is demonstrably unscientific, misleading. 
 
 It has been mentioned that the medical authorities 
 refuse, nowadays, to recognise the fact that the pa- 
 tient has a constitution, and that causes of disease 
 arise in this constitution. But in the Nomenclature 
 hare-lip, cleft-palate, and so on, are classed as " de- 
 formities due to incomplete development," So that 
 " incomplete development " is recognised as a cause 
 of symptoms of disease, and as it undeniably arises 
 in the patient's constitution, the College really recog- 
 nises diseases of intrinsic causation without saying so. 
 When a child of a certain constitution dies with dia- 
 betic symptoms, we all know that the cause is intrinsic 
 in origin, the constitutional defect is precisely analo- 
 gous with the " incomplete development " that is ac- 
 knowledged to be the cause in cases of hare-lip; it is 
 only the perverseness of the " pathologist " that delays 
 candid recognition of the facts. 
 
 It has been shown that if the true meaning of " a 
 disease " be recognised as resting on causation, " dis- 
 eases " fall naturally into groups, under parasitism, 
 poisoning, traumatism, incomplete development, con- 
 stitutional defects, overwork, deficient work, and 
 wear and tear. That " the diseases " of parasitism, 
 of poisoning, of traumatism, and of incomplete de- 
 velopment are recognisable is shown by their inclusion 
 in the Nomenclature; if the other causes of intrinsic 
 origin were added, the classification of the College 
 would correspond with mine. The Committee not 
 only leaves out four groups of diseases of intrinsic 
 causation, but it adds an immense number of " local 
 diseases " of heart, kidneys, liver, stomach, skin, nose, 
 
SPURIOUS DISEASES 57 
 
 tongue, joints, etc. Indeed, to realise the extent to 
 which this localisation of " diseases " is carried the 
 book must be studied ; if repeated in extenso it would 
 sound incredible. 
 
 The dilemma in which the compilers of this index 
 have placed themselves, and the College, may be put 
 in the form of a plain question, susceptible of a plain 
 answer : Are, for instance, " the diseases of the skin," 
 scientifically speaking, analogous to " the diseases of 
 parasitism " ; can typhoid fever and psoriasis be 
 brought under one definition, and if so, what is the 
 definition of " a disease " ? The result of the failure 
 to define ideas at the outset is, that the official No- 
 menclature contains some scores of true diseases, and 
 omits many scores ; and includes also many hundreds 
 of spurious diseases. 
 
VIII 
 
 THE MEANING OF ILLUSORY DIAGNOSIS 
 
 It has been explained that the value attached to the 
 solution of the problem of diagnosis must depend on 
 the meaning attached to " a disease " ; because, diag- 
 nosis means the specifying of " the disease " from an 
 attack of which the patient, under consideration is suf- 
 fering. When, therefore, " a disease " was defined as 
 representing, always, definitely correlated cause and 
 effect, the solution of the problem of diagnosis was at 
 the same time defined as the correlation of effect 
 (symptom-group) with its cause in each patient. 
 
 Such a solution is illustrated in a case of malaria; 
 when the protozoon has been demonstrated in the 
 blood of the patient, the symptom-group has been 
 correlated with its cause, the parasitism of the mi- 
 crobe. The solution of the immediate problem of 
 diagnosis reminds us that the whole question of causa- 
 tion is not thereby cleared up, that the conditions 
 leading to the individual attack must also be investi- 
 gated; but these conditions do not affect the specific 
 character of " the disease " of which the attack under 
 consideration is an example. 
 
 The meaning of illusory diagnosis is equally easy 
 of comprehension; the recognition of genuine "dis- 
 eases " leads to genuine diagnosis, the failure to rec- 
 ognise them, the admission of spurious diseases to our 
 category, leads inevitably to illusory diagnosis. When 
 the College of Physicians gives permission to draw 
 
 58 
 
MEANING OF ILLUSORY DIAGNOSIS 59 
 
 the conception of " diseases " from series of cases 
 presenting symptom-groups of dissimilar, indetermi- 
 nate, and even of wholly unknown causation, it gives 
 its sanction at the same time to illusory diagnosis. 
 Although " purely theoretical," this is not a matter of 
 opinion but of fact; it is demonstrably true or false. 
 In order to avoid a double controversy I shall draw 
 my examples only from diseases of extrinsic causa- 
 tion, such as are recognised by the College. 
 
 When the physician says : This is a case of typhoid 
 fever, this is a case of lead-poisoning, and the third is 
 a case of frost-bite, he has in each case made a diag- 
 nosis; here, the authorities and I are in agreement. 
 But the diagnosis in each case is characterised by the 
 definite correlation of , cause and effect; nothing else is 
 attempted, the antecedent conditions are not taken into 
 account. We will now take three other " diseases " 
 from the Nomenclature; three that are not marked 
 with an asterisk. 1 
 
 When the physician says : This is a case of myxce- 
 dema, this is a case of infantile paralysis, and the 
 third a case of psoriasis, he has again solved the prob- 
 lem of diagnosis in each case, as prescribed by the 
 College. But in not one of these three cases has the 
 physician made any pretence of correlating cause and 
 effect; he has in each case named a symptom-group 
 without making any reference whatever to its causa- 
 tion. From these three examples a description may 
 be drawn that is always applicable to illusory diag- 
 nosis. When the physician pretends to diagnose a 
 case, but in doing so merely names, or renames, the 
 symptoms shown, and does not correlate them with 
 their cause, he makes an illusory diagnosis; in plain 
 terms, he has not made a diagnosis. 
 
60 MEDICAL REVOLUTION 
 
 The reader will now see the reason for going so 
 fully into the question of spurious diseases; the sub- 
 ject may have seemed rather technical in itself, but 
 the genuineness of diagnosis depends absolutely on 
 the nature of " the diseases " that are " diagnosed," 
 and the importance of diagnosis is obvious. What I 
 wish the laymen to grasp clearly is this : when, in 
 offering a diagnosis, the physician names a true dis- 
 ease he has, ipso facto, committed himself to a definite 
 expression of opinion; he has specified the cause of 
 the symptoms complained of. But when, in profess- 
 ing to give a diagnosis, the physician names a spuri- 
 ous disease, he commits himself to nothing more than 
 labelling the symptoms ; he has not even attempted to 
 trace the loss of health complained of to its cause. 
 
 It is necessary to go a step further, and to insist 
 that the failure to make a genuine diagnosis does not 
 merely fail to enlighten on the one vital question in- 
 volved, but that it closes the door against attempt in 
 this direction. I have already said that the orthodox 
 physician, when pressed, will acknowledge that, 
 speaking literally, Bright's disease and psoriasis are 
 not " diseases " in the same sense as are typhoid fever 
 and lead-poisoning. But he holds that it is convenient 
 to retain the right to call them so, on occasions; and 
 he adds, that merely to call them " diseases/' without 
 meaning it literally, in no way stops or impedes the 
 attempt to trace the symptoms to their cause. 
 
 Here, I think, the physician is entirely wrong; my 
 experience leads me to believe that when the student 
 is taught that " Bright's disease " and " psoriasis " 
 are " diseases," he concludes that to name either of 
 them is to make a diagnosis, and that he does not, as 
 as a rule, trouble any further about tracing causation. 
 
MEANING OF ILLUSORY DIAGNOSIS 6l 
 
 That the public imagine that they have received a 
 diagnosis when a spurious disease is named, I have 
 not the slightest doubt. 
 
 Taking, then, the Nomenclature of Diseases as rep- 
 resenting the orthodox position towards the problem 
 of diagnosis and its solution, these are the flaws I find 
 in it. The list of true diseases is incomplete; there 
 are, for instance, very many diseases of traumatism 
 omitted, and of the diseases of intrinsic causation 
 only those due to incomplete development are in- 
 cluded; these are some of the sins of omission. On 
 the other hand, whereas only a few scores of true dis- 
 eases are included — less than half of them — there are 
 hundreds of spurious diseases set down, to the inevi- 
 table confusion and bewilderment of the practitioner. 
 The book includes many true diseases, and this surely 
 implies a knowledge of what is " a disease," which 
 again implies a knowledge of what is not " a disease " ; 
 this proposition and corolllary have been fully set out 
 already. So that all that is necessary when the next 
 revision is undertaken is, that the College should put 
 in front of the book a plain statement as to what is 
 and what is not " a disease," before starting the Com- 
 mittee to work. 
 
IX 
 
 THE FALSE RELATION OF THEORY AND 
 PRACTICE RESULTING FROM ILLUSORY 
 DIAGNOSIS 
 
 The views that have been expressed here on the defi- 
 nition and classification of diseases, and on the mean- 
 ing of diagnosis that follows therefrom, have been 
 before the profession for some years without meeting 
 with any serious contradiction. It is indeed impossible 
 to deny that they are merely an extension and com- 
 pletion, in outline of views that are universally held 
 at the present time to be true as to the nature of dis- 
 ease. At the same time, the profession holds that 
 however indisputable these opinions may be in theory, 
 the present methods yield better practical results than 
 would be likely to follow a rearrangement of science 
 and art on the lines here advocated. This is, of 
 course, the crucial question; the practical test may be 
 applied just as rigorously in medicine as in marine 
 engineering; the medical profession must be judged 
 ultimately by results. 
 
 The true relation of theory and practice is based 
 on the fact that our management of disease will be 
 intelligent and successful in proportion to our knowl- 
 edge of causation. To appreciate this fully it is es- 
 sential not to limit the idea of treatment to cure only, 
 but to include in the management of disease the whole 
 range of prevention, cure, and alleviation. The man- 
 agement of malaria illustrates this well, and will bear 
 
 62 
 
FALSE RELATION OF THEORY AND PRACTICE 63 
 
 repetition. Attacks of malaria used to be treated by 
 the administration of " bark," while practitioners had 
 still no knowledge whatever of causation; malaria has 
 been ascribed to the action of an imaginary " miasm." 
 Patients were often much benefited, and even cured, 
 in those days, although the treatment was purely em- 
 pirical. Then came the discovery of the parasite and 
 the extraction of quinine from the " bark," when the 
 treatment of the attack was put on a scientific footing. 
 
 The diagnosis of malaria was now on a scientific 
 basis; the clinical correlation of cause and effect in 
 each patient was possible ; and this immediately made 
 it evident that our knowledge of causation would not 
 be complete until the conditions leading to the individ- 
 ual attack were also elucidated. When this had been 
 done, but not till then, prevention became possible ; in 
 the light of a full knowledge of causation the practi- 
 cal management of malaria was placed on a completely 
 rational and satisfactory basis. 
 
 I would urge the reader to pause and reflect, so that 
 he may realise that what is so obviously true with re- 
 gard to the management of malaria is, and must be, 
 equally true with regard to the whole subject of the 
 relation of theory and practice in medicine. Put in 
 the simplest form this means, that if we know exactly 
 why the patient is ill we shall be in the best possible 
 position to treat him, and to ensure that he shall not 
 have a recurrence; and that with this full knowledge 
 of causation we shall have a good prospect of prevent- 
 ing similar attacks in others. 
 
 In order to contrast the true and the false relation 
 of theory and practice in medicine, I shall now give a 
 few examples that will show the results of indulging 
 in illusory diagnosis. Bronchitis has been mentioned 
 
64 MEDICAL REVOLUTION 
 
 as a spurious disease, because our conception of bron- 
 chitis is drawn from the observation of a series of 
 cases in which this symptom-group is not always due 
 to one known cause. In the orthodox definition of 
 bronchitis there is, in fact, no mention whatever of 
 causation, it is a mere labelling of symptoms. So that 
 the treatment of bronchitis must of necessity be con- 
 fined to dealing with symptoms; however successful 
 it may be it is empirical. 
 
 This is the essential character of all medical art 
 that is not founded securely on science; the physician 
 who makes a genuine diagnosis traces effect to cause, 
 he is therefore in a position to deal intelligently with 
 the cause ; the physician who is content with an illusory 
 diagnosis, being ignorant of the cause, can only cure 
 or palliate symptoms empirically. 
 
 Infantile paralysis is another spurious disease; the 
 pathologist calls it " acute anterior poliomyelitis," 
 which shows that he has added to our knowledge of 
 the morbid anatomy and physiology of the nervous 
 system. But it also emphasises the fact that we are 
 still as ignorant of the causation of these cases as 
 were our forefathers, who called them children's 
 palsy. The mere labelling of symptoms never does 
 solve the problem of diagnosis. i 
 
 So that the treatment of infantile paralysis is limited 
 to attempts to cure the effects of an unsought cause or 
 causes, and these effects are for the most part abso- 
 lutely incurable ; we cannot and we never shall be able 
 to restore the damaged nerve cells to functional ac- 
 tivity. But worse remains to tell; as long as we are 
 content to deliberately conceal from ourselves the fact 
 that we are ignorant of the causation of infantile 
 paralysis, so long will prevention remain impossible, 
 
FALSE RELATION OF THEORY AND PRACTICE 65 
 
 so long will the individual and the nation be handi- 
 capped with the effects of this " disease." 
 
 There is a vague notion abroad that because plague 
 and cholera are due to the parasitism of microbes 
 therefore they may be prevented, whereas, infantile 
 paralysis being some sort of mysterious visitation 
 must remain amongst the unforeseeable and unpre- 
 ventable calamities of life. This is a remnant of su- 
 perstition; there is no more mystery about the causa- 
 tion of a case of infantile paralysis than about a case 
 of typhoid fever; it is mystification we suffer from. 
 The whole causation of all cases of infantile paralysis 
 will one day be cleared up, and then all such cases 
 will be preventable. Another malignant feature of 
 " the spurious disease " may be pointed out in this 
 connection ; when the " pathologist " calls infantile 
 paralysis " a disease," he implies that the symptoms 
 thus labelled are always due to one cause, and the 
 whole profession lives in the hope that the scientists 
 at headquarters may one day discover this cause; in 
 the meantime, all effort in this direction on the part 
 of the mere practitioner is paralysed. But the assump- 
 tion is utterly unwarranted; if every case of infantile 
 paralysis were independently examined clinically we 
 should be in a very different position to-day. 
 
 Myxcedema is another spurious disease that goes 
 on claiming a number of victims annually ; and in the 
 absence of all knowledge of causation this must re- 
 main so. When cases of myxcedema are well estab- 
 lished, they are, it is true, much relieved by the ad- 
 ministration of thyroid extract, but this is a pure piece 
 of empiricism; until we discover the causation of 
 these cases prevention is not possible. The prac- 
 titioner knows the cause in some cases, he knows that 
 
66 MEDICAL REVOLUTION 
 
 it varies, but it has been laid down authoritatively by 
 the " pathologist " that myxoedema is " a disease " and 
 must be treated as such, and the days of prevention 
 are therefore postponed; science and art are kept in a 
 false relation. < 
 
 " The disease gout " is characterised, according to 
 the " pathologist," by pain and inflammation in the 
 joints, the deposit there and elsewhere of certain 
 chemical substances, and later by changes in the arter- 
 ies and kidneys. There is no mention of causation in 
 the orthodox definition of this * disease " ; what is 
 " defined " is a symptom-group. This means that 
 until this symptom-group is well established, it is im- 
 possible to " diagnose " gout ; and this is the position 
 rigorously maintained by the orthodox physician, the 
 " pathologist." 
 
 But if we cannot diagnose gout we cannot treat it, 
 and so it results that patient and practitioner are 
 taught to wait supinely until gout can be definitely 
 diagnosed before beginning treatment. But, unfor- 
 tunately, all the " classical " symptoms of gout, the 
 deposits, the hard arteries, the cirrhosed kidneys, and 
 so on, are absolutely incurable; the time when the 
 cause or causes might have been dealt with has been 
 allowed to slip away, and we are reduced to attempt- 
 ing to cure incurable effects. 
 
 If the practitioner were taught that he must make 
 himself fully acquainted with every channel through 
 which symptoms of gout advance; if he were taught 
 to interpret all symptoms of disease on the basis of 
 causation, gout would then be seen to consist of a 
 heterogeneous collection of symptoms, of widely vary- 
 ing causation, but all of them preventable, provided 
 the constitution be fairly sound. Here it is evident 
 
FALSE RELATION OF THEORY AND PRACTICE 6j 
 
 once again that if the physician confine his " science " 
 to the detection of symptoms without reference to the 
 cause, his art must be mere empiricism; instead of 
 dealing intelligently with causes he must tinker blind- 
 fold at effects ; prevention is not in sight. 
 
 " The disease diabetes " is also still defined on 
 purely symptomatic grounds; all those who suffer 
 from diabetic symptoms are supposed to exhibit the 
 same " disease." Many cases of diabetes are of purely 
 constitutional origin, and it is evident that to check 
 the production of these unfortunate people it would 
 be necessary to study hereditary tendencies closely, 
 and to educate public opinion. But, at present, these 
 cases are carefully hidden away with others of wholly 
 different causation; until the obligation of tracing the 
 causation of each case is candidly recognised, there 
 cannot be any scientific advance, and art must wait on 
 science. The " treatment " of diabetes is of necessity 
 limited to dealing with established symptoms, since 
 the " diagnosis " on which it is based is so limited ; 
 the failure to trace causation excludes the possibility 
 of prevention; symptoms are treated, but the patient 
 is not. 
 
 Rheumatic fever is now definitely classed amongst 
 the infections, but apart from this we still hear much 
 of " rheumatism," " chronic rheumatism," " muscular 
 rheumatism," and so on; and it is painfully evident 
 that the " diagnosis " in these and many allied cases 
 throws no light whatever on causation. " Treatment " 
 of these symptoms by the methods of hydropathy, 
 balneotherapy, climatotherapy, galvanism, electricity, 
 massage, drugs, exercises, represents a mass of em- 
 piricism that is really appalling. Sciatica is a nearly 
 allied " disease " ; when there is severe and prolonged 
 
68 MEDICAL REVOLUTION 
 
 pain in the sciatic nerve we " diagnose " sciatica, or 
 " sciatic neuritis/' to be more modern. Various treat- 
 ments are recommended, but if it appears that the 
 pain was due to pressure from a tubercular affection 
 of the spine, it may become evident that they have 
 only robbed the patient of what little chance he might 
 have had. 
 
 A case of asthma presents a very striking and 
 easily recognisable picture, and so, this symptom- 
 group is called " a disease," without any reference to 
 causation. A false relation between theory and prac- 
 tice is inevitably established ; we are at once committed 
 to the treatment of symptoms — as such — to empiri- 
 cism. A few years ago, I do not know how it is now, 
 is was the fashion to " treat asthma " by cauterising 
 the inside of the nose. One distinguished specialist 
 said he looked forward to the time " when every 
 practitioner would treat every case of asthma with 
 the cautery." 
 
 One patient, for instance, has a first attack of 
 asthma at the age of two; it is caused by a constitu- 
 tional defect; another patient has her first attack at 
 the age of seventy-two; her kidneys are cirrhosed, 
 her end is near. There are very many patients be- 
 tween these two extremes in whom the cause of the 
 asthmatic symptoms is sometimes purely intrinsic, 
 sometimes purely extrinsic, and in others so complex 
 as to baffle the most astute diagnostician ; but the spe- 
 cialist invites the practitioner to treat them all by 
 touching a certain spot inside the nose with the elec- 
 tric cautery ; fortunately, the practitioner is not such a 
 fool. It would be hard to imagine a more arrant or 
 deliberate piece of empiricism, but it was urged on 
 high professional authority. 
 
FALSE RELATION OF THEORY AND PRACTICE 69 
 
 Phlyctenular ulcer is called " a disease of the eye/' 
 causation has no part in our conception of it ; it repre- 
 sents a symptom-group that is easily recognised. An 
 ulcer in one child may be purely traumatic in origin; 
 a cold draught will disturb the nutrition of the cornea 
 in a healthy child and cause ulceration ; another child 
 will suffer from repeated attacks because it has a 
 strumous constitution. If we " treat the ulcer " in 
 these two cases, we are deliberate empirics; if we 
 treat each child for the symptoms, after discovering 
 the cause, we maintain the theory and practice of 
 medicine in their due relation. Glaucoma is another 
 instance ; as long as it is maintained that this is " a 
 disease of the eye," so long will the specialist fail to 
 attempt the correlation of cause and effect in each case, 
 and so long will his iridectomy, whether it relieve the 
 symptoms or no, remain a piece of pure empiricism. 
 
 A certain rash is called " psoriasis, a disease of the 
 skin "; the cause of the rash is not mentioned. When 
 this rash is " cured," as it often is, by the application 
 of ointments and lotions, we have another instance of 
 the empiricism that must result from illusory diag- 
 nosis. It does not matter in the least who the person 
 is who makes the " diagnosis " ; if effect and cause are 
 not correlated the neccessary foundation for rational 
 treatment is lacking ; there is no escape from this even 
 for the most distinguished specialist. No person in 
 sound health suffers from psoriasis, this rash is a dan- 
 ger signal; if we can find out why it appeared and 
 can remove or avert the cause, the patient will in this 
 respect be put in a position of safety; if we merely 
 suppress the danger signal the benefit to the patient is, 
 to say the least, problematical. 
 
 Urticaria is another rash, falsely called u a dis- 
 
70 MEDICAL REVOLUTION 
 
 ease " ; but in many of these cases the cause is obvious 
 and the treatment consequently rational. But suppos- 
 ing the rash to be, as it sometimes is, a symptom of 
 sewer-gas poisoning, the specialist who knows nothing 
 of the environment of the patient cannot possibly find 
 this out ; if he succeed in " curing the disease " the 
 patient will then continue to absorb sewer-gas until 
 some more serious symptom appears to warn him. 
 
 It is more or less plausible to say that when a child 
 suffers from adenoids it has " a disease of the throat " 
 which may be treated locally and cured. But reflec- 
 tion will show that if the causation of this local in- 
 crease of glandular tissue were completely worked 
 out, it might be prevented in practically every case; 
 and this would have obvious advantages over the pres- 
 ent method. The fundamental error of calling symp- 
 toms " diseases " is responsible for an incalculable 
 waste of health. 
 
 The old craze for cure, rather than prevention, the 
 worship of empiricism, was once more illustrated re- 
 cently. Just when the cancer problem was at last 
 candidly faced, when we had been provided with 
 more than one research department, well equipped and 
 scientifically directed, the seekers after " cure " must 
 needs spend a fortune on the establishment of a Ra- 
 dium Institute. If such experiments must be made, 
 pending scientific inquiry into the causation of cancer, 
 surely the research institutions possess every requisite, 
 in abundance, except money. The Radium Institute, 
 when turned to some better purpose, will serve as a 
 monument to the misguided enthusiasm of the modern 
 empirics. 
 
 These examples will probably suffice to illustrate 
 the false relation of theory and practice that is still 
 
FALSE RELATION OF THEORY AND PRACTICE 7 1 
 
 so widely prevalent in medicine. It may be thought 
 by some that such questions as these are purely tech- 
 nical, and that they ought therefore to be left entirely 
 to the profession for discussion and decision; I shall 
 explain what seems to me the correct attitude of the 
 layman in the matter. The layman cannot too rigor- 
 ously eschew the study and management of disease; 
 its interpretation and treatment ought to be handed 
 over to the regular profession; all self-diagnosis and 
 treatment are not only futile but morbid. Health is 
 to be maintained by those of sound constitution who 
 have plenty of bona fide occupation, plenty of exer- 
 cise, plenty of food, plenty of air; healthy people also 
 provide themselves with wholesome recreation. But 
 health is not to be attained surreptitiously, in the ab- 
 sence of these conditions, by the cultivation of some 
 cunning system of diet, clothing, baths, exercises, 
 drugs, " change," " rest cures " or what not; the pres- 
 ervation of health is a legitimate object for the lay- 
 man as far as common sense guides him, but no 
 further; the habitual, self-conscious attempt to avoid 
 disease is a renunciation of health. 
 
 But while it is essential that the layman should 
 leave the whole subject of disease in the hands of 
 the regular profession, it is equally essential that he 
 should understand the methods of the profession; 
 otherwise he is apt to become sceptical, or to fall a 
 victim of the plausible charlatan. The regular prac- 
 titioner — whether he call himself physician, surgeon, 
 specialist, or practitioner — bases his claim to public 
 confidence, ultimately, on his power to make a diag- 
 nosis, but there is much uncertainty, even inside the 
 profession, as to what is a diagnosis, a genuine diag- 
 nosis. 
 
72 MEDICAL REVOLUTION 
 
 It is clearly most undesirable that the layman should 
 attempt to pursue the subject of true and spurious 
 diseases, of genuine and illusory diagnosis, in detail; 
 but there is one all-embracing question that he may 
 put to the medical man when a diagnosis is offered 
 him, he may ask: Apart from nomenclature, which 
 is unimportant, have you made out exactly why the 
 symptoms have developed? No one could advocate 
 always telling the naked truth to every patient, that is 
 often impossible for obvious reasons ; but in such cases 
 there is practically always some relative or friend 
 who ought to know the whole truth. 
 
 Of all branches of science, medical science is one 
 of the most complex; but even this is after all only 
 " organised common sense," and the common-sense 
 view of the relation of science and art in medicine is 
 summed up in this, that if we know why symptoms 
 develop, cure and prevention are within possible 
 reach; lacking this knowledge, while haphazard, em- 
 pirical cure is just possible, prevention is impossible. 
 If the public would but adopt a common-sense atti- 
 tude towards the problems of disease, they would 
 save themselves a world of disappointment and delu- 
 sion; the regular profession would be placed in an 
 unassailable position, and would be much encouraged 
 and helped in approaching their work in a truly scien- 
 tific manner. 
 
 It would be impossible to enter here on a full dis- 
 cussion of the subject, but reference must be made to 
 the practical effect of the failure to recognise the in- 
 trinsic causes of disease. Diagnosis means the corre- 
 lation of cause and effect in the individual patient; 
 therefore, as long as these constitutional causes are 
 not recognised, every case in which the symptoms re- 
 
FALSE RELATION OF THEORY AND PRACTICE 73 
 
 suit from the action of one of them leads to an illusory 
 diagnosis. And so it results that in cases of intrinsic 
 causation the symptoms are treated and the patient is 
 not. 
 
 This represents what happens when both theory 
 and practice are strictly orthodox; "based on path- 
 ology." It is true that common sense asserts itself to 
 some extent, especially in general practice ; but ortho- 
 doxy dominates the situation, and makes rational 
 practice extremely difficult, sometimes impossible. 
 
X 
 
 MEDICINE 
 
 Hippocrates discarded superstition and established 
 medicine on a scientific basis; he ceased to appeal to 
 the supernatural ; he sought the causation of disease in 
 Nature; the science of medicine was by him made a 
 branch of natural science. But this science that Hip- 
 pocrates inaugurated was a unified science; the phy- 
 sician was not only the diagnostician, he was the only 
 diagnostician; he undertook to make a complete and 
 comprehensive survey of the constitution and environ- 
 ment of each patient, and on this survey he founded 
 his diagnosis. The physician always delegated cer- 
 tain parts of his art to others for performance; for 
 instance, to the surgeon, the barber-surgeon, the ob- 
 stetric surgeon, or the dental surgeon, but " medicine " 
 remained unified and in the hands of the physician 
 from the time of Hippocrates to the time of Virchow. 
 It has been explained how Virchow converted the 
 physician into a morbid anatomist; how he taught 
 him to look for each " disease," with scalpel and mi- 
 croscope, in the organ in which it was " rooted." 
 When Virchow mistook morbid anatomy for " path- 
 ology," for the science of medicine, he had not the 
 least conception of the nature or the consequences of 
 the revolution he inaugurated in medicine. Virchow 
 was completely justified in discarding the Humoral 
 Pathology, but he could not have done a greater dis- 
 service to medicine than he did in breaking away from 
 
 74 
 
MEDICINE 75 
 
 the true Hippocratic tradition. When, at Virchow's 
 dictation, the " physician " resigned the position 
 taken up by Hippocrates he opened the flood-gates of 
 spurious specialism, and " medicine " has been, for 
 the time, submerged. 
 
 Virchow's one great dogma, " every chronic disease 
 is rooted in an organ," was accepted as literally true, 
 and the consequences were inevitable. In the first 
 place, if " disease " cannot be detected until there are 
 " physical signs " in the organ concerned, the " con- 
 stitution " of the patient becomes of no account; the 
 the modern " physician " says, " I do not believe that 
 a knowledge of the constitution matters twopence in 
 diagnosis " ; the patient becomes a mere collection of 
 organs, without individuality. In the second place, 
 the subdivision of " medicine " becomes right and in- 
 evitable ; if there are special " diseases " in each or- 
 gan they ought clearly to be specially studied. If 
 there are " diseases " of eye, ear, throat, nose, skin, 
 there are, a fortiori, " diseases " of heart, lungs, liver, 
 nerves, stomach, colon, thyroid, and so on. If the 
 skin is entitled to its specialist, the claims of the 
 stomach cannot possibly be disputed; and so it hap- 
 pens that " medicine," as understood by Hippocrates, 
 has ceased to flourish, the " physician " is extinct. The 
 modern physician, in his young days, is a morbid ana- 
 tomist, and in his days of practice he is a specialist 
 for heart, lungs, colon, stomach, nerves, gout, liver, 
 or for galvanopeutics, therapeutics, massage, clima- 
 totherapy, balneotherapy. 
 
 It must be insisted once more that all attempts to 
 subdivide the pure science of medicine are based on a 
 misinterpretation of the processes of disease, and must 
 therefore end in disaster. The definition and classi- 
 
j6 MEDICAL REVOLUTION 
 
 fication of diseases, to be true to Nature, must rest 
 on causation ; such definition and classification will be 
 uniform and comprehensive; the true meaning of 
 diagnosis follows as a corollary. For this natural 
 scheme of medical science, Virchow substituted an 
 artificial system ; his " pathological " system of " or- 
 ganic diseases " has lured the physician from the bed- 
 side to the post-mortem room, and, inevitably, to a 
 false specialism. But if the " science " of the morbid 
 anatomist is false, may not his art be true; is he a 
 success as an expert in a narrow branch of treatment? 
 This question has already been answered; illusory 
 diagnosis cannot possibly give a sure foundation; 
 false theory leads inevitably to futile practice. Spe- 
 cialists, for instance, have been studying " Bright's 
 disease " and allied conditions for the last fifty years; 
 the morbid anatomy and physiology of the subject are 
 pretty well exhausted; but there is no corresponding 
 advance in practice. " Bright's disease " is a spurious 
 disease; the conception excludes all recognition of 
 causation; therefore, when we " diagnose " a case we 
 merely recognise symptoms, and symptoms that when 
 recognisable are already incurable; treatment can, 
 therefore, extend only to palliation, cure is impossible 
 and prevention is far out of reach. This instance is 
 characteristic of the whole art of the pathologist-phy- 
 sician; it is of the most pessimistic kind; the patho- 
 logical theory of disease makes the practice of preven- 
 tive medicine impossible. 
 
XI 
 
 SURGERY 
 
 Nothing could well be clearer or more genuine than 
 the proper distinction between medicine and surgery. 
 Medicine is one great whole including a pure science 
 and an applied science or art; the pure science em- 
 braces all our knowledge over the whole territory of 
 human disease; every application of this knowledge, 
 from the administration of a draught to the amputa- 
 tion of a limb, is part of the physician's art. The 
 true physician may delegate certain parts of his art 
 to the surgeon ; he makes no pretence to subdivide his 
 science, still less to resign any part of it. 
 
 But the modern physician declares himself ignorant 
 on the subject of " mental diseases " ; he has no time 
 for the study of dermatology, rhinology, ophthalmol- 
 ogy, laryngology, gynaecology, neurology; he has re- 
 signed some nine-tenths of his pure science; it is not 
 to be wondered at that the surgeon claims to have a 
 science of his own, like the other specialists. The 
 general surgeon, the dental surgeon, and the obstetric 
 surgeon were originally recognised as men who had 
 become experts in the performance of certain small 
 portions of the art of the physician; now, they are 
 " scientific specialists," the surgeon " diagnoses " 
 " surgical diseases " ; the dentist studies odontology, a 
 separate science ; and the obstetrician is a " gynaecolo- 
 gist " dealing in " diseases " peculiar to women. 
 
 It is clearly right, and even necessary, to specialise 
 
 77 
 
7§ MEDICAL REVOLUTION 
 
 certain men in the hospital, and in all populous places, 
 for the cultivation of surgical treatment; but it is fatal 
 to delude ourselves with the idea that there is any un- 
 derlying subdivision in human disease corresponding 
 with this convenient practical expedient. To set apart 
 a group of men to operate is right, to divorce medi- 
 cine and surgery is disastrous. The old physicians 
 were lured into this error; surgical cases were segre- 
 gated in surgical wards, and when they died by scores, 
 of gangrene, the physician became accustomed to leave 
 the responsibility with the surgeon, and to pass by on 
 the other side. And so it happened that the attempt 
 to diagnose septic cases fell practically to the ground. 
 
 Then, guided by the light of Pasteur's genius, Lord 
 Lister took up the neglected work of the absent physi- 
 cian; he made an immortal diagnosis that not only 
 changed the whole aspect of medicine, but brightened 
 the prospects of humanity. When cause and effect 
 were correlated, the septic infections became palpably 
 preventable; and this, simply because Lord Lister re- 
 fused to be a mere craftsman; because he played the 
 intelligent part of the operating physician; because 
 theory and practice had been restored to their true 
 relation. 
 
 When the most distinguished members of the pro- 
 fession are divided into two groups, one group com- 
 posed of " pure surgeons " who will not see a 
 " medical " case, and the other composed of " pure 
 physicians," misunderstanding is inevitable, and bias 
 is deliberately cultivated. 
 
 I read the other day in one of the medical journals 
 an account of a meeting for the discussion of " the 
 treatment of appendicitis." It was attended by " phy- 
 sicians " and " surgeons." Now, our conception of 
 
SURGERY 79 
 
 this " disease " is drawn from cases of the most ex- 
 traordinary diversity; one case may be operated on 
 for pain caused by slight anatomical abnormality in 
 the appendix; at the other extreme would be a case 
 where a pneumococcic infection proves rapidly fatal, 
 in spite of all efforts medical or surgical ; and between 
 these two are all sorts of disturbances and infections 
 by microbes of various kinds and habits. 
 
 It is! extraordinary that a body of scientific men can 
 be induced to discuss the treatment of all these differ- 
 ent cases as a whole, when they know that each case 
 must be diagnosed and treated absolutely on its own 
 merits. However, not only did the discussion take 
 place, but the journal was able to summarise it in say- 
 ing that the " surgeons " advocated the earliest pos- 
 sible operation, while the " physicians " were in favour 
 of non-interference or delay. One physician went 
 very nearly the length of condemning surgical inter- 
 ference altogether, because, " he had never lost a case 
 from this disease." And yet it is a matter of common 
 knowledge that it is often a choice between immediate 
 operation and death. Human nature being what it is. 
 the separation of medicine and surgery — as at pres- 
 ent authorised — must inevitably give rise to a bias of 
 mind that is sometimes fatal to the patient. 
 
 Take a still simpler case; certain microbes gain a 
 footing in the subcutaneous tissues of a limb; if the 
 skin be promptly incised and suitable applications be 
 made the microbes are destroyed and the man is saved ; 
 if treated " medically " the limb, and ultimately the 
 life, may be sacrificed. But if the man attending such 
 a case call himself " physician," that is, if he will not 
 " operate," and will only call in the " surgeon " when 
 he has to confess that " medical treatment has failed," 
 
80 MEDICAL REVOLUTION 
 
 the limb and the life of the patient are in jeopardy. 
 This is the plain practical meaning of our departure 
 from the truej Hippocratic tradition. 
 
 There is only one science of disease, and being 
 founded on the universal, invariable sequence of cause 
 and effect it is indivisible without destruction; there 
 is only one true art of medicine and it is based on the 
 knowledge of causation. These fundamental facts 
 have been lost sight of; they have been obscured by 
 the attaching of an altogether mistaken value to ar- 
 rangements which, however convenient, are local and 
 personal. 
 
XII 
 
 SPECIALISM 
 
 Division of labour, for the attainment of increased 
 individual efficiency and greater collective results, is a 
 feature of civilisation ; there is a feverish demand for 
 specialisation in medicine, so that the cure of disease 
 may be effected completely and rapidly. The plea for 
 specialism was put in a nutshell by a distinguished 
 specialist when he said : " Since it is impossible for 
 any one to know all about everything in medicine, let 
 each of us try to learn all about something." This 
 is very plausible; we shall see presently what is its 
 true value. 
 
 When the specialist assumes that " medicine " is 
 susceptible of subdivision, he assumes too much, for 
 the science and the art of medicine demand separate 
 consideration in this matter. The whole science of 
 medicine is cultivated with but one object, and that is, 
 the gaining of a complete knowledge of causation in 
 disease; the whole art of medicine is based on this 
 knowledge, and cannot therefore be legitimately ex- 
 ercised until the preliminary scientific work is com- 
 plete. This relation of science and art is a funda- 
 mental principle in medicine, from which there is no 
 escape for any member of the regular profession who 
 takes independent charge of his patients. I shall give 
 some illustrations to prove that there is much con- 
 fusion as to what is and what is not specialism, and 
 
 81 
 
82 MEDICAL REVOLUTION 
 
 also, that the modern specialist does not preserve the 
 due relation between his science and his art. 
 
 When a number of mentally deranged patients are 
 segregated for treatment, the man who devotes him- 
 self to their care is called a specialist; he is supposed 
 to specialise in " diseases of the mind." It has been 
 shown that the phrase " diseases of the mind " is a 
 misnomer; that symptoms in these patients are never 
 confined to the mind, and that unless the whole symp- 
 tom-group be correlated with its cause in each case a 
 diagnosis has not been made. 
 
 No one is better aware of this than the modern 
 alienist; he makes an exhaustive examination of the 
 physical condition of his patient, without omitting the 
 domain of a single specialist, he makes the most mi- 
 nute inquiry into the heredity of the patient and then 
 proceeds to acquaint himself fully with every phase of 
 his mental aberration; in fact, without saying so, he 
 makes the most thorough examination of his patient's 
 " constitution." Having done all this with infinite 
 patience, but not before, the alienist gives his diagnosis 
 and, with some confidence, his prognosis. 
 
 This is a sketch in outline of the scientific method 
 of the alienist; it is a slander to call him a specialist 
 as far as his scientific work is concerned ; he does not 
 attempt to subdivide the science of medicine ; he tries 
 to work! out the whole causation of his patient's symp- 
 toms, and in so doing he never dreams of omitting the 
 examination, the complete examination, of both the 
 constitution and the environment of his patient. It 
 would be an equally gross slander to say that the 
 alienist specialised in a particular branch of his art to 
 the exclusion of all others; he does not neglect the 
 slightest detail in the care of his patients. 
 
SPECIALISM 83 
 
 It may be said confidently that no branch of medi- 
 cine is in a more satisfactory state than that which is 
 concerned with the whole management, scientific and 
 practical, of the mentally deranged; and this is so be- 
 cause the alienist is a physician in the true, original 
 sense of the word. His work makes him an expert, 
 but he is certainly not a specialist in the sense that the 
 dermatologist and the rhinologist are specialists. 
 
 The physician who takes charge of infectious cases 
 is another expert of the same description as the 
 alienist. A man may become an expert in the diag- 
 nosis and treatment of some particular disease: ma- 
 laria, diphtheria, plague, or smallpox; but these men 
 do not subdivide the science of medicine, they apply 
 the true scientific method to a particular group of 
 cases: 
 
 The method of the modern specialist is utterly dif- 
 ferent; take the dermatologist as an example. He is 
 a specialist because he confines his attention to " the 
 diseases of the skin," to the exclusion of all others; 
 he says that the whole subject of medicine is too vast 
 for one mind, and he attempts to learn " all about 
 something." The dermatologist says, for instance, 
 that psoriasis is " a disease of the skin," and that by 
 studying many examples of it he will make his investi- 
 gation exhaustive. But in his investigation, the der- 
 matologist does not even attempt to get beyond nam- 
 ing a rash ; his description may be ever so careful, but 
 there is not even a mention of causation in it. 
 
 Such is the inevitable result of pretending to sub- 
 divide the pure science of medicine ; there is only one 
 indivisible science of medicine, and it is concerned 
 with the tracing of causation. And so, when the spe- 
 
84 MEDICAL REVOLUTION 
 
 cialist " treats psoriasis," he is treating symptoms and 
 deliberately ignoring the cause ; he is an empiric. 
 
 The ophthalmologist who " diagnoses " and treats 
 glaucoma as " a disease of the eye," deals also 
 with symptoms regardless of their cause; he is also 
 an empiric. So is the rhinologist who professes to 
 cure asthma by cauterising the inside of the nose; he 
 goes out of his way to declare that " asthma " must 
 be " diagnosed " on a purely symptomatic basis. 
 
 The whole foundation of modern specialism has 
 been examined in the chapters dealing with Spurious 
 Diseases and Illusory Diagnosis; I would refer the 
 reader back to them for details. It has been laid down 
 as a fundamental and indisputable principle that our 
 management of disease will be successful when 
 founded on a full knowledge of causation; but that 
 lacking this knowledge, cure must be empirical and 
 prevention cannot be brought into play. The special- 
 ist attempts to escape from this; he openly ignores 
 causation in his " diagnosis," and deliberately sets 
 about the empirical treatment of symptoms. 
 
 The case against specialism may be summed up thus : 
 in calling symptoms uncorrelated with their cause 
 " diseases," the specialist employs an unscientific 
 method ; the practical result is that he becomes an em- 
 piric, and that he cannot possibly practise or teach 
 prevention. The effect on the whole profession is 
 disastrous; in all cases claimed by any specialist, the 
 search for causation by the general body of practition- 
 ers is forbidden ; ignorance is cloaked and stereotyped. 
 
 We saw, in considering surgery, that the science 
 and the art of medicine were clearly separable, and 
 that when this is candidly recognised, certain parts of 
 the art may with advantage be delegated to men set 
 
SPECIALISM 85 
 
 apart for the purpose, under special conditions. The 
 surgeon who makes an " exploration," without which 
 the physician could not complete his diagnosis, puts 
 his special manipulative skill at the disposal of the 
 physician's brain; although two men act in conjunc- 
 tion, there is no divorce of science and art, of medi- 
 cine and surgery. But when the dermatologist applies 
 an ointment to a rash called " psoriasis," the physician 
 is not there, the brain is lacking; art has taken pre- 
 cedence of science. 
 
XIII 
 
 GENERAL PRACTICE 
 
 The "pure physician" (the pathologist), the "pure 
 surgeon," and the specialists work in an artificial 
 world of their own devising; the general practitioner 
 works in the natural world. The practitioner has to 
 deal with cases as they arise; he cannot limit his at- 
 tention to any particular class of cases selected by 
 himself ; he is the only member of the profession who 
 is not a specialist. If, therefore, specialism were based 
 on truth, the general practitioner would be doomed 
 either to specialisation or extinction ; but as specialism 
 is based on error, the general practitioner represents 
 the type that will survive. As soon as it is clearly 
 recognised outside the profession that diagnosis must 
 precede treatment, that a full knowledge of causation 
 is the only safe foundation of rational practice, the 
 profession will be driven back to the true Hippocratic 
 tradition. 
 
 The general practitioner stands to-day where all 
 physicians stood sixty or seventy years ago; with the 
 exception of a few operating surgeons, who were rec- 
 ognised as expert craftsmen, the profession consisted 
 then of physicians, some practising, some consultant, 
 but all occupying a common scientific ground, all diag- 
 nosing in the same general terms. Then came " path- 
 ology " and, as a consequence, modern specialism ; a 
 complete revolution. No one would accuse the modern 
 
 86 
 
GENERAL PRACTICE &? 
 
 practitioner of having fallen behind the standard of 
 his predecessors of seventy years ago; he is in every 
 way a more enlightened and useful man; he has ad- 
 vanced with the times. And yet he is held to be so 
 inferior to any specialising member of the profession 
 of his own time that comparison is simply impossible. 
 
 This is easily accounted for ; the specialist's dictum, 
 " since it is impossible for any of us to know all about 
 everything, let each of us try to learn all about some- 
 thing in medicine," makes of the general practitioner 
 a Jack of all trades and a master of none. Nothing 
 but a return to common sense can save the practitioner 
 from a position of hopeless inferiority ; until it is rec- 
 ognised that a mere hasty labelling of local symptoms, 
 under the pretence of special knowledge, does not 
 solve the problem of diagnosis, we cannot attain to 
 rational practice. The modern consulting physician 
 is before all things a " pathologist," and to earn this 
 title he must spend a great part of his time, for the 
 first ten or fifteen years of his professional life, in 
 the post-mortem room; this preparation is absolutely 
 out of reach of the practitioner. 
 
 In old days, the consulting and the practising phy- 
 sician were both clinicians, they met on common 
 ground; the one recognised the greater experience of 
 the other, but the experience had been gained in a 
 sphere open to both, in the clinical interpretation of 
 disease. The modern consulting physician claims his 
 superiority on the ground of a vast experience with 
 which the practitioner is only acquainted, practically, 
 by hearsay; the practitioner is not, and never can be, 
 a " pathologist " ; Virchow told him so quite candidly. 
 No one can claim to be a specialist, properly so-called, 
 who is not attached to a special hospital or the spe- 
 
88 MEDICAL REVOLUTION 
 
 cial department of a general hospital ; and seeing that 
 the elite of the profession spend their lives in these 
 hospitals and departments, and find something to learn 
 all the time, the practitioner is clearly debarred from 
 making any pretence to being a specialist. 
 
 So that the practitioner is ! , forced to undertake cases 
 of all sorts, and he is expected to deal with them by 
 many methods, in none of which can he ever attain 
 anything like efficiency. This represents plainly the 
 way in which the profession is at present divided, and 
 if it be borne in mind that the specialists are numbered 
 by dozens, and are confined of necessity to a few great 
 towns, while the practitioners are numbered by thou- 
 sands and do almost the 1 entire work of the profession, 
 it will be seen that the position is grave. Seeing that 
 there are specialists in London for heart, lungs, liver, 
 stomach, nerves, skin, eye, ear, throat, and so on, it is 
 clear that the practitioner has to deal single-handed 
 with cases that are authoritatively divided amongst 
 perhaps twenty specialists at headquarters; so that 
 either the practitioner must remain permanently a 
 mere makeshift, or the official system is unscientific; 
 this dilemma concerns the whole body of the profes- 
 sion and the whole bulk of the community as patients. 
 
 This direct antagonism between the method of the 
 practitioner and the methods of his teachers brings 
 us back to the fundamental question of all medicine: 
 What is the meaning of diagnosis? This question 
 has been answered in an earlier chapter, and need not 
 be discussed again; if the answer here given is right, 
 then the revolution of the nineteenth century must be 
 reversed; we must return to Nature and the Hippo- 
 cratic tradition. 
 
t XlVi 
 
 THE HOSPITAL 
 
 Physicians, surgeons, and specialists have a unique 
 opportunity in the hospital to develop their scientific 
 and practical methods to the full; their authority is 
 undisputed and there is no lack of material. The 
 work done in the surgical wards is admirable and need 
 not be further referred to. Patients admitted to the 
 medical wards are for the most part hopelessly broken 
 down in their vital organs ; palliation is all that can be 
 done, and this is carried out most beneficently; the 
 days when causes might be dealt with instead of 
 symptoms are long past, so that in the great majority 
 of cases the question of diagnosis, properly so-called, 
 hardly arises. It is in the out-patient department that 
 modern methods are fully developed, and to this at- 
 tention will be confined. 
 
 It must be borne in mind that the hospital staff do 
 not act as consultants towards their patients; people 
 are not invited to come for a second opinion, but for 
 diagnosis and treatment; they come, as a matter of 
 fact, for cure. The hospital staff take the entire re- 
 sponsibility of looking after the health of those who 
 entrust themselves to their care. The science of medi- 
 cine is prosecuted, and the whole art of medicine is 
 built on this science, for the, preservation of the health 
 of those dealt with at the highest possible level, by 
 the prevention and cure of disease; the work of the 
 
 89 
 
90 MEDICAL REVOLUTION 
 
 hospital out-patient department must be judged by 
 this standard as applied to results. 
 
 Contagious cases and minor traumatic cases are 
 dealt with at surgical out-patient departments, and 
 here both diagnosis and treatment are rational. But 
 with these exceptions, out-patients are dealt with by 
 physicians and specialists on the " pathological " sys- 
 tem, that is, they are classified and dealt with on the 
 supposition that they suffer from " organic diseases." 
 The physician deals with " diseases " of heart, lungs, 
 liver, kidneys, nerves, and " general diseases" such as 
 anaemia, gout, and so on ; specialists deal with " dis- 
 eases "of skin, eye, ear, throat, and so on. The na- 
 ture of diagnosis and treatment as understood by the 
 pathologist-physician and the specialists has been fully 
 explained already in previous chapters; they do not 
 consider the correlation of cause and effect an essen- 
 tial part of diagnosis, and they are therefore content 
 to treat symptoms. The constitution of the hospital 
 out-patient is completely ignored, neither is any in- 
 quiry made, in the vast majority of cases, as to his 
 environment; he is a mere carrier of symptoms, with- 
 out antecedents or individuality. 
 
 I have laid it down as a fundamental and indis- 
 putable fact that our management of disease will be 
 intelligent and successful, ultimately, in proportion as 
 our knowledge of causation is complete and accurate; 
 no one will deny this in the abstract. But in the con- 
 crete, the hospital method is in flat contradiction to it. 
 Bronchitis, Bright's disease, diabetes, anaemia, new 
 growths, Hodgkin's disease, Graves's disease, haemo- 
 philia, purpura, psoriasis, Hebra's prurigo, eczema, 
 herpes, asthma, chronic rhinitis, adenoids, glaucoma, 
 phlyctenular ulcer, gastric ulcer, and so on, almost the 
 
THE HOSPITAL 91 
 
 whole of the material dealt with by physician and 
 specialists consists simply of labelled symptoms, 
 labelled without any reference whatever to causation. 
 Not only, therefore, is treatment confined in the vast 
 majority of cases to purely empirical attempts at cure 
 or alleviation, but prevention! is altogether excluded. 
 
 This is the climax of the charge that I have to lay 
 against the hospital method, that under it, whatever 
 success may be attained in the alleviation or cure of 
 symptoms, nothing whatever is or can be done to 
 diminish the volume of disease; no attempt is made to 
 stop the supply at the source ; we are content to tinker 
 at effects while remaining deliberately ignorant of 
 their causes. As far as the hospital method is con- 
 cerned, there would be just the same supply of cases 
 a hundred years hence as there is now. Those who 
 think to maintain health by curing symptoms as they 
 arise — irrespective of causation — live, and invite 
 their patients to live, in a fool's paradise. I am no 
 pessimist, the supply of cases is not going to last a 
 hundred years, but the change is not being brought 
 about by the hospital out-patient method. A recent 
 innovation throws a flood of light on the situation. 
 
 Following the example set long ago in Edinburgh, 
 some wise and philanthropic people started an anti- 
 tuberculosis campaign in London, which was carried 
 out at first by one medical man and a couple of 
 trained nurses. These people now pay thousands of 
 visits to the patients in their homes in the course of a 
 year; they thus detect early cases amongst contacts, 
 they remedy unwholesome conditions, they give good 
 advice; "the keynote of their method is prevention." 
 Not only is the hospital not jealous of these tres- 
 passers, but we learn from trustworthy sources that 
 
92 MEDICAL REVOLUTION 
 
 the authorities are very glad to be rid of their trouble- 
 some tuberculous patients. Those in charge of our 
 Modern Temple of Health, at the very headquarters 
 of medicine, are glad to escape the management of 
 the most deadly disease of our times! This is not 
 altogether to be wondered at, when it is remembered 
 that at the Temple of Health tuberculous patients are 
 invited to sit for hours in an overcroweded, ill-venti- 
 lated room with polluted atmosphere, and that this 
 can hardly be to the advantage of themselves or those 
 who are huddled with them. 
 
 But there is no reason why the crusade should be 
 limited to tuberculosis; rickets would be infinitely 
 more easily prevented than tuberculosis, so would 
 anaemia, so would phlyctenular ulcer, so would bron- 
 chitis. It is only a question of time, and not a very 
 long time,' until the rational method now being applied 
 to the extermination of tuberculosis will be unversally 
 recognised in medicine. And when it is recognised 
 that the first step towards preserving health is to find 
 out exactly why people show their several symptoms, 
 either pathologists and specialists will move with the 
 times, or the hospital method will be left high-and- 
 dry, and with it the profession. 
 
 I shall now suggest some changes in the hospital 
 method that are simple but drastic ; their introduction 
 will necessitate changes outside the hospital, but these 
 must be dealt with separately. The grounds on 
 which these changes are recommended may be very 
 briefly recalled. All investigations of disease are 
 directed towards the elucidation of causation, and 
 this problem is a double one. Diagnosis means the 
 tracing of symptoms to their cause; beyond this, we 
 must understand the conditions that favour or retard 
 
THE HOSPITAL 93 
 
 individual attacks. The whole art of medicine is de- 
 pendent for its integrity and ultimate usefulness on 
 the acquirement of this full knowledge of causation. 
 From these facts we may deduce two fundamental 
 principles for the guidance of those in c v arge of hos- 
 pital out-patients. Every patient must be submitted 
 to a complete and thorough examination in order that 
 the causation of his symptoms may be cleared up. All 
 treatment must be postponed until every effort to 
 trace causation is exhausted. 
 
 A few illustrations will make the situation clear. 
 A patient complains of a rash on his skin; the duty 
 of the person he consults is to find out why the rash 
 has appeared. At present, the dermatologist says : 
 This is psoriasis; and supplies an ointment to rub in. 
 He has not attempted to trace the causation of the 
 symptoms, therefore he has deliberately put treatment 
 before diagnosis. Now, if this person were to set 
 himself to trace the causation of the rash called 
 psoriasis, he would have to investigate both the con- 
 stitution and the environment of the patient; but if 
 he did so he would cease, ipso facto, to be a specialist, 
 he would become a physician. 
 
 In the same way, when a child is presented for ex- 
 amination with an undue increase of glandular tissue 
 in its throat, the first duty of the examiner is to find 
 out the reason of the unhealthy symptoms, commonly 
 called " adenoids." Again, to trace causation it is 
 essential to go outside the throat, and to learn every- 
 thing possible about the child's antecedents and sur- 
 roundings; but this task belongs to the physician, not 
 to the specialist. When a patient complains of asth- 
 matic symptoms, and the specialist cauterises the 
 inside of his nose without further, in fact without 
 
94 MEDICAL REVOLUTION 
 
 any, inquiry, not only does treatment precede diag- 
 nosis, but diagnosis is altogether omitted. 
 
 When another patient complains of chronic cough, 
 he is told that he is suffering from " bronchitis," and 
 he is given a bottle of cough mixture; the tracing of 
 causation is not attempted. Patients showing symp- 
 toms of poverty of blood are labelled " anaemia " or 
 " chlorosis " and given iron. No doubt the iron 
 often relieves the symptoms, at least for the time, but 
 the preliminary tracing of causation is conspicuous 
 only by its absence. Symptoms of myxcedema are 
 relieved in the same way by the administration of 
 thyroid extract, but no attempt is made at diagnosis. 
 Cases of infantile paralysis are sent for treatment first 
 to the galvanopeutist and then to the orthopaedic 
 surgeon, but neither the pathologist nor the neu- 
 rologist, to whom the child goes in the first place, 
 makes even a pretence of tracing the causation of the 
 symptoms thus labelled; the child is not supposed to 
 have a constitution, and its environment is not in- 
 quired into. 
 
 If it be true that diagnosis ought to precede treat- 
 ment, and that it must be genuine, then the place of 
 the " pathologist " and the specialist at the out-patient 
 department must be taken by the old-fashioned, the 
 Hippocratic physician. When every effort to trace 
 the causation of the patient's symptoms has been ex- 
 hausted, and the proper time has come for treatment, 
 the question of how far the art of medicine may be 
 profitably subdivided arises. The general surgeon, 
 the obstetric and the dental surgeon have justified 
 their existence; whether any other experts will sur- 
 vive is a question of detail that can be settled only by 
 experience; it need not be considered here. But that 
 
THE HOSPITAL 95 
 
 every patient has an inalienable right to meet first of 
 all the true diagnostician few will be found to deny. 
 I think the influence of this change on the members 
 of the hospital staff, would be entirely for their good ; 
 no one ought to be allowed to specialise permanently 
 in his art until he had served at least five years as 
 diagnostician, as physician ; he would then never reach 
 the condition of narrowness characteristic of the 
 fashionable specialist. 
 
XV 
 
 A SUGGESTION 
 
 The art of medicine that does not include prevention 
 is an incomplete, a maimed and crippled art; the art 
 of medicine that is primarily preventive is complete, 
 and wholly beneficent. There is only one way in 
 which the hospital staff can redeem their art from 
 its present purely curative and largely empirical con- 
 dition and place it on a primarily preventive basis; 
 and that is by acknowledging candidly that it is their 
 invariable duty to trace the causation of all cases 
 submitted to them for diagnosis. This can be done 
 only by gaining a knowledge of the constitution and 
 environment of each patient. It would be clearly 
 impossible for the hospital physician to perform his 
 duties in the hospital and the hospital-school, and at 
 the same time to make the round of visits necessary 
 to acquire the knowledge of his patients that is, never- 
 theless, I maintain, essential in rational diagnosis. 
 My suggestion is designed to extricate the hospital 
 staff from this dilemma. 
 
 The only capacity in which members of the hospital 
 staff can be really useful to out-patients is as con- 
 sultants; the question then arises as to who is to act 
 the part of family physician to these people. I have 
 no wish to disparage any particular class of prac- 
 titioners ; I have no doubt, like the rest of us, they do 
 their best; but the method of the surgery in the 
 crowded parts of London bears a damning resem- 
 
 96 
 
A SUGGESTION 97 
 
 blance to the method that has been condemned at out- 
 patient departments. There can be no doubt that the 
 very same mixtures are dispensed in the two places 
 for the cure or relief of the very same symptoms; 
 advice and medicine in one and medicine and advice 
 in the other are practically identical; the tracing of 
 causation and, consequently, preventive medicine are 
 lacking in both. 
 
 The family physician who would do his duty must 
 live amongst his patients; in no other way is it pos- 
 sible for him to acquire that intimate first-hand 
 knowledge of them, of their habits, tendencies, and 
 surroundings that alone can give a reliable basis for 
 rational practice. The whole area surrounding each 
 great hospital ought to be mapped out into suitable 
 areas, and in the centre of each there ought to be an 
 institute for the accommodation of a group of four 
 or five practitioners. The slums are not the place 
 where the practitioner can well settle down and make 
 his permanent home, and these institutes should be 
 reserved for recently qualified men from the neigh- 
 bouring hospital. They would be in touch with and 
 under the supervision of the hospital staff, who would 
 act as consultants to their patients. 
 
 A limited number of cases would go to the out- 
 patient department for a second opinion and for the 
 instruction of students; those requiring it would be 
 visited at home by the consultant. The hospital 
 would, of course, continue to receive the urgent med- 
 ical and surgical cases as at present. But the cases 
 sent to out-patient departments would come with a 
 complete and intelligently written history ; they would 
 come to help in the elucidation of causation, not for 
 illusory diagnosis. 
 
9§ MEDICAL REVOLUTION 
 
 The time of serving in these institutes would prob- 
 ably have to be limited to, perhaps, a minimum of 
 three and a maximum of five years ; by changing one 
 at a time, and not in batches, continuity of method 
 and treatment would be secured. These young men 
 would not practice midwifery; the practitioner loses 
 much sleep and wastes much time in superintending 
 physiological processes. These institutes would be 
 supplemented by others for trained nurses, who would 
 see as far as possible that the physician's orders were 
 carried out. 
 
 Placed in the centre of a densely populated district, 
 each institute would be within a very short distance 
 of all patients served by it. There would be an out- 
 patient department, a clinic, at which all those requir- 
 ing regular treatment for minor and chronic com- 
 plaints, especially children, would attend. It would 
 probably be found advantageous to all concerned to 
 delegate a good deal of this work to students attached 
 to the hospital, who would attend at regular hours 
 for the purpose, and to nurses in the early part of 
 their district work. As far as possible,' nothing ought 
 to be allowed to interfere with the house-to-house 
 work of the physicians and the fully equipped nurses 
 of the institutes. 
 
 I am no Utopian, but it seems to me undeniable 
 that such an arrangement would inaugurate a most 
 beneficent revolution in our great towns, for it would 
 be confined to London. If the mother of every in- 
 fant were warned, almost daily if necessary, by- 
 physician or nurse, that if she did not feed her child 
 in one way, and insisted on feeding it in another, it 
 would suffer from rickets and become a cripple, the 
 pathologist and the orthopaedic surgeon would have 
 
A SUGGESTION 99 
 
 less to do. When these young men discovered and 
 explained exactly why each anaemic patient suffered 
 from these symptoms, there would be a saving both 
 in iron mixtures and in health. When the connection 
 between impure air and the symptoms at present 
 labelled bronchitis was made clear to every one, open 
 windows might be resorted to as a preventive instead 
 of cough mixtures as a cure. The false and artificial 
 line drawn between preventable and other " diseases " 
 would disappear. 
 
 These practitioners of the future will not wait at 
 home until well-developed symptoms of disease are 
 submitted to them for cure; it will be their duty to 
 make themselves fully acquainted, not only with all 
 symptoms, but with the whole channel of causation 
 through which these symptoms advance. They must 
 take into account all defects in housing, feeding, 
 clothing, sanitation generally. If conditons of work 
 and wages do not admit of healthy life, they must 
 make the fact known. Armed with this knowledge 
 they will be expected to get in touch with every 
 household in their area and by constant advice and 
 guidance to forestall disease ; " prevention will be the 
 keynote of their method." These young physicians 
 and trained nurses would have to be provided with 
 board and lodging and a moderate salary; a levy, on 
 the plan of the provident societies, but graduated 
 according to the means of the patient, would at least 
 partially cover this. 
 
XVI 
 
 MEDICAL EDUCATION 
 
 For some professions, education can hardly be too 
 academical; for medicine, it ought not to be academ- 
 ical at all. Medical education ought to be designed so 
 as to bring out and strengthen whatever there is in 
 the student of independence in thought, observation, 
 and action. Medical science is one of the highest 
 and most complex of the branches of natural science ; 
 it is, therefore, universally recognised that a prelim- 
 inary scientific training is essential for the medical 
 student. This preliminary training is at present 
 often almost farcical; a few months are devoted to 
 an undisguised cram; not with a view of obtaining a 
 foundation for the scientific study of medicine, but 
 with the idea of passing an examnination under a 
 time limit. It is high time the preliminary training 
 were taken seriously. 
 
 A boy cannot profitably begin the study of science 
 until he has reached the age of sixteen, and until he 
 has had a good general education. The future med- 
 ical student ought to be obliged to make up his mind 
 in good time; having reached a good standard of 
 general education, he ought to begin his preliminary 
 scientific training at sixteen. His general education 
 would, of course, go on, but for the next three years 
 he 1 would spend half his time at science. Biology, bot- 
 any, zoology, geology, chemistry, physics, and com- 
 parative anatomy would gradually be added; he 
 
 IOO 
 
MEDICAL EDUCATION IOI 
 
 would also be given a grounding in bacteriology and 
 the intelligent use of the microscope. These subjects 
 would be studied as far as possible in the field and the 
 laboratory, at first-hand. One subject at present 
 omitted for some inscrutable reason from the medical 
 curriculum would be added, that is, an outline of the 
 history of medicine; ours is, I believe, the only profes- 
 sion that hides its origin from its members. 
 
 When the student had reached the age of nineteen, 
 the way would have been cleared, and his mind would 
 have been prepared, so that he might devote the next 
 two years to the study of what may be called the 
 alphabet of medicine, anatomy and physiology. But 
 these subjects will in the future be taught in their 
 entirety; normal anatomy and physiology are the 
 alphabet of health, morbid anatomy and physiology 
 are the alphabet of disease. Why the student is ad- 
 mitted at present to his clinical studies without any 
 knowledge of the morbid phases of anatomy and 
 physiology would be inexplicable if one did not realise 
 the confusion that has followed the mistaking of mor- 
 bid anatomy for the science of medicine, of " path- 
 ology." I have thought it better to mention the pre- 
 liminary training of the medical student, but the sub- 
 ject need not be followed in detail; his clinical 
 teaching is the essential point for consideration here. 
 
 It has been my object all along to bring home to 
 the reader's mind the fact that there are two essen- 
 tially antagonistic and irreconcilable views of med- 
 icine; the Hippocratic view, that survived for two 
 thousand years, and the modern view that is now 
 rather more than fifty years old. There is no scien- 
 tific question to-day that can equal in importance the 
 one that faces the medical profession; according to 
 
102 MEDICAL REVOLUTION 
 
 which view shall the future practitioner be taught 
 clinically? The days of rival " schools " in medicine 
 are long past, the controversy is to-day very narrow 
 and very definite, it is a purely scientific problem and 
 does not admit of the intrusion of personal opinion 
 or individual authority. 
 
 The question is, whether the Hippocratic tradition, 
 founded on the unity of medical science, or the 
 modern revolution that was introduced on the sup- 
 position that our science is susceptible of indefinitely 
 minute subdivision, represents the true interpretation 
 of the processes of disease. This fundamental ques- 
 tion has been fully discussed in the opening chapters ; 
 the conclusion was reached that there is only one 
 true meaning of " diseases " and their " diagnosis," 
 and that medical science must be reunified. The 
 question of true or false takes precedence of the ques- 
 tion of convenient or inconvenient; therefore, the 
 scientific basis of clinical education is already fixed, 
 in my opinion; but it will be instructive to consider 
 things for a moment as they are. 
 
 In the first place, the school — as distinguished from 
 the hospital — is there, simply and solely, for the 
 education of the practitioner; the education of the 
 specialist is universally recognised as a post-graduate 
 affair. But the school has not any real existence 
 apart from the hospital; every real medical school 
 is a hospital-school; the student who attempted to 
 learn his work away from the hospital would in- 
 evitably fail. What the student learns by seeing and 
 doing is his own; it is reliable, and available for 
 future application; what he learns from books and 
 lectures is not his own, it is not reliable, and when 
 first applied is of doubtful utility. The ideal in 
 
MEDICAL EDUCATION IO3 
 
 medicine is to teach clinically, and as far as possible 
 clinically only. The clinical student, the future 
 practitioner, therefore learns his work in the hospital, 
 and in accordance with the methods in vogue there. 
 
 The hospital methods, the methods of the " path- 
 ologist " and the specialists, have been criticised in 
 the light of the views here taken of " diseases " and 
 their " diagnosis " ; they have also been criticised on 
 the ground that they do not conform to the due re- 
 lation of science and art. The future of these prac- 
 titioners must also be borne in mind. They supply 
 the family physicians in town and country, they are 
 in charge of Navy and Army, they supply medical 
 officers for poor law and police work, they take 
 charge of the lives of subject races in our depend- 
 encies; they, practically, do the work of the profes- 
 sion. And in doing this work they cannot be path- 
 ologists, and they must not be specialists; for the 
 practitioner to fix his attention on some small sphere 
 and exclude the rest of disease from his attention 
 would be palpably fatal. Therefore I say that no 
 conceivable reason can be advanced in favour of ed- 
 ucating the future practitioner in twenty different 
 specialisms, of none of which he can obtain more 
 than the veriest smattering in the time at his disposal. 
 
 One may safely go further, and say that it is a 
 physical impossibility for any student to gain even 
 a smattering of all the specialisms now represented 
 at his school; "pathology," skin, eye, ear, throat, 
 orthopaedics, gynaecology, children, electricity and X- 
 rays, are bad enough, but his " physicians " are 
 specialists in heart, lungs, nerves, diabetes, kidneys-, 
 bacteriology, and so on; if he is wise he will spend at 
 least a year at pure surgery, and beyond all this he 
 
104 MEDICAL REVOLUTION 
 
 must learn something of " fevers," insanity, and 
 hygiene. 
 
 The matter is far beyond argument ; the authorities 
 acknowledge that the student is now set an impossible 
 ask; post-graduate schools are springing up for the 
 instruction in specialism of those who live in or near 
 London, and who can afford time and money to travel 
 up and down constantly. But at least ninety-nine 
 practitioners out of every hundred cannot avail them- 
 selves of the opportunity; judged by the specialists' 
 standard, these men are sent away in an avowedly 
 uneducated condition, and this condition must grow 
 rapidly worse, because, from the moment of leaving 
 the school the practitioner discards even the pretence 
 of being a specialist. This is the dilemma in which 
 medical education has been landed by a revolution 
 that is hardly thirty years old yet ; by the introduction 
 of specialism into the hospital. 
 
 Although the school has no real existence apart 
 from the hospital, yet the hospital has an independent 
 existence; it came first into being; for its primary 
 object was the relief of the suffering poor, and this 
 object has never been lost sight of for a moment. 
 The school grew up in the hospital, for obvious 
 reasons, but if it could be shown that the present 
 methods were for the good of the patients, the good 
 of the student could not for a moment claim con- 
 sideration. But there is no possibility of any real 
 antagonism between the interests of the patient and 
 of the future practitioner; it is obvious that both are 
 in search of the best possible method in medicine — 
 using the word in its original, comprehensive sense. 
 
 Some ignorant and fanatical people imagine that 
 the presence of the physiologist and the bacteriologist 
 
MEDICAL EDUCATION IO5 
 
 and other " laboratory men " in the school has some 
 sinister meaning, that the student really does victimise 
 the patient in some uncanny way for his instruction. 
 The physiologist and the bacteriologist are, it is true, 
 not physicians; life is much too short for such a 
 double part; but it may be stated quite confidently 
 that modern medicine could not exist, still less pro- 
 gress, without the help of these and other laboratory 
 workers, and that if their methods, including vivi- 
 section, were interfered with, they would be rendered 
 scientifically impotent. 
 
 The hospital and the hospital-school — and there- 
 fore medical education — are criticised together, both 
 have adopted a right or a wrong method. In dealing 
 with the hospital it was pointed out that the staff have 
 created for themselves an artificial world; they deal 
 with a segregation of sick people whom for con- 
 venience in cure they divide quite arbitrarily into 
 groups. The reason that this grouping is arbitrary 
 and unscientific is, that it is made on the basis of 
 symptoms, and not on the basis of true diseases. 
 The characteristic art of the " pathologist " and of 
 each specialist consists, therefore, in dealing with 
 symptoms, as such, without reference to causation; 
 it is empirical. I have shown that this method does 
 nothing to lessen the supply of disease at its source, 
 that it excludes the possibility of prevention. 
 
 It has also been shown that as soon as the hospital 
 staff are obliged to look beyond the artificial horizon 
 they have made for themselves, and to realise their 
 responsibility towards the inhabitants of their district, 
 there will come complete change of method. When 
 prevention is taken in hand it will have to be recog- 
 nised that each patient has a constitution, that in fact 
 
106 MEDICAL REVOLUTION 
 
 the patient must be treated and not merely the symp- 
 toms ; and that it is impossible to treat the patient in- 
 telligently without a complete knowledge of his en- 
 vironment. It is only necessary to throw down the 
 artificial barrier that separates the hospital staff from 
 the ordinary world to make it clear that the scientific 
 problems with which the profession is called upon to 
 deal are the same all the world over. We shall 
 always have in the hospital whatever experts are 
 necessary, but they must be recognised candidly as 
 experts in some branch of the art of medicine, as 
 craftsmen appointed by the physician. But the 
 science of medicine must be reunified, the old- 
 fashioned physician must be reinstated as diagnos- 
 tician. 
 
 At present, the future practitioner is introduced to 
 a school where there is no one who makes any pre- 
 tence of accomplishing that to which he knows he 
 must aspire; he is told in plain terms that he is at- 
 tempting the impossible. The specialist says : " It is 
 impossible to learn all about everything in medicine " ; 
 this is undeniable, no one ever pretended to do so, nor 
 dreamt that it could be done; it is a platitude. But 
 when the specialist goes on to say that " each one 
 ought therefore to try to learn all about something 
 in medicine," he condemns the practitioner to hope- 
 less inferiority. It is not many years since the prac- 
 titioner would not have looked in vain to the hospital 
 physician to stand by him and disprove the slander; 
 but since the " physician " became a specialist for 
 heart, lungs, kidneys, gout, colon, massage, climat- 
 ology, bacteriology, or what not, the practitioner 
 stands convicted. 
 
 There is no escape from the central problem of 
 
MEDICAL EDUCATION IO7 
 
 medicine, science is the foundation, the whole art is 
 a superstructure; the integrity and the stability of 
 medicine must therefore depend on the truth or the 
 falsehood of our interpretation of the processes of 
 disease. If it be true that " diseases " are localised 
 in organs and regions, and can therefore be properly 
 diagnosed and treated only by the specialist, let the 
 hospital physician resign his old title and declare him- 
 self candidly a specialist. As long as things remain 
 as they are the practitioner will be obliged to take 
 cases as they come, and therefore to obtain some 
 knowledge of everything in medicine; but it is only 
 fair to him and to his patients that there should be 
 some plain pronouncement as to his education. 
 
 If it be true that all we can do to control the pro- 
 cess of disease by prevention, cure, or alleviation 
 ought to based on the completest possible knowledge 
 of causation, than the whole fabric of " pathology " 
 and " specialism " falls to the ground. The prac- 
 titioner is still on the road that Hippocrates pointed 
 out, the " pathologist " and the " specialist " have left 
 it. Teachers and pupils cannot permanently travel on 
 diverging roads: which shall it be? 
 
XVII 
 
 ORGANISATION 
 
 It is taken for granted in a general way that the 
 medical profession is organised for its work; this is 
 only very partially true. I have attempted to show in 
 dealing with the hospital method that the profession 
 is not properly organised for its practical work; but 
 this is not all. Every member of the profession has 
 a double duty to perform ; his immediate, personal con- 
 cern is with the health of his patients ; but as a scien- 
 tific man he has to add his share to the common stock 
 of knowledge. For the performance of this peren- 
 nial scientific task the profession is wholly unor- 
 ganised. 
 
 The science of medicine consists of our organised 
 knowledge of human disease, and the daily experi- 
 ences of the whole profession make up the raw 
 material out of which this science alone can be built 
 up. We have no organisation for the collection, di- 
 gestion, and systematising of these experiences; the 
 vast bulk of our raw material is deliberately allowed 
 to die unorganised and unrecorded with the individ- 
 ual practitioner. There is clearly a double loss in 
 this lack of organisation; the practitioner is prevented 
 from adding to his science, and he is at the same time 
 debarred from learning what his fellow members are 
 doing and thinking. 
 
 An attempt made some years ago by the British 
 
 108 
 
ORGANISATION IO9 
 
 Medical Association to fill this palpable gap served 
 to show the hopelessness of the task in the present 
 unorganised condition of the profession. When the 
 Association, numbering many thousands of members, 
 announced the intention of carrying on collective in- 
 vestigation, there was a good deal of enthusiasm 
 aroused. The scientific work of the Association is 
 in the hands of " pathologists," operating surgeons, 
 and many specialists ; this is shown in the Journal and 
 in the arrangement of sections at the annual meetings. 
 Therefore, to begin with, the whole body of the pro- 
 fession, representing the thousands as distinguished 
 from the dozens, was excluded from participating ; the 
 practitioner is neither " pathologist," pure surgeon, 
 nor specialist. 
 
 But this is not all ; the gynaecologist is not interested 
 in ophthalmology; the laryngologist neither knows 
 nor cares anything about dermatology; the heart 
 specialist must not pretend to be a neurologist. See- 
 ing then that no one specialist can understand, still 
 less criticise or check, the work of any other specialist, 
 the attempt to erect a unified science of medicine on 
 the discrete foundations laid by all the " ologists " 
 was simply a modern attempt to build a Tower of 
 Babel; it ended in a similar, inevitable fiasco. 
 
 I have been warned that the attempt having been 
 made by the Association with such a result it must 
 be abandoned as hopeless ; in my opinion this failure 
 ought to act as a guide and a warning, not as a de- 
 terrent. If the position be looked at calmly, surely 
 the conclusion is inevitable, that unless the profession 
 be organised for the purpose, its scientific task must 
 be hampered and delayed indefinitely. The rational 
 way to proceed is to say that the profession must be 
 
IIO MEDICAL REVOLUTION 
 
 organised, and then to discuss how this may best be 
 done. I shall not reargue the question of method, 
 but shall merely say that our scientific knowledge 
 must be collected and systematised on the basis of 
 causation, and not, as was attempted, on the basis of 
 local symptomatology. This is only to insist that our 
 method shall be uniform, and that it shall correspond 
 with the method that has enabled us already to syste- 
 matise our knowledge of tuberculosis, plague, 
 malaria, phosphorus-poisoning, lead-poisoning, rick- 
 ets, scurvy, the septic infections, and hosts of other 
 true diseases. 
 
 If this fundamental principle be acknowledged, 
 every member of the profession stands on common 
 scientific ground with every other; scientific organ- 
 isation then not only becomes possible but imperative. 
 It is surely a monstrous thing that the moment a 
 member is " qualified " he goes out to his work in 
 town or country, navy or army, and that it is impos- 
 sible for him to give or to receive information on the 
 subject at which he spends the rest of his active life. 
 
 The remedy is obvious and simple : there must be 
 created a central body of experienced men who shall 
 collect information from the whole profession bearing 
 on the causation of disease; this they will systematise 
 and redistribute regularly to every member of the 
 profession. As soon as our knowledge of any par- 
 ticular disease was definite enough for the purpose, 
 it would be drafted into a permanent shape and also 
 distributed to the profession. In this way the foun- 
 dation of the ultimate text-book of medicine would 
 be laid; it would represent the accumulated and sys- 
 tematised experience of the whole profession; it 
 would be comprehensive, and would furnish the prac- 
 
ORGANISATION III 
 
 titioner, at last, with a complete and reliable book of 
 reference. 
 
 Organisation for scientific purposes would inevit- 
 ably lead further; the acquisition of a common scien- 
 tific ideal by the whole profession would suggest co- 
 ordination of practical effort. There is an immense 
 amount of knowledge of causation floating about 
 amongst practitioners in an unorganised and therefore 
 unavailable form; if this were collected and system- 
 atised, the next generation of practitioners would be 
 much better armed to undertake the prevention of 
 disease, and they would act more in unison. As to 
 the cost of the scientific body suggested, it is only 
 necessary to say here that every member of the pro- 
 fession would pay a substantial annual subscription 
 for his literature, and that the State would also con- 
 tribute, in return for services rendered. 
 
 The disciplinary organisation of the profession is 
 not in a satisfactory state. It is inconceivable, for 
 instance, that any one can go through a qualifying 
 course and fail to realise the utility of the Listerian 
 method in surgery. This method is founded on the 
 study of bacteriology, and vivisection is an integral 
 part of the bacteriologist's work. Yet we have 
 avowed and even demonstrative anti-vivisectionists in 
 the profession. This kind of licence does not pass 
 for toleration with the cranks to whom these people 
 minister; it is undoubtedly interpreted and used as a 
 sign of lack of confidence on our part in our own 
 knowledge. 
 
 Other members of the profession make it widely 
 known that they believe they have discovered a pan- 
 acea in the adoption, or avoidance, of some particular 
 diet. It is inevitable that a certain number of men 
 
112 MEDICAL REVOLUTION 
 
 out of all our thousands should develop fads that are 
 in direct opposition to the experience of ordinary- 
 people: they are perfectly within their rights as citi- 
 zens, but they ought to be called upon to ride their 
 hobbies as independent individuals; if they are right, 
 the rest of us are hopelessly wrong. There ought to 
 be some rough limit to the degree of divergence of 
 opinion on professional subjects that can with advan- 
 tage be tolerated ; at present there is apparently none. 
 This leads naturally to the question of how far it 
 is allowable for members of the profession to com- 
 municate directly with the public on professional mat- 
 ters ; here, again, it is impossible at present to discern 
 the enforcement of any limit. It is a very large sub- 
 ject, and one of vital importance to the public and to 
 the profession; I shall confine myself here to a gen- 
 eral and comprehensive suggestion of principle. To 
 begin with, nothing can be effectively done until the 
 profession is completely and compulsorily organised. 
 The more I study modern methods, so much the more 
 am I convinced that the old-fashioned etiquette was 
 right, and that it must be reintroduced. It used to 
 be laid down dogmatically that no member of the 
 regular profession should write or speak in public on 
 the details of professional work; it was held to be 
 detrimental to the interests of both parties concerned. 
 The suggestion of secrecy, of keeping the details of 
 medical investigation for the information of the pro- 
 fession only, will alarm some people. But it must be 
 remembered that the central scientific body would be 
 the servant of the Minister of Health, that their in- 
 formation would all be at his disposal, and that he 
 could call upon them to make public any general 
 knowledge of hygienic matters that was suitable for 
 general information and use. It would be very much 
 
ORGANISATION II3 
 
 to their advantage if the laity could make up their 
 minds to accept such information, and otherwise to 
 leave the subject of disease and its management alone. 
 The domestic clinical theremometer, the chest of 
 household remedies, and all the books that profess to 
 initiate the amateur into medical and surgical matters, 
 might be deposited with advantage in the dustbin. 
 
 We have now arrived at a stage when many med- 
 ical journals are sold broadcast to the public, and in 
 these journals, physicians, surgeons, and specialists 
 give details and statistics of their methods, their 
 operations, and their cases. Extracts from these 
 journals are quoted freely in the daily press; the 
 daily press even have " medical correspondents " who 
 can supply them with reports and the inevitable " snap- 
 shots " of some of the scenes reported from hospital 
 practice. I am quite aware that advertising is still 
 nominally prohibited, but against this we have to 
 reckon with the undisputable fact that the modern 
 medical journal forms a means of direct communi- 
 cation between physicians, surgeons, and specialists 
 on the one hand, and on the other, nervous patients 
 and anxious parents in quest of the speedy cure of 
 symptoms. The publication of works on particular 
 complaints, that are reviewed in the public press and 
 sold to the public, comes under the same head. 
 
 The remedy is simple, obvious, and effective. 
 When the central scientific body suggested above has 
 been brought into existence, it will be a rule that every 
 communication on professional matters from any 
 member of the profession shall be submitted to them 
 before being published in any shape whatever. The 
 journal issued by this body will be the only medical 
 journal, and it will be issued to the profession only. 
 There would, of course, be no limit placed on the 
 
114 MEDICAL REVOLUTION 
 
 right of medical men to form societies for the dis- 
 cussion of any professional subjects; but they would 
 be compelled by law to keep their proceedings from 
 reaching the public directly or indirectly. Every 
 member of the profession will always have ample 
 liberty to tell his own patients whatever he considers 
 right to tell them, but public announcements on pro- 
 fessional subjects ought to come through a represen- 
 tative and authoritative body, never through the in- 
 dividual member. We are probably all agreed that 
 the time has come when something must be done ; we 
 do not wish to advertise, but circumstances seem, for 
 the moment, to have got the better of us. 
 
 Again, as matters stand at present, any particular 
 group of men, or any individual in the profession, 
 may devise and put into execution any method of 
 treatment that commends itself at the moment. 
 There is no authority in the profession, nor, in its 
 present unorganised state, can there be any to which 
 any new method may be submitted; so that all new 
 methods must be judged by each member of the pro- 
 fession for himself, and adopted or rejected on his 
 own responsibility. I shall give one example to illus- 
 trate this anomalous state of things. 
 
 Some people show a very marked and easily recog- 
 nised set of symptoms; the symptom-group is called 
 — without any reference to causation — Graves's 
 disease or exophthalmic goitre. Being based purely 
 on symptomatology, this is, of course, an entirely 
 misleading conception, a spurious disease; it is mere 
 self-delusion to imagine that we have made a diag- 
 nosis in detecting " Graves's disease." And there- 
 fore, when the question of treatment arises, we are 
 driven to adopt empirical methods. 
 
ORGANISATION 115 
 
 Some men, being " pure surgeons," advocate almost 
 indiscriminate operation, in spite of many casualties. 
 Other men, being " pure physicians," practically con- 
 demn " surgical interference " altogether. Their 
 argument — and there seems to be a good deal in it — 
 is that, as the great majority of sufferers either get 
 well, spontaneously, or improve, or at least get no 
 worse; and as hardly any die of this " disease " with 
 proper care, we are not justified in operating. It is 
 obvious that the surgeon can never tell that those he 
 " cures " would not have recovered without operation ; 
 whereas all his disasters are to the bad. 
 
 Surely it is clear that in such a position the creation 
 of a central scientific body, with at least its tremen- 
 dous weight of corporate professional opinion behind 
 it, is essential. The first step taken by such an 
 authority would be to order that every case of 
 " Graves's disease " should be closely investigated 
 with a view to elucidating causation and " natural 
 history," and that all results should be sent in for 
 comparison and digestion. This order would go out 
 not only to hospital specialists but to every prac- 
 titioner. Inside a year, it is safe to say, the pro- 
 fession would have a definite pronouncement on the 
 comparative safety and expediency of the rival 
 methods; and we should be in a fair way to escape 
 from the present condition of deliberate empiricism 
 that the acceptance of illusory diagnosis necessarily 
 perpetuates. 
 
 I have purposely chosen an example that is not at 
 all sensational ; but it will probably suffice to convince 
 any reasonable person — inside or outside the pro- 
 fession — that the present position ought to be ended 
 by immediate organisation. 
 
Il6 MEDICAL REVOLUTION 
 
 The disorganised state of the profession is further 
 well illustrated in the conditions attaching to quali- 
 fication. We have an amazing number of practically 
 independent bodies authorised to teach, and to grant 
 qualifications ; and there is no fixed standard to guide 
 them either as to teaching or as to admission to the 
 profession. The General Medical Council does some- 
 thing in the way of very occasional inspection, but 
 even if it had a fixed standard and wished to enforce 
 it, it has not the authority; the whole business is 
 rather perfunctory. I am not aware that any one 
 disputes the statement, so often repeated, that we 
 require a minimum standard that shall be enforced 
 on all entrants, a one-portal system. It is quite 
 evident, considering all the vested interests at stake, 
 that such a system can only be introduced through 
 State control. j 
 
 From whatever point of view the question of or- 
 ganisation is looked at, it is evident that before it can 
 be carried out there must be an agreement on the 
 fundamental principles that lie at the basis of the 
 work of the profession. We must make up our 
 minds definitely whether the pure science of medicine 
 is to be more and more minutely subdivided or 
 whether it is to be reunified. On the practical side, 
 it must be made clear to all whether the whole art of 
 medicine must be based on knowledge of causation, 
 or whether it is profitable under any circumstances 
 deliberately to treat symptoms as such. These ques- 
 tions admit of and call for plain and direct answers; 
 until these are forthcoming the ideals and interests 
 of the various branches of the profession must re- 
 main antagonistic and irreconcilable; organisation 
 cannot be begun. 
 
XVIII 
 
 THE STATE AND THE MEDICAL 
 PROFESSION 
 
 It is not necessary to argue that the State should 
 recognise the regular profession as being in sole 
 charge of medicine; not only is this done, but there 
 is already an intimate official connection between the 
 two. There cannot be any doubt that as enlighten- 
 ment advances the State appreciates more and more 
 that a large and vital part of its responsibility must 
 be borne for it by the medical profession. When 
 the State first realised its duty in supervising and sub- 
 sidising education, we were told that to make one 
 man pay for the education of another man's children 
 was rank Socialism; we are hearing an echo of this 
 cry already with regard to State subsidies for the 
 work of the medical profession. 
 
 I have no notion to enter into a discussion of the 
 rival merits of Socialism — Collectivism — and Individ- 
 ualism; unless our national character can be revo- 
 lutionised, the triumph of Individualism in these 
 countries is surely inevitable. But whether we like it 
 or no, we are part of the social organism; the health 
 and even the life of the whole of this organism are 
 dependent on the health of every part. Different 
 parts of the social organism perform different func- 
 tions; the wealthier classes supply the greater part of 
 our thoughts and initiative, the bone and muscle for 
 the carrying out of our projects are supplied entirely 
 
 117 
 
Il8 MEDICAL REVOLUTION 
 
 by the poorer classes; failure in either case implies 
 failure for both. 
 
 Every nation is faced with many problems; three 
 of them are for us at present vital : national defence, 
 food supply from abroad, and the maintenance of 
 national health. Seeing that we must import vast 
 supplies, national defence and food supply are for us 
 interdependent; and it is evident that if we became 
 a sickly nation we could neither defend nor feed 
 ourselves. These rudimentary facts have been men- 
 tioned in order to remind those who have money that 
 the making and keeping of this money is dependent 
 on a sufficient supply of healthy men for farms, fac- 
 tories, mines, navy, and army. It is thus quite evi- 
 dent that if the individual workers cannot maintain 
 themselves in health, both self-interest and self-pres- 
 ervation must urge the State to interfere. A very 
 good beginning has been made by the creation of 
 various central and local authorities for the further- 
 ance of Public Health; what is now required is one 
 authority, a Ministry of Health, for the co-ordination 
 of the work of all those engaged in the preservation 
 of health. 
 
 My immediate object is to point out the place that 
 must be taken by the medical profession in this 
 national work, and I shall do so by again referring to 
 the hospital. Individual practitioners are wage- 
 earners, therefore, in accordance with the law of sup- 
 ply and demand, they are drawn in greatest num- 
 bers where the highest wages are to be obtained. 
 Where there are the greatest number of elderly, well- 
 to-do people, one finds most practitioners; where 
 there is a great mass of poor people, there are fewest. 
 It would be absurd to blame well-to-do patients for 
 
STATE AND MEDICAL PROFESSION II9 
 
 providing themselves with the advantage of medical 
 attendance, or the practitioners for looking after 
 them; but from the national point of view the situ- 
 ation is unsatisfactory. The nation will not obtain 
 any more work from these elderly people; it must 
 look to the rising generation of our great towns for 
 many of the workers and many of the soldiers and 
 sailors of the future. 
 
 And this is where the hospital completely fails ; the 
 purely curative suystem in vogue does not supply us 
 with healthy people. Supopsing for a moment that 
 the specialist at out-patient departments 1 do cure every 
 case of phlyctenular ulcer when brought to them, and 
 that they arrest the progress of each case of rickets 
 when first seen, the fact remains that hundreds and 
 thousands of cases of permanently defective vision 
 and permanently distorted frames have already been 
 produced, that reduce the industrial efficiency of the 
 individuals concerned, and destroy their military 
 efficiency. 
 
 There cannot be any improvement, as far as the 
 profession is concerned, until the hospital authorities 
 are forced to recognise the plain fact that only in the 
 light of complete knowledge of causation is it possible 
 to prevent disease, to preserve health. There is a 
 steady if slow improvement in the health of great 
 towns, the municipal and sanitary authorities are do- 
 ing their best, but in the absence of the practitioner 
 they are working to a great extent in the dark. 
 
 I have already given my reasons for saying that it 
 is essential that every household in these crowded 
 areas should be under the supervision of a physician, 
 and that his directions must be carried out when neces- 
 sary by trained nurses; there is no other way of find- 
 
120 MEDICAL REVOLUTION 
 
 ing out exactly why symptoms develop, and until this 
 is known we cannot deal with causes. The hospital 
 would still receive severe cases and the hospital phy- 
 sician would again become a consulting physician. 
 The cost of such a system, above what would be raised 
 by a graduated levy on the patients, would not be very 
 great, and it would be a very profitable investment 
 for the nation. Those unable to contribute anything 
 would receive just the same attention as the rest; the 
 cost would be borne by the State. 
 
 Such a levy could, of course, never be made com- 
 pulsory. At the same time, it is probable that the ad- 
 vantage of the assistance of the trained nurses, the 
 benefit of treatment at the clinic, and the privilege of 
 free consultations with the hospital staff, both at home 
 and at the out-patient department, would make the 
 State-aided service so popular that the private prac- 
 titioner would not be required in any hospital area. 
 
 The question of extending such a system beyond 
 the areas of the present great hospitals would soon 
 arise, i In many poor areas this could be done immedi- 
 ately by attaching clinical medical schools to existing 
 modern Poor Law infirmaries. New hospitals would 
 have to be built in other places, but this will be neces- 
 sary both for the proper treatment of the inhabitants 
 and to find accommodation for the extra medical 
 practitioners who will require training. Some of our 
 medical schools have already too many students in 
 proportion to their clinical material. 
 
 The fact that our slums are not only a disgrace but 
 an absolute danger to the future of the race is uni- 
 versally recognised; all sorts of devices are hit upon 
 to make them habitable, — the anti-tuberculosis cam- 
 paign is a good example, — but it does not seem to 
 occur to any one that, after all, the preser- 
 
STATE AND MEDICAL PROFESSION 121 
 
 vation of health is the work for which the medical 
 profession exists. This utterly anomalous position 
 will be found on reflection to arise from the erroneous 
 division of medicine — as commonly practised — from 
 so-called preventive medicine, and for this division 
 the craze for specialism, illustrated in the hospital 
 method, is responsible. The medical profession can- 
 not take its place in the front of the movement for 
 the preservation of the nation's health until hospital 
 practice and general practice are assimilated. 
 
 The State and the municipalities recognise already 
 that it is their duty to deal with unhealthy conditions 
 in a wholesale manner; what they lack for the guid- 
 ance of their operations is detailed and full informa- 
 tion as to the causes that make our great towns the 
 hotbeds of all sorts of symptoms of disease that are 
 practically unknown in the country a few miles away. 
 This information can be supplied only by those 
 trained in the interpretation of disease, and by them 
 only as a result of constant house-to-house visitation. 
 The central scientific body referred to above would 
 act as a link between individual practitioners and the 
 Ministry of Health, it would organise the knowledge 
 gained by individuals and so make it available for 
 practical application. The cost of all this would no 
 doubt be considerable at the outset, but the nation 
 would reap an immediate return in the increased ef- 
 ficiency of the working population, and it would be 
 a diminishing cost. A few years of co-ordinated, well- 
 directed effort would reduce the volume of disease to 
 be dealt with, and those who had grown up under 
 decent hygienic conditions would not require any- 
 thing like so much supervision as those born under 
 the present conditions, in which it is hardly worth 
 while to struggle for health. 
 
XIX 
 
 DEATH CERTIFICATION 
 
 A Select Committee was apppointed in 1898 to in- 
 quire into this subject, and its report is very interest- 
 ing reading. The feature of this report to which I 
 wish to draw particular attention is this : although it 
 is evident that the problem of diagnosis lies at the 
 root of death certification, it was not touched on this 
 inquiry; it was taken for granted that the medical 
 profession attaches a definite value to the solution of 
 this problem. Another supposition must be particu- 
 larly mentioned : the Committee took for granted that 
 a post-mortem examination was a sufficient means of 
 detecting the cause of death. One of the commonest 
 results of a 1 post-mortem examination is that the path- 
 ologist discovers " Bright's disease," and that on the 
 strength of this the jury returns a verdict of " death 
 from natural causes." Such a case illustrates the mis- 
 leading nature of both the suppositions on which the 
 Committee based its recommendations. 
 
 The pathologist who reports " Bright's disease " 
 names only symptoms; he calls cirrhosis of the kid- 
 neys " a disease," and we have seen that this cirrhosis 
 may be a symptom of gout, alcoholic poisoning, scar- 
 latina, influenza, fatal chill, lead-poisoning, and so on. 
 It is of course quite impossible for the post-mortem 
 diagnostician to say which of these true diseases was 
 represented in the attack that killed the man. The 
 
 122 
 
DEATH CERTIFICATION 1 23 
 
 pathologist, as we saw, moves in a closed circle of 
 symptoms; it is impossible, in at least ninety-nine 
 cases in every hundred, to determine the cause of 
 death by post-mortem examination alone. The falsity 
 of the other supposition is exposed at the same time; 
 the profession takes for granted, and the public 
 must needs follow, that to say " Bright's disease " is 
 to make a diagnosis, but to say this is merely to label 
 symptoms, and the mere labelling of symptoms never 
 does solve the problem of diagnosis. It is only neces- 
 sary to give one or two instances to show how grave 
 may be the results of accepting such an illusory diag- 
 nosis. 
 
 Cirrhosis of the kidneys is sometimes a symptom of 
 lead-poisoning, and cirrhosis of the kidneys is the 
 ground on which the pathologist reports " Bright's 
 disease " as the cause of death. Therefore the cor- 
 oner and the jury never know whether they may not 
 be returning a verdict of death from natural causes in 
 a case where a skilled poisoner has deliberately short- 
 ened life by the careful administration of lead; this is 
 no fancy picture, it is a recital of plain facts. If in 
 another case the pathologist were to report that; broken 
 neck was the cause of death, questions would be asked 
 as to the cause of the broken neck; but there is no 
 more information as to the cause of death contained 
 in the report of damaged kidneys than there is in the 
 discovery of a broken neck. There is just as surely a 
 cause behind the one as behind the other ; broken neck 
 and damaged kidneys are both of them very good 
 pieces of morbid anatomy, nothing more. 
 
 It may be thought that no coroner would rely on 
 the unsupported testimony of the post-mortem diag- 
 nostician, but this is not so. One London coroner 
 
124 MEDICAL REVOLUTION 
 
 habitually dispenses with clinical evidence altogether, 
 he calls in instead his own " special pathologist." The 
 neglected practitioners complained, they appealed to 
 the legal authorities, and they naturally referred the 
 matter to the highest medical authorities. The high- 
 est medical authorities are pathologists, so the verdict 
 was inevitable; they decided that the pathologist is 
 the ultimate authority on the question of the cause of 
 death. 
 
 When a certificate is given to the effect that a 
 child's death is caused by diarrhoea, we have another 
 example of its being ascribed to symptoms. Such a 
 certificate tells, roughly, how, but gives no hint as to 
 why the child died. If a baby-farmer add a little 
 Epsom salts to the contents of a feeding-bottle, the 
 infant concerned will develop symptoms of diarrhoea; 
 if the treatment be continued it will die. As matters 
 stand at present, the certificate will state that death 
 was " caused " by " diarrhoea " ; if the weather be hot 
 the word " summer " may be added, but this, unfor- 
 tunately, does not make the diagnosis any more in- 
 forming. Diarrhoea in an infant is a symptom-group, 
 if it is not caused by Epsom salts it is caused by some- 
 thing else; but to say that these or any other symp- 
 toms cause death, is merely to throw dust in the eyes 
 of the person receiving the certificate. Many people 
 are returned as dying " of bronchitis " ; these symp- 
 toms have many different causes in different cases, 
 but they never arise spontaneously, still less do they 
 " cause " death ; London fog would certainly be the 
 proper cause to attach in some cases to the symptoms 
 at present labelled bronchitis. 
 
 It is needless to multiply examples, the principles 
 underlying true death certification have been fully 
 
DEATH CERTIFICATION 1 25 
 
 discussed already; the whole subject, from the 
 present point of view, may be summed up by say- 
 ing, that as long as symptoms are officially called 
 " diseases " so long will death certification remain, to 
 a great extent, a solemn and expensive farce. If the 
 reader will turn back to the chapters on true and spuri- 
 ous diseases, he will see that whenever the name of a 
 true disease is given in a certificate the cause of death 
 is of necessity included; whereas, when a spurious 
 disease is named, the cause of death is as inevitably 
 omitted. There is no obscurity about the subject; 
 there is not any difficulty in differentiating the useful 
 certificate from the one that is useless, or worse than 
 useless. Here again the Nomenclature of Diseases of 
 the College of Physicians is useful; it gives an excel- 
 lent indication of the attitude of the medical authori- 
 ties towards death certification. 
 
XX 
 
 QUACK MEDICINE 
 
 My object in referring to quackery is to make an op- 
 portunity of pointing out the unsuspected but safe 
 manner in which the quack shelters himself under the 
 shadow of regular medicine. All quacks have some 
 well-marked characteristics in common; these may be 
 summed up by saying that they are all deliberate em- 
 pirics. The deliberate empiric is a person who pro- 
 fesses to have found some means or method of cure 
 that enables those in possession of the secret of the 
 system to deal successfully with manifestations of 
 disease without previously studying the causation. 
 
 The homceopathist stands in a different position 
 from other quacks; he is half in the profession and 
 half out of it, in a way that is beyond the comprehen- 
 sion of the plain practitioner; it is arranged by the 
 General Medical Council on some plan of its own. 
 But he is none the less a quack; his practice is based 
 on " the great scientific principle of similia similibus 
 curantur" When the homceopathist says that like 
 cures like, he cannot possibly refer to anything but 
 symptoms, and their cure by drugs; this is the very 
 definition of quackery. 
 
 The practice of the regular profession is still rid- 
 dled with empiricism, unrecognised; and until it is 
 purged of this, the line between regular and irregular 
 practice cannot possibly be drawn so that the public 
 shall recognise it. The hospital physician gives iron 
 
 126 
 
QUACK MEDICINE 1 27 
 
 for the cure of anaemia without inquiring into the 
 causation of these symptoms; this is no doubt un- 
 witting, but none the less pure empiricism. He does 
 not in the least improve his position by calling the 
 symptoms " chlorosis," the labelling of symptoms does 
 not solve the problem of diagnosis. The physician 
 gives a mixture for the cure of bronchitis; he names 
 the symptoms and he treats them without reference 
 to the cause. When the physician treats myxoedema 
 with thyroid extract he is still an empiric ; every prac- 
 titioner knows some of the causes of myxcedema, but 
 the physician will have nothing to do with them; he 
 teaches the student dogmatically to " spot " myxoe- 
 dema at sight and to administer thyroid. I have 
 never known a physician mention the causation of 
 myxcedema, nor listen to any one who wished to 
 do so. 
 
 The rhinologist who professes to cure asthma — of 
 unknown and unsought causation — by cauterising the 
 inside of the nose is an empiric, for the moment. The 
 otologist who treats deafness with hypodermic injec- 
 tions of pilocarpin, without inquiry into causation, is 
 the same ; so is the ophthalmologist who " diagnoses " 
 glaucoma and treats it, while ignorant of causation, 
 by operation. The mere mention of lumbago, sciatica, 
 uric acid, gout, colitis, neuritis, rheumatism (not rheu- 
 matic fever), brain-fag, obesity, neurasthenia, sug- 
 gests an amount of empiricism inside the profession 
 that is positively appalling. The hydropathist, the 
 balneologist, the spa-specialist, the galvanopeutist, the 
 specialist in massage, the climatologist, and others, 
 deal with sufferers from these symptoms, falsely 
 called diseases, on systems that are almost wholly 
 empirical. 
 
128 MEDICAL REVOLUTION 
 
 The difference between the hospital physician who 
 gives a cough mixture for bronchitis and the quack 
 who advertises one is very palpable; the quack omits 
 even the suggestion of an attempt at individual diag- 
 nosis and deals with his dupes wholesale. Now, if the 
 physician's diagnosis were genuine the distinction 
 would be sharp and unmistakable ; but when the phy- 
 sician's diagnosis is illusory, the distinction partly 
 fails. It is an ugly truth, but as long as the physician 
 pretends to have made a diagnosis, to have traced the 
 causation of the symptoms present, by uttering the 
 words " bronchitis," " Bright's disease," " infantile 
 paralysis," " myxcedema," " gastric ulcer," " chlor- 
 osis," " sciatica," " neuritis," and hosts of others, so 
 long will he remain an empiric. And while the repre- 
 sentative physician remains an empiric, the public can- 
 not be altogether blamed for patronising the quack. 
 If the physician "diagnoses" gout, neuritis, colitis, 
 and proceeds to treat people on the strength of this 
 " information," is the patient to be blamed for trying 
 some rival remedy next time, even if it be the property 
 of a quack? 
 
 Whatever the case of individuals may be, it is clear 
 to the onlooker that the time has come when the pro- 
 fession, as a whole, has everything to gain and noth- 
 ing to lose by taking the public candidly into its confi- 
 dence, as in the case of cancer, and putting the relation 
 of science and art in medicine openly on a right foot- 
 ing. Not only would this cripple if not kill quackery, 
 but it would establish a state of confidence between 
 the profession and the public that is at present sadly 
 lacking. 
 
XXI 
 
 SUMMARY, 
 
 Long before man appeared on the earth, animals 
 lower down in the scale of evolution were afflicted 
 with disease, and made unreasoned attempts to escape 
 the consequent discomforts. Arising thus naturally, 
 medicine has advanced with the higher development 
 of human intelligence. Amongst primitive races, 
 medicine is combined with theology; these people as- 
 cribe disease to supernatural interference and try to 
 deal with it accordingly. In civilised countries it is 
 recognised that disease arises from natural causes, 
 and medicine thenceforth falls into two distinct parts, 
 a pure science and an applied science or art. We 
 pursue the pure science in order to gain knowledge 
 of causation, and in the art that follows we apply 
 this knowledge for the preservation of health by the 
 prevention and cure of disease. 
 
 It is essential that those who interpret and deal 
 with the processes of disease shall have a clear un- 
 derstanding as to the meanings attached to the word 
 " disease." It is used sometimes in a general, nega- 
 tive sense, merely to denote a deficiency of health ; 
 just as cold is made to denote a deficiency of heat. 
 But when we specify " the disease " from an attack of 
 which a patient is suffering, the word is used in the 
 particular, positive sense. When reference is made to 
 a specific disease, when we speak of " a disease " or 
 " the disease," we have in mind a summing-up of ex- 
 
 129 
 
130 MEDICAL REVOLUTION 
 
 periences in the shape of an abstract, or mental con- 
 ception. Every specific disease is derived from the 
 observation of a series of cases presenting symptom- 
 groups of determinate and similar causation. 
 
 There is no other natural and common basis but 
 causation on which we can define our conception of 
 the specific diseases, and the basis of classification 
 must correspond with the basis of definition. All dis- 
 eases fall naturally into two primary divisions ; in the 
 first are all those diseases in which the cause arises in 
 the environment of the patient. These diseases of 
 extrinsic causation fall into three main groups under 
 the heads of parasitism, poisoning, and traumatism. 
 In the second primary division are all those diseases 
 in which the cause arises in the patient's constitution. 
 These diseases of intrinsic causation fall into five 
 groups, under the heads of incomplete development, 
 constitutional defects, overwork, deficient work, and 
 wear and tear. 
 
 To diagnose means, to specify the disease from 
 an attack of which a patient is suffering; in other 
 words, to identify the case as belonging to a known 
 series. Every disease that gives its name to such a 
 series represents correlated cause and effect; there- 
 fore, to diagnose means to correlate cause and effect 
 in each case. 
 
 Diagnosis does not complete our knowledge of 
 causation; in order to do this we must also elucidate 
 the conditions that lead to the individual attack. 
 
 The object aimed at in all branches of the art of 
 medicine is the preservation of health; this may be 
 attained by the prevention of disease, supplemented 
 when necessary by cure. Cure can be consistently 
 carried out only when the cause of the symptoms to 
 
SUMMARY ; 131 
 
 be dealt with is known, and prevention is possible only 
 when a full knowledge of causation has been gained. 
 The true relation of theory and practice in medicine 
 can therefore be maintained only by giving invariable 
 precedence to science. 
 
 The old custom of deriving our conceptions of spe- 
 cific diseases from the observation of recurrent 
 symptom-groups that have not been correlated 
 with their cause still persists; and so it happens that 
 there are vastly more spurious diseases than true in 
 our text-books of medicine. Every true disease rep- 
 resents a series of symptom-groups always correlated 
 with one cause; every spurious disease represents a 
 series of symptom-groups that are not of determinate 
 and similar causation. 
 
 When, therefore, the physician recognises an in- 
 dividual attack as belonging to a series of symptom- 
 groups of indeterminate causation, he has not traced 
 effect to cause, he has made an illusory diagnosis. 
 The art that is founded on such pseudo-science must 
 of necessity be empirical ; random cure may occasion- 
 ally be effected, but in the absence of a full knowledge 
 of causation prevention is impossible. Lacking the 
 power of prevention, the end and object of medicine, 
 the preservation of health, is out of reach. 
 
 The " pure physician," the teacher and consultant 
 of our times, has substituted morbid anatomy, under 
 the name of " scientific pathology," for the science of 
 medicine. He has, as a result, evolved a number of 
 " organic diseases " ; these are spurious diseases, for 
 they represent series of symptom-groups that are not 
 of determinate and similar causation. The patholo- 
 gist-physician has consequently developed in practice 
 into a specialist in " the diseases " of heart, of lungs, 
 
132 MEDICAL REVOLUTION 
 
 of nerves, of stomach, and so on; he no longer at- 
 tempts to make a complete survey of medicine, he 
 treats symptoms, not the patient. 
 
 It is right and necessary to set apart a few men, 
 under the exceptional conditions of the hospital and 
 the school, who shall cultivate the art of operating; 
 they become experts in this branch of our art. But 
 the attempt to practise " surgery " that is not 
 founded on and subordinated to the science of medi- 
 cine is disastrous in its results. The beneficent revo- 
 lution that has followed Lord Lister's diagnosis of 
 septic cases is enough to prove this. 
 
 The specialist bases his claim to eminence on a per- 
 fect knowledge of some particular group of " dis- 
 eases," such as those of skin, nose, eye, ear, or throat; 
 but all such " diseases " are spurious ; they are created 
 by labelling symptoms without any reference to causa- 
 tion. All specialists indulge freely in illusory diag- 
 nosis, with the inevitable result that their practice is, 
 in the main, purely empirical. 
 
 Physicians, surgeons, and specialists at the hospital 
 work in an artificial atmosphere; they deal only with 
 sick and wounded, and are therefore limited in their 
 practice to cure or alleviation; they do not concern 
 themselves with prevention. They exempt themselves, 
 in the vast majority of cases, from the attempt to 
 trace the causation of symptoms ; they label them and 
 at once proceed to cure. When symptoms are thus 
 labelled, division of labour for purposes of cure be- 
 comes simple. The practitioner who has to take all 
 cases as they come and do his best is obliged to follow 
 the example of the physician of fifty years ago, and 
 to study the whole range of disease; he cannot be a 
 " pathologist " and he must not be a specialist. 
 
SUMMARY 133 
 
 The hospital stands in a densely populated and un- 
 healthy area; the staff undertake responsibility for 
 the health of the people living there, without the in- 
 tervention of the practitioner; patients come to phy- 
 sicians and specialists, not for consultation but for 
 cure. Even if every possible allowance be made for 
 the benefit these people derive from the cure of symp- 
 toms, the fact remains that no attempt is made by the 
 hospital staff to deal with the causes of these symp- 
 toms. As far as the hospital is concerned the causes 
 that are operating in the slums go on, not only un- 
 checked but undiscovered, unsought; the constitution 
 of their patients may be built up or broken down by 
 their surroundings, it is not taken into account. 
 
 If it be true that prevention is better than cure, 
 and that it is only possible to exercise prevention by 
 gaining a full knowledge of causation, the hospital 
 system stands condemned and must be remodelled. It 
 is impossible for the members of the staff to gain a 
 first-hand knowledge of the constitution and environ- 
 ment of each patient ; this essential work must be dele- 
 gated to practitioners resident in the district and in 
 touch with the hospital. Causes will then be dealt 
 with instead of effects ; disease will be attacked at the 
 source. 
 
 The reform of medical education and the reform of 
 the hospital system are two aspects of one question. 
 When illusory diagnosis and the consequent empirical 
 methods disappear from the hospital, the future 
 family physician will meet a teaching physician with 
 scientific and practical ideals like his own ; " special- 
 ism " will disappear. 
 
 The medical profession lacks even the pretence of 
 complete scientific organisation; this is a result of a 
 
134 MEDICAL REVOLUTION 
 
 lack of agreement on fundamental principles; until 
 this is reached, organisation is not possible. 
 
 The relation of the State with the medical profes- 
 sion stands in need of complete revision ; especially as 
 regards concerted action for the preservation of the 
 health of the people in great towns, 
 
 As long as spurious diseases are given official rec- 
 ognition, that is, as long as symptoms are allowed to 
 pass for specific diseases, there cannot be any cer- 
 tainty whether a certificate gives the cause of death 
 or no. Every one giving a death certificate ought to 
 be obliged either to give the cause of death, or to 
 state plainly that this has not been done. 
 
 THE END 
 
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