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diff --git a/21965.txt b/21965.txt new file mode 100644 index 0000000..234af93 --- /dev/null +++ b/21965.txt @@ -0,0 +1,12310 @@ +The Project Gutenberg EBook of Preventable Diseases, by Woods Hutchinson + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Preventable Diseases + +Author: Woods Hutchinson + +Release Date: June 29, 2007 [EBook #21965] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK PREVENTABLE DISEASES *** + + + + +Produced by Audrey Longhurst, Janet Blenkinship and the +Online Distributed Proofreading Team at http://www.pgdp.net +(This file was produced from images from the Home Economics +Archive: Research, Tradition and History, Albert R. Mann +Library, Cornell University) + + + + + + + + + + PREVENTABLE DISEASES + + BY + + WOODS HUTCHINSON, A.M., M.D. + + + _Author of "Studies in Human and Comparative Pathology," "Instinct and + Health," etc., etc. Clinical Professor of Medicine, New York Polyclinic, + late Lecturer in Comparative Pathology, London Medical Graduates College + and University of Buffalo_ + + + BOSTON AND NEW YORK HOUGHTON MIFFLIN COMPANY The Riverside Press + Cambridge + + COPYRIGHT, 1907, 1908 AND 1909, BY THE CURTIS PUBLISHING COMPANY + COPYRIGHT, 1909, BY WOODS HUTCHINSON + + ALL RIGHTS RESERVED + + _Published November 1909_ + + FIFTH IMPRESSION + + + * * * * * + + By Woods Hutchinson + + THE CONQUEST OF CONSUMPTION. Illustrated. + 12mo, $1.00 _net_. Postage extra. + + PREVENTABLE DISEASES. 12mo, $1.50 _net_. + Postage 13 cents. + + HOUGHTON MIFFLIN COMPANY + BOSTON AND NEW YORK + + * * * * * + + +CONTENTS + + + I. The Body-Republic and its Defense 1 + + II. Our Legacy of Health: the Power of Heredity + in the Prevention of Disease 31 + + III. The Physiognomy of Disease: what a Doctor + can tell from Appearances 55 + + IV. Colds and how to catch Them 83 + + V. Adenoids, or Mouth-Breathing: their Cause + and their Consequences 103 + + VI. Tuberculosis, a Scotched Snake. I 123 + + VII. Tuberculosis, a Scotched Snake. II 140 + + VIII. The Unchecked Great Scourge: Pneumonia 174 + + IX. The Natural History of Typhoid Fever 198 + + X. Diphtheria: the Modern Moloch 222 + + XI. The Herods of Our Day: Scarlet Fever, + Measles, and Whooping-Cough 243 + + XII. Appendicitis, or Nature's Remnant Sale 267 + + XIII. Malaria: the Pestilence that walketh in Darkness; + the greatest Foe of the Pioneer 289 + + XIV. Rheumatism: what it Is, and particularly + what it Isn't 311 + + XV. Germ-Foes that follow the Knife, or Death + under the Finger-Nail 331 + + XVI. Cancer, or Treason in the Body-State 350 + + XVII. Headache: the most useful Pain in the World 367 + + XVIII. Nerves and Nervousness 387 + + XIX. Mental Influence in Disease, or how the Mind + affects the Body 411 + + Index 439 + + + + +PREVENTABLE DISEASES + + + + +CHAPTER I + +THE BODY-REPUBLIC AND ITS DEFENSE + + +The human body as a mechanism is far from perfect. It can be beaten or +surpassed at almost every point by some product of the machine-shop or +some animal. It does almost nothing perfectly or with absolute +precision. As Huxley most unexpectedly remarked a score of years ago, +"If a manufacturer of optical instruments were to hand us for laboratory +use an instrument so full of defects and imperfections as the human eye, +we should promptly decline to accept it and return it to him. But," as +he went on to say, "while the eye is inaccurate as a microscope, +imperfect as a telescope, crude as a photographic camera, it is all of +these in one." In other words, like the body, while it does nothing +accurately and perfectly, it does a dozen different things well enough +for practical purposes. It has the crowning merit, which overbalances +all these minor defects, of being able to adapt itself to almost every +conceivable change of circumstances. + +This is the keynote of the surviving power of the human species. It is +not enough that the body should be prepared to do good work under +ordinary conditions, but it must be capable, if needs be, of meeting +extraordinary ones. It is not enough for the body to be able to take +care of itself, and preserve a fair degree of efficiency in health, +under what might be termed favorable or average circumstances, but it +must also be prepared to protect itself and regain its balance in +disease. + +The human automobile in its million-year endurance-run has had to learn +to become self-repairing; and well has it learned its lesson. Not only, +in the language of the old saw, is there "a remedy for every evil under +the sun," but in at least eight cases out of ten that remedy will be +found within the body itself. Generations ago this self-balancing, +self-repairing power was recognized by the more thoughtful fathers in +medicine and even dignified by a name in their pompous Latinity--the +_vis medicatrix naturae_, the healing power of nature. + +In the new conception of disease, our drugs, our tonics, our +prescriptions and treatments, are simply means of rousing this force +into activity, assisting its operations, or removing obstacles in its +way. This remedial power does not imply any gift of prophecy on nature's +part, nor is it proof of design, or beneficent intention. It is rather +one of those blind reactions to certain stimuli, tending to restore the +balance of the organism, much as that interesting, new scientific toy, +the gyroscope car, will respond to pressure exerted or weight placed +upon one side by rising on that side, instead of tipping over. Let the +onslaught of disease be sufficiently violent and unexpected, and nature +will fail to respond in any way. + +Moreover, we and our intelligences are a product of nature and a part +of her remedial powers. So there is nothing in the slightest degree +irrational or inconsistent in our attempting to assist in the process. + +However, a great, broad, consoling and fundamental fact remains: that in +a vast majority of diseases which attack humanity, under ninety per cent +of the unfavorable influences which affect us, nature will effect a cure +if not too much interfered with. As the old proverb has it, "A man at +forty is either a fool or a physician"; and nature is a good deal over +forty and has never been accused of lacking intelligence. + +In the first place, nature must have acquired a fair knowledge of +practical medicine, or at least a good working basis for it, from the +fact that the body, in the natural processes of growth and activity, is +perpetually manufacturing poisons for its own tissues. + +In this age of sanitary reform, we are painfully aware that the most +frequent causes of human disease are the accumulations about us of the +waste products of our own kitchens, barns, and factories. The "bad air" +which we hear so frequently and justly denounced as a cause of disease, +is air which we have ourselves polluted. This same process has been +going on within the body for millions of years. No sooner did three or +four cells begin to cling together, to form an organism, a body, than +the waste products of the cells in the interior of the group began to +form a source of danger for the others. If some means of getting rid of +these could not be devised, the group would destroy itself, and the +experiment of cooeperation, of colony-formation, of organization in fact, +would be a failure. + +Hence, at a very early period we find the development of the rudiments +of systems of body-sewerage, providing for the escape of waste poisons +through the food-tube, through the kidneys, through the gills and lungs, +through the sweat glands of the skin. So that when the body is +confronted by actual disease, it has all ready to its hand a remarkably +effective and resourceful system of sanitary appliances--sewer-flushing, +garbage-burning, filtration. In fact, this is precisely what it does +when attacked by poisons from without: it neutralizes and eliminates +them by the same methods which it has been practicing for millions of +years against poisons from within. + +Take, for instance, such a painfully familiar and unheroic episode as an +attack of colic. It makes little difference whether the attack is due to +the swallowing of some mineral poison, like lead or arsenic, or the +irritating juice of some poisonous plant or herb, or to the every-day +accident of including in the menu some article of diet which was +beginning to spoil or decay, and which contained the bacteria of +putrefaction or their poisonous products. The reaction of defense is +practically the same, varying only with the violence and the character +of the poison. If the dose of poisonous substances be unusually large or +virulent, nature may short-circuit the whole attack by causing the +outraged stomach to reject its contents. The power of "playing Jonah" is +a wonderful safety-valve. + +If the poison be not sufficiently irritating thus to short-circuit its +own career, it may get on into the intestines before the body thoroughly +wakes up to its presence. This part of the food-tube being naturally +geared to discharge its contents downward, the simplest and easiest +thing is to turn in a hurry call and cut down the normal schedule from +hours to minutes, with the familiar result of an acute diarrh[oe]a. + +Both vomiting and purging are defensive actions on nature's part, +remedies instead of diseases. Yet we are continually regarding and +treating them as if they were diseases in themselves. Nothing could be +more irrational than to stop a diarrh[oe]a before it has accomplished +its purpose. Intelligent physicians now assist it instead of trying to +check it in its early stages; and paradoxical as it may sound, laxatives +are often the best means of stopping it. It is only the excess of this +form of nature's house-cleaning which needs to be checked. Many of the +popular Colic Cures, Pain-Relievers, and "Summer Cordials" contain opium +which, while it relieves the pain and stops the discharge, simply locks +up in the system the very poisons which it was trying to get rid of. +Laxatives, intestinal antiseptics, and bowel irrigations have almost +taken the place of opiates in the treatment of these conditions in +modern medicine. We try to help nature instead of thwarting her. + +Supposing that the poison be of more insidious form, a germ or a +ptomaine, for instance, which slips past these outer "firing-out" +defenses of the food-tube and arouses no suspicion of its presence until +it has been partially digested and absorbed into the blood. Again, +resourceful nature is ready with another line of defense. It was for a +long time a puzzle why every drop of the blood containing food and its +products absorbed from the alimentary food-canal had to be carried, +often by a most roundabout course, to and through the liver, before it +could reach any part of the general system. Here was the largest and +most striking organ in the body, and it was as puzzling as it was large. +We knew in some crude way that it "made blood," that it prepared the +food-products for use by the body-cells, and that it secreted the bile; +but this latter secretion had little real digestive value, and the other +changes seemed hardly important enough to demand that every drop of the +blood coming from the food-tube should pass through this custom-house. +Now, however, we know that in addition to its other actions, the liver +is a great poison-sponge or toxin-filter, for straining out of the blood +poisonous or injurious materials absorbed from the food, and converting +them into harmless substances. It is astonishing what a quantity of +these poisons, whether from the food or from germs swallowed with it, +the liver is capable of dealing with--destroying them, converting them, +and acting as an absolute barrier to their passage into the general +system. But sometimes it is overwhelmed by appalling odds; some of the +invaders slip through its lines into the general circulation, producing +headache, backache, fever, and a "dark-brown taste in the mouth"; and, +behold, we are bilious, and proceed to blame the poor liver. We used to +pour in remedies to "stir it up," to "work on it"--which was about as +rational as whipping a horse when he is down, instead of cutting his +harness or taking his load off. Nowadays we stop the supply of further +food-poisons by stopping eating, assist nature in sweeping out or +neutralizing the enemies that are still in the alimentary canal, flush +the body with pure water, put it at rest--and trust the liver. +Biliousness is a sign of an overworked liver. If it wasn't working at +all, we shouldn't be bilious: we should be dead, or in a state of +collapse. + +Moral: Don't rush for some remedy with which to club into insensibility +every symptom of disease as soon as it puts in an appearance. Give +nature a little chance to show what she intends to do before attempting +to stop her by dosing yourself with some pain-reliever or colic cure. +Don't trust her too blindly, for the best of things may become bad in +extremes, and the body may become so panic-stricken as to keep on +throwing overboard, not merely the poisons, but its necessary daily +food, if the process be allowed to continue too long. + +This is where the doctor comes in. This is the point at which it takes +brains to succeed in the treatment of disease--to decide just how far +nature knows what she is doing, even in her most violent expulsive +methods, and is to be helped; and just when she has lost her head, or +got into a bad habit, and must be thwarted. This much we feel sure of, +and it is one of the keynotes of the attitude of modern medicine, that a +large majority of the symptoms of disease are really nature's attempts +to cure it. + +This is admirably shown in our modern treatment of fevers. These we now +know to be due to the infection of the body by more or less definitely +recognized disease-germs or organisms. Fever is a complicated process, +and we are still in the dark upon many points in regard to it, but we +are coming more and more firmly to the conclusion that most of its +symptoms are a part of, or at least incidents in, the fight of the body +against the invading army. The flushed and reddened skin is due to the +pumping of large quantities of blood through its mesh, in order that the +poisons may be got rid of through the perspiration. The rapid pulse +shows the vigor with which the heart is driving the blood around the +body, to have its poisons neutralized in the liver, burned up in the +lungs, poured out by the kidneys and the skin. The quickened breathing +is the putting on of more blast in the lung poison-crematory. It is +possible that even the rise of temperature has an injurious effect upon +the invading germs or assists the body in their destruction. + +In the past we have blindly fought all of these symptoms. We shut our +patients up in stove-heated rooms with windows absolutely closed, for +fear that they would "catch cold." We took off the sheets and piled +blankets upon the bed, setting a special watch to see that the wretched +sufferer did not kick them off. We discouraged the drinking of water and +insisted on all drinks that were taken being hot or lukewarm. Nowadays +all this is changed. We throw all the windows wide-open, and even put +our patients out of doors to sleep in the open air, whether it be +typhoid, tuberculosis, or pneumonia; knowing that not only they will not +"catch cold," but that, as their hurried breathing indicates, they need +all the oxygen they can possibly get, to burn up the poison poured out +in the lungs and from the skin. We encourage the patient to drink all +the cool, pure water he will take, sometimes gallons in a day, knowing +that his thirst is an indication for flushing and flooding all the great +systems of the body sewers. Instead of smothering him in blankets, we +put him into cold packs, or put him to soak in cool water. + +In short, we trust nature instead of defying her, cooeperate with her in +place of fighting her,--and we have cut down the death-rate of most +fevers fifty to seventy-five per cent already. Plenty of pure, cool +water internally, externally, and eternally, rest, fresh air, and +careful feeding, are the best febrifuges and antipyretics known to +modern medicine. All others are frauds and simply smother a symptom +without relieving its cause, with the exception of quinine in malaria, +mercury, and the various antitoxins in their appropriate diseases, which +act directly upon the invading organism. + +Underneath all this storm and stress of the fever paroxysm, nature is +quietly at work elaborating her antidote. In some marvelous fashion, +which we do not even yet fully understand, the cells of the body are +producing in ever-increasing quantities an _anti-body_, or _antitoxin_, +which will unite with the toxin or poison produced by the hostile germs +and render it entirely harmless. By a curious paradox of the process, it +does not kill the germs themselves. It may not even stop their further +multiplication. Indeed, it utilizes part of their products in the +formation of the antitoxin; but it domesticates them, as it were--turns +them from dangerous enemies into harmless guests. + +The treaty between these germs and the body, however, is only of the +"most-favored-nation" class; for let these tamed and harmless friends of +the family escape and enter the body of another human being, and they +will attack it as virulently as ever. + +Now, where and how did nature ever succeed in getting the rehearsal and +the practice necessary to build up such an extraordinary and complicated +system of defense as this? Take your microscope and look at a drop of +fluid from the mouth, the gums, the throat, the stomach, the bowels, and +you will find it simply swarming with bacteria, bacilli, and cocci, each +species of which numbers its billions. There are thirty-three species +which inhabit the mouth and gums alone! We are literally alive with +them; but most of them are absolutely harmless, and some of them +probably slightly helpful in the processes of digestion. In fevers and +infections the body merely applies to disease-germs the tricks which it +has learned in domesticating these millions of harmless vegetable +inhabitants. + +Still more curious--there is a distinct parallel between the method in +which food-materials are split up and prepared for assimilation by the +body, and the method adopted in breaking up and neutralizing the toxins +of disease-germs. It is now known that poisons are formed in the process +of digesting and absorbing the simplest and most wholesome foods; and +the liver uses the skill which it has gained in dealing with these +"natural poisons" in disposing of the toxins of germs. + +When a fever has run its course, as we now know nearly all infections +do, within periods ranging from three or four days to as many weeks, it +simply means that it has taken the liver and the other police-cells this +length of time to handle the rioters and turn them into peaceable and +law-abiding, even though not well-disposed citizens. In this process the +forces of law and order can be materially helped by skillful and +intelligent cooeperation. But it takes brains to do it and avoid doing +more harm than good. It requires far more intelligence on the part of +the doctor, the nurse, or the mother, skillfully to help nature than it +did blindly to fight her. + +This is what doctors and nurses are trained for nowadays, and they are +of use in the sick-room simply because they have devoted more time and +money to the study of these complicated processes than you have. Don't +imagine that calling in the doctor is going to interfere with the +natural course of the disease, or rob the patient of some chance he +might have had of recovering by himself. On the contrary, it will simply +give nature and the constitution of the patient a better chance in the +struggle, probably shorten it, and certainly make it less painful and +distressing. + +If these symptoms of the summer fevers and fluxes are indicative of +nature's attempts to cure, those of the winter's coughs and colds are no +less clearly so. As we walk down the streets, we see staring at us in +large letters from a billboard, "_Stop that Cough! It is Killing you!_" +Yet few things could be more obvious to even the feeblest intelligence, +than that this "killing" cough is simply an attempt on the part of the +body to expel and get rid of irritating materials in the upper +air-passages. As long as your larynx and windpipe are inflamed or +tickled by disease-germs or other poisons, your body will do its best to +get rid of them by coughing, or, if they swarm on the mucous membrane of +the nose, by sneezing. To attempt to stop either coughing or sneezing +without removing the cause is as irrational as putting out a +switch-light without closing the switch. Though this, like other +remedial processes, may go to extremes and interfere with sleep, or +upset the stomach, within reasonable limits one of the best things to do +when you have a cold is to cough. When patients with severe +inflammations of the lungs become too weak or too deeply narcotized to +cough, then attacks of suffocation from the accumulation of mucus in the +air-tubes are likely to occur at any time. Young children who cannot +cough properly, not having got the mechanism properly organized as yet, +have much greater difficulty in keeping their bronchial tubes clear in +bronchitis or pneumonia than have grown-ups. Most colds are infectious, +like the fevers, and like them run their course, after which the cough +will subside along with the rest of the symptoms. But simply stopping +the cough won't hasten the recovery. Most popular "Cough-Cures" benumb +the upper throat and stop the tickling; smother the symptoms without +touching the cause. Many contain opium and thus load the system with two +poisons instead of one. + +Lastly, in the realm of the nervous system, take that commonest of all +ills that afflict humanity--headache. Surely, this is not a curative +symptom or a blessing in disguise, or, if so, it is exceedingly well +disguised. And yet it unquestionably has a preventive purpose and +meaning. Pain, wherever found, is nature's abrupt command, "Halt!" her +imperative order to stop. When you have obeyed that command, you have +taken the most important single step towards the cure. _A headache +always means something_--overwork, under-ventilation, eye-strain, +underfeeding, infection. Some error is being committed, some bad +physical habit is being dropped into. There are a dozen different +remedies that will stop the pain, from opium and chloroform down to the +coal-tar remedies (phenacetin, acetanilid, etc.) and the bromides. But +not one of them "cures," in the sense of doing anything toward removing +the cause. In fact, on the contrary they make the situation worse by +enabling the sufferer to keep right on repeating the bad habit, deprived +of nature's warning of the harm that he is doing to himself. As the +penalties of this continued law-breaking pile up, he requires larger and +larger doses of the deadening drug, until finally he collapses, poisoned +either by his own fatigue-products or by the drugs which he has been +taking to deaden him against their effect. + +In fine, follow nature's hints whenever she gives them: treat pain by +rest, infections by fresh air and cleanliness, the digestive +disturbances by avoiding their cause and helping the food-tube to flush +itself clean; keep the skin clean, the muscles hard, and the stomach +well filled--and you will avoid nine-tenths of the evils which threaten +the race. + +The essence of disease consists, not in either the kind or the degree of +the process concerned, but only in its relations to the general balance +of activities of the organism, to its "resulting in discomfort, +inefficiency, or danger," as one of our best-known definitions has it. +Disease, then, is not absolute, but purely relative; there is no single +tissue-change, no group even of changes or of symptoms, of which we can +say, "This is essentially morbid, this is everywhere and at all times +disease." + +Our attainment of any clear view of the essential nature of disease was +for a long time hindered, and is even still to some degree clogged, by +the standpoint from which we necessarily approached and still approach +it, not for the study of the disease itself, but for the relief of its +urgent symptoms. Disease presents itself as an enemy to attack, in the +concrete form of a patient to be cured; and our best efforts were for +centuries almost wasted in blind, and often irrational, attempts to +remove symptoms in the shortest possible time, with the most powerful +remedies at our disposal, often without any adequate knowledge whatever +of the nature of the underlying condition whose symptoms we were +combating, or any suspicion that these might be nature's means of +relief, or that "haply we should be found to fight against God." There +was sadly too much truth in Voltaire's bitter sneer, "Doctors pour drugs +of which they know little, into bodies of which they know less"; and I +fear the sting has not entirely gone out of it even in this day of +grace. + +And yet, relative and non-essential as all our definitions now recognize +disease to be, it is far enough (God knows) from being a mere negative +abstraction, a colorless "error by defect." It has a ghastly +individuality and deadly concreteness,--nay, even a vindictive +aggressiveness, which have both fascinated and terrorized the +imagination of the race in all ages. From the days of "the angel of the +pestilence" to the coming of the famine and the fever as unbidden guests +into the tent of Minnehaha; from "the pestilence that walketh in +darkness" to the plague that still "stalks abroad" in even the prosaic +columns of our daily press, there has been an irresistible impression, +not merely of the positiveness, but even of the personality of disease. +And no clear appreciation can possibly be had of our modern and rational +conceptions of disease without at least a statement of the earlier +conceptions growing out of this personifying tendency. Absurd as it may +seem now, it was the legitimate ancestor of modern pathogeny, and still +holds well-nigh undisputed sway over the popular mind, and much more +than could be desired over that of the profession. + +The earliest conception of disease of which we have any record is, of +course, the familiar Demon Theory. This is simply a mental magnification +of the painfully personal, and even vindictive, impression produced upon +the mind of the savage by the ravages of disease. And certainly we of +the profession would be the last to blame him for jumping to such a +conclusion. Who that has seen a fellow being quivering and chattering in +the chill-stage of a pernicious malarial seizure, or tossing and raving +in the delirium of fever, or threatening to rupture his muscles and +burst his eyes from their sockets in the convulsions of tetanus or +uraemia, can wonder for a moment that the impression instinctively arose +in the untutored mind of the Ojibwa that the sufferer was actually in +the grasp, and trying to escape from the clutch, of some malicious but +invisible power? And from this conception the treatment logically +followed. The spirits which possessed the patient, although invisible, +were supposed to be of like passions with ourselves, and to be affected +by very similar influences; hence dances, terrific noises, beatings and +shakings of the unfortunate victim, and the administration of bitter and +nauseous messes, with the hope of disgusting the demon with his +quarters, were the chief remedies resorted to. And while to-day such +conceptions and their resultant methods are simply grounds for laughter, +and we should probably resent the very suggestion that there was any +connection whatever between the Demon Theory and our present practice, +yet, unfortunately for our pride, the latter is not only the direct +lineal, historic descendant of the former, but bears still abundant +traces of its lowly origin. It will, of course, be admitted at once that +the ancestors of our profession, historically, the earliest physicians, +were the priest, the Shaman, and the conjurer, who even to this day in +certain tribes bear the suggestive name of "medicine men." Indeed, this +grotesque individual was neither priest nor physician, but the common +ancestor of both, and of the scientist as well. And, even if the history +of this actual ancestry were unknown, there are scores of curious +survivals in the medical practice of this century, even of to-day, which +testify to the powerful influence of this conception. The extraordinary +and disgraceful prevalence of bleeding scarcely fifty years ago, for +instance; the murderous doses of calomel and other violent purges; the +indiscriminate use of powerful emetics like tartar emetic and ipecac; +the universal practice of starving or "reducing" fevers by a diet of +slops, were all obvious survivals of the expulsion-of-the-demon theory +of treatment. Their chief virtue lay in their violence and +repulsiveness. Even to-day the tendency to regard mere bitterness or +distastefulness as a medicinal property in itself has not entirely died +out. This is the chief claim of quassia, gentian, calumbo, and the +"simple bitters" generally, to a place in our official lists of +remedies. Even the great mineral-water fad, which continues to flourish +so vigorously, owed its origin to the superstition that springs which +bubbled or seethed were inhabited by spirits (of which the "troubling of +the waters" in the Pool of Bethesda is a familiar illustration). The +bubble and (in both senses) "infernal" taste gave them their reputation, +the abundant use of pure spring water both internally and externally +works the cure, assisted by the mountain air of the "_Bad_," and we +sapiently ascribe the credit to the salts. Nine-tenths of our cells are +still submarine organisms, and water is our greatest panacea. + +Then came the great "humoral" or "vital fluid" theory of disease which +ruled during the Middle Ages. According to this, all disease was due to +the undue predominance in the body of one of the four great vital +fluids,--the bile, the blood, the nervous "fluid," and the lymph,--and +must be treated by administering the remedy which will get rid of or +counteract the excess of the particular vital fluid in the system. The +principal traces of this belief are the superstition of the four +"temperaments," the _bilious_, the _sanguine_, the _nervous_, and the +_lymphatic_, and our pet term "biliousness," so useful in explaining any +obscure condition. + +Last of all, in the fullness of time,--and an incredibly late fullness +it was,--under the great pioneer Virchow, who died less than a decade +ago, was developed the great cellular theory, a theory which has done +more to put disease upon a rational basis, to substitute logic for +fancy, and accurate reasoning for wild speculation, than almost any +discovery since the dawn of history. Its keynote simply is, that every +disturbance to which the body is liable can be ultimately traced to some +disturbance or disease of the vital activities of the individual cells +of which it is made up. The body is conceived of as a cell-state or +cell-republic, composed of innumerable plastid citizens, and its +government, both in health and disease, is emphatically a government "of +the cells, by the cells, for the cells." At first these cell-units were +regarded simply as geographic sections, as it were, sub-divisions of the +tissues, bearing much the same relation to the whole body as the bricks +of the wall do to the building, or, from a little broader view, as the +Hessians of a given regiment to the entire army. They were merely the +creatures of the organism as a whole, its servants who lived but to obey +its commands and carry out its purposes, directed in purely arbitrary +and despotic fashion by the lordly brain and nerve-ganglia, which again +are directed by the mind, and that again by a still higher power. In +fact, they were regarded as, so to speak, individuals without +personality, mere slaves and helots under the ganglion-oligarchy which +was controlled by the tyrant mind, and he but the mouthpiece of one of +the Olympians. But time has changed all that, and already the triumphs +of democracy have been as signal in biology as they have been in +politics, and far more rapid. The sturdy little citizen-cells have +steadily but surely fought their way to recognition as the controlling +power of the entire body-politic, have forced the ganglion-oligarchy to +admit that they are but delegates, and even the tyrant mind to concede +that he rules by their sufferance alone. His power is mainly a veto, and +even that may be overruled by the usual two-thirds vote. + +In fact, if we dared to presume to criticise this magnificent theory of +disease, we would simply say that it is not "cellular" enough, that it +hardly as yet sufficiently recognizes the individuality, the +independence, the power of initiative, of the single constituent cell. +It is still a little too apt to assume, because a cell has donned a +uniform and fallen into line with thousands of its fellows to form a +tissue in most respects of somewhat lower rank than that originally +possessed by it in its free condition, that it has therefore surrendered +all of its rights and become a mere thing, a lever or a cog in the great +machine. Nothing could be further from the truth, and I firmly believe +that our clearest insight into and firmest grasp upon the problems of +pathology will come from a recognition of the fact that, no matter how +stereotyped, or toil-worn, or even degraded, the individual cells of any +tissue may have become, they still retain most of the rights and +privileges which they originally possessed in their free and untrammeled +am[oe]boid stage, just as in the industrial community of the world about +us. And, although their industry in behalf of and devotion to the +welfare of the entire organism is ever to be relied upon, and almost +pathetic in its intensity, yet it has its limits, and when these have +been transgressed they are as ready to "fight for their own hand," +regardless of previous conventional allegiance, as ever were any of +their ancestors on seashore or rivulet-marge. And such rebellions are +our most terrible disease-processes, cancer and sarcoma. More than this: +while, perhaps, in the majority of cases the cell does yeoman service +for the benefit of the body, in consideration of the rations and fuel +issued to it by the latter, yet in many cases we have the curious, and +at first sight almost humiliating, position of the cell absorbing and +digesting whatever is brought to it, and only turning over the surplus +or waste to the body. It would almost seem as if our lordly _Ego_ was +living upon the waste-products, or leavings, of the cells lining its +food-tube. + +Let us take a brief glance at the various specializations and trade +developments, which have taken place in the different groups of cells, +and see to what extent the profound modifications which many of them +have undergone are consistent with their individuality and independence, +and also whether such specialization can be paralleled by actually +separate and independent organisms existing in animal communities +outside of the body. First of all, because furthest from the type and +degraded to the lowest level, we find the great masses of tissue welded +together by lime-salts, which form the foundation masses, leverage-bars, +and protection plates for the higher tissues of the body. Here the +cells, in consideration of food, warmth, and protection guaranteed to +themselves and their heirs for ever by the body-state, have, as it were, +deliberately surrendered their rights of volition, of movement, and +higher liberties generally, and transformed themselves into masses of +inorganic material by soaking every thread of their tissues in +lime-salts and burying themselves in a marble tomb. Like Esau, they have +sold their birthright for a mess of "potash," or rather lime; and if +such a class or caste could be invented in the external industrial +community, the labor problem and the ever-occurring puzzle of the +unemployed would be much simplified. And yet, petrified and mummified as +they have become, they are still emphatically alive, and upon the +preservation of a fair degree of vigor in them depends entirely the +strength and resisting power of the mass in which they are embedded, and +of which they form scarcely a third. Destroy the vitality of its cells, +and the rock-like bone will waste away before the attack of the +body-fluids like soft sandstone under the elements. Shatter it, or twist +it out of place, and it will promptly repair itself, and to a remarkable +degree resume its original directions and proportions. + +So little is this form of change inconsistent with the preservation of +individualism, that we actually find outside of the body an exactly +similar process, occurring in individual and independent animals, in the +familiar drama of coral-building. The coral polyp saturates itself with +the lime-salts of the sea-water, much as the bone-corpuscles with those +of the blood and lymph, and thus protects itself in life and becomes the +flying buttress of a continent in death. + +In the familiar connective-tissue, or "binding-stuff," we find a process +similar in kind but differing in the degree, so to speak, of its +degradation. + +The quivering responsiveness of the protoplasm of the am[oe]boid +ancestral cell has transformed itself into tough, stringy bands and webs +for the purpose of binding together the more delicate tissues of the +body. It has retained more of its rights and privileges, and +consequently possesses a greater amount of both biological and +pathological initiative. In many respects purely mechanical in its +function, fastening the muscles to the bones, the bones to each other, +giving toughness to the great skin-sheet, and swinging in hammock-like +mesh the precious brain-cell or potent liver-lobule, it still possesses +and exercises for the benefit of the body considerable powers of +discretion and aggressive vital action. Through its activity chiefly is +carried out that miracle of human physiology, the process of repair. By +the transformation of its protoplasm the surplus food-materials of the +times of plenty are stored away within its cell-wall against the time of +stress. + +Whatever emergency may arise, nature, whatever other forces she may be +unable to send to the rescue, can always depend upon the +connective-tissues to meet it; and, of course, as everywhere the medal +of honor has its reverse side, their power for evil is as distinguished +as their power for good. From their ranks are recruited a whole army of +those secessions from and rebellions against the body at large--the +tumors, from the treacherous and deadly sarcoma, or "soft cancer," to +the harmless fatty tumor, as well as the tubercle, the gumma of +syphilis, the interstitial fibrosis of Bright's disease. They are the +sturdy farmers and ever ready "minute-men" of the cell-republic, and we +find their prototype and parallel in the external world, both in +material structure and degree of vitality, in the well-known sponge and +its colonies. + +Next in order, and, in fact, really forming a branch of the last, we +find the great group of storage-tissues, the granaries or bankers of the +body-politic, distinguished primarily, like the capitalist class +elsewhere, by an inordinate appetite, not to say greed. They sweep into +their interior all the food-materials which are not absolutely necessary +for the performance of the vital function of the other cells. These they +form first into protoplasm, and then by a simple degenerative process it +is transformed, "boiled down" as it were, into a yellow hydrocarbon +which is capable of storage for practically an indefinite period. Not a +very exalted function, and yet one of great importance to the welfare of +the entire body, for, like the Jews of the Middle Ages, the fat-cells, +possessing an extraordinary appetite for and faculty of acquiring +surplus wealth in times of plenty, can easily be robbed of it and +literally sucked dry in times of scarcity by any other body-cell which +happens to need it, especially by the belligerent military class of +muscle-cells. In fever or famine, fat is the first element of our +body-mass to disappear; so that Proudhon would seem to have some +biological basis for his demand for the _per capita_ division of the +fortunes of millionaires. And yet, rid the fat-cell of the weight of his +sordid gains, gaunt him down, as it were, like a hound for the +wolf-trail, and he becomes at once an active and aggressive member of +the binding-stuff group, ready for the repair of a wound or the barring +out of a tubercle-bacillus. + +And this form of specialization has also its parallel outside of the +body in one of the classes in a community of Mexican ants, whose most +distinguishing feature is an enormously distended [oe]sophagus, capable +of containing nearly double the weight of the entire remainder of the +body. They are neither soldiers nor laborers, but accompany the latter +in their honey-gathering excursions, and as the spoils are collected +they are literally packed full of the sweets by the workers. When +distended to their utmost capacity they fall apparently into a +semi-comatose condition, are carried into the ant-hill, and hung up by +the hind legs in a specially prepared chamber, in which (we trust) +enjoyable position and state they are left until their contents are +needed for the purposes of the community, when they are waked up, +compelled to disgorge, and resume their ordinary life activities until +the next season's honey-gathering begins. It scarcely need be pointed +out what an unspeakable boon to the easily discouraged and unlucky the +introduction of such a class as this into the human industrial community +would be, especially if this method of storage could be employed for +certain liquids. + +Another most important class in the cell-community is the great group +of the blood-corpuscles, which in some respects appear to maintain their +independence and freedom to a greater degree than almost any other class +which can be found in the body. While nearly all other cells have become +packed or felted together so as to form a fixed and solid tissue, these +still remain entirely free and unattached. They float at large in the +blood-current, much as their original ancestor, the am[oe]ba, did in the +water of the stagnant ditch. And, curiously enough, the less numerous of +the two great classes, the white, or leucocytes, are in appearance, +structure, pseudopodic movements, and even method of engulfing food, +almost exact replicas of their most primitive ancestor. + +There is absolutely no fixed means of communication between the +blood-corpuscles and the rest of the body, not even by the tiniest +branch of the great nerve-telegraph system, and yet they are the most +loyal and devoted class among all the citizens of the cell-republic. +They are called hither and thither partly by messenger-substances thrown +into the blood, known as _hormones_, partly by the "smell of the battle +afar off," the toxins of inflammation and infection as they pour through +the blood. + +The red ones lose their nuclei, their individuality, in order to become +sponges, capable of saturating themselves with oxygen and carrying it to +the gasping tissues. The white are the great mounted police, the +sanitary patrol of the body. The moment that the alarm of injury is +sounded in a part, all the vessels leading to it dilate, and their +channels are crowded by swarms of the red and white hurrying to the +scene. The major part of the activity of the red cells can be accounted +for by the mechanism of the heart and blood-vessels. They are simply +thrown there by the handful and the shovelful, as it were, like so many +pebbles or bits of chalk. + +But the behavior of the white cells goes far beyond this. We are almost +tempted to endow them with volition, though they are of course drawn or +driven by chemical and physical attractions, like iron-filings by a +magnet, or an acid by a base. Not only do all those normally circulating +in the blood flowing through the injured part promptly stop and begin to +scatter themselves through the underbrush and attack the foe at close +quarters, but, as has been shown by Cabot's studies in leucocytosis, the +moment that the red flag of fever is hoisted, or the inflammation alarm +is sounded, the leucocytes come rushing out from their feeding-grounds +in the tissue-interspaces, in the lymph-channels, in the great serous +cavities, and pour themselves into the blood-stream, like minute-men +leaving the plough and thronging the highways leading towards the +frontier fortress which has been attacked. Arrived at the spot, if there +be little of the pomp and pageantry of war in their movements, their +practical devotion and heroism are simply unsurpassed anywhere, even in +song and story. They never think of waiting for reinforcements or for +orders from headquarters. They know only one thing, and that is to +fight; and when the body has brought them to the spot, it has done all +that is needed, like the Turkish Government when once it has got its +sturdy peasantry upon the battlefield: they have not even the sense to +retreat. And whether they be present in tens, or in scores, or in +millions, each one hurls himself upon the toxin or bacillus which stands +directly in front of him. If he can destroy the bacillus and survive, so +much the better; but if not, he will simply overwhelm him by the weight +of his body-mass, and be swept on through the blood-stream into the +great body-sewers, with the still living bacillus literally buried in +his dead body. Like Arnold Winkelried, he will make his body a sheath +for a score of the enemy's spears, so that his fellows can rush in +through the gap that he has made. And it makes no difference whatever if +the first ten or hundred or thousand are instantly mowed down by the +bacillus or its deadly toxins, the rear ranks sweep forward without an +instant's hesitation, and pour on in a living torrent, like the Zulu +_impis_ at Rorke's Drift, until the bacilli are battered down by the +sheer impact of the bodies of their assailants, or smothered under the +pile of their corpses. When this has happened, in the language of the +old surgeon-philosophers, "suppuration is established," and the patient +is saved. + +Or if, as often happens, an antitoxin is formed, which protects the +whole body, this is largely built out of substances set free from the +bodies of slain leucocytes. And the only thing that dims our vision to +the wonder and beauty of this drama, is that it happens every day, and +we term it prosaically "the process of repair," and expect it as a +matter of course. Every wound-healing is worthy of an epic, if we could +only look at it from the point of view of these citizens of our great +cell-republic. And if we were to ask the question, "Upon what does +their peculiar value to the body-politic depend?" we should find that it +was largely the extent to which they retained their ancestral +characteristics. They are born in the lymph-nodes, which are simply +little islands of tissue of embryonic type, preserved in the body +largely for the purpose of breeding this primitive type of cells. They +are literally the Indian police, the scavengers, the Hibernians, as it +were, of the entire body. They have the roving habits and fighting +instincts of the savage. They cruise about continually through the +waterways and marshes of the body, looking for trouble, and, like their +Hibernian descendants, wherever they see a head they hit it. They are +the incarnation of the fighting spirit of our ancestors, and if it were +not for their retention of this characteristic in so high a degree, many +classes of our fixed cells would not have been able to subside into such +burgher like habits. + +Although even here, as we shall see, it is only a question of quickness +of response, for while the first bands of the enemy may be held at bay +by the leucocyte cavalry, and a light attack repelled by their +skirmish-line, yet when it comes to the heavy fighting of a +fever-invasion, it is the slow but substantial burgher-like fixed cells +of the body which form the real infantry masses of the campaign. And I +believe that upon the proportional relation between these primitive and +civilized cells of our body-politic will depend many of the singular +differences, not only in degree but also in kind, in the immunity +possessed by various individuals. While some surgeons and anatomists +will show a temperature from the merest scratch, and yet either never +develop any serious infection or display very high resisting power in +the later stages, others, again, will stand forty slight inoculations +with absolute impunity, and yet, when once the leucocyte-barrier is +broken down, will make apparently little resistance to a fatal systemic +infection. And this, of course, is only one of a score of ways in which +the leucocytes literally _pro patria moriuntur_. Our whole alimentary +canal is continually patrolled by their squadrons, poured into it by the +tonsils above and Peyer's patches below; if it were not for them we +should probably be poisoned by the products of our own digestive +processes. + +If, then, the cells of the body-republic retain so much of their +independence and individuality in health, does it not seem highly +probable that they do also in disease? This is known to be the case +already in many morbid processes, and their number is being added to +every day. The normal activities of any cell carried to excess may +constitute disease, by disturbing the balance of the organism. Nay, most +disease-processes on careful examination are found to be at bottom +vital, often normal to the cells concerned in them. The great normal +divisions of labor are paralleled by the great processes of degeneration +into fat, fibrous tissue, and bone or chalk. A vital chemical change +which would be perfectly healthy in one tissue or organ, in another may +be fatal. + +Ninety-nine times out of a hundred any group of cells acts loyally in +the interests of the body; once in a hundred some group acts against +them, and for its own, and disease is the result. There is a perpetual +struggle for survival going on between the different tissues and organs +of the body. Like all other free competition, as a rule, it inures +enormously to the benefit of the body-whole. Exceptionally, however, it +fails to do so, and behold disease. This struggle and turmoil is not +only necessary to life--it is life. Out of the varying chances of its +warfare is born that incessant ebb and flow of chemical change, that +inability to reach an equilibrium, which we term "vitality." The course +of life, like that of a flying express train, is not a perfectly +straight line, but an oscillating series of concentric curves. Without +these oscillations movement could not be. Exaggerate one of them unduly, +or fail to rectify it by a rebound oscillation, and you have disease. + +Or it is like the children's game of shuttlecock. So long as the flying +shuttle keeps moving in its restless course to and fro, life is. A +single stop is death. The very same blow which, rightly placed, sends it +like an arrow to the safe centre of the opposing racket, if it fall +obliquely, or even with too great or too little force, drives it +perilously wide of its mark. It can recover the safe track only by a +sudden and often violent lunge of the opposing racket. The straight +course is life, the tangent disease, the saving lunge recovery. + +One and the same force produces all. + +In the millions of tiny blows dealt every minute in our body-battle, +what wonder if some go wide of the mark! + + + + +CHAPTER II + +OUR LEGACY OF HEALTH: THE POWER OF HEREDITY IN THE PREVENTION OF DISEASE + + +The evil in things always bulks large in our imaginations. It is no mere +coincidence that the earliest gods of a race are invariably demons. Our +first conception of the great forces of nature is that they are our +enemies. This misconception is not only natural, but even necessary on +the sternest of physical bases. The old darky, Jim, in Huckleberry Finn, +hit upon a profound and far-reaching truth when he replied in answer to +Huck's question whether among all the signs and portents with which his +mind was crammed--like black cats and seeing the moon over your left +shoulder and "harnts"--some were not indications of good luck instead of +all being of evil omen:-- + +"Mighty few--an' _dey_ ain't no use to a body. What fur you want to know +when good luck's a-comin'? Want to keep it off?" + +It isn't the good, either in the forces of nature or in our fellows, +that keeps us watchful, but the evil. Hence our proneness to declare in +all ages that evil is stronger than good and that "all men are liars." +One injury done us by storm, by sunstroke, by lightning-flash, will make +a more lasting impression upon our memories than a thousand benefits +conferred by these same forces. Besides, evil has to be sharply looked +out for and guarded against. Well enough can be safely let alone. + +The conviction is steadily growing, among both physicians and +biologists, that this attitude has caused a serious, if not vital, +misconception of the influence of that great conservative and +preservative force of nature--heredity. We hear a great deal of +hereditary disease, hereditary defect, hereditary insanity, but very +little of hereditary powers of recovery, of inherited vigor, and the +fact that ninety-nine and seven-tenths per cent of us are sane. + +One instance of hereditary defect, of inherited degeneracy, fills us +with horror and stirs us to move Heaven and earth to prevent another +such. The inheritance of vigor, of healthfulness, and of sanity we +placidly accept as a matter of course and bank upon it in our plans for +the future, without so much as a thank you to the force that underlies +it. + +When once we clear away these inherited misconceptions and look the +facts of the situation squarely in the face, we find that heredity is at +least ten times as potent and as frequently concerned in the +transmission and securing of health and vigor as of disease and +weakness; that its influence on the perpetuation of bodily and mental +defects has been enormously exaggerated and that there are exceedingly +few hereditary diseases. + +It is not necessary for our present purpose to enter into a discussion +of the innumerable theories of that inevitable tendency of like to beget +like, of child to resemble parent, which we call heredity. One +reference, however, may be permitted to the controversy that has +divided the scientific world: whether _acquired_ characters, changes +occurring during the lifetime of the individual, can be inherited. +Disease is nine times out of ten an acquired character; hence, instead +of the probabilities being that it would be inherited, the balance of +evidence to date points in exactly the opposite direction. The burden of +proof as to the inheritance of disease is absolutely upon those who +believe in its possibility. + +Another fundamental fact which renders the inheritance of disease upon a +_priori_ grounds improbable and upon practical grounds obviously +difficult, is that characters or peculiarities, in order to be inherited +certainly for more than a few generations, must be beneficial and +helpful in the struggle. A moment's reflection will show this to be +mathematically necessary, in that any family or race which tended to +inherit defects and injurious characters would rapidly go down in the +struggle for survival and become extinct. An inherited disease of any +seriousness could not run for more than two or three generations in any +family, simply for the reason that by the end of that time there would +be no family left for it to run in. A slight defect or small peculiarity +of undesirable character might run for a somewhat longer period, but +even this would tend toward disappearance and elimination by the stern, +selective influence of environment. + +Naturally, this great conservative tendency of nature has, like all +other influences, "the defects of its virtues," as the French say. It +has no gifts of prophecy, and in the process of handing down to +successive generations those mechanisms and powers which have been +found useful in the long, stern struggle of the past, it will also hand +down some which, by reason of changes in the environment, are not only +no longer useful, but even injurious. As the new light of biology has +been turned on the human body and its diseases, it has revealed so many +of these "left-overs," or remnants in the body-machine--some of most +dramatic interest--that they at first sight have done much to justify +the popular belief in the malignant tendencies of heredity. + +Yet, broadly considered, the overwhelming majority of them should really +be regarded as honorable scars, memorials of ancient victories, +monuments to difficulties overcome, significant and encouraging +indications of what our body-machine is still capable of accomplishing +in the way of further adjustment to conditions in the future. The really +surprising thing is not their number, but the infrequency with which +they give rise to serious trouble. + +The human automobile is not only astonishingly well built, with all the +improvements that hundreds of thousands of generations of experience +have been able to suggest, but it is self-repairing, self-cleaning, and +self-improving. It never lets itself get out of date. If only given an +adequate supply of fuel and water and not driven too hard, it will stand +an astonishing amount of knocking about in all kinds of weather, +repairing itself and recharging its batteries every night, supplying its +own oil, its own paint and polish, and even regulating its own changes +of gear, according to the nature of the work it has to do. Simply as an +endurance racer it is the toughest and longest-winded thing on earth +and can run down and tire out every paw, pad, or hoof that strikes the +ground--wolf, deer, horse, antelope, wild goat. This is only a sample of +its toughness and resisting power all along the line. + +These wide powers of self-support and adjustment overbalance a hundred +times any little remnant defects in its machinery or gearing. Easily +ninety-nine per cent of all our troubles through life are due to +inevitable wear and tear, scarcity of food-fuel, of water, of rest, and +external accidents--injuries and infectious diseases. Still, it +occasionally happens that these little defects may furnish the point of +least resistance at which external stresses and strains will cause the +machine to break down. They are often the things which prevent us from +living and "going to pieces all at once, all at once and nothing fust, +just as bubbles do when they bust," like the immortal One-Hoss Shay. It +is just as well that they should, for, of all deaths to die, the +loneliest and the most to be dreaded is that by extreme old age. + +These _vestigia_ or remnants--instances of apparently hidebound +conservatism on nature's part--are very much in the public eye at +present, partly on account of their novelty and of their exceptional and +extraordinary character. Easily first among these trouble-breeding +remnants is that famous, or rather notorious, scrap of intestine, the +_appendix vermiformis_, an obvious survival from that peaceful, +ancestral period when we were more largely herbivorous in our diet and +required a longer and more complicated food-tube, with larger side +pouches in the course of it, to dissolve and absorb our food. Its +present utility is just about that of a grain of sand in the eye. Yet, +considering that it is present in every human being born into the world, +the really astonishing thing is not the frequency with which it causes +trouble, but the surprisingly small amount of actual damage that arises +from it. Never yet in even the most appendicitis-ridden community has it +been found responsible for more than one half of one per cent of the +deaths. + +Then there is that curious and by no means uncommon tendency for a loop +of the intestine to escape from the abdominal cavity, which we call +hernia. This is one of a fair-sized group of dangers clearly due to the +assumption of the erect position and our incomplete adjustment thereto. +In the quadrupedal position this necessary weak spot--a partial opening +through the abdominal wall--was developed in that region which was +highest from the point of view of gravity and least exposed to strain. +In the bipedal position it becomes lowest and most exposed; hence the +much greater frequency of hernia in the human species as compared with +any of the animals. + +Another fragment, of the impertinence of whose presence many of us have +had painful proof, is the third or last molar, so absurdly misnamed the +wisdom tooth. If there be any wisdom involved in its appearance it is of +the sort characterized by William Allen White's delicious definition: +"That type of ponderous folly of the middle-aged which we term 'mature +judgment.'" The last is sometimes worst as well as best, and this +belated remnant is not only the last to appear, but the first to +disappear. In a considerable percentage of cases it is situated so far +back in the jaw that there is no room for it to erupt properly, and it +produces inflammatory disturbances and painful pressure upon the nerves +of the face and the jaw. + +Even when it does appear it is often imperfectly developed, has fewer +cusps and fewer roots than the other molars, is imperfectly covered with +enamel and badly calcified. In no small percentage of cases it does not +meet its fellow of the jaw below and hence is almost useless for +purposes of mastication. But it comes in every child born into the +world, simply because at an earlier day, when our jaws were longer--to +give our canine teeth the swing they needed as our chief weapons of +defense--there was plenty of room for it in the jaw and it was of some +service to the organism. If the Indiana State Legislature would only +pass a law prohibiting the eruption of wisdom teeth in future, and +enforce it, it would save a large amount of suffering, inconvenience, +and discomfort, with little appreciable lack of efficiency! + +In this list of admitted charges against heredity must also come the +gall-bladder, that curious little pouch budded out from the bile ducts, +which has so little known utility as compared with its possibility as a +starting-point for inflammations, gall-stones, and cancer. + +Then there is that disfiguring facial defect, hare-lip, due to a failure +of the three parts of which our upper jaw is built to unite +properly,--this triple construction of the jaw being an echo of +ancestral fishlike and reptilian times when our jaws were built in five +pieces to permit of wide distention in the act of swallowing our prey +alive. All over the surface of the body are to be found innumerable +little sebaceous glands originally intended to lubricate hairs, which +have now atrophied and disappeared. These useless scraps, under various +forms of irritation, both external and internal, become inflamed and +give rise to pimples, acne, or "a bad complexion." + +And so the list might be drawn out to most impressive length. But this +length would be no indication of its real importance, inasmuch as the +vast majority of entries upon it would come under the head of +pathological curiosities, or conditions which were chiefly interesting +on account of their rareness and unusual character. With the exception +of the appendix, the gall-bladder, and hernia, these vestigial +conditions may be practically disregarded as factors in the death-rate. + +In the main, when the fullest possible study and recognition have been +made of all the traces of experimentation and even of ancient failure +that are to be found in this Twentieth Century body-machine of ours, the +resulting impression is one of enormously increased respect for and +confidence in the machine and its capabilities. While they are of great +interest as indicating what the past history and experiences of the +engine have been, and of highest value as enabling us to interpret and +even anticipate certain weak spots in its construction and joints in its +armor, their most striking influence is in the direction of emphasizing +the enormous elasticity and resourcefulness of the creature. + +Not only has it met and survived all these difficulties, but it is +continuing the selfsame processes to-day. So far as we are able to +judge, it is as young and as adaptable as it ever was, and just as ready +to "with a frolic welcome greet the thunder and the sunshine" as it ever +was in the dawn of history. + +These ancestral and experimental flaws, even when unrecognized and +unguarded against, have probably not at any time been responsible for +more than one or two per cent of the body's breakdowns; while, on the +other hand, every process with which it fights disease, every trick of +strategy which it uses against invading organisms, every step in the +process of repair after wounds or injury, is a trick which it has +learned in its million-year battle with its surroundings. + +Take such a simple thing as the mere apparently blind habit possessed by +the blood of coagulating as soon as it comes in contact with the edges +of a cut or torn blood-vessel, and think what an enormous safeguard this +has been and is against the possibility of death by hemorrhage. So well +is it developed and so rapidly does it act that it is practically +impossible to bleed some animals to death by cutting across any vessel +smaller than one of the great aortic trunks. The rapidity and toughness +of the clotting, combined with the other ancestral tricks of lowering +the blood pressure and weakening down the heart, are so immensely +effective that a slash across the great artery of the thigh in the +groin of a dog will be closed completely before he can bleed to death. +So delicate and so purposeful is this adjustment that the blood will +continue as fluid as milk for ten, twenty, forty, eighty years--as long +as it remains in contact with healthy blood-vessels. But the instant it +is brought in contact with a broken or wounded piece of a vessel-wall, +that instant it will begin to clot. So inevitable is this result that it +gives rise to some of the sudden forms of death by bloodclot in the +brain or lung (apoplexy, "stroke"), the clot having formed upon the +roughened inner surface of the heart or of one of the blood-vessels and +then floated into the brain or lung. + +Then take that matchless and ingenious process of the healing of wounds, +whose wondrousness increases with every step that we take into the +deeper details of its study. First, the quick outpouring and clotting of +the blood after enough has escaped to wash most poisonous or offending +substances out of the wound. This living, surgical cement, elastic, +self-moulding, soothing, not only plugs the cut or torn mouths of the +blood-vessels, but fills the gap of the wound level with the surface. +Here, by contact with the air and in combination with the hairs of the +animal it forms a tough, firm, protective coating or scab, completely +shutting out cold, heat, irritants, or infectious germs. + +Into the wedge-shaped, elastic clot which now fills the wound from +bottom to top like jelly in a mould, the leucocytes or white blood-cells +promptly migrate and convert it into a mesh of living cells. They are +merely the cavalry and skirmishers of the repair brigade and are +quickly followed by the heavy infantry of the line in the shape of cells +born of the injured tissues on either side of the wound. These join +hands across the gap, the engineer corps and the commissariat department +move up promptly to their support in the form of little +vein-construction switches, which bud out from the wounded +blood-vessels. The clot is transformed into what we term granulation +tissue and begins to organize. A few days later this granulation tissue +begins to contract and pull the lips of the wound together. If the gap +has not been too wide the wound will be completely closed, its lips and +deeper parts drawn together in nearly perfect line, separated only by a +thin scar on the surface with a vertical keel of scar tissue descending +from it. If the lips cannot be drawn together and there be no surgical +skill at hand to assist them with stitches or bandages, then the gap +will be filled up by the fibrous transformation of this granulation +tissue and a thick, heavy scar result. Meanwhile, the skin-cells of the +surface have not been idle, but are budding out on either side of the +healing wound, pushing a little line of colonists forward across the raw +surface. In longer or shorter time, according to the width of the gap, +these two lines meet, and the site of our wound or the scar that it has +left is perfectly coated over with a layer of healthy skin. This drama +has occurred so many score of times in every one of us that custom has +blinded our eyes to its ingenious perfection, but it took a million +years to bring it to its present finish. + +It may be a healthy corrective to our overweening conceit to remind +ourselves that, remarkable and valuable as it is, it is a mere infant +in arms compared to the superb powers of replacement and repair +possessed by our more remote ancestors. Most invertebrates and many of +the lowest two classes of backboned animals, the fishes and the +amphibians, cannot merely stop up a rent, but renew an entire limb, +fin,--yes, even eye or head. Cut an earthworm in two and the rear half +will grow a new head and the front half a new tail. It may even be cut +in four or five segments, each of which will proceed to form a head at +one end and a tail at the other. The lobster can regrow a complete gill +and any number of claws or an eye. A salamander will reproduce a foot +and part of a limb. Take out the crystalline lens in the eye of a +salamander and the edge of the iris, or colored part of the eye, will +grow another lens. Take out both the lens and the iris and the choroid +coat of the eye will reproduce both. + +We are in the A, B, C class in powers of repair by comparison with the +angleworm, the lobster, or the salamander. Yet we are not without +gruesome echoes of this lost power of regeneration in that our whole +brood of tumors, including the deadly cancer and sarcoma, are due to a +strange resumption, on the part of some little knot of our body-cells, +of the power of reproducing themselves or the organ in which they are +situated, without any regard to the welfare of the rest of the body. +Cancer is, in one sense, a throwing off of the allegiance to the +body-state and a resumption of amphibian powers of independent growth on +the part of certain groups of our body-cells--literally, a "rebellion of +the cells." + +These are but a handful of scores of instances that could be adduced, +showing that the majority of the processes upon which we rely in +combating disease and preserving life are the result of the hereditary +experiences of our cells. Intelligent physicians are receding completely +from that curiously warped and jaundiced view which led us to regard +heredity chiefly as a factor in the _production_ of disease. It was, +perhaps, natural enough, since it was inevitably only its injurious, or, +so to speak, malicious, effects which were brought to our attention to +be corrected. But, just as in the growth of our ethnic religions it is +Evil that is worshiped first as strongest and most aggressive, and the +recognition of the greater power of good comes only at a later stage, so +it has been in pathology. + +Not only do we regard heredity as a comparatively small and steadily +receding factor in the production of disease, but we fully and frankly +recognize it as the strongest and most important single force in its +prevention. All our processes of repair, all the reactions of the body +against the attack of accident or of disease, are hereditary endowments, +worked out with infinite pains and labor through tens of thousands of +generations. The utmost that we can do with our drugs and remedies is to +appeal to and rouse into action the great healing power of nature, the +classic "_Vis medicatrix Naturae_," an incarnation of our past +experiences handed down by heredity. Enormously valuable and important +as are the services to human welfare, health, and happiness which can be +rendered by the destruction of the living external causes of disease and +the prevention of contagion, our most permanent and substantial +victories are won by appealing to and increasing this long-descended and +hard-won power of individual resistance. + +"But," says some one at once, "I thought there were a large number of +hereditary diseases." Fifty years ago there were a score of such, twenty +years ago the score had sunk to five or six. Now there is scarcely one +left. There is no known disease which is directly inherited as such. +There is scarcely even a disease in which we now regard heredity as +playing a dominant or controlling part. Among the few diseases in which +there is serious dispute as to this are tuberculosis, insanity, +epilepsy, and cancer. + +Then there are diseases which for a long time puzzled us as to the +possibility of their inheritance, but which have now resolved themselves +clearly into instances of the fact that a mother who happens to contract +an acute infectious disease of any sort may communicate that disease to +the unborn child. If this occurs at an early stage of development the +child will naturally be promptly killed. In fact, this is the almost +invariable result in smallpox and yellow fever. If, on the other hand, +development be further advanced or the infection be of a milder +character, like scarlet fever or syphilis, the child may be born +suffering with the disease or with the virus in its blood, which will +cause the disease to develop within a few days after birth. This, +however, is clearly not inheritance at all, but direct infection. We no +longer use the term _hereditary_ syphilis but have substituted for it +the word _congenital_, which simply means that a child is born with the +disease. + +There is no such thing as this disease extending "unto the third and +fourth generation," like the wrath of Jehovah. One fact must, of course, +be remembered, which has probably proved a source of confusion in the +popular mind, and that is its extraordinary "long-windedness." It takes +not merely two or three weeks or months to develop its complete drama, +but anywhere from three to thirty years, so that it is possible for a +child to be born with the taint in its blood and yet not exhibit to the +non-expert eye any sign of the disease until its eighth, twelfth, or +even fifteenth year. + +The case of tuberculosis is almost equally clear-cut. In all the +thousands of post-mortem examinations which have been held upon newborn +children and upon mothers dying in or shortly after childbirth, the +number of instances of the actual transference of the bacilli of +tuberculosis from mother to child could be counted upon the fingers of +two hands. It is one of the rarest of pathologic curiosities and, for +practical purposes, may be entirely disregarded. When tuberculosis +appears in several members of a family, in eight cases out of ten it is +due to direct infection from parents or older children. This is +strikingly brought out in the admirable work done by the Associated +Dispensaries for Tuberculosis of the Charity Organization Society of New +York. + +One of the first steps in advance which they took was to establish in +connection with every clinic for tuberculosis an attendant nurse, whose +duty it was to visit the patients at their homes and advise and instruct +them as to improvements in their methods of living, ventilation, food, +and the prevention of infection. + +It was not long before these intelligent women began to bring back +reports of other cases in the same family. Now the procedure is +regularly adopted, whenever a case presents itself, of rounding up the +remainder of the family group for examination, with the astounding +result that where a mother or father is tuberculous, from twenty to +sixty per cent of the children will be found to be suffering from some +form of the infection. Instances of three infected children out of five +living in the same room with a tuberculous mother are actually on +record. + +No one can practice long in any of our great climatic health resorts for +tuberculosis, like Colorado or the Pacific Slope, without coming across +scores of painful and distressing instances of children of tuberculous +parents dying suddenly in convulsions from tuberculous meningitis, or by +a wasting diarrh[oe]a from tuberculosis of the bowels, or from a violent +attack of distention of the bowels due to tuberculous peritonitis. The +favorite breeding-place of the tubercle bacillus is unfortunately in the +home. + +On the other hand, while the vast majority of cases of so-called +hereditary tuberculosis are due to direct infection, and may be +prevented by proper disposal of the sputum and other methods for +avoiding contagion, there is probably a hereditary element in the spread +of tuberculosis to this degree: that, inasmuch as all of us have been +exposed to the attack and invasion of the tubercle bacillus, not merely +scores, but hundreds of times, and have been able to resist or throw +off that attack without apparent injury, the development of an invasion +of the tubercle bacillus sufficiently extensive to endanger life is, in +nine cases out of ten, in itself a proof of lowered resisting power on +the part of the patient. This may be, and often is, only temporary, due +to overwork, underfeeding, overconfinement, or that form of gradual +suffocation which we politely term inadequate ventilation. + +In a certain percentage of cases, however, it is due to a chronic lack +of vigor and vitality; a lowering of the whole systemic tone, which may +have existed from birth. In that case it is hardly to be expected that +such an individual, becoming a parent, will be able to transmit to his +or her offspring more vigor than he originally possessed. It is +therefore probable that the children of a considerable percentage of +tuberculous parents would not possess the same degree of resisting power +against tuberculosis, or any other infection, as the average individual. + +It is doubtful whether this factor of inherited lowered resistance plays +any very important part in the propagation of tuberculosis, partly +because it is comparatively seldom that consumptive marries consumptive, +and such tendencies to lowered vigor and vitality as may be transmitted +by one parent will be neutralized by the other; partly also because, by +the superb and beneficent logic of nature, the pedigree of any disease +is of the most mushroom and insignificant length, while the pedigree of +health stretches back to the very dawn of time. In the struggle for +dominance which takes place between the germ cells of the father and +those of the mother, the chances are at least ten to one in favor of +the old ancestral traits of vigor, of resisting power, and of survival. +How deeply this idea is implanted in the convictions of the scientific +world, the bitterly and widely debated biologic question whether +acquired characters or peculiarities can under any circumstances be +inherited clearly shows. Victory for the present rests with those who +deny the possibility of such inheritance, and disease is emphatically an +acquired character. + +Truth here, as everywhere, probably lies between the extremes, and both +biologists and the students of disease have arrived at practically the +same working compromise, namely, that while no gross defect, such as a +mutilation, nor definite disease factor, such as a germ, nor even a +cancer, can possibly be inherited, yet, inasmuch as the two cells, which +by their development form the new individual, are nourished by the blood +of the maternal body, influences which affect the nutritiousness or +healthfulness of that blood may unfavorably influence the development of +the offspring. + +Disease cannot be inherited any more than a mutilating defect, but the +results of both, in so far as they affect the nutrition of the offspring +in the process of formation, may be transmitted, though to a very much +smaller extent than we formerly believed. In the case of tuberculosis, +if the mother, during the months that she is building up the body and +framework of a child, is in a state of reduced or lowered nutrition on +account of consumption or any other disease, or has her tissues +saturated with the toxins of this disease, it is hardly to be expected +that the development of the child will proceed with the same perfection +as it would under perfectly normal maternal surroundings. + +However, even this influence is comparatively small; for one of the most +marvelous things in nature is the perfection of the barrier which she +has erected between the child before birth and any injurious conditions +which may occur in the body of the mother. Here preference, so to speak, +is given to the coming life, and whenever there is a contest for an +adequate supply of nutrition, as, for instance, in cases of underfeeding +or of famine, it is the mother who will suffer in her nutrition rather +than the child. The unborn child, biologically considered, feeds upon +the best she has to offer, rejecting all that is inferior, doing nothing +and giving nothing in return. + +How perfectly the coming generation is protected under the most +unfavorable circumstances we have been given a striking object-lesson in +one family of the lower animals. In the effective crusade against +tuberculosis in dairy cattle waged by the sanitary authorities in +Denmark, it was early discovered that the greatest practical obstacle to +the extermination of tuberculosis in cattle was the enormous financial +sacrifice involved in killing all animals infected. The disease was at +that time particularly rife among the high-bred Jersey, Holstein, and +other milking breeds. It was determined as a working compromise to test +the truth of the modern belief that tuberculosis was transmitted only by +direct infection, by permitting the more valuable cows to be saved alive +for breeding purposes. They were isolated from the rest of the herd and +given the best of care and feeding. The moment that their calves were +born they were removed from them altogether and brought up on the milk +of perfectly healthy cows. The milk of the infected cows was either +destroyed or sterilized and used for feeding pigs. + +The results were brilliantly successful. Scarcely one of the calves thus +isolated developed tuberculosis in spite of their highly infected +ancestry. And not only were they not inferior in vigor and perfection of +type to the remainder of their breed, but some of them have since become +prize-winners. The additional care and more abundant feeding that they +received more than compensated for any problematic defect in their +heredity. + +As to the heredity of cancer, all that can be said is that the burden of +proof rests upon those who assert it. It is really curious how +widespread the belief is that cancer "runs in families," and how +exceedingly slender is the basis of evidence for such a belief. There +are so many things that we do not know about cancer that any positive +statement of any kind would be unbecoming. It would be absurd to declare +that a disease, of which the cause is still unknown, either is or is not +inherited. And this is our position in regard to cancer. An overwhelming +majority of the evidence so far indicates that it is not a parasite; if +it were, of course, we could say positively that it is not inherited. +Although we are getting a discouraging degree of familiarity with the +process and clearly recognize that it consists chiefly in the sudden +revolt or rebellion of some group of cells, a tendency which quite +conceivably might be transmitted to future generations, yet it is highly +improbable, on both biological and pathological grounds, that such is +the case. If this rebellious tendency were transmitted we should at +least have the right to expect that it would appear in the cells of the +same organ or region of the body. It is a singular fact that in all the +hundreds of cases in which cancer has appeared in the child of a +cancerous parent it has almost invariably appeared in some different +organ from that affected in the parent. + +For instance, cancer of the lip in the father may be followed by cancer +of the liver in the son or daughter, while cancer of the breast in the +mother will be followed by cancer of the lip in a son. Further than +this, the percentage of instances in which cancer appears in more than +one member of a family is decidedly small, considering the frequency of +the disease. + +I took occasion to look into the matter carefully from a statistical +point of view some ten or twelve years ago, and out of a collection of +some fifty thousand cases of cancer less than six per cent were found to +give any history of cancer in the family. And this, of course, simply +means that some one of the relatives of the patient had at one time +developed the disease. + +In fact, the consensus of intelligent expert opinion upon the subject of +heredity of cancer is, that though it may occur, we have comparatively +little proof of the fact; that the percentage of cases in which there is +cancer in the family is but little larger than might be expected on the +doctrine of probabilities from the average distribution. Though possibly +the offspring of a cancerous individual may display a slightly greater +tendency toward the development of that strange, curious process of +"autonomy" than the offspring of the average individual, this tendency +is so small and occurs so infrequently as to be a factor of small +practical importance in the propagation and spread of the disease. + +In insanity and epilepsy we have probably the last refuge and almost +only valid instance of the old belief in the remorseless heredity of +disease. But even here the part played by heredity is probably only a +fraction of that which it is popularly, and even professionally, +believed to play. It is, of course, obvious that diseases which tend +quickly to destroy the life of the patient, especially those which kill +or seriously cripple him before he has reached the age of reproduction, +or prevent his long surviving that epoch, will not, for mechanical +reasons, become hereditary. The Black Death, or the cholera, for +instance, could not "run in a family." Supposing that children were born +with a special susceptibility to this disease, there would obviously +soon be no family left. + +The same is true in a lesser degree of milder or more chronic diseases. +The family which was hereditarily predisposed to scarlet fever, measles, +smallpox, or tuberculosis would not last long, and in fact the whole +progress of civilization has been a continuous process of the weeding +out of those who were most susceptible and the survival of those who +were least so. + +But when we come to deal with certain conditions, fortunately rare, such +as functional disturbances of the nervous system, which neither +seriously unfit their possessor for the struggle of life nor prevent +him from reproducing his kind, then it becomes possible that a tendency +to such disease may be transmitted through several successive +generations. + +Such is the case with insanity, with epilepsy, with _hemophilia_, or +"bleeders," and with certain rare and curious disturbances of the +nervous system, such as the hereditary _ataxias_ and "tics" of various +sorts. However, even here the only conditions on which these diseases +can continue to run in a family for more than one or two generations is +either that they shall be mild in form or that only a comparatively +small percentage of the total family shall be affected by them. If, for +instance, two-thirds, one-half, or even a third of the descendants of a +mentally unsound individual were to become insane, it would only need a +few generations for that family to be crushed to the wall. + +While the descendants of insane persons are distinctly more liable to +become insane than the rest of the community, yet, on account of their +fewness, this tendency probably does not account for more than a small +fraction of the total insanity. We should, by all means, prevent the +marriage of the insane and discourage that of their children, and the +development of any well-defined form of insanity should act at once, +_ipso facto_, as a ground and cause of divorce. + +But the consoling fact remains that even of such children, providing, of +course, as usually happens, that the other parent--husband or wife--is +sound and sane, not more than ten or fifteen per cent would probably +become insane. In other words, insanity is acquired and the result of +individual stress and strain at least five times as frequently as it is +inherited. We have absolutely no rational or statistical basis for +gloomy predictions that, at present rates, within a couple of centuries +more, we shall all be shut up in asylums with nobody left to support us +and pay the taxes. The apparent increase of insanity of recent decades +is probably only "on paper," due to better registration. + +To put it very roughly, probably ninety-eight per cent of us are so +born, thanks to heredity, that the possibility of our becoming insane, +even under the severest stress, is almost infinitesimal. Of the two per +cent born with this taint, this possible tendency to mental unbalance, +only about one-tenth now become completely insane,[1] and this +percentage might be greatly diminished by general sanitary improvements. +Our alienists now claim that, by checking the reproduction of the +obviously unstable, and careful hygienic treatment and training of the +predisposed two per cent, insanity is almost as preventable as +tuberculosis. + +[Footnote 1: The proportion of registered insane in civilized countries +to-day ranges from two to three per 1000 of the population.] + +In fine, from all the broad field of pathology, the mists of tradition +which have dimmed the fair name and reputation of heredity are slowly +but surely lifting, until we now behold it, not as our worst enemy, but +as our best friend in the prevention of disease and the upbuilding of +the race. + + + + +CHAPTER III + +THE PHYSIOGNOMY OF DISEASE: WHAT A DOCTOR CAN TELL FROM APPEARANCES + + +It is our pride that medicine, from an art, and a pretty black one at +that, originally, is becoming a science. And the most powerful factor in +this development, its indispensable basis, in fact, has been the +invention of instruments of precision--the microscope, the fever +thermometer, the stethoscope, the ophthalmoscope, the test-tube, the +culture medium, the triumphs of the bacteriologist and of the chemist. +Any man who makes a final diagnosis in a serious case without resorting +to some or all of these means is regarded--and justly--as careless and +derelict in his duty to his patient. + +At the same time, priceless and indispensable as are these laboratory +methods of investigation, they should not be allowed to make us too +scornful and neglectful of the evidence gained by the direct use of our +five senses. We should still avail ourselves of every particle of +information that can be gained by the trained eye, the educated ear, the +expert touch,--the _tactus eruditus_ of the medical classics,--and even +the sense of smell. There is, in fact, a general complaint among the +older members of the profession that the rising generation is being +trained to neglect and even despise the direct evidence of the senses, +and to accept no fact as a fact unless it has been seen through the +microscope or demonstrated by a reaction in the test-tube. As one of our +keenest observers and most philosophic thinkers expressed it a few +months ago:-- + +"I fear that certain physicians on their rounds are most careful to take +with them their stethoscope, their thermometer, their hemoglobin papers, +their sphygmomanometer, but leave their eyes and their brains at home." + +And it is certain that the art of sight diagnosis, which seems like half +magic, possessed in such a wonderful degree by the older physicians of +the passing and past generations, has been almost lost by the new. + +A healthful reaction has, however, set in; and while we certainly do not +love the Caesar of laboratory methods and accuracy the less, we are +beginning to have a juster affection for the Rome of the rich harvest +that may be gained from the careful, painstaking, detective-like +exercise of our eye, ear, and hand. + +As a matter of fact, the conflict between the two methods is only +apparent. Not only is each in its proper sphere indispensable, but they +are enormously helpful one to the other. Instead of our being able to +tell less by the careful, direct eye-and-hand examination of our +patients than the doctor of a century ago, we can tell three to five +times as much. Signs that he could interpret only by the slow and +painful method of two-thirds of a lifetime of plodding experience, or by +occasional flashes of half-inspired insight, we are now able to +interpret absolutely upon a physiological--yes, a chemical--basis from +the revelations of the microscope, the test-tube, and the culture +medium. His only way of determining the meaning of a particular tint of +the complexion, or line about the mouth, or eruption on the skin, was by +slowly and laboriously accumulating a long series of similar cases in +which that particular symptom was found always to occur, and deducing +its meaning. Now, we simply take a drop of our patient's blood, a +scraping from his throat, a portion of some one of his secretions, a +little slice of a tumor or growth, submit them to direct examination in +the laboratory, and get a prompt and decisive answer. + +The observant physician begins to gather information about a patient +from the moment he enters the sick-room or the patient steps into his +consulting-room; and the value of the information obtained in the first +thirty seconds, before a word has been spoken, is sometimes +astonishingly great. While no intelligent man would dream of depending +upon this first _coup d'[oe]il_, "stroke of the eye" as the French so +graphically call it, for his final diagnosis, or accept its findings +until he had submitted them to the most ruthless cross-examination with +the stethoscope and in the laboratory, yet it will sometimes give him a +clew of almost priceless value. It is positively uncanny to see the +swift, intuitive manner in which an old, experienced, and thoughtful +physician will grasp the probable nature of a case in one keen look at a +patient. Often he can hardly explain to you himself how he does it, what +are the data that determine it; yet not infrequently, three times out +of five, your most elaborate and painstaking study of the case with all +the modern methods will bring you to the same conclusion as that sensed +within forty-five seconds by this keen-eyed old sleuth-hound of the +fever trails. Time and again, in my interne days, have I gone the rounds +of the wards or the out-patient departments with some kindly-faced, +keen-eyed old Sherlock Holmes of the profession, and seen him point to a +new case across the ward with the question: "When did that pneumonia +come in?" or pick out a pain-drawn, ashy mask in the waiting line, with +an abrupt, "Bring me that case of cancer of the stomach. He's in pain. +I'll take him first." + +And, in later years, I have had colleagues with whom it was positively +painful to walk down a crowded street, from the gruesome habit that they +had of picking out, and condemning to lingering deaths, the cases of +cancer, of Bright's disease, or of locomotor ataxia, that we happened to +meet. Of course, they would be the first to admit that this was only +what they would term a "long shot," a guess; but it was a guess based +upon significant changes in the patient's countenance or gait, which +their trained eye picked out at once, and it was surprising how often +this snapshot diagnosis turned out to be correct. + +The first thing that a medical student has to learn is that appearances +are _not_ deceptive--except to fools. Every line of the human figure, +every proportion of a limb, every detail of size, shape, or relation in +an organ, _means_ something. Not a line upon any bone in the skeleton +which was not made by the hand-grip or thumbprint of some muscle, +tendon, or ligament; no bump or knuckle which is not a lever or +hand-hold for the grip of some muscle; not a line or a curve or an +opening in that Chinese puzzle, the skull, which was not made to protect +the brain, to accommodate an eye, to transmit a blood-vessel, or to +allow the escape of a nerve. Every minutest detail of structure means +something to the man who will take the pains to puzzle it out. And if +this is true of the foundation structure of the body, is it to be +expected that the law ceases to run upon the surface? + +Not a line, not a tint, not a hollow of that living picture, the face, +but means something, if we will take the time and labor to interpret it. +Even coming events cast their shadows before upon that most exquisitely +responsive surface--half mirror, half sensitive plate--the human +countenance. The place where the moving finger of disease writes its +clearest and most unmistakable message is the one to which we must +naturally turn, the face; not merely for the infantile tenth part of a +reason which we often hear alleged, that it is the only part of the +body, except the hand, which is habitually exposed, and hence open to +observation, but because here are grouped the indicators and registers +of almost every important organ and system in the body. + +What, of course, originally made the face the face, and, for the matter +of that, the head the head, was the intake opening of the food-canal, +the mouth. Around this necessarily grouped themselves the outlook +departments, the special senses, the nose, the eyes, and ears; while +later, by an exceedingly clumsy device of nature, part of the mouth was +split off for the intake of a new ventilating system. So that when we +glance at the face we are looking first at the automatically controlled +intake openings of the two most important systems in the body, the +alimentary and the respiratory, whose muscles contract and relax, ripple +in comfort or knot in agony, in response to every important change that +takes place throughout the entire extent of both. + +Second, at the apertures of the two most important members of the +outlook corps, the senses of sight and of smell. These are not only +sharply alert to every external indication of danger, but by a curious +reversal, which we will consider more carefully later, reflect signals +of distress or discomfort from within. Last, but not least, the +translucent tissues, the semi-transparent skin, barely veiling the +pulsating mesh of myriad blood-vessels, is a superb color index, +painting in vivid tints--"yellow, and ashy pale, and hectic red"--the +living, ever changing, moving picture of the vigor of the life-centre, +the blood-pump, and the richness of its crimson stream. Small wonder +that the shrewd advice of a veteran physician to the medical student +should be: "The first step in the examination is to look at your +patient; the second is to look again, and the third to take another look +at him; and keep on looking all through the examination." + +It is no uncommon thing for an expert diagnostician deliberately to lead +the patient into conversation upon some utterly irrelevant subjects, +like the weather, the crops, or the incidents of his journey to the +city, simply for the purpose of taking his mind off himself, putting +him at his ease, and meanwhile quietly deciphering the unmistakable +cuneiform inscription, often twice palimpsest, written by the finger of +disease upon his face. It takes time and infinite pains. In no other +realm does genius come nearer to Buffon's famous description, "the +capacity for taking pains," but it is well worth the while. And with all +our boasted and really marvelous progress in precise knowledge of +disease, accomplished through the microscope in the laboratory, it +remains a fact of experience that so careful and so trustworthy is this +face-picture when analyzed, that our best and most depended upon +impressions as to the actual condition of patients, are still obtained +from this source. Many and many a time have I heard the expression from +a grizzled consultant in a desperate case, "Well, the last blood-count +was better," or, "The fever is lower," or, "There is less albumen,--but +I don't like the look of him a bit"; and within twenty-four hours you +might be called in haste to find your patient down with a hemorrhage, or +in a fatal chill, or sinking into the last coma. + +It would really be difficult to say just what that careful and loving +student of the _genus humanum_ known as a doctor looks at first in the +face of a patient. Indeed, he could probably hardly tell you himself, +and after he has spent fifteen or twenty years at it, it has become such +a second nature, such a matter of instinct with him, that he will often +put together all the signs at once, note their relations, and come to a +conclusion almost in the "stroke of an eye," as if by instinct, just as +a weather-wise old salt will tell you by a single glance at the sky +when and from what quarter a storm is coming. + +I shall never forget the remark of my greatest and most revered teacher, +when he called me into his consultation-room to show me a case of +typical locomotor ataxia, gave me a brief but significant history, put +the patient through his paces, and asked for a diagnosis. I hesitated, +blundered through a number of further unnecessary questions, and finally +stumbled upon it. After the patient had left the room, I, feeling rather +proud of myself, expected his commendation, but I didn't get it. "My +boy," he said, "you are not up to the mark yet. You should be able to +recognize a disease like that just as you know the face of an +acquaintance on the street." A positive and full-blown diagnosis of this +sort can, of course, only be made in two or three cases out of ten. But +the method is both logical and scientific, and will give information of +priceless value in ninety-nine cases out of a hundred. + +Probably the first, if not the most important, character that catches +the physician's eye when it first falls upon a patient is his +expression. This, of course, is a complex of a number of different +markings, but chiefly determined by certain lines and alterations of +position of the skin of the face, which give to it, as we frequently +hear it expressed, an air of cheerfulness or depression, comfort or +discomfort, hope or despair. These lines, whether temporary or +permanent, are made by the contractions of certain muscles passing from +one part of the skin to another or from the underlying bones to the +skin. These are known in our anatomical textbooks by the natural but +absurd name of "muscles of expression." + +Their play, it is true, does make up about two-thirds of the wonderful +shifting of relations, which makes the human countenance the most +expressive thing in the world; but their original business is something +totally different. Primarily considered, they are solely for the purpose +of opening or closing, contracting or expanding, the different orifices +which, as we have seen, appear upon the surface of the face. This +naturally throws them into three great groups: those about and +controlling the orifice of the alimentary canal, the mouth; those +surrounding the joint openings of the air-tube and organ of smell, and +those surrounding the eyes. + +As there are some twenty-four pairs of these in an area only slightly +greater than that of the outspread hand, and as they are capable of +acting with every imaginable grade of vigor and in every possible +combination, it can readily be seen what an infinite and complicated +series of expressions--or, in other words, indications of the state of +affairs within those different orifices--they are capable of. Only the +barest and rudest outlines of their meaning and principles of +interpretation can be attempted. To put it very roughly, the main +underlying principle of interpretation is that we make our first +instinctive judgment of the site of the disease from noting which of the +three great orifices is distorted furthest from its normal condition. +Then by constructing a parallel upon the similarity or the difference of +the lines about the other two openings, we get what a surveyor would +call our "lines of triangulation," and by following these to their +converging point can often arrive at a fairly accurate localization. + +The greatest difficulty in the method, though at times our greatest +help, is the extraordinary and intimate sympathy which exists between +all three of these groups. If pain, no matter where located, once +becomes intense enough, its manifestations will travel over the +face-dial, overflowing the organ or system in which it occurs, and eyes, +nostrils, and mouth will alike reveal its presence. Here, of course, is +where our second great process, so well known in all clew-following, +elimination, comes in. + +A patient comes in with pain-lines written all over his face. To put it +very roughly--has he cancer of the stomach? Pneumonia? Brain tumor? If +there be no play of the muscles distending and contracting the nostrils +with each expiration, no increased rapidity of breathing, no gasp when a +full breath is drawn, and no deep red fever blush on the cheeks, we +mentally eliminate pneumonia. The absence of these nasal signs throws us +back toward cancer or some other painful affection of the alimentary +canal. If the pain-lines about the mouth are of recent formation, and +have not graved themselves into the furrows of the forehead above and +between the eyebrows; if the color, instead of ashy, be clear and red, +we throw out cancer and think of colic, ulcer, hyperacidity, or some +milder form of alimentary disease. + +If, on the other hand, the pain-lines are heaviest about the brows, the +eyes, and the forehead, with only a sympathetic droop or twist of the +corners of the mouth, if the nostrils are not at all distorted or too +movable, if there is no fever flush and little wasting, and on turning +to the eyes we find a difference between the pupils, or a wide +distention or pin-point-like contraction of both or a slight squint, the +picture of brain tumor would rise in the mind. Once started upon any one +of these clews, then a hundred other data would be quickly looked for +and asked after, and ultimately, assisted by a thorough and exhaustive +examination with the instruments of precision and the tests in the +laboratory, a conclusion is arrived at. This, of course, is but the +roughest and crudest outline suggestive of the method of procedure. + +Probably not more than once in three times will the first clew that we +start on prove to be the right one; but the moment that we find this +barred, we take up the next most probable, and in this manner hit upon +the true scent. + +As to the cause and rationale of these pain-lines, only the barest +outlines can be given. Take the mouth for an example. When all is going +well in the alimentary canal, without pain, without hunger, and both +absorption of food and elimination of waste are proceeding normally, the +tissues about the mouth, like those of the rest of the body, are apt to +be plump and full; the muscles which open the aperture, having fulfilled +their duty and received their regular wages, are quietly at rest; those +that close the opening, having neither anticipation of an early call for +the admission of necessary nutriment, nor an instinctive desire to shut +out anything that may be indigestible or undesirable, are now in their +normal condition of peaceful, moderate contraction; the face has a +comfortable, well-fed, wholesome look. On the other hand, let the +digestive juices fail to do their duty properly, or the swarms of +bacteria pets which we keep in our food-canals get beyond control; or if +for any other reason the tissues be kept from getting their proper +supply of nourishment from the food-canal, the state of affairs is +quickly revealed in the mouth mirror. Those muscles which open the +mouth, instead of resting peacefully in the consciousness of duty well +done, are in a state of perpetual fidget, twitching, pulling, wondering +whether they ought not to open the portal for the entrance of new +supplies of material, since the tissues are crying for food. + +As the strongest of these are those which pull the corners of the mouth +outward and downward, the resultant expression is one of depression, +with downward-curving angles to the mouth. The eyes, and even the +nostrils, sympathetically follow suit, and we have that countenance +which, by the cartoonist's well-known trick, can be produced by the +alteration of one pair of lines, those at the angles of the mouth, +turning a smiling countenance into a weeping one. On the other hand, if +all these processes of nutrition and absorption are proceeding as they +should, they are accompanied by mild sensations of comfort which, +although they no longer reach our consciousness, reveal themselves in +the mouth-opening muscles, and they gently contract upward and outward, +in pleasurable anticipation of the next intake, and we get the grin or +the smile. + +If, on the other hand, these digestive disturbances be accompanied by +pain, then another shading appears on our magic mirror, and that is a +curious contraction of the mouth, with distortion of the lines +surrounding it, so violent in some cases as positively to whiten the +lips or produce lines of paleness along the course of the muscles. This +is the set or twisted mouth of agony, and is due to a curious +transference and reflex on this order: that inasmuch as the last food +which entered the alimentary canal seems to have caused this disturbance +and pain, no more will be allowed to enter it at present under any +conditions. And as our alimentary instincts are the most fundamental of +all, by a due process of transference, mental agony calls into action +this same set of muscles, to shut out any possible addition to the agony +already present. + +The lines of determination, similarly, about the mouth, are those of the +individual who has the courage to say "No" to the tempting morsel when +he doesn't need it; and the lines of weakness and irresolution are those +of the nature which cannot resist either gastronomic or other +temptation. Similarly, the well-known lines of disgust or of discontent +about the corners of the mouth are the unconscious contractions +accompanying nausea, and preparations to expel the offending morsel +whether from stomach or mouth. + +If, on the other hand, our first glance shows us that the deepest +pain-lines are those about the nostrils and upper lip, especially if the +wings of the nostrils can be seen to dilate with each breath, and +breathing be faster than normal, our clew points in the direction of +some disease of the great organs above the diaphragm--that is, the +lungs or heart. + +Signs in this region might refer to either of these, for the reason +that, although a sufficient intake of air is one of the necessary +conditions of proper oxygenation, a free and abundant circulation of the +blood through the air-cells is equally essential. In fact, that common +phenomenon known as "shortness of breath" is more frequently due to +disturbances of the heart and circulation than it is to the lungs, +especially in patients who are able to be up and about. If, in addition +to the danger signal of the rise and fall of the nostrils with each +breath, we have a pale, translucent skin, with a light, hectic flush +showing just below the knife-like lower edge of the cheekbone, a widely +open, shining eye, and a clustering abundance of hair of a glossiness +bordering on dampness, red lips slightly parted, showing the teeth +between, a painfully strong suspicion of consumption would arise +unbidden. + +This pathetic type of face has that fatal gift which the French +clinicians, with their usual happiness of phrase, term _La beaute du +diable_. The eager eyes, dilated nostrils, parted lips, give that weird +air of exaltation which, when it occurs, as it occasionally does in the +dying, is interpreted as the result of glimpses into a spirit world. +When to this is added the mild delirium of fever, when memories of +happier days and of those who have passed before rise unbidden and +babble themselves from the tongue, one can hardly wonder at this +interpretation. + +The last group of lines to be noted is that about the eyes and +forehead. These are less reliable than either of the other two, for the +reason that they are so sympathetic as almost invariably to be present +in addition, whenever the lower dial-plates of the face are disturbed. +It is only when they appear alone that they are significant; then they +may be interpreted as one of three things: first, and commonest, eye +strain; second, disease in some part of the nervous system or muscular +system, not connected with the organs of the chest or abdomen; and +third, mental disturbances. + +This last relation, of course, makes them in many respects the least +reliable of all the face indices, because--as is household +knowledge--they indicate mental conditions and operations, as well as +bodily. "The wrinkled brow of thought," the "deep lines of perplexity," +etc., are in the vocabulary of the grammar grades. They are, however, a +valuable check upon the other two groups. They are not apt to be present +in consumption and in other forms of serious disease, attended by fever, +on account of the curious effect produced by the toxins of the disease, +which is often not only stimulating, but even of an exhilarating nature, +or will produce a slight stupor or lethargy, such as is typical of +typhoid. + +One of the most singular transformations in the sick-room, especially in +serious disease marked by lethargy or stupor, is that in which the +patient's countenance will appear like a sponged-off slate, so +completely have the lines of worry and of thought been obliterated. + +One distinct value of the pain-lines about the eyes and brow is that you +can often test their genuineness. Just engage your hypochondriac or +hysterical patient in lively conversation; or, on the reverse principle, +wound his vanity, so as to produce an outburst of temper, and see how +the lines of undying agony will fade away and be replaced by the curves +of amusement or by the straight-drawn brows of indignation. + +As with the painter, next to line comes color. Every one, of course, +knows that a fresh, rosy color is usually associated with health, while +a pale, sallow complexion suggests disease. But our color signals, while +more vivid, are much less reliable and more apt to deceive than our +line-markings. + +Surprising as it may sound, careful analyses have shown, first, that the +kind of pigment present in the human skin of every race is absolutely +one and the same. The only difference between the negro and the white +man is that the negro has two or three times as much of it. Secondly, +that every skin except that of the albino has a certain, and usually a +considerable, amount of this pigment present in it. + +"The red hue of health" is even more apt to mislead us, because, being +due to the abundance of blood in the meshes of the skin, many fevers, by +increasing the rapidity of the heart-beat and dilating the vessels in +the skin, give a ruddiness of hue equal to or in excess of the normal. + +However, a little careful checking up will eliminate most of the +possible mistakes and enable us to obtain information of the greatest +value from color. For instance, if our patient be of Southern blood, or +tanned from the seashore, the good red blood in his arteries is pretty +safe to show through at the normal blush area on the cheeks; or, failing +that, through the translucent epithelium of the lips and gums. If, on +the other hand, this yellow tint be due to the escape of broken-down +blood-pigments into the tissues, or a damming up of the bile, and a +similar escape of its coloring matter, as in jaundice, then we turn to +the whites of the eyes, and if a similar, but more delicate, yellowish +tint confronts us there, we know we have to deal with a severe form of +anaemia or jaundice, according to the tint. In extreme cases of the +latter, the mucous membrane of the lips and of the gums will even show a +distinctly yellowish hue. The frightful color of yellow fever, and the +yellow "death mask," which appears just before the end of several fatal +forms of blood poisoning, is due to the tremendous breaking down of the +red cells of the blood under the attack of the fever toxins, and their +leaking out into the tissues. A similar process of a milder and less +serious extent occurs in those temporary anaemias of young girls, known +for centuries past in the vernacular as "the green sickness." And a +delicate lemon tint of this same origin, accompanied by a waxy pallor, +is significant of the deadly, pernicious anaemia and the later stages of +cancer. + +The most significant single thing about the red flush, supposed to be +indicative of health, is its location. If this be the normal "blush +area," about the middle of each cheek,--which is one of nature's sexual +ornaments, placed, like a good advertisement, where it will attract most +attention and add most beauty to the countenance,--and it fades off +gradually at the edges into the clear whiteness or brownness of the +healthy skin, it is probably both healthy and genuine. If the work of +either fever or of art, it will generally reveal itself as a base +imitation. In eight cases out of ten of fever, the flush, instead of +being confined to this definite area, extends all over the face, even up +to the roots of the hair. The eyes, instead of being clear and bright, +are congested and heavy-lidded; and if with these you have an increased +rapidity of respiration, and a general air of discomfort and unrest, you +are fairly safe in making a diagnosis of fever. If the first touch of +the tips of the fingers on the wrist shows a hot skin and a rapid pulse, +the diagnosis is almost as certain as with the thermometer. + +Now for two of the instances in which it most commonly puzzles us. The +first of these is consumption; for here the flush, both in position and +in delicacy and gentle fading away at the proper margins, is an almost +perfect imitation of health. It, however, usually appears, not as the +normal flush of health does, upon a plump and rounded cheek, but upon a +hollow and wasted one. It rises somewhat higher upon the cheekbones, +throwing the latter out into ghastly prominence. The lips and the eyes +will give us no clew, for the former are red from fever, and the latter +are bright from the gentle, half-dreamy state produced by the toxins of +the disease, the so-called "_spes phthisica_"--the everlasting and +pathetic hopefulness of the consumptive. But here we call for help upon +another of the features of disease--the hand. If, instead of being cool, +and elastic, this is either dry and hot, or clammy and damp, and feels +as if you were grasping a handful of bones and nerves, and the +finger-tips are clubbed and the nails curved like claws, then you have a +strong _prima facie_ case. + +The other color condition which is apt to puzzle us is that of the plump +and comfortable middle-aged gentleman with a fine rosy color, but a +watery eye and loose and puffy mouth, a wheezy respiration and apparent +excess of adipose. Here the high color is often due to a paralytic +distention of the blood-vessels of the face and neck, and an examination +of his heart and blood-vessels shows that his prospects are anything but +as rosy as his countenance. + +The varying expressions of the face of disease are by no means confined +to the countenance. In fact, they extend to every portion of--in +Trilby's immortal phrase--"the altogether." Disease can speak most +eloquently through the hand, the carriage, the gait, and, in a way that +the patient may be entirely unconscious of, the voice. These forms of +expression are naturally not so frequent as those of the face, on +account of the extraordinary importance of the great systems whose +clock-dials and indices form what we term the human countenance. But +when they do occur they are fully as graphic and more definitely and +distinctively localizing. + +Next in importance to the face comes the hand, and volumes have been +written upon this alone. Containing, as it does, that throbbing little +blood-tube, the radial artery, which has furnished us for centuries with +one of our oldest and most reliable guides to health conditions, the +pulse, it has played a most important part in surface diagnoses. To this +day, in fact, Arabic and Turkish physicians in visiting their patients +on the feminine side of the family are allowed to see nothing of them +except the hand, which is thrust through an opening in a curtain. How +accurate their diagnoses are, based upon this slender clew, I should not +like to aver, but a sharp observer might learn much even from this +limited area. + +We have--though, of course, in lesser degree--all the color and line +pictures with which we have been dealing upon the face. Though not an +index of any special system, it has the great advantage of being our one +approach to an indication of the general muscular tone of the body, as +indicated both in its grasp and in the poses it assumes at rest. The +patient with a limp and nerveless hand-clasp, whose hand is inclined to +lie palm upward and open instead of palm downward and half-closed, is +apt to be either seriously ill, or not in a position to make much of a +fight against the attack of disease. + +The nails furnish one of our best indices of the color of the blood and +condition of the circulation. Our best surface test of the vigor of the +circulation is to press upon a nail, or the back of the finger just +above it, until the blood is driven out of it, and when our thumb is +removed from the whitened area to note the rapidity with which the red +freshet of blood will rush back to reoccupy it. + +In the natural growth of the nail, traveling steadily outward from root +to free edge, its tissues, at first opaque and whitish, and thus +forming the little white crescent, or _lunula_, found at the base of +most nails, gradually become more and more transparent, and hence pinker +in color, from allowing the blood to show through. During a serious +illness, the portion of the nail which is then forming suffers in its +nutrition, and instead of going on normally to almost perfect +transparency, it remains opaque. And the patient will, in consequence, +carry a white bar across two or three of his nails for from three to +nine months after the illness, according to the rate of growth of his +nails. Not infrequently this white bar will enable you to ask a patient +the question, "Did you not have a serious illness of some sort two, +three, or six months ago?" according to the position of the bar. And his +fearsome astonishment, if he answers your question in the affirmative, +is amusing to see. You will be lucky if, in future, he doesn't incline +to regard you as something uncanny and little less than a wizard. + +Another of the score of interesting changes in the hand, which, though +not very common, is exceedingly significant when found, is a curious +thickening or clubbing of the ends of the fingers, with extreme +curvature of the nails, which is associated with certain forms of +consumption. So long has it been recognized that it is known as the +"Hippocratic finger," on account of the vivid description given of it by +the Greek Father of Medicine, Hippocrates. It has lost, however, some of +its exclusive significance, as it is found to be associated also with +certain diseases of the heart. It seems to mean obstructed circulation +through the lungs. + +Next after the face and the hand would come the carriage and gait. When +a man is seriously sick he is sick all over. Every muscle in his body +has lost its tone, and those concerned with the maintenance of the erect +position, being last developed, suffer first and heaviest. The bowed +back, the droop of the shoulders, the hanging jaw, and the shuffling +gait, tell the story of chronic, wasting disease more graphically than +words. We have a ludicrously inverted idea of cause and effect in our +minds about "a good carriage." We imagine that a ramrod-like stiffening +of the backbone, with the head erect, shoulders thrown back and chest +protruded, is a cause of health, instead of simply being an effect, or +one of the incidental symptoms thereof. And we often proceed to drill +our unfortunate patients into this really cramped and irrational +attitude, under the impression that by making them look better we shall +cause them actually to become so. The head-erect, chest-out, +fingers-down-the-seam-of-your trousers position of the drillmaster is +little better than a pose intended chiefly for ornament, and has to be +abandoned the moment that any attempt at movement or action is begun. + +So complete is this unconscious muscular relaxation, that it is +noticeable not only in the standing and sitting position, but also when +lying down. When a patient is exceedingly ill, and in the last state of +enfeeblement, he cannot even lie straight in bed, but collapses into a +curled-up heap in the middle of the bed, the head even dropping from the +pillow and falling on the chest. Between this _debacle_ and the slight +droop of shoulders and jaw indicative of beginning trouble there are a +thousand shades of expression significant instantly to the experienced +eye. + +Though more limited in their application, yet most significant when +found, are the alterations of the gait itself. Even a maker of proverbs +can tell at a glance that "the legs of the lame are not equal." From the +limp, coupled with the direction in which the toe or foot is turned, the +tilt of the hips, the part of the foot that strikes first, the presence +or absence of pain-lines on the face, a snap diagnosis can often be made +as to whether the trouble is paralysis, hip-joint disease, knee or ankle +mischief, or flatfoot, as your patient limps across the room. Even where +both limbs are affected and there is no distinct limp, the form of +shuffle is often significant. + +Several of the forms of paralysis have each its significant gait. For +instance, if a patient comes in with a firm, rather precise, calculated +sort of gait, "clumping" each foot upon the floor as if he had struck it +an inch sooner than he had expected, and clamping it there firmly for a +moment before he lifts it again, as though he were walking on ice, with +more knee action than seems necessary, you would have a strong suspicion +that you had to deal with a case of _locomotor ataxia_, in which loss of +sensation in the soles of the feet is one of the earliest symptoms. If +so, your patient, on inquiry, will tell you that he feels as if there +were a blanket or even a board between his soles and the surface on +which he steps. If a quick glance at the pupils shows both smaller or +larger than normal, and on turning his face to the light they fail to +contract, your suspicion is confirmed; while if, on asking him to be +seated and cross his legs, a tap on the great extensor tendon of the +knee-joint just below the patella fails to elicit any quick upward jerk +of the foot, the so-called "knee-kick," then you may be almost sure of +your diagnosis, and proceed to work it out at your leisure. + +On the other hand, if an elderly gentleman enters with a curiously blank +and rather melancholy expression of countenance, holding his cane out +stiffly in front of him, and comes toward you at a rapid, toddling gait, +throwing his feet forward in quick, short steps, as if, if he failed to +do so, he would fall on his face, while at the same time a vibrating +tremor carries his head quickly from side to side, you are justified in +suspecting that you have to do with a case of _paralysis agitans_, or +shaking palsy. + +Last of all, your physiognomy of disease includes not merely its face, +but its voice; not only the picture that it draws, but the sound that it +makes. For, when all has been allowed and discounted that the most +hardened cynic or pessimistic agnostic can say about speech being given +to man to conceal his thoughts, and the hopeless unreliability of human +testimony, two-thirds of what your patients tell you about their +symptoms will be found to be literally the voice of the disease itself +speaking through them. They may tell you much that is chiefly imaginary, +but even imagination has got to have some physical basis as a +starting-point. They may tell you much that is clearly and ludicrously +irrelevant, or untrue, on account of inaccuracy of observation, +confusion of cause and effect, or a mental color-blindness produced by +the disease itself. But these things can all be brushed aside like the +chaff from the wheat if checked up by the picture of the disease in +plain sight before you. + +In the main, the great mass of what patients tell you is of great value +and importance, and, with proper deductions, perfectly reliable. In +fact, I think it would be safe to say that a sharp observer would be +able to make a fairly and approximately accurate diagnosis in seven +cases out of ten, simply by what his eye and his touch tell him while +listening to symptoms recounted by the patient. Time and again have I +seen an examination made of a reasonably intelligent patient, and when +the recital had been finished and the hawk-like gaze had traveled from +head to foot and back again, from ear-tip to finger-nail, from eye to +chest, a symptom which the patient had simply forgotten to mention would +be promptly supplied; and the gasp with which the patient would +acknowledge the truth of the suggestion was worth traveling miles to +see. + +Of course, you pay no attention to any statement of the patient which +flatly contradicts the evidence of your own senses. But even where +patients, through some preconceived notion, or from false ideas of shame +or discredit attaching to some particular disease, are trying to mislead +you, the very vigor of their efforts will often reveal their secret, +just as the piteous broken-winged utterings of the mother partridge +reveal instantly to the eye of the bird-lover the presence of the young +which she is trying to lure him away from. Only let a patient talk +enough about his or her symptoms, and the truth will leak out. + +The attitude of impatient incredulity toward the stories of our +patients, typified by the story of that great surgeon, but greater bear, +Dr. John Abernethy, has passed, never to return. When a lady of rank +came into his consulting-room, and, having drawn off her wraps and +comfortably settled herself in her chair, launched out into a luxurious +recital of symptoms, including most of her family history and +adventures, he, after listening about ten minutes pulled out his watch +and looked at it. The lady naturally stopped, open-mouthed. "Madam, how +long do you think it will take you to complete the recital of your +symptoms?" "Oh, well,"--the lady floundered, embarrassed,--"I hardly +know." "Well, do you think you could finish in three-quarters of an +hour?" Well, she supposed she could, probably. "Very well, madam. I have +an operation at the hospital in the next street. Pray continue with the +recital of your symptoms, and I will return in three-quarters of an hour +and proceed with the consideration of your case!" + +When you can spare the time,--and no time is wasted which is spent in +getting a thorough and exhaustive knowledge of a serious case,--it is as +good as a play to let even your hypochondriac patients, and those who +are suffering chiefly from "nervous prosperity" in its most acute form, +set forth their agonies and their afflictions in their fullest and most +luxurious length, breadth, and thickness, watching meanwhile the come +and go of the lines about the face-dials, the changes of the color, the +sparkling and dulling of the eye, the droop or pain-cramp, or luxurious +loll of each group of muscles, and quietly draw your own conclusions +from it all. Many and many a time, in the full luxury of +self-explanation, they will reveal to you a clew which will prove to be +the master-key to your control of the situation, and their restoration +to comfort, if not health, which you couldn't have got in a week of +forceps-and-scalpel cross-examination. + +In only one class of patients is this valuable aid to knowledge absent, +and that is in very young children; and yet, by what may at first sight +seem like a paradox, they are, of all others, the easiest in whom to +make not merely a provisional, but a final, diagnosis. They cannot yet +talk with their tongues and their lips, but they speak a living language +in every line, every curve, every tint of their tiny, translucent +bodies, from their little pink toes to the soft spot on the top of their +downy heads. Not only have they all the muscle-signs about the +face-dial, of pain or of comfort, but, also, these are absolutely +uncomplicated by any cross-currents of what their elders are pleased to +term "thought." + +When a baby knits his brows he is not puzzling over his political +chances or worrying about his immortal soul. He has got a pain somewhere +in his little body. When his vocal organs emit sounds, whether the +gurgle or coo of comfort, or the yell of dissatisfaction, they are just +squeezed out of him by the pressure of his own internal sensations, and +he is never talking just to hear himself talk. Further than this, his +color is so exquisitely responsive to every breath of change in his +interior mechanism, that watching his face is almost like observing a +reaction in a test-tube, with its precipitate, or change of color. In +addition, not only will he turn pale or flush, and his little muscles +contract or relax, but so elastic are the tissues of his surface, and so +abundant the mesh of blood-vessels just underneath, that, under the +stroke of serious illness, he will literally shrivel like a green leaf +picked from its stem, or wilt like a faded flower. + +A single glance at the tiny face on the cot pillow is usually enough to +tell you whether or not the little morsel is seriously ill. Nothing +could be further from the truth than the prevailing impression that, +because babies can't talk, it is impossible, especially for a young +doctor, to find out what is the matter with them. If they can't talk, +neither can they tell lies, and when they yell "Pin!" they mean pin and +nothing else. + +In fact, the popular impression of the puzzled discomfiture of the +doctor before a very small, ailing baby is about as rational as the +attitude of a good Quaker lady in a little Western country town, who had +induced her husband to subscribe liberally toward the expenses of a +certain missionary on the West Coast of Africa. On his return, the +missionary brought her as a mark of his gratitude a young half-grown +parrot, of one of the good talking breeds. The good lady, though +delighted, was considerably puzzled with the gift, and explained to a +friend of mine that she really didn't know what to feed it, and it +wasn't quite old enough to be able to talk and tell her what it wanted! + + + + +CHAPTER IV + +COLDS AND HOW TO CATCH THEM + + +Ancient vibrations are hard to stop, and still harder to control. +Whether they date from our driving back by the polar ice-sheet, together +with our titanic Big Game, the woolly rhinoceros, the mammoth, and the +sabre-toothed tiger, from our hunting-grounds in Siberia and Norway, or +from recollections of hunting parties pushing north from our tropical +birth-lands, and getting trapped and stormbound by the advance of the +strange giant, Winter, certain it is that our subconsciousness is full +of ancestral memories which send a shiver through our very marrow at the +mere mention of "cold" or "sleet" or "wintry blasts." + +From the earliest dawn of legend cold has always been ranked, with +hunger and pestilence and storm, as one of the demons to be dreaded and +fought. And, at a little later date, the ancient songs and sayings of +every people have been full of quaint warnings against the danger of a +chill, a draft, wet feet, or damp sheets. There is, of course, a +bitterly substantial basis for this feeling, as the dozens of stiffened +forms whose only winding-sheet was the curling snowdrift, or whose +coffin the frozen sleet, bear ghastly witness. It was, however, long ago +discovered that when we were properly fed and clothed, the Cold Demon +could be absolutely defied, even in a tiny hut made out of pressed snow +and warmed by a smoky seal-blubber lamp; that the Storm King could be +baffled just by burrowing into his own snowdrifts and curling up under +the crust, like an Eskimo dog. Hence, nearly all the legends depict the +hero as finally conquering the Storm King, like Shingebis in the Song of +Hiawatha. + +The ancient terror, however, still clings, with a hold the more +tenacious as it becomes narrowed, to one large group of these calamities +believed to be produced by cold,--namely, those diseases supposed to be +caused by exposure to the weather. Even here, it still has a +considerable basis in fact; but the general trend of opinion among +thoughtful physicians is that this basis is much narrower than was at +one time supposed, and is becoming still more restricted with the +progress of scientific knowledge. For instance, fifty years ago, popular +opinion, and even the majority of medical belief, was that consumption +and all of its attendant miseries were chiefly due to exposure to cold. +Now we know that, on the contrary, abundance of pure, fresh, cold air is +the best cure for the disease, and foul air and overcrowding its chief +cause. An almost equally complete about-face has been executed in regard +to pneumonia. Prolonged and excessive exposure to cold may be the match +that fires the mine, but we are absolutely certain that two other things +are necessary, namely, the presence of the diplococcus, and a lowered +and somewhat vitiated state of bodily resistance, due to age, overwork, +underfeeding, or over-indulgence in alcohol. + +Not only do these two diseases not occur in the land of perpetual cold, +the frozen North, except where they are introduced by civilized +visitors,--and scarce a single death from pneumonia has ever yet +occurred in the crew of an Arctic expedition,--but it has actually been +proposed to fit up a ship for a summer trip through the Arctic regions, +as a floating sanatorium for consumptives, on account of the purity of +the air and the brilliancy of the sunlight. + +There is one realm, however, where the swing of this ancient +superstition vibrates with fullest intensity, and that is in those +diseases which, as their name implies, are still believed to be due to +exposure to a lowered temperature--"common colds." Here again it has a +certain amount of rational basis, but this is growing less and less +every day. The present attitude of thoughtful physicians may be +graphically indicated by the flippant inquiry of the riddle-maker, "When +is a cold not a cold?" and the answer, "Two-thirds of the time." This +much we are certain of already: that the majority of so-called "colds" +have little or nothing to do with exposure to a low temperature, that +they are entirely misnamed, and that a better term for them would be +_fouls_. In fact, this proportion can be clearly and definitely proved +and traced as infections spreading from one victim to another. The best +place to catch them is not out-of-doors, or even in drafty hallways, but +in close, stuffy, infected hotel bedrooms, sleeping-cars, churches, and +theatres. + +Two arguments in rebuttal will at once be brought forward, both +apparently conclusive. One is that colds are vastly more frequent in +winter, and the other that when you sit in a draft until you feel +chilly, you inevitably have a cold afterward. Both these arguments +alike, however, are based upon a misunderstanding. The frequency of +colds in winter is chiefly due to the fact that, at this time of the +year, we crowd into houses and rooms, shutting the doors and windows in +order to keep warm, and thus provide a ready-made hothouse for the +cultivation and transmission from one to another of the influenza and +other bacilli. As the brilliant young English pulmonary expert, Dr. +Leonard Williams, puts it, "a constant succession of colds implies a +mode of life in which all aerial microbes are afforded abundant +opportunities." At the same time, we take less exercise and sit far less +in the open air, thus lowering our general vigor and resisting power and +making us more susceptible to attack. Those who live out-of-doors winter +and summer, and who ventilate their houses properly, even in cold +weather, suffer comparatively little more from colds in the winter-time +than they do in summer; although, of course, the most vigorous +individual, in the best ventilated surroundings, will occasionally +succumb to some particularly virulent infection. + +The second fact of experience, catching cold after sitting in a draft or +a chilly room until you begin to cough or sneeze, is one to which a +majority of us would be willing to testify personally, and yet it is +based upon something little better than an illusion. It is a well-known +peculiarity of many fevers and infections to begin with a chill. The +patient complains of shiverings up and down his spine, his fingernails +and his lips become blue, in extreme cases his teeth chatter, and his +limbs begin to twitch and shake, and he ends up in a typical ague fit. +The best known, because most striking, illustration is malaria, or fever +and ague, "chills and fever," as it is variously termed. But this form +of attack, milder and much slighter in degree, may occur in almost every +known infection, such as pneumonia, typhoid, tuberculosis, scarlet +fever, measles, and influenza. It has nothing whatever to do with either +external or internal temperature; for if you slip a fever-thermometer +under your chilling patient's tongue, it will usually register anywhere +from 102 to 105 deg.. + +This method of attack is especially common, not only in influenza, but +also in all the other so-called "common colds." In fact, when we begin +to shiver and sneeze and hunt around for an imaginary draft or lowering +of the temperature which has caused it, we are actually in the first +stage of the development of an infection which was contracted hours, or +even days, before. + +When you begin to shiver and sneeze and run at the eyes you are not +"catching" cold; you have already caught it long before, and it is +beginning to break out on you. Mere exposure to cold will never cause +sneezing. It takes a definite irritation of the nasal mucous membrane, +by gas or dust from without, or toxins from within, to produce a sneeze. + +As to mere exposure to cold weather and wet and storm being able to +produce it, it is the almost unanimous testimony of Arctic explorers +that, during their sojourn of from two to three years in the frozen +North, they never had so much as a sneeze or a sore throat, even though +frequently sheltered in extemporized huts, and running short of adequate +food-supply before spring. Within a week of their return to civilization +they would begin sneezing and coughing, and catch furious colds. + +Lumbermen, trappers, hunters, and prospectors in Alaska give similar +testimony. I have talked with scores of these pioneers, visiting them, +in fact, in their camps under conditions of wet, cold, and exposure that +would have made one afraid of either pneumonia or rheumatism before +morning, and found that, so long as they remained up in the mountains or +out in the snow, and no case of influenza, sore throat, or cold happened +to be brought into the camp, they would be entirely free from coughs and +colds; but that, upon returning to civilization and sleeping in the +stuffy room of a rude frontier hotel, they would frequently catch cold +within three days. + +One unusually intelligent foreman of a lumber camp in Oregon told me +that an experience of this kind had occurred to him three different +times that he could distinctly recollect. + +It is difficult to catch a cold or pneumonia unless the bacilli are +there to be caught. Boswell has embalmed for us, in the amber of his +matchless biography, the fact that it had been noted, even in those +days, that the inhabitants of one of the Faroe Islands never had colds +in the head except on the rare occasions when a ship would touch +there--usually not oftener than once a year. Then, within a week, half +the population would be blowing and sneezing. The great Samuel commented +upon the fact at length, and advanced the ingenious explanation that, as +the harbor was so difficult of entry, the ships could beat in only when +the wind was in a certain quarter, and that quarter was the nor'east. +_Hinc illae lacrimae!_ (Hence these weeps!) The colds were caused by the +northeast wind of unsavory reputation! How often the wind got into the +northeast without bringing a ship or colds he apparently did not +speculate. + +To come nearer yet, did you ever catch cold when camping out? I have +waked in the morning with the snow drifting across the back of my neck, +been wet to the skin all day, and gone to bed in my wet clothes, and +slept myself dry; and have lain out all day in a November gale, in a +hollow scooped in the half-frozen ground of the duck-marsh, and felt +never a hair the worse. Scores of similar experiences will rise up in +the minds of every camper, hunter, or fisherman. You _may_ catch cold +during the first day or two out, before you have got the foul city air, +with its dust and bacteria, out of your lungs and throat, but even this +rarely happens. + +How seldom one catches cold from swimming, no matter how cold the water; +or from boating, or fishing,--even without the standard prophylactic; or +from picnicking, or anything that is done during a day in the open air. + +So much for the negative side of the evidence, that colds are not often +caught where infectious materials are absent. Now for the positive side. + +First of all, that typical cold of colds, influenza, or the grip, is now +unanimously admitted by authorities to be a pure infection, due to a +definite germ (the _bacillus influenzae_ of Pfeiffer) and one of the most +contagious diseases known. Each of the great epidemics of it--1830-33, +1836-37, 1847-48, and, of most vivid and unblessed memory, 1889-90--can +be traced in its stately march completely across the civilized world, +beginning, as do nearly all our world-epidemics,--cholera, plague, +influenza, etc.,--in China, and spreading, _via_ India or Turkestan, to +Russia, Berlin, London, New York, Chicago. Moreover, its rate of +progress is precisely that of the means of travel: camel-train, +post-chaise, railway, as the case may be. The earlier epidemics took two +years to spread from Eastern Russia to New York; the later ones, forty +to sixty days. Soon it will beat Jules Verne or George Francis Train. So +intensely "catching" is it, that letters written by sufferers have been +known to infect the correspondents who received them in a distant town, +and become the starting-point of a local epidemic. + +Of course, it may be urged that when we have proved the grip to be a +definite infection, we have taken it out of the class of "colds" +altogether, and that its bacterial origin proves nothing in regard to +the rest. But a rather interesting state of affairs developed during the +search for the true bacillus of influenza: this was that a dozen other +bacilli and cocci were discovered, each of which seemed capable of +causing all the symptoms of the _grip_, though in milder form. So that +the view of the majority of pathologists now is that these +"influenzoid," or "grip-like" attacks, under which come a majority of +all _common colds_, are probably due to a number of different milder +micro-organisms. + +The next fact in favor of the infectious character of a cold is that it +begins with a chill, followed with a fever, runs a definite self-limited +course, and, barring complications, gets well of itself in a certain +time, just like the measles, scarlet fever, pneumonia, or any other +frank infection. + +Colds are also followed by inflammations, or toxic attacks in other +organs of the body, lungs, stomach, bowels, heart, kidneys, nerves, +etc., just like diphtheria, scarlet fever, or typhoid, only, of course, +of milder form and less frequently. + +Last, but not least practically convincing, colds may be traced from one +victim to another, may "run through" households, schools, factories, may +occur after attending church or theatre, may be checked by isolating the +sufferers; and are now most effectually treated by the inhalation of +non-poisonous germicidal or antiseptic vapors and sprays. + +One of my first experiences with this last method occurred in a most +unexpected field. An old friend, a most interesting and intelligent +German, was the proprietor of a wild-animal depot, importing foreign +animals and birds and selling them to the zooelogical gardens and +circuses. I used often to drop in there to see if he had anything new, +and he would come up to see me, to tell me his troubles and keep my +dissecting-table supplied with interestingly diseased dead beasts and +birds. + +One day he came up in a state of great excitement, with a very dead and +dilapidated parrot in his hand. + +"Choost look, Dogdor; here's one of dose measley new pollies I god in +from Zingapore. De rest iss coffin' an' sneezin' to plow dere peaks off, +an' all de utter caitches iss kitchen him." + +As parrots are worth from fifteen to thirty dollars apiece, "green" (not +in color, but training), and he had fifty or sixty in the store, the +situation was distinctly serious. Now, I was no specialist in the +peculiar diseases of parrots, but something had to be done, and, with a +boldness born of long practice, I drew my bow at a venture and let fly +this suggestion:-- + +"Try formalin; it's pretty fierce on the eyes and nose, but it won't +kill 'em; and, if you put a teaspoonful in the bottom of each cage, by +the time it evaporates no germ that gets into that cage will live long +enough to do any harm." + +Five days later back he came, red-eyed but triumphant. "Dogdor, dot +vormaleen iss de pest shtuff I effer saw. It mos' shteenk me out of de +shtore, an' de pollies nearly sneeze dere fedders off, but it shtopt de +spret, an' _it's cureenall de seek ones_, an' I het a cold in de het, +_an' it's curt me_." + +Before using it he had fourteen cases and three deaths; after, only +three new cases and no more deaths. I would, however, hardly advise any +human "coldie" to try such heroic treatment offhand, for the pungency +and painfulness of formalin vapor is something ferocious, though the +French physicians, with characteristic courage, are making extensive use +of it for this purpose, with excellent results under careful +supervision. + +Another curious straw pointing in the direction of the infectious nature +of colds is the "annual cold," or "yearly sore throat," from which many +of us suffer. When we have had it we usually feel fairly safe from colds +for some months at least, often for a year. The only explanation that +seems in the least to explain is that colds, like other infections, +confer an immunity against another attack; only, unlike scarlet fever, +measles, smallpox, etc., this immunity, instead of for life, is only for +six months or a year. This immunity is due to the formation in the blood +of protective substances known as _anti-bodies_, which destroy or render +harmless the invading germs. Flabby, under-ventilated individuals, who +are always "catching cold," have such weak resisting powers that they +form hardly enough anti-bodies to terminate the first attack, without +having enough left to protect them from another for more than a few +weeks or months. Dr. Leonard Williams describes chronic cold-catchers as +"people who wear flannel next their skins, ... who know they are in a +draft because it makes them sneeze; who, in short, live thoroughly +unwholesome, coddling lives." Strong and vigorous individuals may form +enough to last them a year, or even two years. + +Now comes the question, "What are we going to do about it?" Obviously, +we cannot "go gunning" for these countless billions of germs, of +fifteen or twenty different species. Nor can we quarantine every one who +has a cold. Fortunately, no such radical methods are necessary. All we +have to do is to take nature's hint of the anti-bodies and improve upon +it. Healthy cells can grow fat on a diet of such germs, and, if we keep +ourselves vigorous, clean, and well ventilated, we can practically defy +the "cold" devil and all his works. + +Here is the _leitmotif_ of the whole fascinating drama of infection and +immunity. We can study only one phrasing here. We shall, of course, +catch cold occasionally, but will throw it off quickly, and probably +form anti-bodies enough to last us a year or more. How can this be done? +First and foremost, by living and sleeping as much as possible in the +open air. This helps in several different ways. First, by increasing the +vigor and resisting power of our bodies; second, by helping to burn up, +clean, and rid our tissues of waste products which are poisons if +retained; third, by greatly reducing the risks of infection. + +You can't catch cold by sitting in a field exposed to the draft from an +open gate; though I understand that casuists of the old school of the +"chill-and-damp" theory of colds are still discussing the case of the +patient who "caught his death o' cold" by having his gruel served in a +damp basin. + +The first thing to do is to get the outdoor habit. This takes time to +acquire, but, once formed, you wouldn't exchange it for anything else on +earth. The next thing is to learn to sit or sleep in a gentle current of +air all the time you are indoors. You ought to feel uncomfortable +unless you can feel air blowing across your face night and day. Then you +are reasonably sure it is fresh, and it is the only way to be sure of +it. + +But drafts are so dangerous! As the old rhyme runs, + + But when a draft blows through a hole, + Make your will and mend your soul. + +Pure superstition! It just shows what's in a name. Call it a gentle +breeze, or a current of fresh air, and no one is afraid of it. Call it a +"draft," and up go hands and eyebrows in horror at once. One of our +highest authorities on diseases of the lungs, Dr. Norman Bridge, has +well dubbed it "The Draft Fetich." It is a fetich, and as murderous as +Moloch. The draft is a friend instead of an enemy. What converted most +of us to a belief in the beneficence of drafts was the open-air +treatment of consumption! Hardly could there have been a more +spectacular proof, a more dramatic defiance of the bogey. To make a +poor, wasted, shivering consumptive, in a hectic one hour and a +drenching sweat the next, lie out exposed to the November weather all +day and sleep in a ten-knot gale at night! It looked little short of +murder! So much so to some of us, that we decided to test it on +ourselves before risking our patients. + +I can still vividly recall the astonishment with which I woke one frosty +December morning, after sleeping all night in a breeze across my head +that literally made + + Each particular hair to stand on end, + Like quills upon the fretful porcupine, + +not only without the sign of a sniffle, but feeling as if I'd been made +new while I slept. + +Then we tried it in fear and trembling on our patients, and the delight +of seeing the magic it worked! That is an old story now, but it has +never lost its charm. To see the cough which has defied "dopes" and +syrups and cough mixtures, domestic, patent, and professional, for +months, subside and disappear in from three to ten days; the night +sweats dry up within a week; the appetite come back; the fever fall; the +strength and color return, as from the magic kiss of the free air of the +woods, the prairies, the seacoast. There's nothing else quite like it on +the green earth. Do you wonder that we become "fresh-air fiends"? + +The only thing we dread in these camps is the imported "cold." Dr. +Lawrence Flick was the first to show us the way in this respect as in +several others. He put up a big sign at the entrance of White Haven +Sanatorium, "No persons suffering from colds allowed to enter," and +traced the only epidemic of colds in the sanatorium to the visit of a +butcher with the grip. I put up a similar sign at the gate of my Oregon +camp, and never had a patient catch cold from tenting out in the snow +and "Oregon mists" until the small son of the cook came back from the +village school, shivering and sneezing, when seven of the thirteen +patients "caught it" within a week. + +What will cure a consumptive will surely not kill a healthy man. I am +delighted to say that it shows signs of becoming a fad now, and sleeping +porches are being put on houses all over the country. No house in +California is considered complete without them. The ideal bedroom is a +small dressing-room, opening on a wide screened porch, or balcony, with +a door wide enough to allow the bed to be rolled inside during storms or +in severest weather. + +Sleep on a porch, or in a room with windows on two sides wide open, and +the average living-room or office begins to feel stuffy and "smothery" +at once. Apply the same treatment here. Learn to sit in a gentle draft, +and you'll avoid two-thirds of your colds and three-fourths of your +headaches. It may be necessary in winter to warm the draft, but don't +let any patent method of ventilation delude you into keeping your +windows shut any hour of the day or night. + +On the other hand, don't fall into the widespread delusion that because +air is cold it is necessarily pure. Some of the vilest air imaginable is +that shut up in those sepulchres known as "best bedrooms," which chill +your very marrow. The rheumatism or snuffles you get from sleeping +between their icy sheets comes from the crop of bacilli which has lurked +there since they were last aired. The "no heat in a bedroom" dogma is +little better than superstition, born of those fecund parents which mate +so often, stinginess and puritanism. Practically, the room which will +_never_ have a window opened in it in winter is the one without any +heat. + +Similarly, the air in an underheated church, hall, or theatre is almost +sure to be foul. The janitor will keep every opening closed in order to +get the temperature up. Some churches are never once decently ventilated +from December to May. The same old air, with an ever richer crop of +germs, is reheated and served up again every Sunday. The "odor of +sanctity" is the residue of the breaths and perspiration of successive +generations. Cleanliness may be next to godliness, but it is sometimes +an astonishingly long step behind it. + +The next important step is to keep clean, both externally and +internally: externally, by cold bathing, internally, by exercise. The +only reason why a draft ever hurts us is because we are full of +self-poisons, or germs. The self-poisons can be best got rid of by +abundant exercise in the open air and plenty of pure, cold H2O, +internally and externally. + +Food has very little to do with these autotoxins, and they are as likely +to form on one diet as another. In fact, they form normally and in +states of perfect health, and are poisonous only if retained too long. +It is simply a question of burning them up, and getting rid of them +quickly enough, by exercise, with its attendant deep breathing and +perspiration. The lungs are great garbage-burners. Exercise every day +till you puff and sweat. + +A blast of cold air suddenly stops the escape of these poisons through +the skin and throws them on the lungs, liver, or kidneys. The resulting +disturbance is the second commonest form of a "cold," and covers perhaps +a third of all cases occurring. This is the cold that can be prevented +by the cold bath. Keep the skin hardened and toned up to such a pitch +that no reasonable chill will stop it from excreting, and you are safe. +Never depend on clothing. The more you pile on, the more you choke and +"flabbify" the skin and make it ready to "strike" on the first breath of +cold air. Too heavy flannels are cold-breeders, and chest-protectors +inventions of the evil one. Trust the skin; it is one of the most +important and toughest organs in the body, if only given half a chance. + +But the most frequent way in which drafts precipitate a cold is by +temporarily lowering the vital resistance. This gives the swarms of +germs present almost constantly in our noses, throats, stomachs, bowels, +etc., the chance they have been looking for--to break through the cell +barrier and run riot in the body. + +So long as the pavement-cells of our mucous membranes are healthy, they +can keep them out indefinitely. Lower their tone by cold, fatigue, +underfeeding, and their line is pierced in a dozen places at once. One +of the many horrifying things which bacteriology has revealed is that +our bodies are simply alive with germs, even in perfect health. One +enthusiastic dentist has discovered and described no less than +_thirty-three_ distinct species, each one numbering its billions, which +inhabit our gums and teeth. Our noses, our stomachs, our +intestines,--each boasts a similar population. Most of them do no harm +at all; indeed, some probably assist in the processes of digestion; +others are camp-followers, living on our leavings; others, captive +enemies which have been clubbed into peaceful behavior by our leucocyte +and anti-body police. + +For instance, not a few healthy noses and throats contain the bacillus +of diphtheria and the diplococcus of pneumonia. We are beginning to find +that these last two groups will bear watching. Like camp-followers +elsewhere, they carry knives, and are not above using them on the +wounded after dark. In fact, they have a cheerful habit of taking a +hand in any disturbance that starts in their bailiwick, and usually on +the side against the body-cells. + +Finally, while clearly realizing that the best defense is attack, and +that our chief reliance should be upon keeping ourselves in such +fighting trim that we can "eat 'em alive" at any time, there is no sense +in running easily avoidable risks, and we should keep away from +infection as far as possible. If a child comes to school heavy-eyed, +hoarse, and snuffling, the teacher should send him home at once. He will +only waste his time attempting to study in that trim, and may infect a +score of others. Moreover, it may be remarked, parenthetically, that +these are also symptoms of the beginning of measles, scarlet fever, and +diphtheria, and two-thirds of all cases of these would be sent home +before they could infect any one else if this procedure were the rule. + +If your own child develops a cold, if mild, keep him playing +out-of-doors by himself; or if severe, keep him in bed, in a +well-ventilated room, for three or four days. He'll get better twice as +quick as if at school, and the rest of the household will escape. + +When you wake with a stuffed head and aching bones, stay at home for a +few days if possible, out of regard for your customers, your +fellow-clerks, or your office force, as well as yourself. If one of your +employees comes to work shivering, give him three days' vacation on full +pay. If it runs through the force, you'll lose five times as much in +enforced sick-leaves, slowness, and mistakes. Above all, don't go to any +public gatherings,--to church, the theatre, or parties,--when you are +snuffling and coughing. You are not exactly a joy to your beholders, +even if you don't infect them. It is advisable, and well worth the +trifling trouble and expense, to fumigate thoroughly with formalin all +churches, theatres, and schoolrooms at least once a month. Reasonable +and public-spirited precautions of this sort are advisable, not only to +avoid colds themselves, which are disagreeable and dangerous enough, but +because mild infections of this sort are far the commonest single means +of making a breach in our body-ramparts through which more serious +diseases like consumption, pneumonia, and rheumatism may force an entry. + +Colds do not "run into" consumption or pneumonia, but they bear much the +same relation to them that good intentions are said to do to the +infernal regions. They release the lid of a perfect Pandora's box of +distempers--tuberculosis, pneumonia, rheumatism, bronchitis, Bright's +disease, neuritis, endocarditis. A cold is no longer a joke. A +generation ago a prominent physician was asked by an anxious mother, +"Doctor, how would you treat a cold?" + +"With contempt, madam," replied the great man. + +That day is past, and has lasted too long. Intelligently regarded and +handled, they are the least harmful of diseases; neglected, one of the +most dangerous, because there are such legions of them. To sum up, if +you wish to revel in colds, all that is necessary is to observe the +following few and simple rules:-- + +Keep your windows shut. + +Avoid drafts as if they were a pestilence. + +Take no exercise between meals. + +Bathe seldom, and in warm water. + +Wear heavy flannels, chest-protectors, abdominal bandages, and electric +insoles. + +Have no heat in your bedroom. + +Never let anything keep you away from church, the theatre, or parties, +in winter. + +Never go out-of-doors when it's windy, or rainy, or wet underfoot, or +cold, or hot, or looks as if it was going to be any of these. + +Be just as intimate and affectionate as possible with every one you know +who has a cold. Don't neglect them on any account. + + + + +CHAPTER V + +ADENOIDS, OR MOUTH-BREATHING: THEIR CAUSE AND THEIR CONSEQUENCES + + +In all ages it has been accounted a virtue to keep your mouth +shut--chiefly, of course, upon moral or prudential grounds, for fear of +what might issue from it if opened. Then came physiology to back up the +maxim, on the ground that the open mouth was also dangerous on account +of what might be inhaled into it. Oddly enough, in this instance, both +morality and science have been beside the mark to the degree that they +have been mistaking a symptom for a cause. This has led us to absurd and +injurious extremes in both cases. On the moral and prudential side it +has led to such outrageous exaggerations as the well-known and +oft-quoted proverb, "Speech is silver, but silence is golden." +Articulate speech, the chiefest triumph and highest single +accomplishment of the human species, the handmaid of thought and the +instrument of progress, is actually rated below silence, the attribute +of the clod and of the dumb brute, the easy refuge of cowardice and of +stupidity. + +Easily eight-tenths of all speech is informing, educative, helpful in +some modest degree; while fully that proportion of silence is due to +lack of ideas, cowardice, or designs that can flourish only in darkness. +It is not the abundance of words, but the scarcity of ideas, that makes +us flee from "the plugless word-spout" and avoid the chatterbox. + +Similarly, upon the physical side, because children who breathe through +the mouth are apt to have a vacant expression, to be stupid and +inattentive, undersized, pigeon-breasted, with short upper lip and +crowded teeth, we have leaped to the conclusion that it is a fearsome +and dangerous thing to breathe through your mouth. All sorts of stories +are told about the dangerousness of breathing frosty air directly into +the lungs. Invalids shut themselves scrupulously indoors for weeks and +even months at a stretch, for fear of the terrible results of a "blast +of raw air" striking into their bronchial tubes. All sorts of absurd +instruments of torture, in the form of "respirators" to tie over the +mouth and nose and "keep out the fog," are invented, and those who have +the slightest tendency to bronchial or lung disturbances are warned upon +pain of their life to wrap up their mouths whenever they go +out-of-doors. + +As a matter of fact, there is exceedingly little evidence to show that +pure, fresh, open air at any reasonable temperature and humidity ever +did harm when inhaled directly into the lungs. In fact, a considerable +proportion of us, when swinging along at a lively gait on the country +roads, or playing tennis or football, or engaged in any form of active +sport, will be found to keep our lips parted and to inhale from a sixth +to a third of our breath in this way, and with no injurious results +whatever. Nine-tenths of all the maladies believed to be due to +breathing even the coldest and rawest of air are now known to be due to +invading germs. + +Nevertheless, mouth-breathing in all ages has been regarded as a bad +habit, and with good reason. It was only about thirty years ago that we +began to find out why. A Danish throat surgeon, William Meyer, whose +death occurred only a few months ago, discovered, in studying a number +of children who were affected with mouth-breathing, that in all of them +were present in the roof of the throat curious spongy growths, which +blocked up the posterior opening of the nostrils. As this mass was made +up of a number of smaller lobules, and the tissue appeared to be like +that of a lymphatic gland, or "kernel," the name "adenoids" (gland-like) +was given to them. Later they were termed _post-nasal growths_, from the +fact that they lay just behind the rear opening of the nostrils; and +these two names are used interchangeably. Our knowledge has spread and +broadened from this starting-point, until we now know that adenoids are +the chief, yes, almost the sole primary cause, not merely of +mouth-breathing, but of at least two-thirds of the injurious effects +which have been attributed to this habit. + +Mouth-breathing is not simply a bad habit, a careless trick on the part +of the child. We have come to realize that physical bad habits, as well +as many mental and moral ones, have a definite physical cause, and that +_no child ever becomes a mouth-breather as long as he can breathe +comfortably through his nose_. + +This clears the ground at once of a considerable amount of useless +lumber in the shape of advice to train the child to keep his mouth shut. +I have even known mothers who were in the habit of going around after +their helpless offspring were asleep and gently but firmly pushing up +the little jaw and pressing the lips together until some sort of an +attempt at respiration was made through the nostrils. Advertisements +still appear of sling-like apparatuses for holding the jaws closed +during sleep. + +To attempt to stop mouth-breathing before providing abundant air-space +through the nostrils is not only irrational, but cruel. Of course, after +the child has once become a mouth-breather, even after the nostrils have +been made perfectly free, it will not at once abandon its habit of +months or years, and disciplinary measures of some sort may then be +needed for a time. But the hundred-times-repeated admonition, "For +heaven's sake, child, shut your mouth! Don't go around with it hanging +open like that!" unless preceded by proper treatment of the nostrils, +will have just about as much effect upon the habit as the proverbial +water on a duck's back. No use trying to close his mouth by any amount +of opening of your own. + +Fortunately, as does not always happen, with our discovery of the cause +has come the knowledge of the cure; and we are able to say with +confidence that, widespread and serious as are disturbances of health +and growth associated with mouth-breathing, they can be absolutely +prevented and abolished. + +What, then, is the cause of this nasal obstruction, and when does it +begin to operate? The primary cause is catarrhal inflammation, with +swelling and thickening of the secretions, and it may begin to operate +anywhere from the seventh month to the seventh year. A neglected +attack, or series of attacks, of "snuffles," colds in the head, +catarrhs, in infants and young children, will set up a slow inflammation +of this glandular mass at the back of the nostrils--a tonsil, by the +way--and start its enlargement. + +Whether we know anything about adenoids themselves or not, we are all +familiar with their handiwork. The open mouth, giving a vacant +expression to the countenance, the short upper lip, the pinched and +contracted nostrils, the prominent and irregular teeth, the listless +expression of the eyes, the slow response to request or demand, we have +seen a score of times in every schoolroom. Coupled with these facial +features are apt to be found on closer investigation a lack of interest +in both work and play, an impaired appetite, restless sleep, and a +curious general backwardness of development, both bodily and mental, so +that the child may be from one to four inches below the normal height +for his years, from five to fifteen pounds under weight, and from one to +three grades behind his proper school position. Very often, also, his +chest is inclined to be narrow, the tip of his breastbone to be sunken, +and his abdomen larger in girth than his chest. Is it possible that the +mere inhaling of air directly into the lungs, even though it be +imperfectly warmed, moistened, and filtered, as compared with what it +would be if drawn through the elaborate "steam-coils" in the nostrils +for this purpose, can have produced this array of defects? It is +incredible on the face of it and unfounded in fact. Fully two-thirds of +these can be traced to the direct influence of the adenoids. + +These adenoids, it may briefly be stated, are the result of an +enlargement of a _tonsil_, or group of small tonsils, identical in +structure with the well-known bodies of the same name which can be seen +on either side of the throat. They have the same unfortunate faculty as +the other tonsils for getting into hot water, flaring up, inflaming, and +swelling on the slightest irritation. And, unfortunately, they are so +situated that their capacity for harm is far greater than that of the +other tonsils. They seem painfully like the chip on the shoulder of a +fighting man, ready to be knocked off at the lightest touch and plunge +the whole body into a scrimmage. Their position is a little difficult to +describe to one not familiar with the anatomy of the throat, especially +as they cannot be seen except with a laryngeal mirror; but it may be +roughly stated as in the middle of the roof of the throat, just at the +back of the nostrils, and above the soft palate. From this coign of +vantage they are in position to produce serious disturbances of two of +our most important functions,--respiration and digestion,--and three out +of the five senses,--smell, taste, and hearing. + +We will begin with their most frequent and most serious injurious +effect, though not the earliest,--the impairment of the child's power of +attention and intelligence. So well known is their effect in this +respect that there is scarcely an intelligent and progressive teacher +nowadays who is not thoroughly posted on adenoids. Some of them will +make a snap diagnosis as promptly and almost as accurately as a +physician; and when once they suspect their presence, they will leave +no stone unturned to secure an examination of the child by a competent +physician, and the removal of the growths, if present. They consider it +a waste of time to endeavor to teach a child weighted with this +handicap. How keenly awake they are to their importance is typified by +the remark of a prominent educator five or six years ago:-- + +"When I hear a teacher say that a child is stupid, my first instinctive +conclusion is either that the child has adenoids, or that the teacher is +incompetent." + +The lion's share of their influence upon the child's intelligence is +brought about in a somewhat unexpected and even surprising manner, and +that is by the _effects of the growths upon his hearing_. You will +recall that this third tonsil was situated at the highest point in the +roof of the pharynx, or back of the throat. The first effect of its +enlargement is naturally to block the posterior opening of the nostrils. +But it has another most serious vantage-ground for harm in its peculiar +position. Only about three-fourths of an inch below it upon either side +open the mouths of the Eustachian tubes, the little funnels which carry +air from the throat out into the drum-cavity of the ear. You have +frequently had practical demonstrations of their existence, by the +well-known sensation, when blowing your nose vigorously, of feeling +something go "pop" in the ear. This sensation was simply due to a bubble +of air being driven out through this tube from the back of the throat, +under pressure brought to bear in blowing the nose. The luckless +position of the third tonsil could hardly have been better planned if it +had been devised for the special purpose of setting up trouble in the +mouths of these Eustachian tubes. + +Just as soon as the enlargements become chronic, they pour out a thick +mucous secretion, which quickly becomes purulent, or, in the vernacular, +"matter." This trickles down on both sides of the throat, and drains +right into the open mouth of the Eustachian tube. Not only so, but these +Eustachian tubes are the remains of the first gill-slits of embryonic +life, and, like all other gill-slits, have a little mass of this same +lymphoid or tonsilar tissue surrounding them. This also becomes infected +and inflamed, clogs the opening, and one fatal day the inflammation +shoots out along the tube, and the child develops an attack of earache. +At least two-thirds of all cases of earache, and, indeed, five-sixths of +all cases of deafness in children, are due to adenoids. + +Earache is simply the pain due to acute inflammation in the small +drum-cavity of the ear. This in the large majority of cases will subside +and drain back again into the throat through the Eustachian tube. In a +fair percentage of instances, however, it will break in the opposite +direction, and we have the familiar ruptured drum and discharge from the +ear. In either case the drum becomes thickened, so that it can no longer +vibrate properly; the delicate little chain of bones behind it, like the +levers of a piano, becomes clogged, and the child becomes deaf, whether +a chronic discharge be present or not. + +This is the secret of his "inattention," his "indifference,"--even of +his apparent disobedience and rebelliousness. What other children hear +without an effort he has to strain every nerve to catch. He +misunderstands the question that is asked of him, makes an absurd +answer, and is either scolded or laughed at. It isn't long before he +falls into the attitude: "Well, I can't get it right, anyhow, no matter +how I try, so I don't care." Up to five or ten years ago the puzzled and +distracted teacher would simply report the child for stupidity, +indifference, and even insubordination. In nine cases out of ten, when +children are naughty or stupid, they are really sick. + +Not content with dulling one of the child's senses, these thugs of the +body-politic proceed to throttle two others--smell and taste. Obviously +the only way of smelling anything is to sniff its odor into your nose. +And if this be more or less, or completely, blocked up, and its delicate +mucous membranes coated with a thick, ropy discharge, you will not be +able to distinguish anything but the crudest and rankest of odors. But +what has this to do with taste? Merely that two-thirds of what we term +"taste" is really smell. Seal the nostrils and you can't "tell chalk +from cheese," not even a cube of apple from a cube of onion, as scores +of experiments have shown. We all know how flat tea, coffee, and even +our own favorite dishes taste when we have a bad cold, and this, +remember, is the permanent condition of the palate of the poor little +mouth-breather. No wonder his appetite is apt to be poor, and that even +what food he eats will not produce a flow of "appetite juice" in the +stomach, which Pavloff has shown to be so necessary to digestion. No +wonder his digestion is apt to go wrong, ably assisted by the continual +drip of the chronic discharge down the back of his throat; his bowels to +become clogged and his abdomen distended. + +But the resources for mischief of this pharyngeal "Old Man of the Sea" +are not even yet exhausted. Next comes a very curious and unexpected +one. We have all heard much of "the struggle for existence" among plants +and animals, and have had painful demonstrations of its reality in our +own personal experience. But we hardly suspected that it was going on in +our own interior. Such, however, is the case; and when once one organ or +structure falls behind the others in the race of growth, its neighbors +promptly begin to encroach upon and take advantage of it. Emerson was +right when he said, "I am the Cosmos," the universe. + +Now, the mouth and the nose were originally one cavity. As Huxley long +ago remarked, "When Nature undertook to build the skull of a land animal +she was too lazy to start on new lines, and simply took the old +fish-skull and made it over, for air-breathing purposes." And a clumsy +job she made of it! + +It may be remarked, in passing, that mouth-breathing, as a matter of +history, is an exceedingly old and respectable habit, a reversion, in +fact, to the method of breathing of the fish and the frog. "To drink +like a fish" is a shameful and utterly unfounded aspersion upon a +blameless creature of most correct habits and model deportment. What the +poor goldfish in the bowl is really doing with his continual "gulp, +gulp!" is breathing--not drinking. + +This remodeling starts at a very early period of our individual +existence. A horizontal ridge begins to grow out on either side of our +mouth-nose cavity, just above the roots of the teeth. This thickens and +widens into a pair of shelves, which finally, about the third month of +embryonic life, meet in the middle line to form the hard palate or roof +of the mouth, which forms also the floor of the nose. Failure of the two +shelves to meet properly causes the well-known "cleft-palate," and, if +this failure extends forward to the jaw, "hare-lip." In the growth of a +healthy child a balance is preserved between these lower and upper +compartments of the original mouth-nose cavity, and the nose above +growing as rapidly in depth and in breadth as the mouth below, the +horizontal partition between--the floor of the nose and the roof of the +mouth--is kept comparatively flat and level. In adenoids, however, the +nostrils no longer being adequately used, and consequently failing to +grow, and the mouth cavity below growing at the full normal rate, it is +not long before the mouth begins to encroach upon the nostrils by +pushing up the partition of the palate. As soon as this upward bulge of +the roof of the mouth occurs, then there is a diminution of the +resistance offered by the horizontal healthy palate to the continual +pressure of the muscles of the cheeks and of mastication upon the sides +of the upper jaw, the more readily as the tongue has dropped down from +its proper resting position up in the roof of the mouth. These are +pushed inward, the arch of the jaw and of the teeth is narrowed, the +front teeth are made to project, and, instead of erupting, with plenty +of room, in even, regular lines, are crowded against and overlap one +another. + +When from any cause the lower jaw habitually hangs down, as in the open +mouth, it tends to be thrown slightly forward in its socket. Then, when +the jaws close again, the arches of the upper and lower teeth no longer +meet evenly. Instead of "locking" at almost every point, as they should, +they overlap, or fall behind, or inside, or outside, of each other. So +that instead of every tooth meeting its fellow of the jaw above evenly +and firmly, they strike at an angle, slip past or even miss one another, +and thus increase the already existing irregularity and overlapping. +Each individual tooth, missing its best stimulus to healthy growth and +vigor, firm and regular pressure and exercise against its fellow in the +jaw above or below, gets a twist in its socket, wears away irregularly, +and becomes an easy prey to decay, while from failure of the entire +upper and lower arches of the teeth to meet squarely and press evenly +and firmly against one another, the jaws fail to expand properly and the +tendency to narrowing of the tooth-arches and upward vaulting of the +palate is increased. + +In short, we are coming to the conclusion that from half to two-thirds +of all cases of "crowded mouth," irregular teeth, and high-arched palate +in children are due to adenoids. Progressive dentists now are insisting +upon their little patients, who come to them with these conditions, +being examined for adenoids, and upon the removal of these, if found, as +a preliminary measure to mechanical corrective treatment. Cases are now +on record of children with two, three, or even four generations of +crowded teeth and narrow mouths behind them, but who, simply by being +sharply watched for nasal obstruction and the symptoms of adenoids, by +the removal of these latter as soon as they have put in an appearance, +have grown up with even, regular, well-developed teeth and wide, healthy +mouths and jaws. Unfortunately, attention to the adenoids will not +remove these defects of the jaws and teeth after they have been +produced. But, if the child be under ten, or even twelve, years of age, +their removal may yet do much permanently to improve the condition, and +is certainly well worth while on general principles. + +Take care of the nose, and the jaws will take care of themselves. An +ounce of adenoids-removal in the young child is worth a pound of +_orthodontia_--teeth-straightening--in the boy or girl; though both are +often necessary. + +The dull, dead tone of the voice in these children is, of course, an +obvious effect of the blocked nostrils. Similarly, the broken sleep, +with dreams of suffocation and of "Things Sitting on the Chest," are +readily explained by the desperate efforts that the little one makes to +breathe through clogging nostrils, in which the discharges, blown and +sneezed out in the daytime, dry and accumulate during sleep, until, +half-suffocated, it "lets go" and draws in huge gulps of air through the +open mouth. No child ever became a mouth-breather from choice, or until +after a prolonged struggle to continue breathing through its nose. + +This brings us to the question, What are these adenoids, and how do +they come to produce such serious disturbances? This can be partially +answered by saying that they are tonsils and with all a tonsil's +susceptibility to irritation and inflammation. But that only raises the +further question, What is a tonsil? And to that no answer can be given +but Echo's. They are one of the conundrums of physiology. All we know of +them is that they are not true _glands_, as they have neither duct nor +secretion, but masses of simple embryonic tissue called _lymphoid_, +which has a habit of grouping itself about the openings of disused +canals. This is what accounts for their position in the throat, as they +have no known useful function. The two largest, or throat-tonsils, +surround the inner openings of the second gill-slits of the embryo; the +lingual tonsil, at the base of the tongue below, encircles the mouth of +the duct of the thyroid gland (the _goitre_ gland); and our own +particular Pandora's Box above, in the roof of the pharynx, is grouped +about the opening of another disused canal, which performs the singular +and apparently most uncalled-for office of connecting the cavity of the +brain with the throat. They can all of them be removed completely +without any injury to the general health, and they all tend to shrink +and become smaller--in the case of the topmost, or pharyngeal, almost +disappear--after the twelfth or fourteenth year. + +Not only have they an abundant crop of troubles of their own, as most of +us can testify from painful experience, but they serve as a port of +entry for the germs of many serious diseases, such as tuberculosis, +rheumatism, diphtheria, and possibly scarlet fever. They appear to be a +strange sort of survival or remnant,--not even suitable for the +bargain-counter,--a hereditary leisure class in the modern democracy of +the body, a fertile soil for all sorts of trouble. + +Here, then, we have this little bunch of idle tissue, about the size of +a small hazelnut, ready for any mischief which our Satan-bacilli may +find for its hands to do. A child kept in a badly ventilated room +inhales into his nostrils irritating dust or gases, or, more commonly +yet, the floating germs of some one or more of those dozen mild +infections which we term "a common cold." Instantly irritation and +swelling are set up in the exquisitely elastic tissues of the nostrils, +thick, sticky mucous, instead of the normal watery secretion, is poured +out, the child begins to sneeze and snuffle and "run at the nose," and +either the bacteria are carried directly to this danger sponge, right at +the back of the nostrils, or the inflammation gradually spreads to it. +The mucous membrane and tissues of the nose have an abundance of +vitality,--like most hard workers,--and usually react, overwhelm, and +destroy the invading germs, and recover from the attack; but the useless +and half-dead tissue of the pharyngeal tonsil has much less power of +recuperation, and it smoulders and inflames, though ultimately, perhaps, +it may swing round to recovery. Often, however, a new cold will be +caught before this has fully occurred, and then another one a month or +so later, until finally we get a chronically thickened, inflamed, and +enlarged condition of this interesting, but troublesome, body. What its +capabilities are in this respect may be gathered from the fact that, +while normally of the size of a small hazelnut, it is no uncommon thing +to find a mass which absolutely blocks up the whole of the upper part of +the pharynx, and may vary from the size of a robin's egg to that of a +large English walnut, or even a small hen's egg, according to the age of +the child and the size of the throat. + +Dirt has been defined as "matter out of place," and the pharyngeal +tonsil is an excellent illustration. Nature is said never to make +mistakes, but she is apt to be absent-minded at times, and we are +tracing now not a few of the troubles that our flesh is heir to, to +little oversights of hers--scraps of inflammable material left lying +about among the cogs of the body-machine, such as the appendix, the +gall-bladder, the wisdom teeth, and the tonsils. One day a spark drops +on them, or they get too near a bearing or a "hot-box," and, in a flash, +the whole machine is in a blaze. + +Never neglect snuffles or "cold in the head" in a young child, and +particularly in a baby. Have it treated at once antiseptically, by +competent hands, and learn exactly what to do for it on the appearance +of the earliest symptoms in the future, and you will not only save the +little ones a great deal of temporary discomfort and distress,--for it +is perfect torment to a child to breathe through its mouth at +first,--but you will ward off many of the most serious troubles of +infancy and childhood. We can hardly expect to prevent all development +of adenoids by these prompt and painless stitches in time, for some +children seem to be born peculiarly subject to them, either from the +inheritance of a particular shape of nose and throat,--"the family +nose," as it has been called,--or from some peculiar sponginess and +liability to inflammation and enlargement of all these tonsilar or +lymphoid "glands" and "kernels" of the body generally--the old +"lymphatic temperament." + +We are, however, now coming to the opinion that this so-called +"hereditary" narrow nose, short upper lip, and high-arched palate are, +in a large percentage of cases, the _result of adenoids in infancy_ in +each successive generation of parents and grandparents. At all events, +there are now on record cases of children whose parents, grandparents, +and great-grandparents are known to have been mouth-breathers, and who +have on that account been sharply watched for the possible development +of adenoids in early life, and these removed as soon as they appeared, +and they have grown up with well-developed, wide nostrils, broad, flat +palates, and regular teeth, overcoming "hereditary defect" in a single +generation. + +Curiously enough, their origin and ancestral relations may have an +important practical bearing, even in the twentieth century. At the upper +end of this curious _throat-brain_ canal lies another mass, the +so-called _pituitary body_. This has been found to exert a profound +influence over development and growth. Its enlargement is attended by +giantism and another curious giant disease in which the hands, feet, and +jaws enlarge enormously, known as _acromegaly_. It also pours into the +blood a secretion which has a powerful effect upon both the circulation +and the respiration. It is found shrunken and wasted in dwarfs. Some +years ago it was suggested by my distinguished friend, the late Dr. +Harrison Allen, and myself, that some of the extraordinary dwarfing and +growth-retarding effects of adenoids might be due to a reflex influence +exerted on their old colleague, the pituitary body. This view has found +its way into several of the textbooks. Blood is thicker than water, and +old ancestral vibrations will sometimes be set up in most unexpected +places. + +Now comes the cheerful side of the picture. I should have hesitated to +draw at such full length and in such lugubrious detail the direful +possibilities and injurious effects of adenoids if its only result could +have been to arouse apprehensions which could not be relieved. + +Fortunately, just the reverse is the case, and there are few conditions +affecting the child, so common and such a fertile source of all kinds of +mischief, and at the same time so completely curable, and whose cure +will be attended by such gratifying improvement on the part of the +little sufferer. In the first place, as has been said, their formation +may usually be prevented altogether by intelligent and up-to-date +hygienic care of the nose and the throat. In the second place, even +after they have occurred and developed to a considerable degree, they +can be removed by a trifling and almost painless operation, and, if +taken early enough, all their injurious effects overcome. If, however, +they have been neglected too long, so that the child has passed the +eighth or ninth year before any interference has been attempted, and +still more, of course, if it has passed the twelfth or thirteenth year, +then only a part of the disturbances that have been caused can be +remedied by their removal. So soft and pulpy are these growths, so +poorly supplied with blood-vessels or nerves, and so slightly connected +with the healthy tissues below them, that they may, in skilled hands, be +completely removed by simply scraping with a dull surgical spoon +(curette) or curved forceps, but never anything more knife-like than +this. In fact, in the first seven years of life, when their removal is +both easiest and will do most good, it is hardly proper to dignify the +procedure by the name of an operation. It is attended by about the same +degree of risk and of hemorrhage as the extraction of a tooth, and by +less than half the amount of pain. + +But, trifling and free from danger as is the operation, there is nothing +in the entire realm of surgery which is followed by more brilliant and +gratifying results. It seems almost incredible until one has seen it in +half a dozen successive cases. Not merely doctors, but teachers and +nurses, develop a positive enthusiasm for it. This was the operation +that led to the comical, but pathetic, "Mothers' Riots" in the New York +schools. The word went forth, "The Krishts are cutting the throats of +your children"; and, with the shameful echoes of Kishineff ringing in +their ears, the Yiddish mothers swarmed forth to battle for the lives of +their offspring. + +It is no uncommon thing to have a child of seven jump three to five +inches in height, six to twelve pounds in weight, and one to three +grades in his schooling, within the year following the operation. Ten +years more of intelligence and hygienic teaching should see this scourge +of childhood completely wiped out, or at least robbed of its +possibilities for harm. When this is done, at least two-thirds of all +cases of deafness, more than half of all cases of arrested development, +and three-fourths of those of backwardness in children will disappear. + + + + +CHAPTER VI + +TUBERCULOSIS, A SCOTCHED SNAKE + + +I + +One of the darling habits of humanity is to discover that we are facing +a crisis. One could safely offer a large prize for a group of ten +commencement orations, or political platforms, at least a third of which +did not announce this momentous fact. Either we are facing it or it +confronts us, and unutterable things will happen unless we "gird up our +loins," and vote the right ticket. An interesting feature about these +loudly heralded crises is that they hardly ever "crise." The real crisis +either strikes us so hard that we never know what hit us, or is over +before we recognize that anything was going to happen. And most of our +reflections about it are after ones--trying to explain what caused it. +In fact, in public affairs, as in medicine, a crisis is a sign of +recovery. Its occurrence is an indication that nature is preparing to +throw off the disease. Nowhere is this truth more vividly illustrated +than in the tuberculosis situation. When, about thirty years ago, the +world began to awake from its stupor of centuries, and to realize that +this one great disease alone was _killing one-seventh of all people born +under civilization_, and crippling as many more; that its killed and +wounded every year cast in the shade the bloodiest wars ever waged, and +that it was apparently caused by the civilization which it ravaged,--no +wonder that we were appalled at the outlook. + +Here was a disease of civilization, caused by the conditions of that +civilization. Could it be cured without destroying its cause and +reverting to barbarism? Yet this very apprehension was a sign of hope, a +promise of improvement. That we were able to feel it was a sign that we +were shaking off the old fatalistic attitude toward disease,--as +inevitable or an act of Providence. It was brought about by the more +accurate and systematic study of disease. We had long been sadly +familiar with the fact that death by consumption, by "slow decline," by +"wasting" or "slow fever," was frightfully common. "To fall into a +decline" and die was one of the standard commonplaces of romantic +literature. But that was quite different from knowing in cold, hard +figures and inescapable percentages exactly how many of the race were +killed by it. It is one of the striking illustrations of the advantages +of good bookkeeping. Boards and departments of health had just fairly +got on their feet and started an accurate system of state accounts in +matters of deaths and births. We were beginning to recognize national +health as an asset, and to scrutinize its fluctuations with keen +interest accordingly. + +We may decry statistics as much as we like, but when we see the effects +of a disease set down in cold columns of black and white we have no +longer any idea of submitting to it as inevitable. We are going to get +right up and do some fighting. "One-seventh of all the deaths" has +literally become the war cry of our new Holy War against tuberculosis. +Still another stirring phrase of inestimable value in rousing us from +our torpor was that coined by the brilliant and lovable +physician-philosopher, Oliver Wendell Holmes: "The Great White Plague of +the North." This vivid epithet, abused as it may have been in later +years, was of enormous service in fixing the public mind on consumption +as a definite, individual disease, something to be fought and guarded +against. Before that, we had been inclined to look upon it as just a +natural failing of the vital forces, a thing that came from within, and +was in no sense caused from without. The fair young girl, or the +delicate boy whose vitality was hardly sufficient to carry him through +the stern battle of life, under some slight shock, or even mental +disappointment, would sink into a decline, gradually waste away, and +die. What could be done in such a case, except to bow in submission to +the inscrutable ways of Providence? + +It seems incredible now, but such was the light in which smallpox was +regarded by physicians of the Arabian and mediaeval schools: a natural +oozing forth of "peccant humors" in the blood of the young, a +disagreeable, but perfectly natural, and even necessary, process. For if +the patient did not get rid of these humors either he would die or his +growth would be seriously impaired. Now smallpox has become little more +than a memory in civilization, and consumption is due to follow its +example. + +Sanitary pioneers had already begun casting about eagerly for light upon +the influence of housing, of drainage, of food, in the causation of +tuberculosis, when a new and powerful weapon was suddenly placed in +their hands by the infant science of bacteriology. This was the now +world-famous discovery by Robert Koch that consumption and other forms +of tuberculosis were due to the attack of a definite bacillus. No +tubercle bacillus--no consumption. + +At first sight this discovery appeared to be anything but encouraging. +In fact, it seemed to make the situation and the outlook even more +hopeless. And when within a few years it was further demonstrated in +rapid succession that most of the diseases of the spine in children, of +the group of symptoms associated with enlarged glands or kernels in the +neck and known as "scrofula" or struma, most cases of hip-joint disease, +of white swelling of the knee, a large percentage of chronic ulcerations +of the skin known as _lupus_, a common form of fatal bowel disease in +children, and many instances of peritonitis in adults, together with +fully half of the fatal cases of convulsions in children, were due to +the activity of this same ubiquitous bacillus, it looked as if the enemy +were hopelessly entrenched against attack. And when it was further found +that a similar bacillus was almost as common a cause of death and +disease in cattle, particularly dairy cattle, and another in domestic +fowls, it looked as if the heavens above and the earth beneath were so +thickly strewn and so hopelessly infested with the germs that to war +against them, or hope to escape from them, was like fighting back the +Atlantic tides with a broom. + +But this chill of discouragement quickly passed. Our foe had come down +out of the clouds, and was spread out in battle array before us, in +plain sight on the level earth. We were ready for the conflict, and +proposed to "fight it out on this line if it takes all summer." It was +not long before we began to see joints in the enemy's armor and +weaknesses in his positions. Then, when we lowered our field-glasses and +turned to count our forces and prepare for the defense, we discovered +with a shock of delighted relief that whole regiments of unexpected +reinforcements had come up while we were studying the enemy's position. +These new allies of ours were three of the great, silent forces of +nature, which had fallen into line on either side and behind us, without +hurry and without excitement, without even a bugle-blast to announce +their coming. + +The first was the great resisting power and vigor of the human organism, +which we had gravely underestimated. The second, that power of +adaptation to new circumstances, including even the attack of infectious +diseases, which we call "survival of the fittest." The third, that +great, sustaining, conservative power of nature--heredity. More cheering +yet, these forces came, not merely fully armed, but bearing new weapons +fitted for our hands. The vigor and unconquerable toughness of the human +animal presented us with three glittering weapons, sunshine, food, and +fresh air. + +"If the deadly bacillus breaks through the lines, put me in the gap! +With these weapons, with this triad, I will engage to hurl him back, +shattered and broken." "Equip your vanguard with them, and the enemy +will never break the line." + +The survival of the fittest held out to us two weapons of strange and +curious make, one of them labeled "immunity," the other "quarantine." +"Give me a little time," she said, "and with the first of these I will +make seven-tenths of the soldiers in your army proof against the spears +of the enemy, as Achilles was when dipped in the Styx. With the other, +surround and isolate every roving band of the enemy that you can find; +drive him out of the holes and caves in which he lives, into the +sunlight. Hold him in the open for forty-eight hours, and he will die of +light-stroke and starvation. Divide and conquer!" + +These reinforcements of ours have proved no mere figure of speech. They +have won many a battle for us already upon the tented field. They have +not merely made good their promises, but gone beyond them, and we are +only just beginning to appreciate their true worth, and how absolutely +we can rely upon them. + +The first outpost of the enemy was captured with the sunshine-food-air +weapons, and a glorious victory it was,--great in itself, and even more +important for its moral effect and its encouragement for the future. To +pronounce an illness "consumption" had been from time immemorial +equivalent to signing a death-warrant. Even the doctors could hardly +believe it, when the first open-air enthusiasts began to claim that they +had actually cured cases of genuine consumption. For long there was a +tendency to mutter in the beard, "Well, it wasn't _genuine_ consumption, +or it wouldn't have got better." + +But after a period of incredulity this gave way to delighted confidence. +The open-air method would cure, and _did_ cure, and the patients +remained cured for years afterward. Our first claims were barely for +twenty-five or thirty per cent of the threatened victims. Then we were +able to increase it to fifty per cent; sixty, seventy, and finally +eighty were successively reached. But with the increase of our power +over the cure of this disease came a realization of our knowledge of its +limitations. It quickly proved itself to be no sovereign and universal +panacea, which would cure all cases, however desperate, or however +indiscriminately it was applied. And emphatically it had to be mixed +with brains, on the part both of the physician and of the patient. + +In the first place, the likelihood of a cure depended, with almost +mathematical certainty, upon the earliness of the stage at which it was +begun. Eight or ten years ago the outlook crystallized itself into the +form which it has practically retained since: of cases put under +treatment in the very early stage, from seventy to ninety per cent were +practical cures; of ordinary so-called "first-stage" cases, sixty to +seventy per cent; second-stage cases, or those in whom the disease was +well developed, thirty to sixty per cent; and well-advanced cases, +fifteen to thirty per cent of apparent cures. _The crux of the whole +proposition lies in the early recognition of the disease by the +physician_, and the prompt acceptance of the diagnosis by the patient, +and his willingness to drop everything and fight intelligently and +vigorously for his life. Physicians are now thoroughly awake on this +point, and are concentrating their most careful attention and study upon +methods of recognition at the earliest possible stages. At the same time +those magnificent associations for the study and prevention of +tuberculosis, international, national, state, and local,--the greatest +of which, the International Tuberculosis Congress, has just honored +America, by meeting in Washington,--are straining every nerve to educate +the public to understand the importance of recognizing the earliest +possible symptoms of this disease, no matter how trivial they may +appear, and making every other consideration bend to the fight. + +This new Word of Power, the open-air treatment, alone has transformed +one of the most hopeless, most pathetic, and painful fields of disease +into one of the most cheerful and hopeful. The vantage-ground won is +something enormous. No longer need the family physician hang back, in +dread and horror, from allowing himself even to recognize that the slow +loss of weight, the increasing weakness, the flushed evening cheek, and +the restless sleep, are signs of this dread malady. Instead of shrinking +from pronouncing the patient's doom, he knows now that he has everything +to gain and nothing to lose by promptly warning him of his danger, even +while it is still problematical. On the other hand, the patient need no +longer recoil in horror when told that he has consumption, and either go +home to set his house in order and make his will, or hunt up another +medical adviser who will take a more cheerful view of his case. All that +he has to do is to turn and fight the disease vigorously, intelligently, +persistently, with the certain knowledge that the chances are five to +one in his favor; and that's a good fighting chance for any one. + +Even should there be reasonable ground for doubt as to the positive +nature of the disease, he has nothing to lose and everything to gain by +taking the steps required to cure it. There is nothing magical or +irrational, least of all injurious, in any way about them. Simply rest, +abundant feeding, and plenty of fresh air. Even if the bacillus has not +yet lodged in his tissues, this treatment will relieve the conditions of +depression from which he is suffering, and which would sooner or later +render him a favorable lodging-place for this omnipresent, tiny enemy. + +If he has the disease the treatment will cure it. If he hasn't got it, +it will prevent it; and the gain in vigor, weight, and general +efficiency will more than pay him for the time lost from his business or +his study. It always pays to take time to put yourself back into a +condition of good health and highest efficiency. + +It was early recognized that the campaign could not be won with this +weapon alone. Inexpressibly valuable and cheering as it was, it had +obvious limitations. The first of these was the obvious reflection that +it was idle to cure even eighty per cent of all who actually developed +tuberculosis, unless something were done to stop the disease from +developing at all. "Eighty per cent of cures," of course, sounds very +encouraging, especially by contrast with the almost unbroken succession +of deaths before. But even a twenty per cent mortality from such a +common disease, if it were to proceed unchecked, would make enormous +inroads every year upon our national vigor. + +Secondly, it was quickly seen that those who recovered from the disease +still bore the scars; that while they might recover a fair degree of +health and vigor, yet they were always handicapped by the time lost and +the damage inflicted by this slow and obstinate malady; that many of +them, while able to preserve good health under ideal conditions, were +markedly and often distressingly limited in the range of their business +activities for years after, and even for life. Finally, that as these +cases were followed further and further, it was found that even after +becoming cured they were sadly liable to relapse under some unexpected +strain, or to slacken their vigilance and drop back into their former +bad physical habits; while the conviction began to grow steadily upon +men who had devoted one, two, or more decades to the study of this +disease in the localities most resorted to for its cure, that the +general vigor and vitality of these cured consumptives were apt to be +not of the best; that their duration of life was not equal to the +average; and that, even if they escaped a return of the disease, they +were apt to go down before their normal time under the attack of some +other malady. In short, _cure_ was a poor weapon against the disease as +compared with _prevention_. + +But before this, a careful study of the enemy's position and +investigation of our own resources had brought another most important +and reassuring fact to light, and that is, that while a distressingly +large number of persons died of tuberculosis, these represented only a +comparatively small percentage of all who had actually been attacked by +the disease. One of the reasons why consumption had come to be regarded +as such a deadly disease was that the milder cases of it were never +recognized. It was, and is yet, a common phrase in the mouths of both +the laity and of the medical profession: "He was seriously threatened +with consumption"; "She came very near falling into a decline,"--_but_ +they recovered. If they didn't die of it, it wasn't "real" tuberculosis. +Now we have changed all that, and have even begun to go to the opposite +extreme, of declaring with the German experts, "_Jeder Mann ist am ende +ein bischen tuberkuloese_." (Every one is some time or another a little +bit tuberculous.) This sounds appalling at first hearing, but as a +matter of fact it is immensely encouraging. Our first suspicion of it +came from the records of that gruesome, but pricelessly valuable, +treasure-house of solid facts in pathology--the post-mortem room, the +dead-house. Systematic examinations of all the bodies brought to autopsy +in our great hospitals and elsewhere revealed at first thirty, then, as +the investigation became more minute and skillful, forty, sixty, +seventy-five per cent of scars in the apices of the lungs, remains of +healed cavities, infected glands, or other signs of an invasion by the +tubercle bacillus. Of course, the skeptic challenged very properly at +once:-- + +"But how do you know that these masses of chalky-material, these +enlarged glands, are the result of tuberculosis? They may be due to some +half-dozen other infections." + +Almost before the question was asked a test was made by the troublesome +but convincing method of cutting open these scars, dividing these +enlarged glands, scraping materials out of their centre, and injecting +them into guinea pigs. Result: from thirty to seventy per cent of the +guinea pigs died of tuberculosis. In other cases it was not necessary to +inoculate, as scrapings or sections from these scar-masses showed +tubercle bacilli, clearly recognizable by their staining reaction. + +Here, then, we have indisputable evidence of the fact that the tubercle +bacillus may not only enter some of the openings of the body,--the +nostrils, the mouth, the lungs,--but may actually form a lodgment and a +growth-colony in the lungs themselves, and yet be completely defeated by +the antitoxic powers of the blood and other tissues of the body, +prevented from spreading throughout the rest of the lung, most of the +invaders destroyed, and the crippled remnants imprisoned for life in the +interior of a fibroid or chalky mass. + +It gave one a distinct shock at the meeting of the British Medical +Association devoted to tuberculosis, some ten years ago, to hear Sir +Clifford Allbutt, one of the most brilliant and eminent physicians of +the English-speaking world, remark, on opening his address, "Probably +most of us here have had tuberculosis and recovered from it." + +Here is evidently an asset of greatest and most practical value, which +changes half the face of the field. Instead of saving, as best we may, +from half to two-thirds of those who have allowed the disease to get the +upper hand and begin to overrun their entire systems, it places before +us the far more cheering task of building up and increasing this natural +resisting power of the human body, until not merely seventy per cent of +all who are attacked by it will throw it off, but eighty, eighty-five, +ninety! We can plan to stop _consumption by preventing the consumptive_. +A very small additional percentage of vigor or of resisting power--such +as could be produced by but a slight improvement in the abundance of the +food-supply, the lighting and ventilating of the houses, the length and +"fatiguingness" of the daily toil--might be the straw which would be +sufficient to turn the scale and prevent the tuberculous individual from +becoming consumptive. + +Here comes in one of the most important and valuable features of our +splendid sanatorium campaign for the cure of tuberculosis, and that is +the nature of the methods employed. If we relied for the cure of the +disease upon some drug, or antitoxin, even though we might save as many +lives, the general reflex or secondary effect upon the community might +not be in any way beneficial; at best it would probably be only +negative. But when the only "drugs" that we use are fresh air, sunshine, +and abundant food, and the only antitoxins those which are bred in the +patient's own body; when, in fact, we are using for the cure of +consumption _precisely those agencies and influences which will prevent +the well from ever contracting it_, then the whole curative side of the +movement becomes of enormous racial value. The very same measures that +we rely upon for the cure of the sick are those which we would recommend +to the well, in order to make them stronger, happier, and more vigorous. + +If the whole civilized community could be placed upon a moderate form of +the open-air treatment, it would be so vastly improved in health, +vigor, and efficiency, and saved the expenditure of such enormous sums +upon hospitals, poor relief, and sick benefits, that it would be well +worth all that it would cost, even if there were no such disease as +tuberculosis on earth. + +This is coming to be the real goal, the ultimate hope of the far-sighted +leaders in our tuberculosis campaign,--to use the cure of consumption as +a lever to raise to a higher plane the health, vigor, and happiness of +the entire community. + +Enormously valuable as is the open-air sanatorium as a means of saving +thousands of valuable and beloved lives, its richest promise lies in its +function as a school of education for the living demonstration of +methods by which the health and happiness of the ninety-five per cent of +the community who never will come within its walls may be built up. +Every consumptive cured in it goes home to be a living example and an +enthusiastic missionary in the fresh-air campaign. The ultimate aim of +the sanatorium will be to turn every farmhouse, every village, every +city, into an open-air resort. When it shall have done this it will have +fulfilled its mission. + +Our plan of campaign is growing broader and more ambitious, but more +hopeful, every day. All we have to do is to keep on fighting and use our +brains, and victory is certain. Our Teutonic fellow soldiers have +already nailed their flag to the mast with the inscription:-- + +"No more tuberculosis after 1930!" + +So much for the serried masses of the centre of our anti-tuberculosis +army, upon which we depend for the heavy, mass fighting and the great +frontal attacks. But what of the right and the left wings, and the cloud +of skirmishers and cavalry which is continually feeling the enemy's +position and cutting off his outposts? Upon the right stretch the +intrenchments of the bacteriologic brigade, with the complicated but +marvelously effective weapons of precision given us by the discovery of +the definite and living cause of the disease, the _Bacillus +tuberculosis_. Upon the left wing lie camp after camp of native +regiments, whose loyalty until of very recent years was more than +doubtful,--heredity, acquired immunity, and the so-called improvements +of modern civilization, steam, electricity, and their kinsmen. + +To the artillerymen of the bacteriologic batteries appears to have been +intrusted the most hopeless task, the forlorn hope,--the total +extermination of a foe so tiny that he had to be magnified five hundred +times before he was even visible, and of such countless myriads that he +was at least a billion times as numerous as the human race. But here +again, as in the centre of the battle-line, when we once made up our +minds to fight, we were not long in discovering points of attack and +weapons to assault him with. + +First, and most fundamental of all, came the consoling discovery that +though there could be no consumption without the bacillus, not more than +one individual in seven, of fair or average health, who was exposed to +its attack in the form of a definite infection, succumbed to it; and +that, as strongly suggested by the post-mortem findings already +described, even those who developed a serious or fatal form of the +disease had thrown off from five to fifteen previous milder or slighter +infections. So that, to put it roughly, all that would be necessary +practically to neutralize the injuriousness of the bacillus would be to +prevent about one-twentieth of the exposures to its invasion which +actually occurred. The other nineteen-twentieths would take care of +themselves. The bacilli are not the only ones who can be numbered in +their billions. If there are billions of them there are billions of us. +We are not mere units--scarcely even individuals--except in a broad and +figurative sense. We are confederacies of billions upon billions of +little, living animalcules which we call cells. These cells of ours are +no Sunday-school class. They are old and tough and cunning to a degree. +They are war-worn veterans, carrying the scars of a score of victories +written all over them. _They_ are animals; bacteria, bacilli, +micrococci, and all _their_ tribe are _vegetables_. The daily business, +the regular means of livelihood of the animal cell for fifteen millions +of years past has been eating and digesting the vegetable. And all that +our body-cells need is a little intelligent encouragement to continue +this performance, even upon disease germs; so that we needn't be afraid +of being stampeded by sudden attack. + +The next cheering find was that the worst enemies of the bacillus were +our best friends. Sunlight will kill them just as certainly as it will +give us new life. The germs of tuberculosis will live for weeks and even +months in dark, damp, unventilated quarters, just precisely such +surroundings as are provided for them in the inside bedrooms of our +tenements, and the dark, cellar-like rooms of many a peasant's cottage +or farmhouse. In bright sunlight they will perish in from three to six +hours; in bright daylight in less than half a day. This is one of the +factors that helps to explain the apparent paradox, that the dust +collected from the floors and walls of tents and cottages in which +consumptives were treated was almost entirely free from tuberculous +bacilli, while dust taken from the walls of tenement houses, the floors +of street-cars, the walls of churches and theatres in New York City, was +found to be simply alive with them. One of the most important elements +in the value of sunlight in the treatment of consumption is its powerful +germicidal effect. + + + + +CHAPTER VII + +TUBERCULOSIS, A SCOTCHED SNAKE + + +II + +Closely allied to the discovery that sunlight and fresh air are fatal to +the microoerganisms of tuberculosis came the consoling fact that these +bacilli, though most horribly ubiquitous and apparently infesting both +the heavens above and the earth beneath, had neither wings nor legs, and +were absolutely incapable of propelling themselves a fraction of an +inch. They do not move--_they have to be carried_. More than this, like +all other disease-germs, while incredibly tiny and infinitesimal, they +have a definite weight of their own, and are subject to the law of +gravity. They do not flit about hither and thither in the atmosphere, +thistledown fashion, but rapidly fall to the floor of whatever room or +receptacle they may be thrown in. And the problem of their transference +is not that of direct carrying from one victim to the next, but the +intermediate one of infected materials, such as are usually associated +with visible dust or dirt. In short, keep dust or dirt from the floor, +out of our food, away from our fingers or clothing or anything that can +be brought to or near the mouth, and you will practically have abolished +the possibility of the transference of tuberculosis. The consumptive +himself is not a direct source of danger. It is only his filthy or +unsanitary surroundings. Put a consumptive, who is careful of his sputum +and cleanly in his habits, in a well-lighted, well-ventilated room, or, +better still, out of doors, and there will be exceedingly little danger +of any other member of his family or of those in the house with him +contracting the disease. Wherever there is dirt or dust there is danger, +and there almost only. Thorough and effective house-reform--not merely +in tenements, alas! but in myriads of private houses as well--would +abolish two-thirds of the spread of tuberculosis. + +It is not necessary to isolate every consumptive in order to stop the +spread of the disease. All that is requisite is to prevent the bacilli +in his sputum from reaching the floor or the walls, to have both the +latter well lighted and aired, and, if possible, exposed to direct +sunlight at some time during the day, and to see that dust from the +floor is not raised in clouds by dry sweeping so as to be inhaled into +the lungs or settle upon food, fingers, or clothing, and that children +be not allowed to play upon such floors as may be even possibly +contaminated. These precautions, combined with the five-to-one resisting +power of the healthy human organism, will render the risk of +transmission of the disease an exceedingly small one. To what +infinitesimal proportions this risk can be reduced by intelligent and +strict sanitation is illustrated by the fact, already alluded to, of the +almost complete germ-freeness of the dust from walls and floors of +sanitorium cottages, and by the even more convincing and conclusive +practical result, that scarcely a single case is on record of the +transmission of this disease to a nurse, a physician, or a servant, or +other employee in an institution for its cure. + +There is absolutely no rational basis for this panic-stricken dread of +an intelligent, cleanly consumptive, or for the cruel tendency to make +him an outcast and raise the cry of the leper against him: "Unclean! +Unclean!" + +It cannot be too strongly emphasized that consumption is transmitted _by +way of the floor_; and if this relay-station be kept sterile there is +little danger of its transmission by other means. + +Practically all that is needed to break this link is the absolute +suppression of what is universally and overwhelmingly regarded as not +merely an unsanitary and indecent, but a filthy, vulgar, and disgusting +habit--promiscuous expectoration. There is nothing new or unnatural in +this repression, this _tabu_ on expectoration. In fact, we are already +provided with an instinct to back it. In every race, in every age, in +every grade of civilization, the human saliva has been regarded as the +most disgusting, the most dangerous and repulsive of substances, and the +act of spitting as the last and deepest sign of contempt and hatred; and +if directed toward an individual, the deadliest and most unbearable +insult, which can be wiped out only by blood. Primitive literature and +legend are full of stories of the poisonousness of human saliva and the +deadliness of the human bite. It was the "bugs" in it that did it. It is +most interesting to see how science has finally, thousands of years +afterward, shown the substantial basis of, and gone far to justify, this +instinctive horror and loathing. + +Not merely are the fluids of the human mouth liable to contain the +tubercle bacillus, and that of diphtheria, of pneumonia, and half a +dozen other definite disorders, but they are in perfectly healthy +individuals, especially where the teeth are in poor condition, simply +swarming with millions of bacteria of every sort, some of them harmless, +others capable of setting up various forms of suppuration and septic +inflammation if introduced into a wound, or even if taken into the +stomach. Even if there were no such disease as tuberculosis a campaign +to stamp out promiscuous expectoration would be well worth all it cost. + +Of course, as a counsel of perfection, the ideal procedure would be +promptly to remove each consumptive, as soon as discovered, from his +house and place him in a public sanatorium, provided by the state, for +the sake of removing him from the conditions which have produced his +disease, of placing him under those conditions which alone can offer a +hopeful prospect of cure, and of preventing the further infection of his +surroundings. The only valid objections to such a plan are those of the +expense, which, of course, would be very great. It would be not merely +best, but kindest, for the consumptive himself, for his immediate +family, and for the community. And enormous as the expense would be, +when we have become properly aroused and awake to the huge and almost +incredible burden which this disease, with its one hundred and fifty +thousand deaths a year, is now imposing upon the United States,--five +times as great as that of war or standing army in the most military-mad +state in Christendom,--the community will ultimately assume this +expense. So long, however, as our motto inclines to remain, "Millions +for cure, but not one cent for prevention," we shall dodge this issue. + +There can be no question but that each state and each municipality of +more than ten thousand inhabitants ought to provide an open-air camp or +colony of sufficient capacity to receive all those who are willing to +take the cure but unable to meet the expense of a private institution; +and, also, some institution of adequate size, to which could be sent, by +process of law, all those consumptives who, either through perversity, +or the weakness and wretchedness due to their disease, or the apathy of +approaching dissolution, fail or are unable to take proper precautions. + +When we remember that the careful investigations of the various +dispensaries for the treatment of tuberculosis in our larger cities, New +York, Boston, Cleveland, report that on an average twenty to thirty per +cent of all children living in the same room or apartment with a +consumptive member of their family are found to show some form of +tuberculosis, it will be seen how well worth while, from every point of +view, this provision for the removal and sanatorium treatment of the +poorer class of these unfortunates would be. These dispensaries now +have, as a most important part of their campaign against the disease, +one or more visiting nurses, who, whenever a patient with tuberculosis +is brought into the dispensary, visit him in his home, show him how to +ventilate and light his rooms as well as may be, give practical +demonstrations of the methods of preventing the spread of the disease, +advise him as to his food, and see that he is supplied with adequate +amounts of milk and eggs, and, finally, round up all the children of the +family and any adults who are in a suspicious condition of health, and +bring them to the dispensary for examination. Distressing as are these +findings, reaching in some cases as high as fifty and sixty per cent of +the children, they have already saved hundreds of children, and +prevented hundreds of others from growing up crippled or handicapped. + +It must be remembered that the tubercle bacillus causes not merely +disease of the lungs in children but also a large majority of the +crippling diseases of the bones, joints, and spine, together with the +whole group of strumous or scrofulous disorders, and a large group of +intestinal diseases and of brain lesions, resulting in convulsions, +paralysis, hydrocephalus, and death. The battle-ground of the future +against tuberculosis is the home. + +We speak of the churchyard as "haunted," and we recoil in horror from +the leper-house or the cholera-camp. Yet the deadliest known hotbed of +horrors, the spawning ground of more deaths than cholera, smallpox, +yellow fever, and the bubonic plague combined, is the dirty floor of the +dark, unventilated living-room, whether in city tenement or village +cottage, where children crawl and their elders spit. + +It is scarcely to the credit of our species that for convincing, actual +demonstrations of what can be done toward stamping out tuberculosis, by +measures directed against the bacillus alone, we are obliged to turn to +the lower animals. By a humiliating paradox we are never quite able to +put ourselves under those conditions which we know to be ideal from a +sanitary point of view. There are too many prejudices, too many vested +interests, too many considerations of expense to be reckoned with. But +with the lower animals that come under our care we have a clear field, +free from obstruction by either our own prejudices or those of others. +In this realm the stamping out of tuberculosis is not merely a rosy +dream of the future but an accomplished fact, in some quarters even an +old story. Two illustrations will suffice, one among domestic animals, +the other among wild animals in captivity. The first is among pure-bred +dairy cattle, the pedigreed Jerseys and Holsteins. No sooner did the +discovery of the bacillus provide us with a means of identification, +than the well-known "_perlsucht_" of the Germans, or "grapes" of the +English veterinarians--both names being derived from the curious rounded +masses or nodules of exudate found in the pleural cavity and the +peritoneum (around the lungs and the bowels), and supposed to resemble +pearls and grapes respectively--were identified as tuberculosis, and +cows were found very widely infected with it. This unfortunately still +remains the case with the large mass of dairy cattle. But certain of the +more intelligent breeders owning valuable cattle proceeded to take steps +to protect them. + +The first step was to test their cows with tuberculin, promptly weeding +out and isolating all those that reacted to the disease. It was at first +thought necessary to slaughter all these at once. But it was later found +that, if they were completely isolated and prevented from communicating +the disease to others, this extreme measure was necessary only with +those extensively diseased. The others could be kept alive, and if their +calves were promptly removed as soon as born, and fed only upon +sterilized or perfectly healthy milk, they would be free from the +disease. And thus the breeding-life of a particularly valuable and +high-bred animal might be prolonged for a number of years. They must, +however, be kept in separate buildings and fields, and preferably upon a +separate farm from the rest of the herd. + +Those cows found healthy were given the best of care, including a marked +diminution of the amount of housing or confinement in barns, and were +again tested at intervals of six months, several times, to weed out any +others which might still have the infection in their systems. In a short +time all signs of the disease disappeared, and no other cases developed +in these herds unless fresh infection was introduced from without. To +guard against this, each farm established a quarantine station, where +all new-bought animals, after having been tested with tuberculin and +shown to be free from reaction, are kept for a period of at least a +year, for careful observation and study, before being allowed to mix +with the rest of the herd. It is now a common requirement among +intelligent breeders of pedigreed cattle to demand, as a formal +condition of sale, their submission to the tuberculin test, or the +certificate of a competent veterinarian that the animal has been so +tested without reacting. Protected herds have now been in existence +under these conditions, notably in Denmark, where the method was first +reduced to a system under the able leadership of Professor Bang, of +Copenhagen, for ten years with scarcely a single case of tuberculosis +developing. Only a fraction of one per cent of calves from the most +diseased mothers are born diseased. + +Not only is the method spreading rapidly among the more intelligent +class of breeders, but many progressive countries of Europe and states +of our Union require the passing of the tuberculin test as a requisite +to the admission within their borders of cattle intended for breeding +purposes. So that, while the problem is still an enormous one, it is now +confidently believed that complete eradication of bovine tuberculosis is +only a question of time. + +The other instance furnishes a much more crucial test, as it is carried +out upon wild animals under the unfavorable conditions of captivity in a +strange climate, like our slum-dwellers from sunny Italy, and comes home +to us more closely in many respects, inasmuch as it is concerned with +our nearest animal relatives on the biological side--monkeys and apes, +in zooelogical gardens. + +Tuberculosis is a perfectly frightful scourge to these unfortunate +captives, causing not infrequently thirty, fifty, and even sixty per +cent of the deaths. This, however, is only in keeping with their +frightful general mortality. The collection of monkeys in the London +Zoo, for instance, some fifteen years ago, was absolutely exterminated +by disease and started over afresh _every three years_, a death-rate of +thirty-five per cent per annum as compared with our human rate of about +two per cent per annum. Here, it would seem, was an instance where there +was little need to call in the bacillus. Brought from a tropical climate +to one of raw, damp fog and smoke, from the freedom of the air-roads +through the tree-tops to the confinement of dismal and often dirty cages +in a stuffy, overheated house, condemned to a diet which at best could +be but a feeble and far-distant imitation of their natural food, it +seemed little wonder that they "jes' natcherly pined away an' died." + +But let the results speak. A thorough system of quarantine was enforced, +beginning with one of the Vienna gardens, and finally reaching one of +its most brilliant and successful exemplifications in our own New York +Zooelogical Gardens in the Bronx. All animals purchased or donated were +tested with tuberculin, and those that reacted were either painlessly +destroyed or disposed of. Those which appeared to be immune were kept in +a thoroughly healthy, sanitary quarantine station for six months or a +year, and again tested by tuberculin before being introduced into the +cages. The original stock of monkeys was treated in the same manner or +else destroyed completely, and the houses and cages thoroughly cleaned +and sterilized or new ones constructed. Keepers employed in the +monkey-house were carefully tested for signs of tuberculosis, and +rejected or excluded if any appeared. Signs were posted forbidding any +expectoration or feeding of the animals (which latter is often done +with nuts or fruit which had been cracked or bitten before being handed +to the monkeys) by the general public, and these rules were strictly +enforced. + +At the same time the houses were thoroughly ventilated and exposed to +sunlight as much as possible, and the animals were turned out into open +air cages whenever the weather would possibly permit. As a result the +mortality from tuberculosis promptly sank from thirty per cent to five +or six per cent. In our Bronx Zoo, for instance, it has become decidedly +rare as a cause of death in monkeys, no case having occurred in the +monkey-house for eighteen months past. What is even more gratifying, the +general mortality declined also, though in less proportion, so that, +instead of losing twenty-five to thirty per cent of the animals in the +house every year, a mortality of ten to fifteen per cent is now +considered large. + +And to think that we might achieve the same results in our own species +if we would only treat ourselves as well as we do our monkey captives! +To "make a monkey of one's self" might have its advantages from a +sanitary point of view. + +"But this method," some one will remind us, "would silence only a part +of the enemy's infection batteries." Even supposing that we could +prevent the spread of the disease from human sources, what of the animal +consumptives and their deadly bacilli? If the milk that we drink, and +the beef, pork, and poultry that we eat, are liable to convey the +infection, what hope have we of ever stopping the invasion? + +The question is a serious one. But here again a thorough and careful +study of the enemy's position has shown the danger to be far less than +it appeared at first sight. Even bacilli have what the French call "the +defects of their virtues." Their astonishing and most disquieting powers +of adjustment, of accommodation to the surroundings in which they find +themselves, namely, the tissues and body-fluids of some particular host +whom they attack, bring certain limitations with them. Just in so far as +they have adjusted themselves to live in and overcome the opposition of +the body-tissues of a certain species of animals, _just to that degree +they have incapacitated themselves to live in the tissues of any other +species_. + +Some of the most interesting and far-reachingly important work that has +been done in the bacteriology of tuberculosis of late years has +concerned itself with the changes that have taken place in different +varieties and strains of tubercle bacilli as the result of adjusting +themselves to particular environments. The subject is so enormous that +only the crudest outlines can be given here, and so new that it is +impossible to announce any positive conclusions. But these appear to be +the dominant tendencies of thought in the field so far. + +Though nearly all domestic animals and birds, and a majority of wild +animals under captivity, are subject to the attack of tuberculosis, +practically all the infections hitherto studied are caused by one of +three great varieties or species of the tubercle bacillus: the _human_, +infesting our own species; the _bovine_, attacking cattle; and the +_avian_, inhabiting the tissues of birds, especially the domestic fowl. +These three varieties or species so closely resemble one another that +they were at one time regarded as identical, and we can well remember +the wave of dismay which swept over the medical world when Robert Koch +announced that the "_perlsucht_" of cattle was a genuine and +unquestioned tuberculosis due to an unmistakable tubercle bacillus. But +as these varieties were thoroughly and carefully studied, it was soon +found that they presented definite marks of differentiation, until now +they are universally admitted to be distinct varieties, each with its +own life peculiarities, and, according to some authorities, even +distinct species. + +"But," we fancy we hear some one inquire impatiently, "what do those +academic, technical distinctions matter to us? Whether the avian +tuberculosis germ is a variety or a true species may be left to the +taxonomists, but it is of no earthly importance to us." + +On the contrary, it is of the greatest importance. For the distinctive +feature about a particular species of parasite is that it will live and +flourish where another species will die, and, vice versa, _will die in +surroundings where its sister species might live and thrive_. + +One of the first differences found to exist among these three types of +bacteria was the extraordinary variation in their power of attacking +different animals. For instance, while the guinea-pig and the rabbit +could be readily inoculated with _human_ bacilli, they could only be +infected with difficulty by cultures of the _bovine_ bacillus; while the +only animal that could be inoculated at all with the _avian_ or bird +bacillus was the rabbit, and he only occasionally. In fact, +bacteriologists soon came to the consoling conclusion that the _avian_ +bacillus might be practically disregarded as a source of danger to human +beings, so widely different were the conditions in their moist and +moderately warm tissues to those of the dry and superheated tissues of +the bird to which it had adjusted itself for so many generations. + +And next came the bold pronunciamento of no less an authority than Koch +himself, that the bovine bacillus also was so feebly infective to human +beings that it might be practically disregarded as a source of danger. +This promptly split the bacteriologists of the world into two opposing +camps, and started a warfare which is still being waged with great +vigor. As the question is still under hot dispute by even the highest +authorities, it is, of course, impossible to pronounce any definite +conclusions. But the net result to date appears to be that while Koch +made a serious error of judgment in declaring that meat and milk as a +source of danger to human beings of tuberculosis might be disregarded, +yet, for practical purposes, his position is, in the main, correct: the +actual danger from the bovine bacillus to human beings is relatively +small. + +There was nothing whatever improbable, in the first place, in the +correctness of Koch's position. + +It is one of the few consoling facts, well known to all students of +comparative pathology or the diseases of the different species of +animals, how peculiarly specialized they are in the choice of their +diseases, or, perhaps, to put it more accurately, how particular and +restricted disease-germs are in their choice of a host. For instance, +out of twenty-eight actually infectious diseases which are most common +among the domestic animals and man, other than tuberculosis, only +one--_rabies_--is readily communicable to more than three species; only +three--_anthrax_, _tetanus_, and _foot-and-mouth disease_--are +communicable to two species; while the remainder are almost absolutely +confined to one species, even though this be thrown into closest contact +with half a dozen others. + +Again, we have half a dozen similar instances in the case of +tuberculosis itself. The horse and the sheep, for instance, are both +most intimately associated with cattle, pastured in the same fields, fed +upon the same food, and yet tuberculosis is almost unknown in sheep and +decidedly uncommon in horses, and when it does occur in them is from a +human source. The goat is almost equally immune from both human and +_bovine_ forms, while the cat and the dog, although developing the +infection with a low degree of frequency, almost invariably trace that +infection to a human source. + +There is, therefore, no _a priori_ reason whatever why we should be any +more susceptible to bovine tuberculosis than the remainder of the +domestic animals. It is only fair to say, however, that the animal whose +diet--and appetite--most closely resembles ours, the hog, is quite +fairly susceptible to bovine tuberculosis if fed upon the milk or meat +of tuberculous cattle. + +Next came the particularly consoling fact that although nothing has been +more striking than the great increase in the amounts of meat and milk +consumed by the mass of the community during our last twenty years' +progress in civilization, this has been accompanied not by any increase +of tuberculosis, but by a _diminution of from thirty-five to forty-five +per cent_. The allegation so frequently made that there has been an +increase in the amount of infantile tuberculosis has been shown, upon +careful investigation by Shennan of Edinburgh, Guthrie of London, Kossel +in Germany, Comby in France, Bovaird in New York, and others, to be +practically without foundation. + +Then, while repetitions of Koch's experiment, upon which his +announcement was based, of inoculating calves and young cattle with +_human_ bacilli have proved that a certain number of them can be, under +appropriate circumstances, made to develop tuberculosis, that number has +never been a large percentage of the animals tested, and in many cases +the infection has been a local one, or of a mild type, which has +resulted in recovery. Lastly, while a number of bacilli, with _bovine_ +culture and other characteristics, have been recovered from the bodies +of children dying of tuberculosis, and these bacilli have proved +virulent to calves when injected into them, yet, as a matter of +historical fact, the actual number of instances in which children or +other human beings have been definitely proved to have contracted the +disease from the milk of a tuberculous cow is still exceedingly and +encouragingly small. A careful study of the entire literature of the +past twenty years, some three years ago, revealed _only thirty-seven +cases_; and of these thirty-seven Koch's careful investigations have +since disproved the validity of nine. + +On the other hand, it is anything but safe to accept Koch's practical +dictum and neglect the meat and milk of cattle as a source of danger in +tuberculosis. First, because the degree of our immunity against the +bovine bacilli is still far from settled; and, second, because, while +bacteriologists are fairly agreed that the _avian_, the _bovine_, and +the _human_ represent three distinct and different variations, if not +species, of the bacillus, they are almost equally agreed that they are +probably the descendants of one common species, which may possibly be a +bacillus commonly found upon meadow grasses, particularly the well-known +timothy, and hence very frequently in the excreta of cattle, and known +as the _grass bacillus_ or _dung bacillus_ of M[oe]ller. This bacillus +has all the staining, morphological, and even growth characteristics of +the tubercle bacillus except that it produces only local irritation and +little nodular masses, if injected into animals. Our knowledge of its +existence is, however, of great practical importance, inasmuch as it +warned us that in our earlier studies of the bacilli contained in milk +and butter we have been mistaking this organism for a genuine tubercle +bacillus. As a consequence, of late years our tests for the presence of +tubercle bacilli in milk are made not only by searching for the organism +with the microscope, but also by injecting the centrifugated sediment of +the infected milk into guinea pigs, to see if it proves infectious. Many +of our earlier statements as to the presence of tubercle bacilli in milk +and butter are now invalidated on this account. + +Not only are the three varieties of tubercle bacilli probably of common +origin, but they may, under certain peculiar conditions, be transformed +into one another, or, at least, enabled to live under the conditions +favorable to one another. This was shown nearly fifteen years ago by the +ingenious experiments of Nocard, the great veterinary pathologist. He +took a culture of bovine bacilli, which were entirely harmless to fowls, +and, inclosing them in a collodion capsule, inserted them into the +peritoneal cavity of a hen. The collodion capsule permitted the fluids +of the body to enter and provide food for the bacilli, but prevented the +admission of the leucocytes to attack and destroy them. After several +weeks the capsule was removed, the bacilli found still alive, and +transferred to another capsule in another fowl. When this process had +been repeated some five or six times, the last generation of bacilli was +injected into another fowl, which promptly developed tuberculosis, +showing that by gradually exposing the bacilli for successive +generations to the high temperature of the bird's body (from five to +fifteen degrees above that of the mammal), they had become acclimated, +as it were, and capable of developing. So that it is certainly quite +conceivable that bovine bacilli introduced in milk or meat might manage +to find a haven of refuge or lodgment in some out-of-the-way gland or +tissue of the human body, and there avoid destruction for a sufficiently +long time to become acclimated and later infect the entire system. + +This is the method which several leaders in bacteriology, including +Behring (of antitoxin fame), believe to be the principal source and +method of infection of the human species. The large majority, however, +of bacteriologists and clinicians are of the opinion that ninety per +cent of all cases of human tuberculosis are contracted from some human +source. So that, while we should on no account slacken our fight against +tuberculosis in either cattle or birds, and should encourage in every +way veterinarians and breeders to aim for its total destruction,--a +consummation which would be well worth all it would cost them, purely +upon economic grounds, just as the extermination of human tuberculosis +would be to the human race,--yet we need not bear the burden of feeling +that the odds against us in the fight for the salvation of our own +species are so enormous as they would be, had we no natural protection +against infection from animals and birds. + +The more carefully we study all causes of tuberculosis in children, the +larger and larger percentage of them do we find to be clearly traceable +to infection from some member of the family or household. In Berlin, for +instance, Kayserling reports that seventy per cent of all cases +discovered can be traced to direct infection from some previous human +case. + +Lastly, what of the left wing of our army of extermination, composed of +those light-horse auxiliaries--the general progress and new developments +of civilization, and the net results upon the individual of the +experiences of his ancestors, which we designate by the term "heredity"? +For many years we were in serious doubt how far we could depend upon the +loyalty of this group of auxiliaries, and many of the faint-hearted +among us were inclined to regard their sympathies as really against us +rather than with us, and prepared to see them desert to the enemy at any +time. It was pointed out, as of great apparent weight, that consumption +was decidedly and emphatically a disease of civilization; that it was +born of the tendency of men to gather themselves into clans and nations +and crowd themselves into villages and those hives of industry called +cities; that the percentage of deaths from tuberculosis in any community +of a nation or any ward of a city was high in direct proportion to the +density of its population; and that the whole tendency of civilization +was to increase this concentration, this congestion of ground space, +this piling of room upon room, of story upon story. How could we +possibly, in reason, expect that the influences which had caused the +disease could help us to cure it? + +But the improbable has already happened. Never has there been a more +rapid and extraordinary growth of our great cities as contrasted with +our rural districts, never has there been a greater concentration of +population in restricted areas than during the past thirty-five years. +And yet, the prevalence of tuberculosis in that time, in all civilized +countries of the earth, has shown not only no increase, _but a decrease +of from thirty-five to fifty per cent_. To-day the world power which has +the largest percentage of its inhabitants gathered within the limits of +its great cities, England, has the lowest death-rate in the civilized +world from tuberculosis, although closely pressed within the last few +years by the United States, whose percentage of urban population is +almost equally large, while England's sister island, Ireland, with one +of the highest percentages of rural and the lowest of urban population, +has one of the highest death-rates from tuberculosis, and one which is, +unfortunately, increasing. + +The real cure for the evils of civilization would appear to be _more +civilization_, or, better, perhaps, _higher_ civilization. Nor are these +exceptional instances. Take practically any city, state, or province in +the civilized world, which has had an adequate system of recording all +births and deaths for more than thirty years, and you will find a +decrease in the percentage of deaths from tuberculosis in that time of +from twenty to forty per cent. The city of New York's death-roll, for +instance, from tuberculosis, per one thousand living, is some +thirty-five per cent less than it was thirty years ago. So that our +fight against the disease is beginning to bear fruit already. As Osler +puts it, we run barely half the risk of dying of tuberculosis that our +parents did and barely one-fourth of that of our grandparents. + +But this gratifying improvement goes deeper, and is even more +significant than this. It is, of course, only natural to expect that our +vigorous fight against the spread of the infection of the disease would +give us definite results. But the interesting feature of the situation +is that this diminution in England and in Germany, for instance, began +not merely twenty, but thirty, forty, even fifty years ago--two decades +before we even knew that tuberculosis was an infectious disease with a +contagion that could be fought. + +In the case of England, for instance, we have the, at first sight, +anomalous and even improbable fact that the rate of decline in the +death-rate from tuberculosis for the twenty years preceding the +discovery of Koch's bacillus was almost as great as it has been in the +twenty years since. In other words, the general tendency, born of +civilization, toward sanitary reform, better housing, better drainage, +higher wages and consequently more abundant food, rigid inspection of +food materials, factory laws, etc., is of itself fighting against and +diminishing the prevalence of the "great white plague" by improving the +resisting power and building up the health of the individual. +Civilization is curing its own ills. + +It must be remembered that vital statistics, showing the decrease of a +given disease within the past forty or fifty years, probably represent +not merely a real decrease of the amount indicated by the figures but an +even greater one in fact; because each succeeding decade, as our +knowledge of disease and the perfection of our statistical machinery +improves and increases, is sure to show a prompter recognition and a +more thorough and complete reporting of all cases of the disease +occurring. Statistics, for instance, showing a moderate apparent rate of +_increase_ of a disease within the last thirty years are looked upon by +statisticians as really indicating that it is at a standstill. It is +almost certain that at least from ten to twenty per cent more of the +cases actually occurring will be recognized during life and reported +after death than was possible with our more limited knowledge and less +effective methods of registration thirty years ago. So we need not +hesitate to encourage ourselves to renewed effort by the reflection that +we are enlisted in a winning campaign, one in which the battle-line is +already making steady and even rapid progress, and which can have only +one termination so long as we retain our courage and our common-sense. + +This decline of the tuberculosis death-rate is, of course, only a part +of the general improvement of physique which is taking place under +civilization. If we could only get out from under the influence of the +"good old times" obsession and open our eyes to see what is going on +about us! There is nothing mysterious about it. The soundest of physical +grounds for improving health can be seen on every hand. We point with +horror, and rightly, to the slum tenement house, but forget that it is a +more sanitary human habitation than even the houses of the nobility in +the Elizabethan age. We become almost hysterical over the prospect that +the very fibre of the race is to be rotted by the adulteration of our +food-supply, by oleomargarine in the butter, by boric acid in our canned +meats, by glucose in our sugar, and aniline dyes in our candies, but +forget that all these things represent extravagant luxuries unheard of +upon the tables of any but the nobility until within the past two +hundred, and in some cases, one hundred, years. Up to three hundred +years ago even the most highly civilized countries of Europe were +subject to periodic attacks of famine; our armies and navies were swept +and decimated with scurvy, from bad and rotten food-supplies; almost +every winter saw epidemics breaking out from the use of half-putrid +salted and cured foods; only forty years ago, a careful investigation of +one of our most conservative sociologists led him to the conclusion +that in Great Britain _thirty per cent of the population never in all +their lives had quite as much as they could eat_, and for five months +out of the year were never comfortably warm. The invention of steam, +with its swift and cheap transportation of food-supplies, putting every +part of the earth under tribute for our tables, meat every day instead +of once a week for the workingman, and the introduction of sugar in +cheap and abundant form, with the development of the dietary in fruits +and cereals which this has made possible, have done more to improve the +resisting power and build up the physique of the mass of the population +in our civilized communities, than ten centuries of congestion and +nerve-worry could do to break it down. + +We shake our heads, and prate fatuously that "there were giants in those +days," ignorant of the thoroughly attested fact, that the average +stature of the European races has increased some four inches since the +days of the Crusaders, as shown by the fact that the common British +soldier of to-day--Mr. Kipling's renowned "Tommy Atkins," who is looked +upon by the classes above him in the social scale as a short, undersized +sort of person--can neither fit his chest and shoulders into their +armor, get his hands comfortably on the hilts of their famous two-handed +swords, nor even lie down in their coffins. + +We are at last coming to acknowledge with our lips, although we scarcely +dare yet to believe it in our heart of hearts, that not merely the +death-rate from tuberculosis, but the general death-rate from all causes +in civilized communities, is steadily and constantly declining; that +the average longevity has increased nearly ten years within the memory +of most of us, chiefly by the enormous reduction in the mortality from +infant diseases; and that, though the number of individuals in the +community who attain a great or notable age is possibly not increasing, +the percentage of those who live out their full, active life, play their +man's or woman's part in the world, and leave a group of properly fed, +vigorous, well-trained, and educated children behind them to carry on +the work of the race, is far greater than ever before. Even in our +much-denounced industrial conditions, made possible by the discovery of +steam with its machinery and transportation, the gain has far exceeded +the loss. While machinery has made the laborer's task more monotonous +and more confining, the net result has been that it has shortened his +hours and increased his efficiency. + +Even more important, it has increased his intelligence by demanding and +furnishing a premium for higher degrees of it. Naturally, one of the +first uses which he has made of his increased intelligence has been to +demand better wages and to combine for the enforcement of his demands. +The premium placed upon intelligence has led both the broader-minded, +more progressive, and more humane among employers, and the more +intelligent among employees, to recognize the commercial value of +health, and of sanitary surroundings, comfort, and healthy recreations, +as a means of promoting this. The combined results of these forces are +seen in the incontestable, living fact that the death-rate from +tuberculosis among intelligent artisans and in well-regulated factory +suburbs is already below that of many classes of outdoor and even farm +laborers, whose day is from twelve to fourteen hours, and whose children +are worked, and often overworked, from the time that they can fairly +walk alone, with as disastrous and stunting results as can be found in +any mine or factory. Child-labor is one of the oldest of our racial +evils, instead of, as we often imagine, the newest. + +All over the civilized world to-day the average general death-rate of +each city, slums included, is now below that of many rural districts in +the same country. If I were to be asked to name the one factor which had +done more than any other to check the spread and diminish the death-rate +from tuberculosis I should unhesitatingly say, the _marked increase of +wages among the great producing masses of the country_, with the +consequent increased abundance of food, better houses, better sanitary +surroundings, and last, but not least, shorter hours of labor. + +_Underfeeding and overwork are responsible for more deaths from +tuberculosis than any other ten factors._ Rest and abundant feeding are +the only known means for its cure. + +This is one of the reasons why the medical profession has abandoned all +thought of endeavoring to fight the disease single-handed, and is +striving and straining every nerve to enlist the whole community in the +fight. Its burden rests, not upon the unfortunate individual who has +become tuberculous, but _upon the community_ which, by its ignorance, +its selfishness, and its greed, has done much to make him so. What +civilization has _caused_ it is under the most solemn obligation to +_cure_. + + * * * * * + +One more brigade of irregular troops on the extreme left remains to be +briefly reviewed, and that is those forces resulting from the successive +exposure of generations to the physical influences of civilization, +including the infectious diseases. For years we never dreamed of even +attempting to raise any levies among these border tribes of more than +doubtful loyalty. Indeed, they were supposed to be our open enemies. + +When we first attempted to take a world-view of tuberculosis, the first +great fact that stood out plainly was that it was emphatically a disease +of the walled town and the city; that the savage and the nomad barbarian +were practically free from it; that range cattle and barnyard fowls +seldom fell victims to it, while their housed and confined cousins in +the dairy barn and the breeding-pens suffered frightfully. It was one of +our commonplace sayings that we must "get back to nature," get away from +the walled city into the open country, revert from the conditions of +civilization in a considerable degree to those of barbarism, in order to +escape. While, as for heredity, its influence was almost dead against +us. How could a race be exposed to a disease like tuberculosis, +generation after generation, without having its vital resistance +impaired? + +But a marked and cheering change has come over our attitude to this wing +of the battle of life. So far from regarding it as in any sense +necessary to revert to barbarism, still less to savagery, for either +the prevention or the cure of disease, we have discovered by the most +convincing, practical experience, that we can, in the first place, with +the assistance of the locomotive and trolley, combined with modern +building skill and sanitary knowledge, put even our city-dwellers under +conditions, in both home and workshop, which will render them far less +likely to contract tuberculosis than if they were in a peasant's cottage +or _the average farmhouse or merchant's house_ of a hundred years ago, +to say nothing of the cave, the dugout, or the hut of the savage. + +In the second place, instead of simply "going back to nature" and living +in brush-shelters on what we can catch or shoot, it takes _all the +resources of civilization_ to place our open-air patients in the ideal +conditions for their recovery. Let any consumptive be reckless enough to +"go back to nature," unencircled by the strong arm of civilized +intelligence and power, and unprotected by her sanitary shield, and +nature will kill him three times out of five. There could not be a more +dangerous delusion than the all-too-common one--that all that is +necessary for the cure of consumption is to turn the victim loose among +the elements, even in the mildest and most favorable of climates. + +He must be fed upon the most abundant and nutritious of foods, even the +simplest being milk of a richness which is given by no kind of wild +cattle, and which, indeed, only the most carefully bred and highly +civilized strains of domestic cattle are capable of producing; eggs such +as are laid by no wild bird or by any but the most highly specialized +of domestic poultry at the season of the year when they are most +required; steaks and chops, hams and sides of bacon, sugar and fruits +and nuts, which simply _are not produced anywhere outside of +civilization_, and often only in the most intelligent and progressive +sections of civilized communities. + +Put him upon even the average diet of many people in this progressive +and highly civilized United States the year round,--with its thin milk, +its pulpy, half-sour butter, its tough meat, its half-rancid pickled +pork, its short three months of really fresh vegetables and good fruit, +and six months of eternal cabbage, potatoes, dried apples, and +prunes,--and he will fail to build up the vigor necessary to fight the +disease, even in the purest and best of air. + +The saddest and most pitiful tragedies which the consumptive +health-resort physician can relate are those of wretched +sufferers,--even in a comparatively early stage of the disease,--whose +misguided but well-meaning friends have raised money enough to pay their +fare out to Colorado, California, Arizona, or New Mexico, and expect +them to get work on a ranch, so as to earn their living and take the +open-air treatment at the same time. + +Three things are absolutely necessary for a reasonable prospect of cure +of consumption. One is, abundance of fresh air, day and night. Another, +abundance of the best quality of food. And the third, absolute--indeed, +enforced--rest during the period of fever. Let any one of these be +lacking, and your patient will die just as certainly as if all three +were. _Not one in five_ of those who go out to climates with even a high +reputation as health-resorts--expecting to earn their own living or to +"rough it" in shacks or tents on three or four dollars a week, doing +their own cooking and taking care of themselves--recovers. They have a +four-to-one chance of recovery in _any_ climate in which they can obtain +these three simple requisites, and a four-to-one chance of dying in any +climate in which any one of these is lacking. + +Instead of nature being able to cure the consumptive unaided, as a +matter of fact she has neither the ability nor the inclination to do +anything of the sort. There is no class of patients whose recovery +depends more absolutely upon a most careful and intelligent study and +regulation of their diet, of every detail of their life throughout the +entire twenty-four hours, and of the most careful adjustment of air, +food, heat, cold, clothing, exercise, recreation, by the combined forces +of sanitarian, nurse, and physician. So that, instead of feeling that +only by reverting to savagery can consumption be prevented, we have no +hesitation in saying that it is _only under civilization, and +civilization of the highest type, that we have any reasonable prospect +of cure_. + +Finally, we are getting over our misgivings as to the intentions of the +hereditary brigade. It is certainly not our enemy, and may probably turn +out to be one of our best friends. + +Our first sidelight on this question came in rather a surprising manner. +It was taken for granted, almost as axiomatic, that if the conditions of +savage life were such as to discourage, if not prevent, tuberculosis, +certainly, then, the race which had been exposed to these conditions for +countless generations would have a high degree of resisting power to the +disease. But what an awakening was in store for us! No sooner did the +army surgeon and medical missionary settle down in the wake of that +extraordinary world-movement of Teutonic unrest, which has resulted in +the colonization of half the globe within the past two or three hundred +years, than it was discovered that, although the hunting or nomad savage +had not developed tuberculosis, and the disease was emphatically born of +civilization, yet the moment that these healthy and vigorous children of +nature were exposed to its infection, instead of showing the high degree +of resisting power that might be expected, they died before it like +sheep. + +From all over the world--from the Indians of our Western plains, the +negroes of our Southern States, the islanders of Polynesia, New Zealand, +Hawaii, Samoa--came reports of tribes practically wiped out of existence +by the "White Plague" of civilization. To-day the death-rate from +tuberculosis among our Indian wards is from _three to six times_ that of +the surrounding white populations. The negro population of the Southern +States has nearly three times the death-rate of the white populations of +the same states. Instead of centuries of civilization having made us +more susceptible to the disease than those savages who probably most +nearly parallel our ancestral conditions of a thousand to fifteen +hundred years ago, we seem to have acquired from three to five times +their resisting power against it. Not only this, but those races among +us which have been continuous city-dwellers for a score of generations +past have acquired a still higher degree of immunity. + +In every civilized land the percentage of deaths from tuberculosis among +the Jews, who, from racial and religious prejudices, have been prisoners +of the Ghetto for centuries, is about half to one-third that of their +Gentile neighbors. In certain blocks of the congested districts of New +York and Chicago, for instance, the Jewish population shows a death-rate +of only one hundred and sixty-three per hundred thousand living, while +the Gentile inhabitants of similar blocks show the appalling rate of +five hundred and sixty-five. Similarly, by a strange apparent paradox, +the highest mortality from tuberculosis in the United States is not in +those states having the greatest urban population, but, on the contrary, +in those having the largest rural population. + +The ten highest state tuberculosis death-rates contain the names of +Tennessee, Kentucky, West Virginia, Virginia, and South Carolina, while +New York, Pennsylvania, and Massachusetts are among the lowest. + +The subject is far too wide and complicated to admit of any detailed +discussion here. But, explain it as we may, the consoling fact remains +that civilized races, including slum-dwellers, have a distinctly lower +death-rate from tuberculosis than have savage tribes which are exposed +to it even under most favorable climatic and hygienic conditions; that +those races which have survived longest in city and even slum +surroundings have a lower death-rate than the rest of the community +under those conditions; and that certain of our urban populations have +lower death-rates than many of our rural ones. + +As for the immediate effect of heredity in the production of the +disease, the general consensus of opinion among thoughtful physicians +and sanitarians now is that direct infection is at least five times as +frequent a factor as is heredity; that at least eight-tenths of the +cases occurring in the children of tuberculous parents are probably due +to the direct communication of the disease, and that if the spread of +the infection could be prevented, the element of heredity could be +practically disregarded. + +We are inclined to regard even the well-marked tendency of tuberculosis +to attack a considerable number of the members of a given family to be +due largely, in the first place, to direct infection; secondly, to the +fact that that family were all submitted to the same unfavorable +environment in the matter of food, of housing, of overwork, or of the +New England conscience, with its deadly belief that "Satan finds some +mischief still for idle hands to do." + +Upon direct pathological grounds nothing is more definitely proven than +that the actual inheritance of tuberculosis, in the sense of its +transmission from a consumptive mother to the unborn child, is one of +the rarest of occurrences. On the other hand, the feeling is general +that, inasmuch as probably four-fifths of us are repeatedly exposed to +the infection of tuberculosis and throw it off without developing a +systemic attack of the disease, the development of a generalized +infection, such as we term consumption, is in itself a sign of a +resisting power below the average. Should such an individual as this +become a parent, the strong probability is that his children--unless, as +fortunately often happens, their other parent should be as far above the +average of vigor and resisting power--would not be likely to inherit +more vigor than that possessed by their ancestry. So that upon _a +priori_ grounds we should expect to find that the children born of +tuberculous parents would be more susceptible to the infection to which +they are so sure to be exposed than the average of the race. So that the +marriage of consumptives should, unquestionably, upon racial grounds, be +discouraged except after they have made a complete recovery and remained +well at least five years. + +To sum up: while the earlier steps of civilization unquestionably +provide that environment which is necessary for the development of +tuberculosis, the later stages, with their greatly increased power over +the forces of nature, their higher intelligence and their broader +humanity, not merely have it in their power to destroy it, but are +already well on the way to do so. + + + + +CHAPTER VIII + +THE GREAT SCOURGE + + +Not only have most diseases a living cause, and a consequent natural +history and course, but they have a special method of attack, which +looks almost like a preference. It seems little wonder that the +terror-stricken imagination of our Stone Age ancestors should have +personified them as demons, "attacking" or leaping upon their victims +and "seizing" them with malevolent delight. The concrete comparison was +ready to their hand in the attack of fierce beasts of prey; and as the +tiger leaps for the head to break the neck with one stroke of his paw, +the wildcat flies at the face, the wolf springs for the slack of the +flank or the hamstring, so these different disease demons appear each to +have its favorite point of attack: smallpox, the skin; cholera, the +bowels; the Black Death, the armpits and the groin; and pneumonia, the +lung. + +There are probably few diseases which are so clearly recognized by every +one and about which popular impressions are in the main so clear-cut and +so correct as pneumonia. The stabbing pain in the chest, the cough, the +rusty or blood-stained expectoration, the rapid breathing, all stamp it +unmistakably as a disease of the lung. Its furious onset with a +teeth-chattering chill, followed by a high fever and flushed face, and +its rapid course toward recovery or death, mark it off sharply from all +other lung infections. + +Its popular names of "lung fever," "lung plague," "congestion of the +lungs," are as graphic and distinctive as anything that medical science +has invented. In fact, our most universally accepted term for it, +pneumonia, is merely the Greek equivalent of the first of these. + +It is remarkable how many of our disease-enemies appear to have a +preference for the lung as a point of attack. In the language of _Old +Man Means_ in "The Hoosier Schoolmaster," the lung is "their fav'rit +holt." Our deadliest diseases are lung diseases, headed by consumption, +seconded by pneumonia, and followed by bronchitis, asthma, etc.; +together, they manage to account for one-fourth to one-third of all the +deaths that occur in a community, young or old. No other great organ or +system of the body is responsible for more than half such a mortality. +Now this bad eminence has long been a puzzle, since, foul as is the air +or irritating as is the gas or dust that we may breathe into our lungs, +they cannot compare for a moment with the awful concoctions in the shape +of food which are loaded into our stomachs. Even from the point of view +of infections, food is at least as likely to be contaminated with +disease-germs as air is. Yet there is no disease or combination of +diseases of the whole food canal which has half the mortality of +consumption alone, in civilized communities, while in the Orient the +pneumonic form of the plague is a greater scourge than cholera. + +It has even been suggested that there may possibly be a historic or +ancestral reason for this weakness to attack, and one dating clear back +to the days of the mud-fish. It is pointed out that the lung is the last +of our great organs to develop, inasmuch as over half of our family tree +is under water. When our mud-loving ancestor, the lung-fish (who was +probably "one of three brothers" who came over in the Mayflower--the +records have not been kept) began to crawl out on the tide-flats, he had +every organ that he needed for land-life in excellent working condition +and a fair degree of complexity: brain, stomach, heart, liver, kidneys; +but he had to manufacture a lung, which he proceeded to do out of an old +swim-bladder. This, of course, was several years ago. But the lung has +not quite caught up yet. The two or three million year lead of the other +organs was too much to be overcome all at once. So carelessly and +hastily was this impromptu lung rigged up that it was allowed to open +from the front of the gullet or [oe]sophagus, instead of the back, while +the upper part of the mouth was cut off for its intake tube, as we have +already seen in considering adenoids, thus making every mouthful +swallowed cut right across the air-passages, which had to be provided +with a special valve-trap (the epiglottis) to prevent food from falling +into the lungs. + +So, whenever you choke at table, you have a right to call down a +benediction upon the soul of your long departed ancestor, the lung-fish. +However applicable or remote we may regard "the bearin's of this +observation," the practical and most undesirable fact confronts us +to-day that this crossing and mutual interference of the air and the +food-passages is a fertile cause of pneumonia, inasmuch as the germs of +this disease have their habitat in the mouth, and are from that +lurking-place probably inhaled into the lung, as is also the case with +the germs of several milder bronchitic and catarrhal affections. + +It may be also pointed out that, history apart, our lung-cells at the +present day are at another disadvantage as compared with all the other +cells of the body, except those of the skin; and that is, that they are +in constant contact with air, instead of being submerged in water. +Ninety-five per cent of our body-cells are still aquatic in their +habits, and marine at that, and can live only saturated with, and bathed +in, warm saline solution. Dry them, or even half-dry them, and they die. +Even the pavement-cells coating our skin surfaces are practically dead +before they reach the air, and are shed off daily in showers. + +We speak of ourselves as "land animals," but it is only our lungs that +are really so. All the rest of the body is still made up of sea +creatures. It is little wonder that our lungs should pay the heaviest +penalty of our change from the warm and equable sea water to the gusty +and changeable air. + +Even if we have set down the lung as a point of the least resistance in +the body, we have by no means thereby explained its diseases. Our point +of view has distinctly shifted in this respect within recent years. +Twenty years ago pathologists were practically content with tracing a +case of illness or death to an inflammation or disease of some +particular organ, like the heart, the kidney, the lung, or the stomach. +Now, however, we are coming to see that not only may the causation of +this heart disease, kidney disease, lung disease, have lain somewhere +entirely outside of the heart, kidney, or lung, but that, as a rule, the +entire body is affected by the disease, which simply expresses itself +more violently, focuses, as it were, in this particular organ. In other +words, diseases of definite organs are most commonly the local +expressions of general diseases or infections; and this local +aggravation of the disease would never have occurred if the general +resisting power and vigor of the entire body had not been depressed +below par. So that even in guarding against or curing a disease of a +particular organ it is necessary to consider and to treat the whole +body. + +Nowhere is this new attitude better illustrated than in pneumonia. Frank +and unquestioned infection as it is, wreaking two-thirds of its visible +damage in the lung itself, the liability to its occurrence and the +outlook for its cure depend almost wholly upon the general vigor and +rallying power of the entire body. It is perfectly idle to endeavor to +avoid it by measures directed toward the protection of the lung or of +the air-passages, and equally futile to attempt to arrest its course by +treatment directed to the lung, or even the chest. The best place to +wear a chest-protector is on the soles of the feet, and poulticing the +chest for pneumonia is about as effective as shampooing the scalp for +brain-fag. + +This clears the ground of a good many ancient misconceptions; for +instance, that the chief cause of pneumonia is direct exposure to cold +or a wetting, or the inhalation of raw, cold air. Few beliefs were more +firmly fixed in the popular mind--and, for the matter of that, in the +medical--up to fifteen or twenty years ago. It has found its way into +literature; and the hero of the shipwreck in an icy gale or of weeks of +wandering in the Frozen North, who must be offered up for artistic +reasons as a sacrifice to the plot, invariably dies a victim of +pneumonia, from his "frightful exposure," just as the victim of +disappointed love dies of "a broken heart," or the man who sees the +ambitions of years come crashing about his ears, or the woman who has +lost all that makes life worth living, invariably develops "brain +fever." + +There is a physical basis for all of these standard catastrophes, but it +is much slenderer than is usually supposed. For instance, almost every +one can tell you how friends of theirs have "brought on congestion of +the lungs," or pneumonia, by going without an overcoat on a winter day, +or breaking through the ice when skating, or even by getting their feet +wet and not changing their stockings; and this single dramatic instance +has firmly convinced them that the chief cause of "lung fever" is a +chill or a wetting. Yet when we come to tabulate long series of causes, +rising into thousands, we find that the percentage in which even the +patients themselves attribute the disease to exposure, or a chill, sinks +to a surprisingly small amount. For instance, in the largest series +collected with this point in mind, that of Musser and Norris, out of +forty-two hundred cases only seventeen per cent gave a history of +exposure and "catching cold"; and the smaller series range from ten to +fifteen per cent. So that, even in the face of the returns, not more +than one-fifth of all cases of pneumonia can reasonably be attributed to +chill. And when we further remember that under this heading of exposure +and "catching cold" are included many mere coincidences and the chilly +sensations attending the beginning of those milder infections which we +term "common colds," it is probable that even this small percentage +could be reduced one-half. Indeed, most cautious investigators of the +question have expressed themselves to this effect. This harmonizes with +a number of obstinate facts which have long proved stumbling-blocks in +the way of the theory of exposure as a cause of pneumonia. One of the +classic ones was that, during Napoleon's frightful retreat from Moscow +in the dead of winter, while his wretched soldiers died by thousands of +frost-bite and starvation, exceedingly little pneumonia developed among +them. Another was that, as we have already seen with colds, instead of +being commoner and more frequent in the extreme Northern climate and on +the borders of the Arctic Zone, pneumonia is almost unknown there. Of +course, given the presence of the germ, prolonged exposure to cold may +depress the vital powers sufficiently to permit an attack to develop. + +Again, the ages at which pneumonia is both most common and most deadly, +namely, under five and over sixty-five, are precisely those at which +this feature of exposure to the weather plays the most insignificant +part. Last and most conclusive of all, since definite statistics have +begun to be kept upon a large scale, pneumonia has been found to be +emphatically a disease of cities, instead of country districts. Even +under the favorable conditions existing in the United States, for +instance, the death-rate per hundred thousand living, according to the +last census, was in the cities two hundred and thirty-three, and for the +country districts one hundred and thirty-five,--in other words, nearly +seventy per cent greater in city populations. + +How, then, did the impression become so widely spread and so firmly +rooted that pneumonia is chiefly due to exposure? Two things, I think, +will explain most of this. One is, that the disease is most common in +the winter-time, the other, that like all febrile diseases it most +frequently begins with sensations of chilliness, varying all the way +from a light shiver to a violent chill, or _rigor_. The savage, +bone-freezing, teeth-rattling chill which ushers in an attack of +pneumonia is one of the most striking characteristics of the disease, +and occurs in twenty-five to fifty per cent of all cases. + +Its chief occurrence in the winter-time is an equally well-known and +undisputed fact, and it has been for centuries set down in medical works +as one of the diseases chiefly due to changes in temperature, humidity, +and directions of the wind. Years of research have been expended in +order to trace the relations between the different factors in the +weather and the occurrence of pneumonia, and volumes, yes, whole +libraries, published, pointing out how each one of these factors, the +temperature, humidity, direction of wind, barometric pressure, and +electric tension, is in succession the principal cause of the spread of +this plague. Many interesting coincidences were shown. But one thing +always puzzled us, and that was, that the heaviest mortality usually +occurred, not just at the beginning of winter, when the shock of the +cold would be severest, nor even in the months of lowest temperature, +like December or January, but in the late winter and the early spring. +Throughout the greater part of the temperate zone the death-rate for +pneumonia begins to rise in December, increases in January, goes higher +still in February, reaching its climax in that month or in March. April +is almost as bad, and the decline often doesn't fairly set in until May. + +No better illustration could probably be given of the danger of drawing +conclusions when you are not in possession of all the facts. One thing +was entirely overlooked in all this speculation until about twenty years +ago,--that pneumonia was due not simply to the depressing effects of +cold, but to a specific germ, the pneumococcus of Fraenkel. This threw +an entirely new light upon our elaborate weather-causation theories. And +while these still hold the field by weight of authority and that mental +inertia which we term conservatism, yet the more thoughtful physicians +and pathologists are now coming to regard these factors as chiefly +important according to the extent to which we are crowded together in +often badly lighted and ill-ventilated houses and rooms, with the +windows and doors shut to save fuel, thus affording a magnificent +hothouse hatching-ground for such germs as may be present, and ideal +facilities for their communication from one victim to another. At the +same time, by this crowding and the cutting off of life and exercise in +the open air which accompanies it, the resisting power of our bodies is +lowered. And when these two processes have had an opportunity of +progressing side by side for from two to three months; when, in other +words, the soil has been carefully prepared, the seed sown, and the +moist heat applied as in a forcing-house, then we suddenly reap the +harvest. In other words, the heavy crop of pneumonia in January, +February, and March is the logical result of the seed-sowing and forcing +of the preceding two or three months. + +The warmth of summer is even more depressing in its immediate effects +than the cold of winter, but the heat carries with it one blessing, in +that it drives us, willy-nilly, into the open air, day and night. And on +looking at statistics we find precisely what might have been expected on +this theory, that the death-rate for pneumonia is lowest in July and +August. + +It might be said in passing that, in spite of our vivid dread of +sunstroke, of cholera, and of pestilence in hot weather, the hot months +of the year in temperate climates are invariably the months of fewest +diseases and fewest deaths. Our extraordinary dread of the summer heat +has but slender rational physical basis. It may be but a subconscious +after-vibration in our brain cells from the simoons, the choleras, and +the pestilences of our tropical origin as a race. Open air, whether hot, +cold, wet, dry, windy, or still, is our best friend, and house air our +deadliest enemy. + +If this view be well founded, then the advance of modern civilization +would tend to furnish a more and more favorable soil for the spread of +this disease. This, unfortunately, is about the conclusion to which we +are being most unwillingly driven. Almost every other known infectious +disease is diminishing, both in frequency and in fatality, under +civilization. Pneumonia alone defies our onslaughts. In fact, if +statistics are to be taken at their surface-value, we are facing the +appalling situation of an apparently marked increase both in its +prevalence and in its mortality. For a number of years past, ever since, +in fact, accurate statistics began to be kept, pneumonia has been listed +as the second heaviest cause of death, its only superior being +tuberculosis. + +About ten years ago it began to be noticed that the second competitor in +the race of death was overtaking its leader, and this ghastly rivalry +continued until about three years ago pneumonia forged ahead. In some +great American cities it now occupies the bad eminence of the most fatal +single disease on the death-lists. + +The situation is, however, far from being as serious and alarming as it +might appear, simply from this bald statement of statistics. First of +all, because the forging ahead of pneumonia has been due in greater +degree to the falling behind of tuberculosis than to any actual advance +on its part. The death-rate of tuberculosis within the last thirty years +has diminished between thirty and forty per cent; and pneumonia at its +worst has never yet equaled the old fatality of tuberculosis. +Furthermore, all who have carefully studied the subject are convinced +that much of this apparent increase is due to more accurate and careful +diagnosis. Up to ten years or so ago it was generally believed that +pneumonia was rare in young children. Now, however, that we make the +diagnosis with a microscope, we discover that a large percentage of the +cases of capillary bronchitis, broncho-pneumonia, and acute congestion +of the lung in children are due to the presence of the pneumococcus. +Similarly, at the other end of the line, deaths that were put down to +bronchitis, asthma, heart failure, yes, even to old age, have now been +shown on bacteriological examination to be due to this ubiquitous imp of +malevolence; so that, on the whole, all that we are probably justified +in saying is that pneumonia is not decreasing under civilization. This +is not to be wondered at, inasmuch as the inevitable crowding and +congestion which accompanies civilization, especially in its derivative +sense of "citification," tends to foster it in every way, both by +multiplying the opportunities for infection and lowering the resisting +power of the crowded masses. + +Moreover, it was only in the last ten years, yes, within the last five +years, that we fairly grasped the real method and nature of the spread +of the disease, and recognized the means that must be adopted against +it. And as all of these factors are matters which are not only +absolutely within our own control, but are included in that programme of +general betterment of human comfort and vigor to which the truest +intelligence and philanthropy of the nation are now being directed, the +outlook for the future, instead of being gloomy, is distinctly +encouraging. + +Our chief difficulty in discovering the cause of pneumonia lay in the +swarm of applicants for the honor. Almost every self-respecting +bacteriologist seemed to think it his duty to discover at least one, and +the abundance and variety of germs constantly or accidentally present in +the human saliva made it so difficult positively to isolate the real +criminal that, although it was identified and described as long ago as +1884 by Fraenkel, the validity of its claim was not generally recognized +and established until nearly ten years later. + +It is a tiny, inoffensive-looking little organism, of an oval or +lance-head shape, which, after masquerading under as many aliases as a +confidence man, has finally come to be called the pneumococcus, for +short, or "lung germ." Though by those who are more precise it is still +known as the _Diplococcus pneumoniae_ or _Diplococcus lanceolatus_, from +its faculty of usually appearing in pairs, and from its lance-like +shape. Its conduct abounds in "ways that are dark and tricks that are +vain," whose elucidation throws a flood of light upon a number of +interesting problems in the spread of disease. + +First of all, it literally fulfills the prognostic of Scripture, that "a +man's foes shall be they of his own household," for its chosen abiding +place and normal habitat is no less intimate a place than the human +mouth. Outside of this warm and sheltering fold it perishes quickly, as +cold, sunlight, and dryness are alike fatal to it. + +We could hardly believe the evidence of our senses when studies of the +saliva of perfectly healthy individuals showed this deadly little +bacillus to be present in considerable numbers in from fifteen to +forty-five per cent of the cases examined. Why, then, does not every one +develop pneumonia? The answer to this strikes the keynote of our modern +knowledge of infectious disease, namely, that while an invading germ is +necessary, a certain breaking down of the body defenses and a lowering +of the vital resistance are equally necessary. These invaders lie in +wait at the very gates of the citadel, below the muzzles of our guns, as +it were, waiting for some slackening of discipline or of watchfulness to +rush in and put the fortress to sack. Nowhere is this more strikingly +true than in pneumonia. It is emphatically a disease where, in the +language of the brilliant pathologist-philosopher Moxon, "While it is +most important to know what kind of a disease the patient has got, it is +even more important to know what kind of a patient the disease has got." + +The death-rate in pneumonia is an almost mathematically accurate +deduction from the age, vigor, and nutrition of the patient attacked. No +other disease has such a brutal and inveterate habit of killing the +weaklings. The half-stifled baby in the tenement, the underfed, +overworked laboring man, the old man with rigid arteries and stiffening +muscles or waning life vigor, the chronic sufferer from malnutrition, +alcoholism, Bright's disease, heart disease--_these_ are its chosen +victims. + +Another interesting feature about the pneumococcus is its vitality +outside of the body. If the saliva in which it is contained be kept +moist, and not exposed to the direct sunlight and in a fairly warm place, +it may survive as long as two weeks. If dried, but kept in the dark, it +will survive four hours. If exposed to sunlight, or even diffuse +daylight, it dies within an hour. In other words, under the conditions +of dampness and darkness which often prevail in crowded tenements it may +remain alive and malignant for weeks; in decently lighted and ventilated +rooms, less than two hours. This explains why, in private practice and +under civilized conditions, epidemics of this admittedly infectious +disease are rare; while in jails, overcrowded barracks, prison ships, +and winter camps of armies in the field they are by no means uncommon. +This is vividly supported by the fact brought out in our later +investigations of the sputum of slum-dwellers, carried out by city +boards of health, that the percentage of individuals harboring the +pneumococcus steadily increases all through the winter months, from ten +per cent in December to forty-five, fifty, and even sixty per cent in +February and March. The old proverb, "When want comes in at the door, +Love flies out at the window," might be revised to read, "When sunlight +comes in at the window the pneumococcus flies 'up the flue.'" + +Authorities are still divided as to the meaning and even the precise +frequency of the occurrence of the pneumococcus in the healthy human +mouth. Some hold that its presence is due to recent infection which has +either been unable to gain entrance to the system or is preparing its +attack; others, that it is a survival from some previous mild attack of +the disease, and the body tissues having acquired immunity against it, +it remains in them as a harmless parasite, as is now well known to be +the case with the germs of several of our infectious diseases--for +instance, typhoid--for months and even years afterward. Others hold the +highly suggestive view that it is a normal inhabitant of the healthy +mouth, which can become injurious to the body, or _pathogenic_, only +under certain depressed or disturbed conditions of the latter. In +defense of this last it may be pointed out that dental bacteriologists +have now already isolated and described some thirty different forms of +organisms which inhabit the mouth and teeth; and the pneumococcus may +well be one of these. Further, that a number of our most dangerous +disease germs, like the typhoid bacillus, the bacillus of tuberculosis, +and the bacillus of diphtheria, have almost perfect "doubles," +law-abiding relatives, so to speak, among the germs that normally +inhabit our throats, our intestines, or our immediate surroundings. The +ultimate foundation question of the science of bacteriology is, How did +the disease germs become disease germs? But the question is still +unanswered. + +However, fortunately, here, as in other human affairs, imperfect as our +knowledge is, it is sufficient to serve as a guide for practical +conduct. Widely present as the pneumococcus is, we know well that it is +powerless for harm except in unhealthful surroundings. There is another +interesting feature of its life history which is of practical +importance, and that is, like many other bacilli it is increased in +virulence and infectiousness by passing through the body of a patient. +Flushed with victory over a weakened subject, it acquires courage to +attack a stronger. This is the reason why, in those comparatively +infrequent instances in which pneumonia runs through a family, it is the +strongest and most vigorous members of the family who are the last to be +attacked. It also explains one of the paradoxes of this disease, that, +while emphatically a disease of overcrowding and foul air, and attacking +chiefly weakened individuals, it is a veritable scourge of camps, +whether mining or military. When once three or four cases of pneumonia +have occurred in a mining camp, even though this consist almost +exclusively of vigorous men, most of them in the prime of life, it +acquires a virulence like that of a pestilence, so that, while +ordinarily not more than fifteen to twenty per cent of those attacked +die, death-rates of forty, fifty, and even seventy per cent are by no +means uncommon in mining camps. The fury and swiftness of this "miners' +pneumonia" is equally incredible. Strong, vigorous men are taken with a +chill while working in their sluicing ditches, are delirious before +night, and die within forty-eight hours. So widely known are these +facts, and so dreaded is the disease throughout the Far West and in +mountain regions generally, that there is a widespread belief that +pneumonia at high altitudes is particularly deadly. + +I had occasion to interest myself in this question some years ago, and +by writing to colleagues practicing at high elevations and collecting +reports from the literature, especially of the surgeons of army posts in +mountain regions, was somewhat surprised to find that the mortality of +all cases occurring above five thousand feet elevation was almost +identical with that of a similar class of the population at sea-level. +It is only when a sufficient number of cases occur in succession to +raise the virulence of the pneumococcus in this curious manner that an +epidemic with high fatality develops. + +That this increase in virulence in the organism does occur was clearly +demonstrated by a bacteriologist friend of mine, who succeeded in +securing some of the sputum from a fatal case in the famous Tonopah +epidemic of some years ago, an epidemic so fatal that it was locally +known as the "Black Death." Upon injecting cultures from this sputum +into guinea-pigs, the latter died in one-quarter of the time that it +usually took them to succumb to a similar dose of an ordinary culture of +the pneumococcus. + +It is therefore evident that just as "no chain is stronger than its +weakest link," so in the broad sense no community is stronger than its +weakest group of individuals, and pneumonia, like other epidemics, may +be well described as the vengeance which the "submerged tenth" may wreak +from time to time upon their more fortunate brethren. + +Now that we know that under decent and civilized conditions of light and +ventilation the pneumococcus will live but an hour to an hour and a +half, this reduces the risk of direct infection under these conditions +to a minimum. It is obvious that the principal factors in the control of +the disease are those which tend to build up the vigor and resisting +power of all possible victims. The more broadly we study the disease the +more clearly do the data point in this direction. + +First of all, is the vivid and striking contrast between hospital +statistics and those gathered from private practice. While many +individuals of a fair wage-earner's income and good bodily vigor are +treated in our hospitals, yet the vast majority of hospital patients are +technically known as the "hospital classes," apt to be both underfed, +overworked, and overcrowded. On the other hand, while a great many both +of the very poor and even of the destitute are treated in private +practice, yet the majority of such cases who feel "able to afford a +doctor," as they say, are among the comparatively vigorous, well-fed, +and well-housed section of the community. And the difference between the +death-rate of the two classes in pneumonia is most significant. In +private practice, while epidemics differ in virulence, the rate ranges +all the way from five per cent to fifteen per cent, the average being +not much in excess of ten per cent, occasionally falling as low as three +per cent. In the hospital reports on the contrary the death-rate begins +at twenty per cent and climbs to thirty, forty, and forty-five per cent. +It is only fair to say, of course, that hospital statistics probably +include a larger percentage of more serious cases, the milder ones being +taken care of at home, or not presenting themselves for treatment at +all. But even when this allowance has been made, the contrast is +convincing. + +A similar influence is exercised by age. Although pneumonia is common at +all ages, its heaviest death-rate falls at the two extremes, under six +years of age and over sixty, with a strong preponderance in the latter. +Under five years of age, the mortality may reach twenty to thirty per +cent; from five to twenty-five, not more than four to five per cent; +from twenty-five to thirty-five, from fifteen to twenty per cent; and so +on, increasing gradually with every decade until by sixty years of age +the mortality has reached fifty per cent, and from sixty to seventy-five +may be expressed in terms of the age of the patient. One consoling +feature, however, about it is that its mortality is lowest in the ages +at which it is most frequent, namely, from ten to thirty-five years of +age. And its frequency diminishes even more rapidly than its fatality +increases in later years. So that while it is much more serious in a +middle-aged man, he is less liable to develop it than a younger one. +Where the mortality from pneumonia is highest, is in the most densely +populated wards, especially among negroes and foreigners of the hospital +class, in individuals who are victims of chronic alcoholism, and also +among those who are for long periods insufficiently nourished. Lastly, +it is only within comparatively recent years that we have come clearly +to recognize the large role which pneumonia plays in giving the +finishing stroke to chronic diseases and degenerative processes. It is, +for instance, one of the commonest actual causes of death in Bright's +disease, in diabetes, in lingering forms of tuberculosis, and in heart +disease; and last of all, in that progressive process of normal +degeneration and decay which we term "Old Age." It is one of the most +frequent and fatal of what Flexner described a decade ago as "terminal +infections." Very few human beings die by a gradual process of decay, +still less go to pieces all at once, like the immortal "One-Hoss Shay." +Just as soon as the process has progressed far enough to lower the +resisting power below a certain level, some acute infection steps in and +mercifully ends the scene. This is peculiarly true of pneumonia in old +age. + +To the medical profession to "die of old age" is practically equivalent +to dying of pneumonia. The disease is so mild in its symptoms and so +rapid in its course that it often utterly escapes recognition as such. + +The old man complains of a little pain in his chest, a failure of +appetite, a sense of weakness and dizziness. He takes to his bed, within +forty-eight hours he becomes unconscious, and within twenty-four more he +is peacefully breathing his last. After death, two-thirds of the lung +will be found consolidated. So mild and rapid and painless is the +process that one physician-philosopher actually described pneumonia as +"the friend of old age." + +When once the disease has obtained a foothold in the body its course, +like one of Napoleon's campaigns, is short, sharp, and decisive. +Beginning typically with a vigorous chill, sometimes so suddenly as to +wake the patient out of a sound sleep, followed by a stabbing pain in +the side, cough, high fever, rapid respiration, the sputum rusty or +orange-colored from leakage of blood from the congested lung, within +forty-eight hours the attacked area of the lung has become congested; in +forty-eight more, almost solidified by the thick, sticky exudate poured +out from the blood-vessels, which coagulates and clots in the air cells. +So complete is this solidification that sections of the attacked lung, +instead of floating in water as normal lung-tissue will, sink promptly. +The severe pain usually subsides soon, but the fever, rapid respiration, +flushed face, with or without delirium, will continue for from three to +seven or eight days. Then, as suddenly as the initial attack, comes a +plunge down of the temperature to normal. Pain and restlessness +disappear, the respiration drops from thirty-five or forty to fifteen or +twenty per minute, and the disease has practically ended by "_crisis_." +Naturally, after such a furious onslaught, the patient is apt to be +greatly weakened. He may have lost twenty or thirty pounds in the week +of the fever, and from one to three weeks more in bed may be necessary +for him to regain his strength. But the chief risk and danger are +usually over within a week or ten days at the outside. + +Violent and serious as are the changes in the lung, it is very seldom +that death comes by interference with the breathing space. In fact, +while regarded as a lung disease, we are now coming to recognize that +the actual cause of death in fatal cases is the overwhelming of the +heart by the toxins or poisons poured into the circulation from the +affected lung. The mode of treatment is, therefore, to support the +strength of the patient in every way, and measures directed to the +affected lung are assuming less and less importance in our arsenal of +remedies. Our attitude is now very similar to that in typhoid, to +support the strength of the patient by judicious and liberal feeding, to +reduce the fever and tone up his blood-vessels by cool sponging, +packing, and even bathing; to relieve his pain by the mildest possible +doses of sedatives, knowing that the disease is self-limited, and that +in patients in comfortable surroundings and fair nutrition from eighty +to ninety per cent will throw off the attack within a week. So +completely have we abandoned all idea of medicating or protecting the +lung as such, that in place of overheated rooms, loaded with vapor by +means of a steam kettle, for its supposed soothing effect upon the +inflamed lung, we now throw the windows wide open. And some of our more +enthusiastic clinicians of wide experience are actually introducing the +open-air cure, which has worked such wonders in tuberculosis, in the +treatment of pneumonia. In more than one of our New York hospitals now, +particularly those devoted to the care of children, following the +brilliant example of Dr. William Northrup, wards are established for +pneumonia cases out on the roof of the hospital, even when the snow is +banked up on either side, and the covering is a canvas tent. Nurses, +physicians, and ward attendants are clothed in fur coats and gloves, the +patients are kept muffled up to the ears, with only the face exposed; +but instead of perishing from exposure, little, gasping, struggling +tots, whose cases were regarded as practically hopeless in the wards +below, often fall into the sleep that is the turning point toward +recovery within a few hours after being placed in this winter +roof-garden. + +In short, our motto may be said to be, "Take care of the patient, and +the disease will take care of itself." + +Though pneumonia is one of our most serious and most fatal of diseases, +yet it is one over whose cause, spread, and cure we are obtaining +greater and greater control every day, and which certainly should, +within the next decade, yield to our attack, as tuberculosis and typhoid +are already beginning to do. + + + + +CHAPTER IX + +THE NATURAL HISTORY OF TYPHOID FEVER + + +Why should not a disease have a natural history, as well as an +individual? At first sight, this might appear like a reversion to the +old, crude theory of disease as a demonic obsession, or invasion by an +evil spirit, of which traces still remain in such expressions as, "She +was _seized_ with a convulsion," "He was strong enough to _throw off_ +the illness," "He was _attacked_ by a fever," etc. But apart entirely +from such conceptions, which were perfectly natural in the infancy of +the race, while clearly recognizing that disease is simply a perverted +state of nutrition or well-being in the body of the patient, a +disturbance of balance, so to say, yet it is equally true that it has a +birth, an ancestry, a life-course, and a natural termination, or death. + +This recognition of the natural causation and development of disease has +been one of the greatest triumphs, not merely of pathology, but of +intelligence and rationalism. It has done more to diminish that dread of +the unknown which hangs like a black pall of terror over the mind of the +savage and the semi-civilized mind than any other one advance. It +contributes enormously to our courage, our hopefulness, and our power of +protection in more ways than one: first of all, by revealing to us the +external cause of disease, usually some careless, dirty, or bad habit +on the part of an individual or of the community, and thus enabling us +to limit its spread and even exterminate it; secondly, by assuring us +that nearly all diseases, excepting a few of the most obstinate and +serious, have not only a definite beginning, but a definite end, are, in +fact, if left to themselves, self-limited, either by the exhaustion and +loss of virulence of their cause, or by the resisting power of the body. + +All infectious diseases, and many others, tend to run a definite course +of so many days, or so many weeks, within certain limits, and at least +ninety per cent of them tend to terminate in recovery. It is a most +serious and fatal disease which has a death-rate of more than twenty per +cent. Typhoid, pneumonia, diphtheria, and yellow fever all fall below +this, smallpox barely reaches it, and only the bubonic plague, cholera, +and lockjaw rise habitually above it. The recognition of this fact has +enormously increased the efficiency of the medical profession in dealing +with disease, by putting us on the track of imitating the methods which +the body itself uses for destroying, or checking the spread of, invading +germs and leading us to trust nature and try to work with her instead of +against her. Our antitoxins and anti-serums, which are our brightest +hope in therapeutics at present, are simply antidotes which are formed +in the blood of some healthy, vigorous animal against the bacillus whose +virulence we wish to neutralize, such as that of diphtheria or +septicemia. + +Diphtheria antitoxin, for instance, the first and best known triumph of +the new medicine, is the antidotal substance formed in the blood of a +horse in response to a succession of increasing doses of the bacilli of +diphtheria. Similar antidotal substances are formed in the blood in all +other non-fatal cases of infectious diseases, such as typhoid, +pneumonia, blood-poisoning, etc.; and the point at which they have +accumulated in sufficient amounts to neutralize the poison of the +invading germs, forms the crisis, or "turn" of the disease. So that when +we speak of a disease "running its course," we mean continuing for such +length of time as the body needs to produce anti-bodies in sufficient +amounts to check it. + +The principal obstacle to the securing of antitoxins like that of +diphtheria for all our infectious diseases is, that their germs form +their poison so slowly that it is difficult to collect it in sufficient +amounts to produce a strong concentrated antitoxin in the animal into +which it is injected. But the overcoming of this difficulty is probably +only a question of time. + +Obviously, if infectious disease be, as we say, "self-limited," that is +to say, if the body will defeat the invaders with its own weapons, on an +average in nine cases out of ten, our wisest course, as physicians, is +to back up the body in its fight. This we now do in every possible way, +by careful feeding, by rest, by bathing, by an abundance of pure water +and fresh air, with the gratifying result that we have already reduced +the death-rate in most fevers, even such as we have no antitoxin +against, or may not even have discovered the causal germ of, to one-half +and even three-fourths of their former fatality. The recognition of the +fact that disease has a natural history, a birth, a term of natural +life and a death, has already turned a hopeless fight in the dark into a +victorious campaign in broad daylight. Huxley's pessimistic saying that +typhoid was like a fight in the dark between the disease and the +patient, and the doctor like a man with a club striking into the melee, +sometimes hitting the disease and sometimes the patient, is no longer +true since the birth of bacteriology. + +Nowhere can the natural history of disease be more clearly seen or more +advantageously studied than in the case of typhoid fever. + +The cause of typhoid is simplicity itself, merely drinking the excreta +of some one else, "eating dirt," in the popular phrase; simple, but of a +deadly effectiveness, and disgracefully common. The demon may be +exorcised by an incantation of one sentence: _Keep human excreta out of +the drinking water._ This sounds simple, but it is n't. Eternal +vigilance is the price of health as well as of liberty. + +We can, however, make our pedigree of typhoid a little more precise. It +is not merely dirt of human origin which is injurious, but dirt of a +particular type, namely, discharges from a previous case of the disease. +Just as in the fight against malaria we have not the enormous problem of +the extermination of all varieties of mosquito, but only of one +particular genus, and only the infected specimens of that, so in +typhoid, the contamination of water or food which we have to guard +against is that from previous cases. From one point of view, this leaves +the problem as wide as ever, for, obviously, the only way to insure +against poisoning of water by typhoid discharges is to shut out +absolutely all sewage contamination. On the other hand, it is of immense +advantage in this regard,--it enables us to fight the enemy at both ends +of the line, to turn his flank as well as crush his centre. + +While we are protecting our water-supplies against sewage, we can, in +the meantime, render that sewage comparatively harmless by thoroughly +disinfecting and sterilizing all discharges from every known case of the +disease. A similar method is used in the fight against yellow fever and +malaria. Not only are the breeding places of the two mosquito criminals +broken up, but each known case of the disease is carefully screened, _so +as to prevent the insects from becoming infected_, and thus able to +transmit the disease to other human victims. + +It cannot be too emphatically insisted upon that every case of typhoid, +like every case of yellow fever and of malaria, _comes from a previous +case_. It is neither healthy nor exhilarating to drink a clear solution +of sewage, no matter how dilute; but, as a matter of fact, it is +astonishing how long communities may drink sewage-laden water with +comparative impunity, so long as the sewage contains no typhoid +discharges. One case of typhoid fever imported into a watershed will set +a city in a blaze. + +The malevolent _Deus_ in the sewage _machina_ is, of course, a germ--the +_Bacillus typhosus_ of Eberth. The astonishing recentness of much of our +most important knowledge is nowhere better illustrated than in the case +of typhoid. Although there had been vague descriptions of a fatal fever, +slow and lingering in its character and accompanied by prolonged stupor +and delirium, which was associated with camps and dirty cities and +famines, from as far back as the age of Caesar, the first description +clear enough to be recognizable was that of Willis, of an epidemic +during the English civil war in 1643, both Royalist and Roundhead armies +being seriously crippled by it. Since that time a smouldering, slowly +spreading fever has been pretty constantly associated with armies in +camps, besieged cities, filthy jails, and famines, to which accordingly +have been given the names, familiar in historical literature, of "famine +fever," "jail fever," and "military fever." + +So slowly, however, did accurate knowledge come, that it was actually +not until 1837 that it was clearly and definitely recognized that this +famine fever was, like Mrs. Malaprop's Cerberus, "two gentlemen at +once," one form of it being typhus or "spotted fever," which has now +become almost extinct in civilized communities; the other, the milder, +but more persistent form, which, like the poor, we have always with us, +called, from its resemblance to the former, "typhoid" (typhus-like). + +Typhus was a far more virulent, rapid, and fatal fever than its twin +survivor, though as to the relations between the two diseases, if any, +we are quite in the dark, as the former practically disappeared before +the days of bacteriology. The fact of its disappearance is both +significant and interesting, in that it was unquestionably due to the +ranker and viler forms of both municipal and individual filthiness and +unsanitariness, which even our moderate progress in civilization has +now abolished. There can be no question that, with a step higher in the +scale of cleanliness, and further quickening of the biologic conscience, +typhoid will also disappear. + +Typhus, the bubonic plague, the sweating sickness, were alike plagues +and products of times when table-scraps were thrown on the dining-room +floor and covered daily with fresh rushes for a week at a stretch, and +fertilizer accumulated in a living-room as now in a modern stable. +Clothing was put on for the season, shirts were unknown, and strong +perfumes took the place of a bath. Michelet's famous characterization of +the Middle Ages in one phrase as _Un mille ans sans bain_ (a thousand +years without a bath) was painfully accurate. + +Doubtless certain habits of our own to-day will be regarded with equal +disgust by our descendants. Typhus, by the way, may possibly be +remembered by the dramatic "Black Assize" of Oxford, in 1577, in which +not merely the wretched prisoners in the jail, but the jurors, the +lawyers, the judges, and every official of the court were attacked, and +many of them died. + +It was only in 1856 that the method of transmission of the disease was +clearly recognized, and in 1880 that the bacillus was discovered and +identified by the bacteriologist Eberth, whose name it bears, so that it +is only within the last thirty years that real weapons have been put +into our hands with which to begin a fight of extermination against the +disease. + +What is the habitat of our organism, and is it increasing its spread? +Its habitat is the entire civilized world, and it goes wherever +civilization goes. In this sense its spread is increasing, but, in every +other, we have good ground for believing that it is on the wane. +Positive assurance, either one way or the other, is, of course, +impossible, simply for the reason that the disease was not recognized +until such a short time ago that no statistics of any real value for +comparison are available; and, secondly, because even to-day, on account +of its insidious character and the astonishing variety of its forms, and +degrees of mildness and virulence, a considerable percentage of cases +are yet unrecognized and unreported. + +It might be mentioned in passing that this statement applies to the +alleged increase of nearly all diseases which are popularly believed to +be modern inventions, like appendicitis, insanity, and cancer. We have +no statistics more than thirty years old which are of real value for +purposes of comparison. + +However, when it comes to the number of deaths from the disease, there +is a striking and gratifying diminution for twenty years past, which is +increasing in ratio instead of diminishing. That we are really getting +control of typhoid is shown by the, at first sight, singular and +decidedly unexpected fact that it is no longer a disease of cities, but +of the country. The death-rate per thousand living in the cities of the +United States is lower than in the rural districts. For instance, the +mortality in the State of Maryland, outside of Baltimore, is two and +one-half times as great as that in the city itself. Our period of +greatest outbreak in the large cities is now the month of September, +when city dwellers have just returned from their vacations in the pure +and healthful country, bringing the bacilli in their systems. + +The moral is obvious. Great cities are developing some sort of a +sanitary conscience. Farmers and country districts have as yet little or +none. Bad as our city water often is, and defective as our systems of +sewage, they cannot for a moment compare in deadliness with that most +unheavenly pair of twins, the shallow well and the vault privy. A more +ingenious combination for the dissemination of typhoid than this +precious couple could hardly have been devised. The innocent householder +sallies forth, and at an appropriate distance from his cot he digs two +holes, one about thirty feet deep, the other about four. Into the +shallower one he throws his excreta, while upon the surface of the +ground he flings abroad his household waste from the back stoop. The +gentle rain from heaven washes these various products down into the soil +and percolates gradually into the deeper hole. When the interesting +solution has accumulated to a sufficient depth, it is drawn up by the +old oaken bucket or modern pump, and drunk. Is it any wonder that in +this progressive and highly civilized country three hundred and fifty +thousand cases of typhoid occur every year, with a death penalty of ten +per cent? Counting half of these as workers, and the period of illness +as two months, which would be very moderate estimates, gives a loss of +productive working time equivalent to thirty thousand years. Talk of +"cheap as dirt"! It is the most expensive thing there is. + +Typhoid still abundantly earns its old name of "military fever," and its +sinister victories in war are even more renowned than its daily triumphs +in peace. Strange as it may seem, the deadliest enemies of the soldier +are not bullets but bacilli, and sewage is mightier than the sword. For +instance, in the Franco-Prussian War, typhoid alone caused sixty per +cent of all the deaths. In the Boer War it caused nearly six thousand +deaths as compared with seven thousand five hundred from wounds in +battle, while other diseases caused five thousand more. In the majority +of modern campaigns, from two-thirds to five-sixths of all deaths are +due to disease and not to battle. It may be that we sanitarians will +achieve the ends of the peace congresses by an unexpected route, and +make war a healthful and comparatively harmless form of national +gymnastics. Its battle-mortality rate, for the number engaged, is not so +very far above football now! + +Given the bacillus, how does it get into the human system? Here the +evidence is so abundant and overwhelming that we may content ourselves +with bald statements of fact. The three great routes of this pestilence +are water, milk, and flies. Of the three, the first is far the most +common and important. While only a rough statement is possible, probably +eighty-five per cent of all cases from water, five per cent from milk, +five per cent through flies, and five per cent through other channels, +would fairly represent the percentage. + +That it is conveyed through water is as certain as that the sun rises +and sets. The only embarrassment in proving it lies in selecting from +the swarm of instances. There is the classic case of the Swiss villages +on opposite sides of the same mountain chain, the second of which drew +its water-supply from a spring that came through the mountain from a +brooklet running by the first village. Typhoid fever broke out in the +first village, and twenty days later it appeared in the second village, +twenty miles away on the other side of the mountain. Colored particles +thrown into the brook on one side promptly appeared in the spring upon +the other. Then there was the gruesome modern instance of Plymouth, +Pennsylvania, in 1885. A single case of imported typhoid occurring on +the watershed of a reservoir was followed, thirty days later, by an +epidemic of eleven hundred cases in a population of eight thousand. + +An equally vivid instance came under my own observation. A school and a +penitentiary drew their water-supply from the same power-flume, carrying +a superb volume of purest water from a mountain stream. Early in the +autumn a single case of typhoid appeared in a small town near the head +of the flume. The discharges were thrown into the swiftly running water. +Two weeks later an epidemic of typhoid broke out in the school, and +three weeks later in the penitentiary. An unexpected freak, however, was +the appearance of fifteen or twenty cases in another state institution +farther down on the same stream, which did not draw its water-supply +from the flume, but from deep wells of tested purity. This was a puzzle, +until it was found that, owing to a fall in the wells, the water from +the flume had been used for sprinkling and washing purposes in the +institution, being allowed to run through the water-pipes only at night, +while the well-water was used in the daytime. This was enough to +contaminate the pipes, and a small epidemic began, which promptly +stopped as soon as the cause was suspected and the flume-water no longer +used. + +This last instance is peculiarly interesting, as illustrating how +typhoid infection gets into milk, the second--though at a long +interval--most frequent means of its spread. It does not come from the +cow, for, fortunately, none of the domestic animals, with the possible +exception of the cat, is subject to typhoid. Nor is it possible that +cattle, drinking foul and even infected water, can transmit the bacillus +in their milk. That superstition was exploded long ago. Every epidemic +of typhoid spread by milk--and there are scores of them now on +record--can be traced to the handling of the milk by persons suffering +from mild forms of typhoid, or engaged in waiting upon members of the +family who are ill of the disease, or the dilution of milk with infected +water, or even, almost incredible as it may seem, to such slight +contamination as washing the cans with infected water. + +Health officers now watch like hawks for the appearance of any case of +typhoid among or in the families of dairymen. The New York City Board of +Health, for instance, requires the weekly filing of a certificate from +the family physician of all dairymen that no such cases exist. And the +more intelligent dairymen keep a vigilant eye upon any appearance of +illness accompanied by fever among their employees, some that I have +known even keeping a fever thermometer in the barn for the purpose of +testing every suspicious case. How effective such precautions can be +made may be illustrated by the fact that, in the past five years, there +has not been a single epidemic of typhoid traceable to milk in Greater +New York, even with its inadequate corps of ten inspectors, and the six +states they have to cover. The moment a single case of typhoid appears, +the dairy or milkman supplying that customer is given a most rigid +special inspection, and, if any source of infection can be discovered, +the milk is shut out of New York City until the department is satisfied +that all danger has been removed. One or two lessons of this sort are +enough for a whole county of dairymen. The danger of transmission of +typhoid through milk has been enormously exaggerated, and, as in the +case of all other milk-borne diseases, is entirely due to filthy +handling, and may be prevented by intelligent sanitary policing. Even +with our present exceedingly imperfect systems, probably not more than +between five and ten per cent of typhoid is transmitted in this way; +and, if the water-supply were kept clean, this would practically +disappear. + +Typhoid may not only be transmitted from the earth beneath and the water +under the earth, but also from the heavens above, through the medium of +flies and dust. The first method is bulking larger every day, especially +in country districts and in camps. The _modus operandi_ is simplicity +itself. The fly lives and moves and has its being in dirt. It breeds in +dirt and it feeds on food, and, as it never wipes its feet, the +interesting results can be imagined. Just to dispel any possible doubt, +plates of gelatine have been exposed where flies could walk on them, +then placed in an incubator, and within forty-eight hours there was a +clearly recorded track of the footprints of the flies written in clumps +of bacilli sown by their filthy feet. More definitely, flies have been +caught in the houses of typhoid patients, put under the microscope, and +their feet, stomachs, and specks found swarming with typhoid bacilli. A +single flyspeck may contain three thousand. + +Fortunately, we have a simple and effective remedy. We cannot disinfect +the fly nor make him wipe his feet, but we _can_ exterminate him +utterly! This sounds difficult, but it isn't. Like the mosquito, the fly +can only breed in one particular kind of place, and that place is a heap +of dirt, preferably horse manure, but, at a pinch, dust-bins, +garbage-cans, sweepings under porches or behind furniture, +vaults,--anywhere that dirt is allowed to remain undisturbed for more +than a week at a stretch. Abolish, screen, or poison these dirt +accumulations, and flies will disappear, and with them not merely risks +from typhoid, but half a dozen other diseases, as well as all sorts of +filth and much discomfort and inconvenience. It was largely through +flies that the disgraceful epidemic of typhoid, which ravaged our camps +on our own soil during the Spanish-American War and killed many times +more than fell by Spanish bullets, was spread. + +It is also believed that typhoid bacilli may be carried in the infected +dust of streets and camps. Here again we are dealing with a dangerous +public enemy to both health and comfort, which can and ought to be +abated by cleanliness, oilings, and sprinklings. Typhoid bacilli are +also occasionally carried by shellfish, especially oysters, on account +of the interesting modern custom of planting them in bays and harbors +near the mouths of sewers to fatten them. The cheerful motto of the +oysterman is, "The muddier the water the fatter the oyster." And nowhere +do the bivalves plump up more quickly than near the mouth of a sewer. + +The last method of transmission is by direct contact with the sick. This +is a relatively rare means of spread, so much so that it is generally +stated that typhoid is not contagious; but it is a real source of danger +and one against which precautions should by all means be taken. The only +method is, of course, by the soiling of the hands of the nurse or other +attendant, and then eating or touching food, or putting the fingers into +the mouth before thoroughly cleansing. If the hands be washed with a +strong antiseptic solution after waiting upon the patient, and the +cheerful habit sometimes indulged in of putting fruit or other +delicacies into the sick-room for a day or so, in the hope that they may +tempt the appetite of the patient, and then taking them out and letting +the children eat them as a treat, be abolished, and the nurse be not +allowed to officiate in the kitchen, risk from this source will be done +away with. + +When the bacillus has been introduced into the stomach through food or +drink, it rapidly proceeds to diffuse itself throughout the tissues of +the body. Because the most striking symptoms of the disease are +diarrh[oe]a, abdominal distention, and pain, and the most striking +lesions after death ulcers in the small intestine, it was supposed that +the process was confined to the abdominal organs. This is now known to +be an error, as cultures and examinations made from the blood and +various parts of the body have shown the presence of the typhoid +bacillus in almost every organ and tissue. This process of scattering, +or invasion of the body, takes from three to ten days to accomplish; and +the first sign of trouble is usually a feeling of depression, with +headache, and perhaps slight nausea, before any characteristic bowel +symptoms begin to show themselves. + +The general invasion of the system throws an interesting sidelight upon +the subject of premonitions. There are several well authenticated cases +on record where individuals just before coming down with typhoid have +been strangely impressed with a sense of impending death, and have even +gone so far as to make their wills and set their affairs in order. +Because these strong impressions appeared before any clearly marked +intestinal symptoms of the disease, they have been put down in popular +literature as instances of the "second sight," or "sixth sense," which +popular superstition believes many of us to possess under certain +circumstances. Now, however, we know that the tissues of that individual +were already swarming with bacilli, and his fear of impending death was +simply the effect of his toxin-laden blood upon his brain centres. In +other words, it was prophecy after the fact, like nearly all prophecies +that happen to come true; and the "premonition" was an early symptom of +the disease itself. + +As it is, of course, difficult to fix the precise drink of water or +mouthful of food in which the infection was conveyed, we were for a long +time in doubt as to the length of time which it took to spread through +the system,--the "period of incubation," as it is termed,--although we +knew in a general way that it averaged somewhere about ten days. But, +about a year ago, fortune was kind to us. A nurse in one of the Parisian +hospitals, in a fit of despondency, decided to commit suicide. Like a +true Parisienne, she would be nothing if not up to date, and chose, as +the most _recherche_ and original method of departing this life, to +swallow a pure culture of typhoid germs, which she abstracted from the +laboratory. Three days later she began to complain of headache, and +within a week had developed a beautiful crop of symptoms, and a typical +case of typhoid, from which, under modern treatment, she promptly +recovered,--a wiser and, we trust, a happier woman. + +By just what avenue the infecting bacilli go from the stomach into the +general system we do not know. Metschnikoff suggests that they can only +penetrate the intestinal wall through wounds or abrasions of the mucous +membrane, made by intestinal worms or other parasites. Certain it is +that the average stomach has a considerable degree of resisting power +against them, for in no known civil epidemic has the number of those who +caught the disease exceeded ten per cent of the total number drinking +the infected water or milk. In one or two camps in time of war the +percentage has risen as high as eighteen or twenty per cent of those +exposed, but this is exceptional. However, now that we know that +intestinal symptoms do not constitute the entire disease, and may even +be entirely absent, we strongly suspect that many cases of slight +depression, with feverishness, loss of appetite, and disturbances of the +digestion, which occur during an epidemic, may really have been very +mild cases of the disease. + +One of the singular features of the disease is that, unlike many other +infections, we are entirely unable to say what conditions or influences +seem either to protect against it or to predispose toward it. In the +days when we believed it to be an exclusively intestinal disease it was +naturally supposed that chronic digestive disturbances, and especially +acute attacks of bowel trouble or dysentery, would predispose to it, but +this has been entirely disproved. Soldiers in barracks with chronic +digestive disturbances, and even with dysentery, have shown no higher +percentage of typhoid during an epidemic than others. Nor does it seem +much more likely to occur in those who are constitutionally weak, or run +down, or overworked, as some of the most violent and unmanageable cases +occur in vigorous men and women, who were previously in perfect health. +So that, although we have unquestionably a high degree of resistance +against it, since not more than one in ten exposed contracts it, and +only one in ten of those who contract it dies, we have not the least +idea in what direction, so to speak, to build up our resisting powers in +order to increase them. + +The best remedy is to destroy the disease altogether, and this could be +done in five years by intelligent concerted effort. It was at one time +supposed that typhoid fever was a disease exclusively confined to adult +life; but it is now known to occur frequently in children, though often +in such a mild and irregular form as to escape recognition. Something +like seventy per cent of all cases occur between the fifteenth and the +fortieth year, and it is, for some reason, though rarer, peculiarly +serious and more often fatal after the fiftieth year. + +When once the outer wall has been pierced, the sack of the city rapidly +proceeds. The bacilli multiply everywhere, but seem for some reason to +focalize chiefly in the alimentary canal, and especially the middle part +of it, the small intestines. After headache, backache, and loss of +appetite comes usually a mild diarrh[oe]a. This diarrh[oe]a is due to an +attack of the bacillus or its toxins upon certain clumps of lymphoid +tissue in the wall of the small intestine, known as the "patches of +Peyer." This produces inflammation, followed by ulceration, which in +severe cases may eat through the wall of a blood-vessel, causing profuse +hemorrhages, or even perforate the bowel wall and set up a fatal +peritonitis. The temperature begins to swing from two to five degrees +above the normal level, following the usual daily vibration, and ranging +from 100 degrees to 101 degrees in the morning up to 102 degrees to 105 +degrees in the afternoon. The face becomes flushed. + +There is usually comparatively little pain, and the patient lies in a +sort of mild stupor, paying little attention to his surroundings. He is +much enfeebled and seldom cares to lift his head from the pillow. A +slight rash appears upon the surface of the body, but this is so faint +that it would escape attention unless carefully looked for. Little +groups of vesicles, containing clear fluid, appear upon the chest and +abdomen. If one of these faint rose-colored spots be pricked with a +needle and a drop of blood be drawn, typhoid bacilli will often be found +in it, and they will also be present in the clear fluid of the tiny +sweat blisters. + +This condition will last for from ten days to four weeks, the patient +gradually becoming weaker and more apathetic, and the temperature +maintaining an afternoon level of 102 to 104 degrees. Then, in the vast +majority of cases, a little decline of the temperature will be noticed. +The patient begins to take a slight interest in his surroundings. He +will perhaps ask for something to drink, or something to eat, instead of +apathetically swallowing what is offered to him. Next day the +temperature is a little lower still, and within a week, perhaps, will +have returned to the normal level. The patient has lost from twenty to +forty pounds, is weak as a kitten, and it may be ten days after the +fever has disappeared before he asks to sit up in bed. + +Then follows the period of return to health. The patient becomes a +walking appetite, and, after weeks of liquid diet, will beg like a +spoiled child for cookies or hard apples or pie, or something that he +can set his teeth into. But his tissues are still swarming with the +bacilli, and any indiscretion, either of diet, exposure, or exertion, at +this time, may result in forming a secondary colony, or abscess, +somewhere in the lungs, the liver, or the muscles. He must be kept quiet +and warm, and abundantly, but judiciously, fed, for at least three +weeks after the disappearance of the fever, if he wishes to avoid the +thousand and one ambuscades set by the retreating enemy. + +Now, what has happened when recovery begins? One would suppose that +either the bacilli had poisoned themselves, exhausted the supplies of +nourishment in the body of the patient, so that the fever had "burnt +itself out," as we used to say, or that the tissues had rallied from the +attack and destroyed or thrown out the invaders. But, on the contrary, +we find that our convalescent patient, even after he is up and walking +about, is still full of the bacilli. + +To put it very crudely, what has really happened is that the body has +succeeded in forming such antidotes against the poison of the bacilli +that, although they may be present in enormous numbers, they can no +longer produce any injurious effect. In other words, it has acquired +immunity against this particular germ and its toxin. In fact, one of our +newest and most reliable tests for the disease consists in a curious +"clumping" or paralyzing power over cultures of the _Bacillus typhosus_, +shown by a drop of the patient's blood, even as early as the seventh or +eighth day of the illness. And, while it is an immensely difficult and +complicated subject, we are justified in saying that this immunity is +not merely a substance formed in the body, the stock of which will +shortly become exhausted, but a faculty acquired by the body-cells, +which they will retain, like other results of education, for years, and +even for life. When once the body has learned the wrestling trick of +throwing and vanquishing a particular germ or bacillus, it no longer +has much to dread from that germ. This is why the same individual is +seldom attacked the second time by scarlet fever, measles, typhoid, and +smallpox. + +While, however, the individual may be entirely immune to the germs of a +given disease, he may carry them in his body in enormous numbers, and +infect others while escaping himself. + +This is peculiarly true of typhoid, and we are beginning to extend our +sanitary care over recovered patients, not merely to the end of acute +illness, but for the period of at least a month after they have +apparently recovered. Several most disquieting cases are on record of +so-called "typhoid carriers," or individuals who, having recovered from +the disease itself, carried and spread the infection wherever they went +for months and even years afterward. This, however, is probably a rare +state of affairs, though a recent German health bulletin reports the +discovery of some twenty cases during the past year. The lair of the +bacilli is believed to be the gall-bladder. + +As to treatment, it may be broadly stated that all authorities and +schools are for once practically agreed:-- + +First, that we have no known specific drug for the cure of the disease. + +Second, that we are content to take a leaf out of nature's book, and +follow--so to speak--her instinctive methods: first of all, by putting +the patient to bed the moment that a reasonable suspicion of the disease +is formed; this conserves his strength, and greatly diminishes the +danger of serious complications; cases of "walking typhoid" have among +the highest death-rates; second, by meeting the great instinctive +symptom of fever patients since the world began, thirst, encouraging the +patient to drink large quantities of water, taking care, of course, that +the water is pure and sterile. The days when we kept fever patients +wrapped up to their necks in woolen blankets in hot, stuffy rooms, and +rigorously limited the amount of water that they drank--in other words, +fought against nature in the treatment of disease--have passed. A +typhoid-fever patient now is not only given all he wants to drink, but +encouraged to take more, and some authorities recommend an intake of at +least three or four quarts, and, better, six and eight quarts a day. +This internal bath helps not only to allay the temperature, but to make +good the enormous loss by perspiration from the fevered skin, and to +flush the toxins out of the body. + +Third, by liberal and regular feeding chiefly with some liquid or +semi-liquid food, of which milk is the commonest form. The old attitude +of mind represented by the proverb, "Feed a cold and starve a fever," +has completely disappeared. One of the fathers of modern medicine asked +on his death-bed, thirty years ago, that his epitaph should be, "He fed +fevers." + +Fourth. We respond to the other great thirst of fever patients, for +coolness, by sponge baths and tub baths, whenever the temperature rises +above a certain degree. + +Simple as these methods sound, they are extremely troublesome to put +into execution, and require the greatest skill and judgment in their +carrying out. But intelligent persistence in the careful elaboration of +these methods of nature has resulted in already cutting the death-rate +in two,--from fifteen or twenty per cent to less than ten per cent,--and +where the full rigor of the tub bath is carried out it has been brought +down to as low as five per cent. + +Meanwhile the bacteriologists are steadily at work on a vaccine or +antitoxin. Wright, of the English Army Medical Staff, has already +secured a serum, which has given remarkable results in protecting +regiments sent out to South Africa and other infected regions. +Chantemesse has imported some six hundred successive cases treated with +an antitoxin, whose mortality was only about a third of the ordinary +hospital rate, and the future is full of promise. + + + + +CHAPTER X + +DIPHTHERIA + + +That was a dark and stern saying, "Without the shedding of blood there +is no remission," and, like all the words of the oracles, of limited +application. But it proves true in some unexpected places outside of the +realm of theology. Was there something prophetic in the legend that it +was only by the sprinkling of the blood of the Paschal Lamb above the +doorway that the plague of the firstborn could be stayed? To-day the +guinea-pig is our burnt offering against a plague as deadly as any sent +into Egypt. + +Scarcely more than a decade ago, as the mother sat by the cradle of her +firstborn, musing over his future, one moment fearfully reckoning the +gauntlet of risks that his tiny life had to run, and the next building +rosy air-castles of his happiness and success, there was one shadow that +ever fell black and sinister across his tiny horoscope. Certain risks +there were which were almost inevitable,--initiation ceremonies into +life, mild expiations to be paid to the gods of the modern underworld, +the diseases of infancy and of childhood. Most of these could be passed +over with little more than a temporary wrinkle to break her smile. They +were so trivial, so comparatively harmless: measles, a mere reddening of +the eyelids and peppering of the throat, with a headache and purplish +rash, dangerous only if neglected; chicken-pox, a child's-play at +disease; scarlatina, a little more serious, but still with the chances +of twenty to one in favor of recovery; diphtheria--ah! that drove the +smile from her face and the blood from her lips. Not quite so common, +not so inevitable as a prospect, but, as a possibility, full of terror, +once its poison had passed the gates of the body fortress. The fight +between the Angel of Life and the Angel of Death was waged on almost +equal terms, with none daring to say which would be the victor, and none +able to lift a hand with any certainty to aid. + +Nor was the doctor in much happier plight. Even when the life at stake +was not one of his own loved ones,--though from the deadly +contagiousness of the disease it sadly often was (I have known more +doctors made childless by diphtheria than by any other disease except +tuberculosis),--he faced his cases by the hundred instead of by twos and +threes. The feeling of helplessness, the sense of foreboding, with which +we faced every case was something appalling. Few of us who have been in +practice twenty years or more, or even fifteen, will ever forget the +shock of dismay which ran through us whenever a case to which we had +been summoned revealed itself to be diphtheria. Of course, there was a +fighting chance, and we made the most of it; for in the milder epidemics +only ten to twenty per cent of the patients died, and even in the +severest a third of them recovered. But what "turned our liver to +water"--as the graphic Oriental phrase has it--was the knowledge which, +like Banquo's ghost, would not down, that while many cases would recover +of themselves, and in many border-line ones our skill would turn the +balance in favor of recovery, yet if the disease happened to take a +certain sadly familiar, virulent form we could do little more to stay +its fatal course than we could to stop an avalanche, and we never knew +when a particular epidemic or a particular case would take that turn. +"Black" diphtheria was as deadly as the Black Death of the Middle Ages. + +The disease which caused all this terror and havoc is of singular +character and history. It is not a modern invention or development, as +is sometimes believed, for descriptions are on record of so-called +"Egyptian ulcer of the throat" in the earliest centuries of our era; and +it would appear to have been recognized by both Hippocrates and Galen. +Epidemics of it also occurred in the Middle Ages; and, coming to more +recent times, one of the many enemies which the Pilgrim Fathers had to +fight was a series of epidemics of this "black sore throat," of +particularly malignant character, in the seventeenth century. +Nevertheless, it does not seem to have become sufficiently common to be +distinctly recognized until it was named as a definite disease, and +given the title which it now bears, by the celebrated French physician, +Bretonneau, about eighty years ago. Since then it has become either more +widely recognized or steadily more prevalent, and it is the general +opinion of pathologists that the disease, up to some thirty or forty +years ago, was steadily increasing, both in frequency and in severity. + +So that we have not to deal with a disease which, like the other +so-called diseases of childhood, has gradually become milder and milder +by a sort of racial vaccination, with survival of the less susceptible, +but one which is still full of virulence and of possibilities of future +danger. + +Unlike the other diseases of childhood, also, one attack confers no +positive immunity for the future, although it greatly diminishes the +probabilities; and, further, while adults do not readily or frequently +catch the disease, yet when they do the results are apt to be +exceedingly serious. Indeed, we have practically come to the conclusion +that one of the main reasons why adults do not develop diphtheria so +frequently as children, is that they are not brought into such close and +intimate contact with other children, nor are they in the habit of +promptly and indiscriminately hugging and kissing every one who happens +to attract their transient affection, and they have outgrown that +cheerful spirit of comradeship which leads to the sharing of candy in +alternate sucks, and the passing on of slate-pencils, chewing-gum, and +other _objets d'art_ from hand to hand, and from mouth to mouth. +Statistics show that of nurses employed in diphtheria wards, before the +cause or the exact method of contagion was clearly understood, nearly +thirty per cent developed the disease; and even with every modern +precaution there are few diseases which doctors more frequently catch +from their patients than diphtheria. It is a significant fact that the +risk of developing diphtheria is greatest precisely at the ages when +there is not the slightest scruple about putting everything that may be +picked up into the mouth,--namely, from the second to the fifth +year,--and diminishes steadily as habits of cleanliness and caution in +this regard are developed, even though no immunity may have been gained +by a mild or slight attack of the disease. The tendency to discourage +and forbid the indiscriminate kissing of children, and the crusade +against the uses of the mouth as a pencil-holder, pincushion, and +general receptacle for odds and ends, would be thoroughly justified by +the risks from diphtheria alone, to say nothing of tuberculosis and +other infections. + +In addition to being almost the only common disease of childhood which +is not mild and becoming milder, diphtheria is unique in another +respect, and that is its point of attack. Just as tuberculosis seizes +its victims by the lungs, and typhoid fever by the bowels, +diphtheria--like the weasel--grips at the throat. Its bacilli, entering +through the mouth and gaining a foothold first upon the tonsils, the +palate, or back of the throat (pharynx), multiply and spread until they +swarm down into the larynx and windpipe, where their millions, swarming +in the mesh of fibrin poured out by the outraged blood-vessels, grow +into the deadly false membrane which fills the air-tube and slowly +strangles its victim to death. + +The horrors of a death like that can never fade from the memory of one +who has once seen it, and will outweigh the lives of a thousand +guinea-pigs. No wonder there was such a widespread and peculiar horror +of the disease, as of some ghostly thug or strangler. + +But not all of the dread of diphtheria went under its own name. Most of +us can still remember when the commonest occupant of the nursery shelf +was the bottle of ipecac or soothing-syrup as a specific against croup. +The thing that most often kept the mother or nurse of young children +awake and listening through the night-watches was the sound of a cough, +and the anxious waiting to hear whether the next explosion had a +"croupy" or brassy sound. It was, of course, early recognized that there +were two kinds of croup, the so-called "spasmodic" and the "membranous," +the former comparatively common and correspondingly harmless, the latter +one of the deadliest of known diseases. The fear that made the mother's +heart leap into her mouth as she heard the ringing croup-cough was lest +it might be membranous, or, if spasmodic, might turn into the deadly +form later. To-day most young mothers hardly know the name of wine of +ipecac or alum, and the coughs of young children awaken little more +terror than a similar sound in an adult. Croup has almost ceased to be +one of the bogies of the nursery. And why? Because membranous croup has +been discovered to be diphtheria, and children will not develop +diphtheria unless they have been exposed to the contagion, while, if +they should be, we have a remedy against it. + +He was a bold man who first ventured to announce this, and for years the +battle raged hotly. It was early admitted that certain cases of +so-called membranous croup in children occurred after or while other +members of the family or household had diphtheria; and for a time the +opposing camps used such words as "sporadic" or scattered croup, which +was supposed to come of itself, and "epidemic" or contagious croup, +which was diphtheria. Now, however, these distinctions are swept away, +and boards of health require isolation and quarantine against croup +exactly as against any other form of diphtheria. + +Cases of fatal croup still occasionally occur which cannot be directly +traced to other cases of diphtheria, but the vast majority of them are +clearly traceable to infection, usually from some case in another child, +which was so mild that it was not recognized as diphtheria until the +baby became "croupy" and search was made through the family throats for +the bacilli. + +For years we were in doubt as to the cause of diphtheria. Half a dozen +different theories were advanced, bad sewerage, foul air, overcrowding; +but it was not until shortly after the Columbus-like discovery, by +Robert Koch, of the new continent of bacteriology, that the germ which +caused it was arrested, tried, and found guilty, and our real knowledge +of and control over the disease began. This was in 1883, when the +bacteriologist Klebs discovered the organism, followed a few months +later (in 1884) by Loeffler, who made valuable additions to our knowledge +of it; so that it has ever since been known as the Klebs-Loeffler +bacillus. This put us upon solid ground, and our progress was both sure +and rapid: in ten years our knowledge of the causation, the method of +spread, the mode of assault upon the body-fortress, and last, but not +least, the cure, stood out clear cut as a die, a model and a prophecy of +what may be hoped for in most other contagious diseases. + +Great as is the credit to which bacteriologists are entitled for this +splendid piece of scientific progress, there was another co-laborer, a +silent partner, with them in all this triumph, an unsung hero and martyr +of science who deserves his meed of praise--the tiny guinea-pig. He well +deserves his niche in the temple of fame; and as other races and ages +have worshiped the elephant, the snake, and the sacred cow, so this age +should erect its temples to the guinea-pig. From one of the most +trifling and unimportant,--kept merely as a pet and curiosity by the +small boys of all ages,--he has become, after the horse, the cow, the +pig, and the sheep, easily our most useful and important domestic +animal. It may be urged that he deserves no credit, since his +sacrifice--though of inestimable value--was entirely involuntary on his +own part; but this should only make us the more deeply bound to +acknowledge our obligation to him. + +By a stern necessity of fate, which no one regrets more keenly than the +laboratory workers themselves, the guinea-pig has had to be used as a +stepping-stone for every inch of this progress. Upon it were conducted +every one of the experiments whose results widened our knowledge, until +we found that this bacillus and no other would cause diphtheria; that +instead of getting, like many other disease-germs, into the blood, it +chiefly limited itself to growing and multiplying upon a comparatively +small patch of the body-surface, most commonly of the throat; that most +of its serious and fatal results upon the body were produced, not by the +entrance of the germs themselves into the blood, but by the absorption +of the toxins or poisons produced by them on the moist surface of the +throat, just as the yeast plant will produce alcohol in grape juice or +sweet cider. + +Here was a most important clew. It was not necessary to fight the germs +themselves in every part of the body, but merely to introduce some +ferment or chemical substance which would have the power of neutralizing +their poison. Instantly attention was turned in this direction, and it +was quickly found that if a guinea-pig were injected with a very small +dose of the diphtheria toxin and allowed to recover, he would then be +able to throw off a still larger dose, until finally, after a number of +weeks, he could be given a dose which would have promptly killed him in +the beginning of the experiments, but which he now readily resisted and +recovered from. Evidently some substance was produced in his blood which +was a natural antidote for the toxin, and a little further search +quickly resulted in discovering and filtering out of his body the now +famous antitoxin. A dose of this injected into another guinea-pig +suffering from diphtheria would promptly save its life. + +Could this antitoxin be obtained in sufficient amounts to protect the +body of a human being? The guinea-pig was so tiny and the process of +antitoxin-forming so slow, that we naturally turned to larger animals as +a possible source, and here it was quickly found that not only would the +goat and the horse develop this antidote substance very quickly and in +large amounts, but that a certain amount of it, or a substance acting as +an antitoxin, was present in their blood to begin with. Of the two, the +horse was found to give both the stronger antitoxin and the larger +amounts of it, so that he is now exclusively used for its production. + +After his resisting power had been raised to the highest possible pitch +by successive injections of increasing doses of the toxin, and his serum +(the watery part of the blood which contains the healing body) had been +used hundreds and hundreds of times to save the lives of +diphtheria-stricken guinea-pigs, and had been shown over and over again +to be not merely magically curative but absolutely harmless, it was +tried with fear and trembling upon a gasping, struggling, suffocating +child, as a last possible resort to save a life otherwise hopelessly +doomed. Who could tell whether the "heal-serum," as the Germans call it, +would act in a human being as it had upon all the other animals? In +agonies of suspense, vibrating between hope and dread, doctors and +parents hung over the couch. What was their delight, within a few hours, +to see the muscles of the little one begin to relax, the fatal blueness +of its lips to diminish, and its breathing become easier. In a few hours +more the color had returned to the ashen face and it was breathing +quietly. Then it began to cough and to bring up pieces of the loosened +membrane that had been strangling it. Another dose was eagerly injected, +and within twenty-four hours the child was sleeping peacefully--out of +danger. And the most priceless and marvelous life-saving weapon of the +century had been placed in the hand of the physician. + +Of course there were many disappointments and failures in the earlier +cases. Our first antitoxins were too weak and too variable. We were +afraid to use them in sufficient doses. Often their injection would not +be consented to until the case had become hopeless. But courage and +industry have conquered these difficulties one after another, until now +the fact that the prompt and intelligent use of antitoxin will effect a +cure of from ninety to ninety-five per cent of all cases of diphtheria +is as thoroughly established as any other fact in medicine. The mass of +figures from all parts of the world in support of its value has become +so overwhelming that it is neither possible nor necessary to specify +them in detail. The series of Bayeaux, covering two hundred and thirty +thousand cases of diphtheria, chiefly from hospitals and hence of the +severest type, showing that the death-rate had been reduced from over +_fifty-five_ per cent to below _sixteen_ per cent already, and that this +decrease was still continuing, will serve as a fair sample. + +Three-quarters of even this sixteen per cent mortality is due to delay +in the administration of the antitoxin, as is vividly shown in thousands +of cases now on record, classified according to the day of the disease +on which the antitoxin was given, of which MacCombie's "Report of the +London Asylums Board" is a fair type. Of one hundred and eighty-seven +cases treated the first day of the disease, none died; of eleven hundred +and eighty-six injected on the second day of the disease, four and a +half per cent died; of twelve hundred and thirty-three not treated until +the third day of the disease, eleven per cent died; of nine hundred and +sixty-three cases escaping treatment until the fourth day, seventeen per +cent died; while of twelve hundred and sixty not seen until the fifth +day, twenty per cent died. In other words, the chances for cure by the +antitoxin are in precise proportion to the earliness with which it is +administered, and are over four times as great during the first two days +of the disease as they are after the fourth day. One "stick" in time +saves five. + +This brings us sharply to the fact that the most important factor in the +cure of diphtheria, just as in the case of tuberculosis, is early +recognition. How can this be secured? Here again the bacteriologist +comes to our relief, and we needed his aid badly. The symptoms of a mild +case of diphtheria for the first two, or even three, days are very much +like those of an ordinary sore throat. As a rule, even the well-known +membrane does not appear in sufficient amounts to be recognizable by the +naked eye until the middle of the second, or sometimes even of the +third, day. By any ordinary means, then, of diagnosis, we would often be +in doubt as to whether a case were diphtheria or not, until it was both +well advanced and had had time to infect other members of the family. +With the help of the laboratory, however, we have a prompt, positive, +and simple method of deciding at the very earliest stage. We merely take +a sterilized swab of cotton on the end of a wire, rub it gently over the +surface of the throat and tonsils, restore it to its glass tube, +smearing it over the surface of some solidified blood-serum placed at +the bottom of the tube, close the tube and send it to the nearest +laboratory. The culture is put into an incubator at body heat, the germs +sown upon the surface of the blood-serum grow and multiply, and in +twelve hours a positive diagnosis can be made by examining this growth +with a microscope. Often, just smearing the mucus swabbed out of the +throat over the surface of a glass slide, staining this smear, and +putting it under a microscope, will enable us to decide within an hour. +These tubes are now provided by all progressive city boards of health, +and can be had free of charge at depots scattered all over the city, for +use in any doubtful case, within half an hour. Twelve hours later a free +report can be had from the public laboratory. If every case of +suspicious sore throat in a child were promptly swabbed out, and a smear +from the swab examined at a laboratory, it would not be long before +diphtheria would be practically exterminated, as smallpox has been by +vaccination, and this is what we are working toward and looking forward +to. + +Our knowledge of the precise cause of diphtheria, the Klebs-Loeffler +bacillus, has furnished us not only with the cure, but also with the +means of preventing its spread. While under certain circumstances, +particularly the presence of moisture and the absence of light, this +germ may live and remain virulent for weeks outside of the body, careful +study of its behavior under all sorts of conditions has revealed the +consoling fact that its vitality outside of the human or some other +living animal body is low; so that it is relatively seldom carried from +one case to another by articles of clothing, books, or toys, and +comparatively seldom even through a third party, except where the latter +has come into very close contact with the disease, like a doctor, a +nurse, or a mother, or--without disrespect to the preceding--a pet cat +or dog. + +More than this, the bacillus must chiefly be transmitted in the moist +condition and does not float in the air at all, clinging only to such +objects as may have become smeared with the mucus from the child's +throat, as by being coughed or sneezed upon. As with most of our +germ-enemies, sunlight is its deadliest foe, and it will not live more +than two or three days exposed to sunshine. So the principal danger +against which we must be on our guard is that of direct personal +contact, as in kissing, in the use of spoons or cups in common, in the +interchange of candy or pencils, or through having the hands or clothing +sprayed by a cough or a sneeze. + +The bacillus comparatively seldom even gets on the floor or walls of a +room where reasonable precautions against coughing and spitting have +been taken; but it is, of course, advisable thoroughly to disinfect and +sterilize the room of a patient and all its contents with corrosive +sublimate and formalin, as a number of cases are on record in which the +disease has been carried through books and articles of clothing which +had been kept in damp, dark places for several months. The chief method +of spread is through unrecognized mild cases of the disease, especially +of the nasal form. For this reason boards of health now always insist +upon smears being made from the throats and noses of every other child +in the family or house where a case of diphtheria is recognized. No +small percentages of these are found to be suffering from a mild form of +the disease, so slight as to cause them little inconvenience and no +interference with their attending school. Unfortunately, a case caught +from one of these mild forms may develop into the severest laryngeal +type. If a child is running freely at the nose, keep it at home or keep +your own child away from it. A profuse nasal discharge is generally +infectious, in the case of influenza or other "colds," if not of +diphtheria. + +This also emphasizes the necessity for a thorough and expert medical +inspection of school-children, to prevent these mild cases from +spreading disease and death to their fellows. By an intelligent +combination of the two methods, home examination of every infected +family and strict school inspection, there is little difficulty in +stamping out promptly a beginning infection before it has had time to +reach the proportions of an epidemic. + +One other step makes assurance doubly sure, and that is the prompt +injection of all other children and young adults living in the family, +where there is a case of diphtheria, with small doses of the antitoxin +for preventive purposes. Its value in this respect has been only +secondary to its use as a cure. There are now thousands of cases on +record of children who had been exposed to diphtheria or were in +hospitals where they were in danger of becoming exposed to it, with the +delightful result that only a very small per cent of those so protected +developed the disease, and of these not a single one died! This +protective vaccination, however, cannot be used on a large scale, as in +the case of smallpox, for the reason that the period of protection is a +comparatively short one, probably not exceeding two or three weeks. + +Suppose that, in spite of all our precautions, the disease has gained a +foothold in the throat, what will be its course? This will depend, first +of all, upon whether the invading germs have lodged in their commonest +point of attack, the tonsils, palate, and upper throat, or have +penetrated down the air-passages into the larynx or voice-organ. In the +former, which is far the commoner case, their presence will cause an +irritation of the surface cells which brings out the leucocyte cavalry +of the body to the defense, together with squads of the serum or watery +fluid of the blood containing fibrin. These, together with the +surface-cells, are rapidly coagulated and killed by the deadly toxin; +and their remains form a coating upon the surface, which at first is +scarcely perceptible, a thin, grayish film, but which in the course of +twenty-four to forty-eight hours rapidly thickens to the well-known and +dreaded false membrane. Before, however, it has thickened in more than +occasional spots or patches, the toxin has begun to penetrate into the +blood, and the little patient will complain of headache, feverishness, +and backache, often--indeed, usually--before any very marked soreness in +the throat is complained of. Roughly speaking, attacks of sore throat, +which begin first of all with well-marked soreness and pain in the +throat, followed later by headache, backache, and fever, are not very +likely to be diphtheria. The bacilli multiply and increase in their +deadly mat on the surface of the throat, larger and larger amounts of +the poison are poured into the blood, the temperature goes up, the +headache increases, the child often begins to vomit, and becomes +seriously ill. The glands of the neck, in their efforts to arrest and +neutralize the poison, become swollen and sore to the touch, the breath +becomes foul from the breaking down of the membrane in the throat, the +pulse becomes rapid and weak from the effect of the poison upon the +heart, and the dreaded picture of the disease rapidly develops. + +This process in from sixty to eighty per cent of cases will continue for +from three to seven days, when a check will come and the condition will +gradually improve. This is a sign that the defensive tissues of the body +have succeeded in rallying their forces against the attack, and have +poured out sufficient amounts of their natural antitoxin to neutralize +the poisons poured in by the invaders. The membrane begins to break down +and peel off the throat, the temperature goes down, the headache +disappears, the swelling in the glands of the neck may either subside or +go on to suppuration and rupture, but within another week the child is +fairly on the way to recovery. + +Should the invaders, however, have secured a foothold in the larynx, +then the picture is sadly different. The child may have even less +headache, temperature, and general sense of illness; but he begins to +cough, and the cough has a ringing, brassy sound. Within forty-eight, or +even twenty-four, hours he begins to have difficulty in respiration. +This rapidly increases as the delicate tissues of the larynx swell under +the attack of the poison, and the very membrane which is created in an +attempt at defense becomes the body's own undoing by increasing the +blocking of the air-passages. The difficulty of breathing becomes +greater and greater, until the little victim tosses continually from +side to side in one constant, agonizing struggle for breath. After a +time, however, the accumulation of carbon dioxide in the blood produces +its merciful narcotic effect, and the struggles cease. The breathing +becomes shallower and shallower, the lips become first blue, then ashy +pale, and the little torch of life goes out with a flicker. This was +what we had to expect, in spite of our utmost effort, in from seventy to +ninety per cent of these laryngeal cases, before the days of the blessed +antitoxin. Now we actually reverse these percentages, prevent the vast +majority of cases from developing serious laryngeal symptoms at all, and +save from seventy to eighty per cent of those who do. + +Our only resource in this form of the disease used to be by mechanical +or surgical means, opening the windpipe below the level of the +obstruction and inserting a curved silver tube--the so-called +tracheotomy operation; or later, and less heroic, by pushing forcibly +down into the larynx, and through and past the obstruction at the vocal +cords, a small metal tube through which the child could manage to +breathe. This was known as intubation. But these were both distressing +and painful methods, and, what was far worse, pitifully broken reeds to +depend upon. In spite of the utmost skill of our surgeons, from fifty to +eighty per cent of cases that were tracheotomized, and from forty to +sixty per cent of those that were intubated, died. In many cases they +were enabled to breathe, their attacks of suffocation were relieved--but +still they died. + +This leads us to the most important single fact about the course of the +disease, and that is that the chief source of danger is not so much from +direct suffocation as from general collapse, and particularly failure of +the heart. + +This has given us two other data of great importance and value, namely, +that while the immediate and greatest peril is over when the membrane +has become loosened and the temperature has begun to subside, in both +ordinary throat and in laryngeal forms of the disease, the patient is by +no means out of danger. While the antitoxins poured out by his body have +completely defeated the invading toxins in the open field of the blood, +yet almost every tissue of the body is still saturated with these latter +and has often been seriously damaged by them before their course was +checked. For instance, nearly two-thirds of our diphtheria cases, which +are properly examined, will show albumin in the urine, showing that the +kidney-cells have been attacked and poisoned by the toxin. This may go +on to a fatal attack of uremia; but fortunately, not commonly, far less +so than in scarlet fever. The kidneys usually recover completely, but +this may take weeks and months. Again, many cases of diphtheria will +show a weak and rapid pulse, which will persist for weeks after the +patient has apparently recovered; and if the little ones are allowed to +sit up too soon, or to indulge in any sudden movements or muscular +strains, this weak and rapid pulse will suddenly change into an attack +of heart failure and, possibly, fatal collapse. This, again, illustrates +the saturation of the poison, as these effects are now known to be due +in part to a direct poisoning of the muscle of the heart itself, and +later to serious damage done to the nerves controlling the heart, +chiefly the pneumo-gastric. Moral: Keep the little patient in bed for at +least two weeks or, better, three. He will have to spend a month or more +in quarantine, anyway. + +Last of all, and by no means least interesting, are the effects which +are produced upon the nervous system. One day, while the child is +recovering, and is possibly beginning to sit up in bed, a glass of milk +is handed to him. The little one drinks it eagerly and attempts to +swallow, but suddenly it chokes, half strangles, and back comes the +milk, pouring out through the nostrils. Paralysis of the soft palate has +occurred from poisoning of the nerves controlling it, caused by direct +penetration of the toxin. Sometimes the muscles of the eye become +paralyzed and the little one squints, or can no longer see to read. + +Fortunately, most of these alarming results go only to a certain degree, +and then gradually fade away and disappear; but this may take months or +even longer. In a certain number, however, the nerves of respiration, or +those controlling the heart-beat, become affected, and the patient dies +suddenly from heart failure. + +This strange after-effect upon the nervous system, which was first +clearly noticed in diphtheria and syphilis, has now been found to occur +in lesser degree in a large number of our infectious diseases, so that +many of our most serious paralyses and other diseases of the nervous +system are now traceable to such causes. + +These effects of the diphtheria toxin are also of interest for a +somewhat unexpected reason, since it has been claimed that they are +effects of the antitoxin, by those who are opposed to its use. Every one +of them was well recognized as a possible result of diphtheria long +before the antitoxin was discovered, and every one of them can be +readily produced by injections of diphtheria bacilli or their toxin into +animals. + +It is quite possibly true that there are more cases of nerve-poisoning +(neuritis) and of paralysis following diphtheria than there were before +the use of antitoxin, but that is for the simple and sufficient reason +that there are more children left alive to display them! And between a +child with a temporary squint and a dead child few mothers would +hesitate long in their choice. + + + + +CHAPTER XI + +THE HERODS OF OUR DAY: SCARLET FEVER, MEASLES, AND WHOOPING-COUGH + + +Why is a disease a disease of childhood? First and fundamentally, +because that is the earliest period at which a human being can have it. +But the problem goes deeper than this. There is no more interesting and +important group of diseases in the whole realm of pathology than those +which we calmly dub "the diseases of childhood," and thereby dismiss to +the limbo of unavoidable accidents and discomforts, like flies, +mosquitoes, and stubbed toes, which are best treated with a shrug of the +shoulders and such stoic philosophy as we can muster. They are +interesting, because the moment we begin to study them intelligently we +stumble upon some of the profoundest and most far-reaching problems of +resistance to disease; important, because, trifling as we regard them, +and indeed largely just because we so regard them, they kill, or +handicap for life, more children in civilized communities than the most +deadly pestilence. Measles, for instance, according to the last United +States census, causes yearly nearly thirteen thousand deaths, while +smallpox causes so few that it is not listed among the important causes +of death. Scarlet fever causes sixty-three hundred and thirty-three +deaths, as compared with barely five thousand from appendicitis and the +same number from rheumatism. Whooping-cough causes ninety-nine hundred +and fifty-eight deaths, more than double the mortality from diabetes and +nearly equal to that of malarial fever. + +In medicine, as in war, the gravest and deadliest mistake that you can +make is to despise your enemy. These trivial disorders, these trifling +ailments, which every one takes as a matter of course, and expects to go +through with, like teething, tight shoes, and learning to smoke, sweep +away every year in these United States the lives of from forty to fifty +thousand children, reaching the bad eminence of fifth upon our mortality +lists, only consumption, pneumonia, heart disease, and diarrh[oe]al +diseases ranking above them. Of course, it is obvious that these +diseases outrank many other more serious ones among the "captains of the +men of death," largely upon the familiar principle of the old riddle, +whereby the white sheep eat more grass than the black, "because there +are more of them." + +While only a relatively small percentage of us ever have the bad luck to +be attacked by typhoid fever, rheumatism, or appendicitis, to say +nothing of cholera and smallpox, the vast majority of us have gone +through two or more of these diseases of childhood; so that, though the +death-rate of each and all of them is low, yet the number of cases is so +enormous that the absolute total mounts high. But the pity and, at the +same time, the practical importance of this heavy death-roll is that _at +least two-thirds of it is absolutely preventable_, and by the exercise +of only a very moderate amount of intelligence and vigilance. It is, of +course, obvious that in a group of diseases which numbers its victims +literally by the million every year there will inevitably occur a +certain minute percentage of fatal results due to what might be termed +unavoidable causes, like a badly nourished condition of the child +attacked, unusual circumstances preventing proper shelter or nursing, or +an exceptional virulence of the disease, such as will occur in two or +three cases of every thousand in even the most trifling infectious +malady. But even after making liberal allowance for what might be termed +the unavoidable fatalities, at least two-thirds, and more probably +nine-tenths, of the deaths from children's diseases might be prevented +upon two grounds:-- + +First, that they are contagious and absolutely dependent upon a living +germ, whose spread can be prevented; and secondly, and practically even +more important, that more than half the deaths from them are due, not to +the disease itself, but to complications occurring during the period of +recovery, caused, for the most part, by gross carelessness on the part +of the mother or nurse. A large majority, for instance, of the nearly +thirteen thousand deaths attributed to measles are due to bronchitis, +caught by letting the child go out-of-doors too soon after recovery, +which means, of course, either a chill falling upon the irritated and +weakened bronchial mucous membrane, or an infection by one of the score +of disease-germs, such as those of influenza, pneumonia, bronchitis, and +even tuberculosis, which are continually lying in wait for just such an +emergency as this--just such a weakening of the vital resistance. + +It is a sadly familiar statement in the history of fatal cases of +tuberculosis that the trouble "began with an attack of measles," or +whooping-cough, or a bad cold, and was mistaken for a mere "hanging on" +of one of these milder maladies until it had gained a foothold that +there was no dislodging. As breakers of the wall of the hollow square of +the body-cells, drawn up to resist the cavalry charges of tuberculosis, +pneumonia, and rheumatism, few can be compared in deadliness with the +diseases of childhood and "common colds." + +Further, while all of them except scarlet fever have a mortality so low +that it might almost be described as what the French delicately term +_une quantite negligeable_, yet a surprisingly large number of the +survivors do not escape scot-free, but bear scars which they may carry +to their graves, or which may even carry them to that bourne later. +Again, the actual percentage of the survivors who are marked in this +fashion is small, but such milliards of children are attacked every year +that, on the old familiar principle, "if you throw plenty of mud some of +it will stick," quite a serious number are more or less handicapped by +these remainders. For instance, quite a noticeable percentage of cases +of chronic eye troubles, particularly of the lids and conjunctiva, such +as "granulated" lids, styes, ulcers of the cornea, date from an attack +of measles or even whooping-cough. Many cases of nasal catarrh or +chronic throat trouble or bronchitis in children date from the same +source. A large group of chronic discharges from the ear and +perforations of the ear-drum are a direct after-result of scarlet fever; +and the frequency with which this disease causes serious disturbances of +the kidneys is almost a household word. Less definitely traceable, but +even more serious in their entirety, are the large group of chronic +depression of vigor, loss of appetite, various forms of indigestion and +of bowel trouble, which are left behind after the visitation of one of +these minor pests, particularly among the children of the poorer +classes, who are unable to obtain the highly nutritious, appetizing, and +delicately cooked foods which are so essential to the full recovery of +the little invalids. + +One of the English commissions which was investigating the alleged +physical deterioration of city and town populations stumbled upon a +singularly interesting and significant fact in this connection, while +plotting the curves of the rate of growth of the children in a given +district in Scotland during a series of years. They were struck with the +fact that children born in certain years in the same families, +neighborhoods, and presumably the same circumstances, grew more rapidly +and had a lower death-rate than those born in other years; and that, on +the other hand, children born in other years fell almost as far below +the normal in their rate of growth. The only factor which they found to +coincide with these differences was that in the years in which those +children who made the slowest growth were born there had been unusually +heavy epidemics of children's diseases and a high mortality; while, on +the other hand, those years whose "crop" of children made the best +growth had been unusually free from such epidemics and had a +correspondingly low mortality, showing clearly that even the survivors +of children's diseases were not only not benefited, but distinctly +handicapped and set back in their growth by the energy, so to speak, +wasted in resisting the onslaught. + +This brings us to an aspect of these diseases which from both a +philosophic and a practical point of view is most interesting and +profoundly significant; and that is the question with which we opened: +Why is a disease a disease of childhood? The old, primitive view was as +guileless and as simple as the age in which the diseases occurred. They +were regarded not merely by the laity but by grave and reverend +physicians of the Dark Ages as a sort of necessary vital crisis peculiar +and appropriate to each particular age of life,--a sort of sweating out +and erupting of "peccant humors" of the blood, which must be got rid +of or else the individual would not thrive. Incredible as it may +seem, so far was this idea extended, that the great Arabian +physician-philosopher, Rhazes, actually included smallpox in this group, +as the last of the "crises of growth" which had to appear and have its +way in young manhood or womanhood. Quaint little echoes of this simple +faith still ring in the popular mind, as, for instance, in the +widespread notion about the dangerousness of doing anything to check the +eruption in measles and cause it to "strike in." Any mother in Israel +will tell you, the first time you propose a bath or a wet pack to reduce +the temperature in measles, that if you so much as touch water to the +skin of that child it will "drive the rash in" and cause it to die in +convulsions. And, of course, one of the commonest of a physician's +memories is the expression of relief from the mother or aunt in any of +these mild eruptive fevers, where the skin was well reddened and +spotted: "Well, anyway, doctor, it is a splendid thing to get the rash +so well out!" Until within the last ten or fifteen years it was no +uncommon thing to hear the expression: "Well, I suppose we might just as +well let Willie and Susie go on to school and get the measles and have +done with it. It seems to be a real mild sort this time." Of course this +view was scientifically shattered two or more decades ago by our +recognition of the infectious nature of these diseases, but practically +its hold on the public mind constitutes one of the most serious and +vital obstacles in the way of the health-officer when he endeavors to +attack and break up an epidemic of measles, whooping-cough, or +chicken-pox. + +It cannot be too strongly emphasized that, mild and in their immediate +results trifling, as most of these "little diseases" are, they are +genuine members of that class of pathologic poison-snakes, the +germ-infections; that when they bite, they bite to kill; that two to +five times in every hundred they do kill; that, like all other +infections, they are capable of inflicting serious and permanent damage +upon the great vital organs, the heart, the kidneys, the liver, and the +brain; and that they are the very jackals of diseases, tracing down and +pointing out the prey to the lions that work in partnership with them. +With whatever we may treat measles and whooping-cough, _never_ treat +them with contempt! + +The next conception of the "whyness" of children's diseases was that as +one star differs from another in glory, so does one germ differ from +another in virulence; that the germs of these particular diseases just +happened to be from the beginning unusually mild and at the same time +highly contagious, so that they remained permanently scattered about +throughout the community, and attacked each successive brood of newborn +children as quickly as they could conveniently get at them. Being so +mild and so comparatively seldom fatal, little or no alarm was excited +by them and few efforts made to check their spread, so that they +continued to flourish, generation after generation. Upon this theory the +germs of measles, chicken-pox, whooping-cough, mumps, would be in +something like the same class as the numerous species of bacteria and +other germs that normally inhabit the human mouth, stomach, and +intestines; for the most part, comparatively harmless parasites, or what +are technically now known as "_symbiotes_" (from two Greek words, +_bios_, "life," and _syn_, "with"), a sort of little partners or +non-paying boarders, for the most part harmless, but occasionally +capable of making trouble. There are scores of species of such germs in +our food-canals, some of which may be even slightly helpful in the +process of digestion. Only a very small per cent of the bacilli of any +sort in the world are harmful; the vast majority are exceedingly +helpful. + +There is evidently some truth in this view of children's diseases, +especially so far as the reason for their steady persistence and +undiminished spread is concerned, namely, the comparative carelessness +and indifference with which they are regarded and treated. But some +rather striking developments of recent years have raised grave doubts in +our minds as to whether they were always the mild and inoffensive "house +cats" that they pass for at present. These are the astonishing and +almost incredible developments that occur when for the first time these +mild and harmless "diseaselets" are introduced to a savage or +half-civilized tribe. Like an Arabian Nights' transformation, our +sleepy, purring, but still able to scratch, "pussy cat" flashes out as a +ravenous man-eating tiger, killing and maiming right and left. +Measles--harmless, tickly, snuffly, "measly" little measles--kills from +thirty to sixty per cent of whole villages and tribes of Indians and +cripples half the remainder! + +My first direct experience with this feature of our "household pets" was +on the Pacific Coast. All the old settlers told me of a dread pestilence +which had preceded the coming of the main wave of invading civilization, +sweeping down the Columbia River. Not merely were whole clans and +villages swept out of existence, but the valley was practically +depopulated; so that, as one of the old patriarchs grimly remarked, "It +made it a heap easier to settle it up quietly." So swift and so fatal +had been its onslaught that villages would be found deserted. The canoes +were rotting on the river bank above high-water mark. The curtains of +the lodges were flapped and blown into shreds. The weapons and garments +of the dead lay about them, rusting and rotting. The salmon-nets were +still standing in the river, worn to tatters and fringes by the +current. Yet, from the best light that I was able to secure upon it, it +appeared to have been nothing more than an epidemic of the measles, +caught from the child of some pioneer or trapper and spreading like +wildfire in the prairie grass. A little later I had an opportunity to +see personally an epidemic of mumps in a group of Indians, and I have +seldom seen fever patients, ill of any disease, who were more violently +attacked and apparently more desperately ill than were sturdy young +Indian boys attacked by this trifling malady. Their temperatures rose to +one hundred and five or one hundred and six degrees, they became +delirious, their faces were red and swollen, they ached in every limb, +and the complications that occasionally follow mumps even in civilized +patients were frequent and exceedingly severe. In like manner, influenza +will slay its hundreds in a tribe of less than a thousand members. +Chicken-pox will become so virulent as to be mistaken for smallpox. +Several of the epidemics of alleged smallpox that have occurred among +Indians and other savage tribes are now known to have been only measles. +At first, pathologists were inclined to receive these reports with some +degree of skepticism, and to regard them either as travelers' tales, or +as instances of exceptional and accidental virulence in that particular +tribe, the high death-rate due to bad nursing or horrible methods of +voodoo treatment. + +But from all over the world came ringing in the same story, not merely +from scores of travelers, but also from army surgeons, medical +missionaries, and medical explorers, until it has now become a +definitely established fact that the mild, trifling diseases of infancy, +"colds" and influenzas of civilized races, leap to the proportions of a +deadly pestilence when communicated to a savage tribe. Whether that +tribe be the Eskimo of the Northern ice-sheet or the Terra del Fuegian +of the Southern, the Hawaiian of the islands of the Pacific or the +Aymaras of the Amazon, all fall like grain before the scythe under the +attack of a malady which is little more than the proverbial "little +'oliday" of three days in bed to civilized man. Evidently civilized man +has acquired a degree and kind of immunity that uncivilized man has not. +Either the disease has grown milder or civilized man tougher with the +ages. + +The probability is that both of these explanations are true. These +diseases may originally have been comparatively severe and serious; but +as generation after generation has been submitted to their attack, those +who were most susceptible died or were so crippled as to be seriously +handicapped in the race of life and have left fewer and less vigorous +offspring. So that, by a gradual process of weeding out the more +susceptible, the more resisting survived and became the resistant +civilized races of to-day. + +On the other hand, any disease which kills its victim so quickly that it +has not time to make sure of its transmission to another one before his +death, will not have so many chances of survival as will a milder and +more chronic disorder. Hence, the milder and less fatal strains of germs +would stand the better chance of survival. This, of course, is a very +crude outline, but it probably represents something of the process by +which almost all known diseases, except a few untamable hyenas, like the +Black Death, the cholera, and smallpox, have gradually grown milder with +civilization. If we escape the attack of these attenuated diseases of +infancy until fifteen or sixteen years of age, we can usually defy them +afterward; though occasionally an unusually virulent strain will attack +an adult, with troublesome consequences. + +At all events, whatever explanation we may give, the consoling fact +stands out clearly that civilized man is decidedly more resistant to +these pests of civilization than is any half-civilized race, and there +is good reason to believe that this is a typical instance of his +comparative vigor and endurance all along the line. + +If this view of the original character and taming of these diseases be +correct, it also accounts for the extraordinary and otherwise +inexplicable cases where they suddenly assume the virulence of cholera, +or yellow fever, and kill within forty-eight or ninety-six hours, not +merely in children but also in adults. + +To group these three diseases together simply because they all happen to +occur in children would appear scarcely a rational principle of +classification. Yet, practically, widely different as they are in their +ultimate results and, probably, in their origin, they have so many +points in common as to their method of spread, prevention, and general +treatment, that what is said of one will with certain modifications +apply to all. + +I said "probably" of widely different origin, because, by one of those +strange paradoxes which so often confront us in real life, though the +infectiousness and the method of spread of all these diseases is as +familiar as the alphabet and as firmly settled, the most careful study +and innumerable researches have failed to identify positively the germ +in any one of them. There are a number of "suspects" against which a +great deal of circumstantial evidence exists: a streptococcus in scarlet +fever, a bacillus in whooping-cough, and a protozoan in measles; but +none of these have been definitely convicted. The principal reason for +our failure is a very common one in bacteriological research, whose +importance is not generally known, and that is, that there is not a +single species of the lower animals that is subject to the diseases or +can be inoculated with them. This unfortunate condition is the greatest +barrier which can now exist to our discovery of the causation of any +disease. We were absolutely blocked, for instance, by it in smallpox and +syphilis until we discovered that our nearest blood relatives, the ape +and the monkey, are susceptible to them; and then the _Cytoryctes +Variolae_ and the _Treponema pallida_ were discovered within +comparatively a few months. Some lucky day, perhaps, we may stumble on +the animal or bird which will take measles, scarlet fever, or +whooping-cough, and then we will soon find out all about them. + +But, fortunately, our knowledge of these little diseases, like +Mercutio's wound, is "not so deep as a well, nor so wide as a church +door; but 't is enough" for all practical purposes. The general plan of +treatment in all of them might be roughly summed up as, rest in bed in a +well-ventilated room; sponge-baths and packs for the fever; milk, eggs, +bread, and fruit diet, with plenty of cool water to drink, either plain, +or disguised as lemonade or "fizzy" mixtures; mild local antiseptic +washes for nose and throat, and mild internal antiseptics, with +laxatives, for the bowels and kidneys. There is no known drug which is +specific in any one of them, though their course may be made milder and +the patient more comfortable by the intelligent use of a variety of +remedies, which assist nature in her fight against the toxin. Not +knowing the precise cause, we have as yet no reliable antitoxin for any. + +Now very briefly as to the earmarks of each particular member of this +children's group. It may be said in advance that the "openings" of all +of them (as chess-players call the first moves) are very much alike. +All of them are apt to begin with a little redness and itching of the +mucous membranes of the nose, the throat, and the eyes, with consequent +snuffling and blinking and complaints of sore throat. These are +followed, or in severe, swift cases may be preceded, by flushed cheeks, +complaints of headache or heaviness in the head, fever, sometimes rising +very quickly to from one hundred and four to one hundred and five +degrees, backache, pains in the limbs, and, in very severe cases, +vomiting. In fact, the symptoms are almost identical with those of an +attack of that commonest of all acute infections, a bad cold, and +probably for the same reason, namely, that the germs, whatever they may +be, attack and enter the system by way of the nose and throat. + +One of the most difficult practical points about the beginning of this +group of diseases is to distinguish them from one another, or from a +common cold. The important thing to remember is that, theoretically +important as it may be to make this distinction, practically it isn't +necessary at all, as they should all be treated exactly alike in the +beginning. The only vital thing is to recognize that you are dealing +with an infection of some sort, isolate promptly the little patient, put +him to bed, and make your diagnosis later as the disease develops. +Fortunately neither scarlet fever nor measles usually becomes acutely +infectious until the rash appears, and as neither is particularly +dangerous to adults, especially to such as have had them already, a +one-room quarantine is sufficient for the first few days of any of these +diseases. We will lose nothing and gain enormously by adopting this +routine plan in all cases of snuffling noses, sore throats, headache, +and fever in children, for these are the early symptoms of all their +febrile diseases, from colds to diphtheria; all alike are infectious and +all, even to the mildest, benefited by a few days of rest and seclusion. + +After this first general blare of defiance on the part of the system to +the enemy, whoever he may be, the battle begins to take on its +characteristic form according to the nature of the invader. We will take +first the campaign of scarlet fever, since this is the swiftest and +first to disclose itself. After the preliminary snuffles and headache +have lasted for a few hours, the temperature usually begins to rise; and +when it does, by leaps and bounds often reaching one hundred and four or +one hundred and five degrees within twelve hours, the skin becomes dry +and hot, the throat sore, the tongue parched, and the little patient +drowsy and heavy-eyed. Within from twenty-four to forty-eight hours a +bright red or pinkish rash appears, first on the neck and chest, and +then rapidly spreading all over the surface of the body within another +twenty-four hours. + +Meanwhile the throat becomes sore and swollen, ranging, according to the +severity of the case, from a slight reddening and swelling to a furious +ulcerative inflammation, with the formation of a thick membrane-like +exudate, which sometimes is so severe as to raise a suspicion of +possible diphtheria. The tongue becomes red and naked, with the papillae +showing light against a red ground, so as to give rise to what has been +known as "the strawberry tongue." The temperature is usually high, and +the little patient when he drowses off to sleep is quite apt to become +more or less delirious. In the vast majority of cases, after two to four +days of this, the temperature goes down almost as swiftly as it came up, +the rash begins to fade, the throat gets less sore, and the rebound +toward recovery sets in. About this time the daily examination of the +urine will begin to show traces of albumin, but this, under strict rest +in bed and careful diet, will usually diminish and ultimately disappear. +In the event of a relapse, however, or setback from any cause, the +kidneys may become violently attacked, and a considerable per cent of +the fatal cases die from suppression of the urine. After this crisis has +occurred, however, in ninety-nine per cent of all cases it is +comparatively plain sailing; the throat is still sore and troublesome, +the skin itches and tickles, and the eyes smart, but the little patient +steadily improves day by day. Anywhere from three to five days after +the break in the fever the skin begins to get rough and scaly, and +gradually peels off, until in some cases the entire coating of the body +is shed, having been killed, as it were, by the violence of the +eruption. These _flakes and scales of the skin are exceedingly +contagious_, and no case should be regarded as fit to be released from +isolation until every particle has been shed and got rid of. This +constitutes one of the most tiresome and annoying periods of the +disease, as complete shedding is seldom finished before two weeks, and +sometimes may last from three to five. + +However, this long period of contagiousness has been found to be really +a blessing in disguise, inasmuch as we now know that even more +strikingly than in the other children's diseases it is the period of +_recovery_ that is the period of _greatest danger_ in scarlet fever. +Like the Parthians of Greek history it is most dangerous when in +retreat. Keeping the child at rest for the greater part of the time, in +bed or on a lounge, in a well-ventilated room, or later on a porch or +terrace, for five weeks from the beginning of the disease, is well worth +all the trouble and inconvenience that it causes, for the sake of the +almost absolute protection it gives against dangerous and even fatal +complications, particularly of the kidneys, heart, or lungs. + +This is a fair description of what might be termed an average case of +the disease. We also have the sadly familiar type described as the +fulminant or, literally, "lightning-stroke" variety. The child goes down +as if struck by an invisible hand; vomiting is one of the first +symptoms; delirium follows within ten or twelve hours; the eruption +becomes not merely scarlet but purplish from hemorrhage under the skin, +giving the name of "black" scarlet fever to this type. The throat +becomes furiously swollen, the urine is absolutely suppressed, the child +goes into convulsions, and dies within forty-eight hours from the +beginning of the attack. Fortunately, this type is rare, but the +important thing to remember is that it may develop in a child who caught +the disease from one of the mildest of all possible cases! Hence every +case should be treated with the strictest isolation, as if it were +itself of the most malignant type. + +Naturally, the mortality of scarlet fever varies according to the type. +Not only may it assume a malignant form in individual cases, but whole +epidemics may be of this character, with a mortality of from twenty to +thirty per cent. Generally speaking, however, the death-rate is about +one in twelve, ranging from as low as one in twenty-five to as high as +one in five. + +As in the case of diphtheria, the greatest danger and most powerful +means of spread of the disease is through the mild, unrecognized cases, +which are supposed to have nothing but a cold and are allowed to +continue in school or play with other children. We have no antitoxin and +no bacteriologic means of positive diagnosis. But one method will stop +the spread and within ten or fifteen years exterminate every one of +these infections--_isolate at once every child_ that shows symptoms of a +cold, sore throat, or feverishness, both for its own sake and for that +of the community! + +In measles we have to deal with a much more harmless and more nearly +domesticated "beast of prey," but one of a prevalence to correspond. +Though probably (exact data being as yet lacking) not more than +one-third of all individuals are attacked by scarlet fever, it would be +safe to say that not more than one-third, and possibly not more than +one-fifth, of us escape measles. Hence, though its mortality is scarcely +one-fourth that of scarlet fever, it more than holds its own in the +Herod class, as grimly shown by its total death-roll of over twelve +thousand, compared with only a little over six thousand to the credit of +scarlet fever. + +After the preliminary disturbances of snuffles, hot throat, headache, +and feverishness, which it shares with all the other "little fevers," +the first thing to mark off measles is usually that the itching and +running at the nose and eyes become more prominent, the child begins to +turn its face away from the light because it makes its eyes smart, and +complains not so much of soreness as of a peppery, burning, itching +sensation in its nose and throat. The tongue is coated, the stomach +mildly upset; the little patient is more uncomfortable and fretful than +seriously ill. This condition drags on, without apparently getting +anywhere, for from two to four days, during which time it is often very +difficult even for the most experienced physician to say positively what +the sufferer has. But about the fourth day a rash begins to appear, +typically first upon the cheeks or forehead in the shape of little +widely separated dull-red blotches. These grow larger and deeper in +color, rising in the middle and spreading at their edges, so that +shortly the whole skin becomes puffed and swollen and of a mottled, +pinkish-purple color. If the child's lower lip be pulled down, little +red spots will be seen scattered over the lining membrane of the mouth, +showing that the eruption is not confined to the skin. Indeed, these +Koplik's spots (as they are called, after their discoverer) in the mouth +will often appear a day or more before the eruption upon the skin and +give the first clew to the nature of the disease. These are significant, +because they probably illustrate the process of eruption, or, at least, +irritation, which is taking place, not merely upon the skin, but also +upon the mucous membranes of the eyes, nose, and throat, the windpipe +and the bronchial tubes, and which is the cause of the burning, running, +and, later, occasional serious inflammatory symptoms in all these +regions. + +When you look at the hot, angry-looking, swollen skin of the little +victim of measles, the weeping eyes and running nose, and remember that +this same sort of process is either going on or is likely to occur all +over his entire lining, so to speak, from lungs to bowels, you can +easily grasp how important it is to keep him absolutely at rest and +protected from every possible risk in the way of chill, over-exertion, +or injudicious feeding, until the whole process has completely subsided +and been forgotten. Neglect of these precautions is the reason why so +many cases of measles, on the least and most trifling exposure and +overstrain during the two or three weeks following the disease, will +blaze up into a fatal bronchitis or pneumonia. + +The rash takes about two or three days to get out, then it begins to +fade and the skin to peel off in tiny, branny scales, so small and thin +as to be almost invisible--unlike the huge flakes of scarlet fever. At +the same time all the other symptoms recede. + +But, as in scarlet fever, all cases should be treated alike, by rest, +sponging and packing for the fever, light diet with plenty of milk and +fruit, and confinement to the room for at least ten days after the +disappearance of the fever. The very mildest and most insignificant of +attacks may be followed, through carelessness or exposure, by a fatal +bronchitis. Indeed, in view of the distressing frequency with which our +histories of tuberculosis in children contain the words, "Came on after +measles," it is highly advisable to watch carefully every child as +regards abundant feeding, avoidance of overwork or overstrain, and of +all unnecessary exposure to infection, wind, or wet, for two months +after an attack of measles instead of the customary two weeks. As the +disease is acutely infectious, the little victim should be isolated for +at least three weeks after the disappearance of the fever; but this +again, as in the case of scarlet fever, is emphatically a blessing in +disguise from his point of view, as well as a protection to the rest of +the community. + +Should the "little fever" prove to be whooping-cough, it will be later +still in positively declaring its definite intentions. The cold or +catarrhal stage will be much milder, the fever lower, the cough a trifle +more marked, but will drag on for from a week to ten days before +anything definite happens. Usually the child is supposed to be suffering +with a slight cold, hence the prevailing impression that colds run into +whooping-cough, if neglected. Then one day the child is suddenly seized +with a coughing fit, consisting of from ten to fifteen short coughs in +rapid succession of increasing intensity, until all the air seems +literally pumped out of the lungs of the poor little patient; then, with +a tremendous whoop, the youngster gets his breath again and the +diagnosis is made. This distressing performance may occur only four or +five times a day, or it may be repeated every half-hour or so. So +violent is the paroxysm that the eyes of the child protrude, it becomes +literally black in the face, and runs to its mother or nurse, or +clutches a chair, to keep from falling. + +As the same great nerves which supply the lungs supply the stomach, the +irritation frequently "radiates," or spills over, from one division of +it to the other, and the coughing fit is frequently followed by +vomiting. Unexpectedly enough this may often become the most serious +practical symptom of the disease, inasmuch as the stomach is emptied so +frequently that the poor little victim is unable to retain any +nourishment long enough to absorb it, and may waste away frightfully, +and even literally starve to death, or have its resisting power so +greatly lowered that an attack of bronchial trouble or bowel disturbance +will prove rapidly fatal. + +So serious are the disturbances of the circulation all over the body by +these spasmodic suffocation-fits, that rupture of small blood-vessels +may occur in the eyes, the brain, in the lungs, and on the surface of +the skin. The heart becomes distended, and if originally weakened may be +seriously dilated or overstrained; the lungs become congested and +inflamed, and any of the numerous accidental germs which may be present +will set up a broncho-pneumonia, which is the commonest cause of death +in this disease, as in measles. + +Strangely enough, while, as we do not positively know the germ, and +hence cannot state definitely either the cause or the principal seat of +the trouble, it is not generally believed that the condition of the +lungs or the throat has much to do with the cough. + +At all events, it is perfectly idle to treat the disease with cough +mixtures or expectorants. The view toward which the majority of +intelligent observers are inclined is that whooping-cough is an +infection, the germ or toxin of which attacks the nervous system, and +particularly the great "lung-stomach" (pneumo-gastric) nerve. At all +events, the only remedies which appear to have any effect upon the +disease are, in the early stages, mild local antiseptics in the nose and +throat, and later those which diminish the irritability of the nerves +without upsetting the appetite or depressing the general vigor. The +disease is, for all its mildness, one of the most obstinate known. + +A small percentage of cases run a violent course, in spite of the most +intelligent and anxious care, both medical and household; but the vast +majority of such complications as occur are either caused by +carelessness or become serious only if neglected. Treating all children +with whooping-cough as emphatically sick children, entitled to every +care and excuse from exertion, every exemption and privilege that can be +given them until the last whoop has been whooped, would prevent at least +two-thirds of the almost ten thousand deaths from whooping-cough that +yearly disgrace the United States. + +To sum up in fine: intelligent, effective isolation of all cases, the +mild no less than the severe, would stamp out these Herods of the +twentieth century within ten years. In the meantime, six weeks' +sick-leave, with all the privileges and care appertaining thereto, will +rob them of two-thirds of their terrors. + + + + +CHAPTER XII + +APPENDICITIS, OR NATURE'S REMNANT SALE + + +We were not made all at once, nor do we go to pieces all at once, like +the "one-hoss shay." This is largely because we are not all of the same +age, clear through. Some parts of us are older than other parts. We have +always felt a difficulty, not to say a delicacy, in determining the age +of a given member of the human species--especially of the gentler sex. +Now we know the reason of it. From the biologic point of view, we are +not an individual, but a colony; not a monarchy, but a confederacy of +organ-states, each with its millions of cell-citizens. It is not merely +editors and crowned heads who have a biologic right to say "We." +Therefore, obviously, any statement that we make as to our age can be +only in the nature of an average struck between the ages of our heart, +lungs, liver, stomach; and as these vary in ancientness by thousands of +years, the average must be both vague and misleading. The only reason +why there is a mystery about a woman's age is that she is so intensely +human and natural. The only statement as to our age that the facts would +strictly justify us in making must partake of the vagueness of Mr. A. +Ward's famous confession that he was "between twenty-three summers." + +As we individually climb our own family-tree, from the first, one-celled +droplet of animal jelly up, none of our organs is older than we are, +but a number of them are younger. The appendix is one of these. Now, by +some curious coincidence, explain it as we may, some of our oldest +organs are youngest, in the sense of most vigorous, elastic, and +resisting, while some of our youngest are oldest, in the sense of +decrepit, feeble, and unstable. It is perhaps only natural that an organ +like the stomach, for instance, which has a record of honorable service +and active duty millions of years long, should be better poised, more +reliable, and more resourceful than one which, like the lung or the +appendix, has, as it were, a "character" of only about one-tenth of that +length. However this may be, the curious fact confronts us that +scattered about through the body are structures and fragments, the +remains of organs which at one time in our ancestral career were, under +the then existing circumstances, of utility and value, but have now +become mere survivals, remnants,--in the language of the day, "back +numbers." Some of these have still a certain degree of utility, though +diminished and still diminishing in size and functional importance, like +our third molars or "wisdom" teeth, our fifth or "little" toes, our +gall-bladder, our coccyx or tail-bone, the hair-glands scattered all +over the now practically hairless surface of our bodies, and our once +movable ears, which can no longer be "pricked," or laid back. These, +though of far less utility and importance than they obviously were at +one time, still earn their salt, and, though all capable of causing us +considerable annoyance on slight provocation, seldom give rise to +serious trouble or inconvenience. There are, however, a few of these +"oversights" which are of little or no known utility, and yet which, +either by their structure or situation, may become the starting-point of +serious trouble. + +The best known members of this small group are the openings through the +abdominal wall, which, originally placed at the strongest and safest +position in the quadrupedal attitude, are now, in the erect attitude, at +the weakest and most dangerous, and furnish opportunity for those +serious and sometimes fatal escapes of portions of the intestines which +we call hernia; the tonsils; and our friend the _appendix vermiformis_. + +For once its name expresses it exactly. It _is_ an "appendix," an +afterthought; and it is "_vermiformis_," a worm-like creature,--and, +like the worm, will sometimes turn when trodden on. Its worm-likeness is +significant in another sense also, in that it is this very +diminutiveness in size--the coils into which it is thrown, the spongy +thickness of its walls, and the readiness with which its calibre or its +circulation is blocked--that is the fundamental cause of its tendency to +disease. + +The cause of appendicitis is the appendix. + +"Despise not the day of small things" is good pathology as well as +Scripture. Here we have a little, worm-shaped tag, or side branch, of +the food-tube, barely three or four inches long, of about the diameter +of a small quill and of a calibre that will barely admit an ordinary +knitting needle. And yet we speak of it with bated breath. When we +remember that this little, twisted, blind tube opens directly out of one +of the largest pouches of the intestines (the _caecum_), and that it is +easy for anything that may be present in the large pouch--food, +irritating fragments of waste matter, or bacteria--to find its way into +this fatal little trap, but very difficult to find the way out again, we +can form some idea of what a literal death-trap it may become. + +How did such a useless and dangerous structure ever come to develop in a +body in which for the most part there is mutual helpfulness, utility, +and perfect smoothness of working through all the great machine? To +attempt to answer this would carry us very far back into ancient +history. But to make such backward search is absolutely the only means +of reaching an answer. + +"But," some one will object, "how perfectly irrational, not to say +absurd, to propose to go back hundreds of thousands of years into +ancient history, to account for a disease which has been +discovered--according to some, invented--within the past twenty-five +years!" + +Appendicitis is a mark, not a result, of a high grade of civilization. +To have had an operation for it is one of the insignia of modern rank +and culture. Our new biologic aristocracy, the "Appendix-Free," look +down with gentle disdain upon their appendiciferous fellows who still +bear in their bodies this troublesome mark of their lowly origin. In +short, the general impression prevails that appendicitis is a new +disease, a disease which has become common, or perhaps occurred at all, +only within the last quarter of a century, and which therefore--with the +usual flying leap of popular logic--is a serious menace to our future, +if it keeps on increasing in frequency and ferocity at anything like +the same rate which it has apparently shown for the past fifteen years. + +As this feeling of apprehension is in many minds quite genuine, it may +be well to say briefly, before proceeding further, first, that, if there +be any disease which absolutely and almost exclusively depends upon +definite peculiarities of structure, it is appendicitis, and that these +structural peculiarities of this tiny, cramped tag of the food-canal +have existed from the earliest infancy of the race. So it is almost +unthinkable that man should not have been subject to fatal disturbances +of this organ from the very earliest times. On the post-mortem table, +the appendix of the lowest savage is the same useless, shriveled, and +inflammable worm as that of the most highly civilized Aryan, though +perhaps an inch or so longer. Secondly, there is absolutely no adequate +proof that appendicitis is increasing in frequency among civilized +races. It is only about twenty-five years ago that it was first +definitely described, and barely fifteen that the profession began at +all generally to recognize it. + +But all of us whose memory extends backward a quarter of a century can +clearly recall that, while we did not see any cases of "appendicitis," +we saw dozens of cases of "acute enteritis," "idiopathic (self-caused) +peritonitis," "acute inflammation of the bowels," "acute obstruction of +the bowels," of which patients died both painfully and promptly, and +which we now know were really appendicitis. + +In short, from a careful study of all the data, including the claims so +frequently made of freedom from appendicitis on the part of Oriental +races, colored races, less civilized tribes, vegetarians, and others, we +are tending toward the conclusion that the percentage of appendicitis in +a given community is simply the percentage of its recognition,--in other +words, of the intelligence and alertness, first of its physicians, and +then of its laity. As an illustration, my friend Dr. Bloodgood kindly +had the statistics of the surgical patients treated in the great Johns +Hopkins Hospital at Baltimore investigated for me, and found almost +precisely the same percentage of cases of appendicitis among colored +patients as among white patients. + +The earlier impression, first among physicians and now in the laity, +that appendicitis is an almost invariably fatal disease, is not well +founded, and we now know that a large percentage of cases recover, at +least from the first attack; so that it is quite possible for from half +to two-thirds of the cases of appendicitis actually occurring in a given +community to escape recognition, unless promptly reported, carefully +examined, and accurately diagnosed. Thirdly, in spite of the remarkable +notoriety which the disease has attained, the general dread of its +occurrence,--which has been recently well expressed in a statement that +everybody either has had it, or expects to have it, or knows somebody +who has had it,--the actual percentage of occurrence of grave +appendicitis is small. In the United States census of 1900, which was +the first census in which it was recognized as a separate cause of +death, it was responsible for only 5000 deaths in the entire United +States for the ten years preceding, or about one death in two hundred. +This rate is corroborated by the data, now reaching into thousands, from +the post-mortem rooms of our great hospitals, which report an average of +between a half and one per cent. A disease which, in spite of the +widespread terror of it, kills only one in two hundred of those who +actually die--or about one in every ten thousand of our population--is +certainly nothing to become seriously excited over from a racial point +of view. + +While appendicitis is one of the "realest" and most substantial of +diseases, and, in its serious form, highly dangerous to life, there can +be little doubt that there has come, first of all, a state of mind +almost approaching panic in regard to it; and, second, a preference for +it as a diagnosis, as so much more _distingue_ than such plebeian names +as "colic," "indigestion," "enteritis," or the plain old Saxon +"belly-ache," which has reached almost the proportions of a fad. It is +certain that nowadays physicians have almost as frequently to refuse to +operate on those who are clamoring for the distinction, as to urge a +needed operation upon those unwilling to submit to it. + +The satirical proposal that a "closed season" should be established by +law for appendicitis as for game birds, during which none might be +taken, would apply almost as often to the laity as to the profession, +even the surgical half. + +Since the chief cause of appendicitis is the appendix, the first +question for disposal is, How did the appendix become an appendix? To +this biology can render a fairly satisfactory answer. It is the remains +of one of Mother Nature's experiments with her 'prentice hand upon the +mammalian food-tube. As is now generally known, the food-canal in +animals was originally a comparatively straight tube, running the length +of the body from mouth to anus. It early distends into a moderate pouch, +about a third of the way down from the mouth, forming a _stomach_, or +storage and churning-place for the food. Below this, it lengthens into +coils (the so-called _small intestine_), which, as the body becomes more +complex, increase in number and length until they reach four to ten +times the length of the body. Later, the lower third of the tube +distends and sacculates out into a so-called _large intestine_, in which +the last remnants of nutritive material and of moisture are extracted +from the food-residues before they are discharged from the body. Just at +the junction of this large intestine with the small intestine, nature +took it into her head to develop a second pouch, a sort of copy of the +stomach. This pouch, from the fact that it ends in a blind sac, is known +as the _caecum_ (or "blind" pouch), and is apparently simply a means of +delaying the passage of the foodstuffs until all the nutriment and +moisture have been absorbed out of them for the service of the body. +Naturally, it has developed to the largest degree and size in those +animals which have lived upon the bulkiest and grassiest of foods, the +so-called _Herbivora_, or grass-eaters. In the _Carnivora_, or +flesh-eaters, it is usually small, and in one family, the bears, +entirely absent. This pouch is no mere figure of speech, as may be +gathered from the fact that in certain of the rodent _Herbivora_, like +the common guinea-pig, it may have a capacity equal to all of the rest +of the alimentary canal, and in the horse it will hold something like +four times as much as the stomach. Oddly enough, among the grass-eaters, +for some reason which we do not understand, it appears to occur in a +sort of inverse proportion to the stomach; those which have large, +sacculate, pouched stomachs, like the cow, sheep, and the ruminants +generally, having smaller _caeca_. In other _Herbivora_ with small +stomachs, like the rabbit and the horse, it develops greater size. + +Our primitive ancestors were mixed feeders, and, though probably more +largely herbivorous than we are to-day, had a medium-sized _caecum_, and +maintained it up to the point at which the anthropoid apes began to +branch off from our family-tree. But at about this point, for some +reason, possibly connected with the increasing variety and improved +quality and concentration of the food, due to greater intelligence and +ability to obtain it, this large _caecum_ became unnecessary, and began +to shrivel. + +Here, however, is where nature makes her first afterthought mistake. +Instead of allowing this pouch to contract and shrivel uniformly +throughout its entire length, she allowed the farther (or _distal_) +two-thirds of it to shrivel down at a much faster rate than the central +(or _proximal_) third; so that the once evenly distended sausage-shaped +pouch, about six to eight inches long and two inches in diameter, has +become distorted down into a narrow, contracted end portion, about a +quarter of an inch in diameter, and a distended first portion, for all +the world like a corncob pipe with a crooked stem and an unusually large +bowl. And behold--the modern _appendix vermiformis_, with all its fatal +possibilities! + +If we want something distinctly human to be proud of, we may take the +appendix, for man is the only animal that has this in its perfection. A +somewhat similarly shriveled last four inches of the _caecum_ is found in +the anthropoid apes and in the wombat, a burrowing marsupial of +Australia. In some of the monkeys, and in certain rodents like the +guinea-pig, a curious imitation appendix is found, which consists simply +of a contracted last four or five inches of the _caecum_, which, however, +on distention with air, is found to relax and expand until of the same +size as the rest of the gut. + +The most strikingly and distinctly human thing about us is not our +brain, but our appendix. And, while recognizing its power for mischief, +it is only fair to remember that it is an incident and a mark of +progress, of difficulties overcome, of dangers survived. In all +probability, it was our change to a more carnivorous diet, and +consequently predatory habits, which enabled our ancestors to step out +from the ruck of the "_Bandar-Log_," the Monkey Peoples. An increase in +carnivorousness must have been a powerful help to our survival, both by +widening our range of diet, so that we could live and thrive on anything +and everything we could get our hands on, and by inspiring greater +respect in the bosoms of our enemies. Let us therefore respect the +appendix as a mark and sign of historic progress and triumph, even +while recognizing to the full its unfortunate capabilities for mischief. + +But what has this ancient history to do with us in the twentieth +century? Much in every way. First, because it furnishes the physical +basis of our troubles; and second, and most important, because, like +other history, it is not merely repeating itself, but continuing. This +process of shriveling on the part of the appendix is not ancient history +at all, but exceedingly modern; indeed, it is still going on in our +bodies, unless we are over sixty-five years of age. + +In the first place, we have actually passed through two-thirds of this +process in our own individual experience. + +At the first appearance of the _caecum_, or blind pouch, in our prenatal +life, it is of the same calibre as the rest of the intestine, and of +uniform size from base to tip. About three weeks later the tip begins to +shrivel, and from this on the process steadily continues, until at birth +it has contracted to about one-fifteenth of the bulk of the _caecum_. But +the process doesn't stop here, though its progress is slower. By about +the fifth year of life the stem of the caeco-appendix pipe has diminished +to about one-thirtieth of the size of the bowl, which is the proportion +that it maintains practically throughout the rest of adult life. For a +long time we concluded that the process was here finished, and that the +appendix underwent no further spontaneous changes during life; but, +after appendicitis became clearly recognized, a more careful study was +made of the condition of the appendix in bodies coming to the +post-mortem table, dead of other diseases, at all ages of life. This +quickly revealed an extraordinary and most significant fact, that, while +the appendix was no longer decreasing in apparent size, its internal +capacity or calibre was still diminishing, and at such a rate that by +the thirty-fifth year it had contracted down so as to become cut off +from the cavity of the _caecum_ in about twenty-five to thirty per cent +of all individuals. By the forty-fifth year, according to the anatomist +Ribbert (who has made the most extensive study of the subject), nearly +fifty per cent of all appendices are found to be cut off, and by the +sixty-fifth year nearly seventy per cent. + +This explains at once why appendicitis is so emphatically a disease of +young life, the largest number of cases occurring before the +twenty-fifth year (fifty per cent of all cases occur between ten and +thirty years of age), and becoming distinctly rarer after the +thirty-fifth, only about twenty per cent occurring after this age. As +soon as the cavity of the appendix is cut off from that of the +intestine, it is of course obvious that infectious or other irritating +materials can no longer enter its cavity to cause trouble, although, of +course, it is still subject to accidents due to kinks, or twists, or +interference with its blood-supply; but these are not so dangerous, +providing there be no infectious germs present. + +Here, then, we have a clear and adequate physical basis for +appendicitis. A small, twisted, shriveling spur or side twig of the +intestine, opening from a point which has become a kind of settling +basin in the food-tube, its mouth gaping, as it were, to admit any +poisonous or irritating food, infectious materials, disease-germs, the +ordinary bacteria which swarm in the alimentary canal, or irritating +foreign bodies, like particles of dirt, sand, hairs, fragments of bone, +pins, etc., which may have been accidentally swallowed. Once these +irritating and infectious materials have entered it, spasm of its +muscular coat is promptly set up, their escape is blocked, and a violent +inflammation easily follows, which may end in rupture, perforation, or +gangrene. + +Not only may any infection which is sweeping along the alimentary canal, +thrown off and resisted by the vigorous, full-sized, well-fed intestine, +find a point of lowered resistance and an easy victim for its attack in +the appendix, but there is now much evidence to indicate that the +ordinary bacteria which inhabit the alimentary canal, particularly that +first cousin of the typhoid bacillus, the colon bacillus, when once +trapped in this _cul-de-sac_, may quickly acquire dangerous powers and +set up an acute inflammation. It is not necessary to suppose that any +particular germ or infection causes appendicitis. Any one which passes +through, or attacks, the alimentary canal is quite capable of it, and +probably does cause its share of the attacks. + +Numerous attempts have been made to show that appendicitis is +particularly likely to follow typhoid fever, rheumatism, influenza, +tonsilitis, and half a dozen other infectious or inflammatory processes. +But about all that has been demonstrated is that it may follow any of +them, though in none with sufficient frequency or constancy to enable it +to be regarded as one of the chief or even one of the important causes +of the disease. + +One dread, however, we may relieve our anxious souls of, and that is the +famous grape-seed or cherry-stone terror. To use a Hibernianism, one of +our most positive conclusions in regard to the cause of appendicitis is +a negative one: that it is not chiefly, or indeed frequently, due to the +presence of foreign bodies. This was a most natural conclusion in the +early days of the disease, since, given a tiny blind pouch with a +constricted opening gaping upon the cavity of the food-canal, nothing +could be more natural than to suppose that small irritating food +remnants or foreign bodies, slipping into it and becoming lodged, would +block it and give rise to serious inflammation. And, moreover, this _a +priori_ expectation was apparently confirmed by the discovery, in many +appendices removed by operation, of small oval or rounded masses, +closely resembling the seed of some vegetable or fruit. Whereupon +anxious mothers promptly proceeded to order their children to "spit +out," with even more religious care than formerly, every grape-seed and +cherry-stone. The increased use of fresh and preserved fruits was +actually gravely cited, particularly by our Continental brethren, as one +of the causes of this new American disease. Barely ten years ago I was +spending the summer in the Adirondacks, and was bitterly reproached by +the host of one of the Lake hotels, because the profession had so +terrified the public about the dangers of appendicitis from fruit-seeds +that he was utterly unable to serve upon his tables a large stock of +delicious preserved and canned raspberries, blackberries, and grapes +which he had put up the previous years. "Why," he said, "more than half +the people that come up here will no more eat them than they would +poison, for fear that some of the seeds will give 'em appendicitis." +This dread, however, has been deprived of all rational basis, first, by +finding that many inflamed appendices removed, after the operation +became more common, contained no foreign body whatever; secondly, that +many perfectly healthy appendices examined on the post-mortem table, +death being due to other diseases, contain these apparently foreign +bodies; and thirdly, that when these "foreign bodies" were cut into, +they were found to be not seeds or pits of any description, but hardened +and, in some cases, partially calcareous masses of the faeces. + +We are in a nearly similar position in regard to the third alleged cause +of appendicitis, and that is food. Many are the accusations which have +been made in this field. On the one hand, meat and animal foods +generally have been denounced, on account of their supposed "heating" or +"uric-acid-forming" properties; while on the other, vegetables and +fruits have been equally hotly incriminated, on account of their seeds, +fibres, husks, and irritating substances, and the danger of their being +contaminated by bacteria and other parasites from the soil. These +charges appear to have little adequate foundation, and, so far as we are +in a position now to judge, the only way a food can give, or be +accessory to, appendicitis is by its being taken in such excessive +amounts as to set up fermentive or putrefactive changes in the +alimentary canal, or by its being in an unsound, decaying, or actually +diseased condition. Any amounts or quality of food which are capable of +giving rise to an attack of acute indigestion may secondarily lead to an +attack of appendicitis. The only single article of diet whose ingestion +is declared by Osler to be rather frequently followed by an attack of +appendicitis is the peanut. + +Therefore, the best thing to do in the way of taking precautions against +the occurrence of appendicitis is, in the language of the day, to +"forget it" as completely as possible, reassuring ourselves that, in +spite of its extraordinary notoriety and popularity, it is a +comparatively rare disease in its fatal form, responsible for not more +than one-half of one per cent of the deaths, and that the older we grow, +the better become our chances of escaping it. + +Whatever we may have decided in regard to our brains, by the time we +reach fifty, we may feel reasonably sure we've no appendix. + +But the question will at once arise, if the appendix be so tiny in size, +so insignificant in capacity, and so devoid of useful function, what is +the use of disturbing ourselves over the question of what may become of +it? If it is going to decay and drop off, why not permit it to do so, +with the philosophic indifference with which we would sacrifice the tip +of our little fingers in a planing-mill? Here, however, is just the rub, +and the fact that gives to appendicitis all its terrors, and to the +question of what to do in each particular case its difficulties and +perplexities. + +The appendix does not, unfortunately, hang out from the surface of the +body, where it could peacefully decay and drop off without prejudice to +the rest of the body, or be quickly lopped off in the event of its +giving trouble. On the contrary, it projects its stubby and +insignificant length right into the midst of the most delicate and +susceptible cavity of the body, the general cavity of the abdomen, or +peritoneum. The thin, sensitive sheet of peritoneum which lines this +cavity covers every fold and part of the food-tube, from the stomach +down to the rectum. And when once infection or inflammation has occurred +at any point in it, there is nothing to prevent its spreading like a +prairie fire, all over the entire abdominal cavity from diaphragm to +pelvis. If this wretched little remnant were a coil of explosive fuse +within the brain-cavity itself, which any jar might set off, it could +hardly be richer in possibilities of danger. + +A redeeming feature of appendicitis is that the appendix lies--so to +speak--in a corner, or wide-mouthed pouch, of the great peritoneal +cavity; and if the inflammation set up in it can be "walled off" from +the rest of the peritoneal cavity, and limited strictly to this little +corner or pouch, all will be well. This is what occurs in those cases of +severe appendicitis which spontaneously recover. If, however, this +disturbance bursts its barriers, and lights up an inflammation of the +entire peritoneal cavity, then the result is likely to be a fatal one. +Just how far nature can be trusted in each particular case to limit and +stamp out the process in this manner is the core of the problem that +confronts us, as attending physicians. + +In the majority of cases, fortunately, the peritoneal fire brigade acts +promptly, pours out a wall of exudate, and locks up the appendix in a +living prison, to fight out its own battles and sink or swim by itself. +But unfortunately, in a minority of cases, by a wretched sort of +"senatorial courtesy" which exists in the body, the appendix is given +its ancestral or traditional rights and allowed to inflict its petty +troubles upon the entire abdominal cavity, and include the body in its +downfall. + +Lastly come the two most pertinent and appealing questions:-- + +What is the outlook for me if I should develop appendicitis? And what is +to be done? + +In regard to the first of these, it is safe to say that our answer is +much less alarming than it was in the earlier stage of our knowledge. +Naturally enough, in the beginning, only the severest and most +unmistakable forms of the disease and those which showed no tendency to +localization, were recognized, or at least came under the eye of the +surgeon; and as a large percentage of these resulted fatally, the +conclusion was reached, both in the medical profession and by the laity, +that appendicitis was an exceedingly dangerous disease, with a high +fatality in all cases. As, however, physicians became more expert in the +recognition of the disease, it was discovered to be vastly more common, +while side by side came the consoling knowledge that a considerable +percentage of cases got well of themselves, in the sense of the +inflammation being limited to the lower right-hand corner of the +abdominal cavity, though, of course, with the possibility of leaving a +smouldering fuse which might light up another explosion under any stress +in future. + +Further, as the attention of the post-mortem investigators at our large +hospitals was directed to the subject, it was found that a very +considerable percentage of all bodies, ranging from twenty to--according +to some estimates--as high as sixty per cent, showed changes in the +appendix and its neighborhood which were believed to be due to old +inflammations; so that, while it is possible to speak only with great +caution and reserve, the balance of opinion among clinicians and +pathologists of wide experience and the more conservative surgeons +appears to be that from one-half to two-thirds of all cases of +appendicitis will recover of themselves, in the sense of subsiding more +or less permanently, without causing death. + +On the other hand, it must be remembered that the appendix is an organ +which, so far as any evidence has been adduced, is entirely without +useful function; that it is in process of shriveling and disappearance, +if left entirely alone, and that the best result which can be expected +from a self-cured attack of appendicitis is the destruction of the +appendix and its elimination as a further possible cause of mischief. By +avoiding an operation in appendicitis, we may be practically certain +that we save nothing that is worth saving--except the fee. Moreover, +even though only from one-fourth to one-third of all cases develop +serious complications, you never can be quite sure in which division +your particular case will fall. + +The situation is in fact a little bit like one related in the +experience of Edison, the inventor. The trustees of a church in a +neighboring town had just completed a beautiful new church building with +a high spire, projecting far above any other building in the town. When +it was nearing completion, the question arose, should they put on a +lightning-rod. The great church itself had strained their financial +resources, and one party in the board were of the opinion that they +should avoid this unnecessary expense, supporting their economic +attitude by the argument that, to put on a lightning-rod, would argue a +lack of trust in Providence. Finally, after much debate, it was decided, +as the great electrician was readily accessible, to submit the question +to him. Mr. Edison listened gravely to the arguments presented, pro and +con. + +"What is the height of the building, gentlemen?" + +The number of feet was given. + +"How much is that above that of any surrounding structures?" + +The data were supplied. + +"It is a church, you say?" + +"Yes." + +"Well," said the great man, "on the whole, I should advise you to put on +a lightning-rod. Providence is apt to be, at times, a trifle +absent-minded." + +The chances are in favor of your recovery, but--put on a lightning-rod, +in the shape of the best and most competent doctor you know, and be +guided entirely by his opinion. An attack of appendicitis is like +shooting the Grand Lachine Rapids. Probably you will come through all +right; but there is always the possibility of landing at a moment's +notice on the rocks or in the whirlpools. With a good pilot your risk +doesn't exceed a fraction of one per cent. And fortunately this +condition has been not merely theoretically but practically reached +already; for the later series of case-groups of appendicitis treated in +this intelligent way by cooeperation between the physician and surgeon +from the start, with prompt interference in those cases which to the +practiced eye show signs of making trouble, has reduced the actual +recorded mortality of the disease to between two and five per cent. Even +of those cases which come to operation now, the death-rate has been +reduced as low as five per cent, in series of from 400 to 600 successive +operations. When we contrast this with the first results of operation, +when the cases as a rule were seen too late for the best time of +interference, and from twenty per cent to thirty per cent died; and with +the intermediate stage, when surgeons as a rule were inclined to advise +operation at the earliest possible moment that the disease could be +recognized, and from ten per cent to fifteen per cent died, we can see +how steady the improvement has been, and how encouraging the outlook is +for the future. + +Cases which have weathered one attack of appendicitis are of course by +no means free from the risk of another. Indeed, at one time it was +believed that a recurrence was almost certain to occur. Later +investigations, based upon larger numbers of cases, now running up into +the thousands, give the reassuring result that though this danger is a +real one, it is not so great as it was at one time supposed, as the +average number in whom a second attack occurs appears to be about +twenty per cent. This, however, is a large enough risk to be worthy of +serious consideration; and in view of the fact that the mortality of +operations done between attacks is less than one per cent, it is +generally the feeling of the profession that, where there is any +appreciable soreness, or tenderness, or liability to attacks of pain in +the right iliac region, in an individual who has had one attack of +appendicitis, the really conservative and prudent procedure is to have +the source of the trouble removed once and for all. + +The four principal symptoms of appendicitis are: pain, which is usually +felt most keenly somewhere between the umbilicus and the right groin, +though this is by no means invariable; tenderness in that same region +upon pressure; rigidity of the muscles of the abdominal wall on the +right side; and temperature, or fever. + +No matter how much and how variegated pain you may have in the abdomen, +or how high your temperature may run, if you are not distinctly sore on +firm pressure down in this right lower or southwest quadrant of the +abdomen,--but be careful not to press too hard, it isn't safe,--you may +feel fairly sure that you haven't got appendicitis. If you are, you may +still not have it, but you'd better send for the doctor, to be sure. + + + + +CHAPTER XIII + +MALARIA: THE PESTILENCE THAT WALKETH IN DARKNESS; THE GREATEST FOE OF +THE PIONEER + + +Malaria has probably killed more human beings than all the wars that +have ever devastated the globe. Some day the epic of medicine will be +written, and will show what a large and unexpected part it has played in +the progress of civilization. Valuable and essential to that progress as +were the classic great discoveries of fire, ships, wheeled carriages, +steam, gunpowder, and electricity, they are almost paralleled by the +victories of sanitary science and medicine in the cure and prevention of +that greatest disrupter of the social organism--disease. No sooner does +the primitive human hive reach that degree of density which is the one +indispensable condition of civilization, than it is apt to breed a +pestilence which will decimate and even scatter it. Smallpox, cholera, +and bubonic plague have blazed up at intervals in the centres of +greatest congestion, to scourge and shatter the civilization that has +bred them. No civilization could long make headway while it incurred the +dangers from its own dirtiness; and to-day the most massive and imposing +remains of past and gone empires are their aqueducts, their sewers, and +their public baths. What chance has a community of building up a steady +and efficient working force, or even an army large enough for adequate +defense, when it has a constant death-rate of ten per cent per annum, +and an ever recurrent one of twenty to thirty per cent, by the sweep of +some pestilence? The bubonic plague alone is estimated to have slain +thirty millions of people within two centuries in Mediaeval Europe, and +to have turned whole provinces into little better than deserts. + +In malaria, however, we have a disease enemy of somewhat different class +and habits. While other great infections attack man usually where he is +strongest and most numerous, malaria, on the contrary, lies in wait for +him where he is weakest and most scattered, upon the frontiers of +civilization and the borders of the wilderness. It is only of late years +that we have begun to realize what a deadly and persistent enemy of the +frontiersman and pioneer it is. We used to hear much of climate as an +obstacle to civilization and barrier to settlement. Now, for climate we +read "malaria." Whether on the prairies or even the tundras of the +North, or by the jungles and swamps of the Equator, the _thing that +killed_ was eight times out of ten the winged messenger of death with +his burden of malaria-infection. The "chills and fever," "fevernager," +"mylary," that chattered the teeth and racked the joints of the pioneer, +from Michigan to Mississippi, was one and the same plague with the +deadly "jungle fever," "African fever," "black fever" of the tropics, +from Panama to Singapore. Hardly a generation ago, along the advancing +front of civilization in the Middle West, the whole life of the +community was colored with a malarial tinge and the taste of quinine +was as familiar as that of sugar. To this day, over something like +three-quarters of the area of these United States, the South, Middle +West, and Far West, if you feel headachy and bilious and "run down," you +sum it all up by saying that you are feeling "malarious." Dwellers upon +the rich bottom-lands expected to shake every spring and fall with +almost the same regularity as they put on and shed their winter +clothing. Readers of Frank Stockton will remember the gales of merriment +excited by his quaint touch of the incongruous in making the prospective +bridegroom of the immortal Pomona change the date of their wedding day +from Tuesday to Monday, because, on figuring the matter out, he had +discovered that Tuesday was his "chill-day." + +Though the sufferer from ague seldom received very much sympathy at the +time, but was considered a fair butt for genial ridicule and chaff, yet +even there the trouble had its serious side. Through all those +communities there stalked a well-known and dreaded spectre, the +so-called "congestive chill," what is now known in technical language as +the pernicious malarial paroxysm. These were like the three warnings of +death in the old parable. You would probably survive the first and might +never have another; but if you had your second, it was considered +equivalent to a notice to quit the country promptly and without counting +the cost. In my boyhood days in the Middle West, I can recall hearing +old pioneers tell of little groups of one or more families moving out on +to some particularly rich and virgin bottom-land and losing two or +three or more members out of each family by congestive chills within +the first year, and in some cases being driven in from the outpost and +back to civilization by the fearful death-loss. + +A pall of dread hangs over the whole west coast of Africa. The factories +and trading-posts are haunted by the ghosts of former agents and +explorers who have died there. Some years ago one German company had the +sinister record that of its hundreds of agents sent out to the Gold +Coast under a three years' contract, not one had fulfilled the term! All +had either died, or been invalided and returned home. It was malaria +more than any other five influences combined that thwarted the French in +their attempt to dig the Panama Canal and that made the Panama Railroad +bear the ghastly stigma of having built its forty miles of track with a +human body for every tie. + +Malaria ever has been, and is yet, the great barrier against the +invasion of the tropics by the white races; nor has its injurious +influence been confined to the deaths that it causes, for these gaps in +the fighting line might be filled by fresh levies drawn from the +wholesome North. Its fearfully depressing and degenerating effects upon +even those who recover from its attacks have been still more injurious. +It has been held by careful students of tropical disease and conditions +that no small part of that singular apathy and indifference which steal +over the mind and body of the white colonist in the tropics, numbing +even his moral sense, and alternating with furious outbursts of what the +French have termed "tropical wrath," characterized by unnatural cruelty +and abnormal disregard for the rights of others, is the deadly work +of malaria. It is the most powerful cause, not merely of the +extinction of the white colonist in the tropics, but of the peculiar +degeneracy--physical, mental, and moral--which is apt to steal over even +the survivors who succeed in retaining a foothold. Two particularly +ingenious investigators have even advanced the theory that the +importation of malaria into the islands of Greece and the Italian +peninsula by soldiers returning from African and Southern Asiatic +conquests had much to do with accelerating, if not actually promoting, +the classic decay of both of these superb civilizations. + +To come nearer home, there can be little question that the baneful, +persistent influence of malaria, together with the hookworm disease, has +had much to do both with the degeneracy of the Southern "cracker," or +"mean white," and with those wild outbursts of primitive ferocity in all +classes which take the form of White Cap raids and lynching mobs. + +However this may be, the disease and the colonization habit brought in a +crude way their own remedy. The Spanish conquerors of Peru were told by +the natives that a certain bark which grew upon the slopes of the Andes +was a sovereign remedy for those terrible ague seizures. Indian remedies +did not stand as high in popular esteem as they do now; but they were in +desperate straits and jumped at the chance. To their delight, it proved +a positive specific, and a Spanish lady of rank, the Countess Chincona, +was so delighted with her own recovery that she carried back a package +of the precious Peruvian bark on her return to Europe, and endeavored to +introduce it. So furious was the opposition of the Church, however, to +this "pagan" remedy that she was completely defeated in her praiseworthy +attempt and was obliged to confine her ministrations to those who +belonged to her, the peasantry on her own estate. About half a century +later, the new remedy excited so much discussion by the numerous cures +that it effected, that it was considered worthy of a special council of +the Jesuits, who formally pronounced it suitable for the use of the +faithful, thereby attaching to it for many years the name of "Jesuit's +bark." Virtue, however, is sometimes rewarded in this world, and the +devoted and enlightened countess has, all unknown to herself, attained +immortality by attaching her name, Chincona, softened into _cinchona_, +and hardened into _quinine_, to the greatest therapeutic gift of the +gods to mankind. It is not too much to say that the modern colonization +of the tropics and subtropics by Northern races, which is one of the +greatest and most significant triumphs of our civilization, would have +been almost impossible without it. Its advance depended upon two +powders, one white and the other black,--quinine and gunpowder. + +For nearly three centuries we rested content with the knowledge that in +quinine we had a remedy for malaria, which, if administered at the +proper time and in adequate doses, would break up and cure ninety per +cent of all cases. Just how it did it we were utterly in the dark, and +many were the speculations that were indulged in. It was not until +1880, that Laveran, a French army surgeon stationed in Algeria, +announced the discovery in the blood of malarial patients of an organism +which at first bore his name, the _Hematozoon-Laveran_, now known as the +_Plasmodium malariae_. This organism, of all curious places, burrowed +into and found a home in the little red corpuscles of the blood. At +periods of forty-eight hours it ripened a crop of spores, and would +burst out of the corpuscles, scattering throughout the blood and the +tissues of the body, and producing the famous paroxysm. This accounted +for the most curious and well-marked feature of the disease, namely, its +intermittent character, chill and fever one day, and then a day of +comparative health, followed by another chill day and so on, as long as +the infection continued. One problem, however, was left open, and that +was why certain forms of the disease had their chills every fourth day +and so were called _quartan_ ague. This was quickly solved by the +discovery of another form of the organism, which ripened its spores in +three days instead of two. So the whole curious rhythm of the disease +was established by the rate of breeding or ripening of the spores of the +organism. Later still another form was discovered, which had no such +regular period of incubation and gave rise to the so-called irregular, +or _autumnal_, malarial fevers. That form of the fever which had a +paroxysm every day, the classic _quotidian_ ague, remained a puzzle for +a little longer, but was finally discovered to be due chiefly to the +presence of two broods, or infections, of the organism, which ripened +on alternate days and hence kept the entire time of the unfortunate +patient occupied. + +The mystery of the remedial effect of quinine was also solved, as it was +found that, if administered at the time which centuries of experience +has shown us to be the most effective, between or shortly before the +paroxysms, it either prevented sporulation or killed the spores. So that +at one triumphant stroke the mystery of centuries was cleared up. + +But here will challenge some twentieth-century _Gradgrind_: "This is all +very pretty from the point of view of abstract science, but what is the +practical value of it? The discovery of the plasmodium and its +peculiarities has merely shown us the how and the why of a fact that we +had known well and utilized for centuries, namely, that quinine will +cure malaria." Just listen to what follows. The story of the plasmodium +is one of the most beautiful illustrations of the fact that there is no +such thing as useless or unpractical knowledge. The only thing that +makes any knowledge unpractical is our more or less temporary ignorance +of how to apply it. The first question which instantly raised itself +was, "How did the plasmodium get into human blood?" The very +sickle-shape of the plasmodium turned itself into an interrogation mark. +The first clew that was given was the new and interesting one that this +organism was a new departure in the germ line in that it was an animal, +instead of a plant, like all the other hitherto known bacilli, bacteria, +and other disease-germs. + +It may be remarked in passing that its discovery had another incidental +practical lesson of enormous value, and that was that it paved the way +for the identification of a whole class of animal parasites causing +infectious diseases, which already includes the organisms of Texas fever +in cattle, dourine in horses, the _tsetse_ fly disease, the dreaded +sleeping sickness, and finally such world-renowned plagues as syphilis +and perhaps smallpox. + +Being an animal, the plasmodium naturally would not grow upon +culture-media like the vegetable bacilli and bacteria, and this very +fact had delayed its recognition, but raised at once the probability +that it must be conveyed into the human body by some other animal. +Obviously, the only animals that bite our human species with sufficient +frequency and regularity to act as transmitters of such a common disease +are those Ishmaelites of the animal world, the insects. As all the +evidence pointed toward malaria being contracted in the open air, +attested by its popular though unscientific name _mal-aria_, "bad air," +and as of all forms of "bad air" the night air was incomparably the +worst, it must be some insect which flew and bit by night; which by +Sherlock Holmes's process promptly led the mosquito into the dock as the +suspected criminal. It wasn't long before he was, in the immortal +language of Mr. Devery, "caught with the goods on"; and in 1895 Dr. +Ronald Ross, of the Indian Medical Service, discovered and positively +identified the plasmodium undergoing a cycle of its development in the +body of the mosquito. He attempted to communicate the disease to birds +and animals by allowing infected mosquitoes to bite them, but was +unsuccessful. Two Italian investigators, Bignami and Grassi, saw that +the problem was one for human experiment and that nothing less would +solve it. Volunteers were called for and promptly offered themselves. +Their blood was carefully examined to make sure that they were not +suffering from any latent form of malaria. They then allowed themselves +to be bitten by infected mosquitoes, and within periods varying from six +to ten days, eight-tenths of them developed the disease. It may be some +consolation to our national pride to know that although the organism was +first identified in the mosquito by an Englishman and its transmission +to human beings in its bite by Italians, the first definite and +carefully worked-out statement of the relation of the mosquito to +malaria was made by an American, King of Washington, in 1882; though it +is only fair to say that suggestions of the possible connection between +mosquitoes and malaria had, so to speak, been in the air and been made +from scores of different sources, from the age of Augustus onward. + +Another mystery was solved--and what a flood of light it did pour upon +our speculations as to the how and wherefore of the catching of malaria! +In some respects it curiously corroborated and increased our respect for +popular beliefs and impressions. While "bad air" had nothing to do with +causing the disease, except in so far as it was inhabited by songsters +of the _Anopheles_ genus, yet it was precisely the air of marshy places +which was most likely to be "bad" in this sense. So that, while in one +sense those local wiseacres, who would point out to you the pearly mists +of evening as they rose over low-lying meadows and bottom-lands, and +inform you that there before your very eyes was the "mylary just +a-risin' out of the ground," were ludicrously mistaken, in another their +practical conclusion was absolutely sound; for it is in just such air, +at such levels above the surface of the water, that the _Anopheles_ most +delights to disport himself. Furthermore, while all raw or misty air is +"bad," the night air is infinitely more so than that of the day, because +this is the time at which mosquitoes are chiefly abroad. In fact, there +can be little doubt that this is part of the foundation for that rabid +and unreasonable dread of the night air which we fresh-air crusaders +find the bitterest and most tenacious foe we have to fight. We have +literally discovered the Powers of Darkness in both visible and audible +form, and they have wings and bite, just like the vampire. + +It was also a widespread belief in malarial regions that the hours when +you are most likely to "git mylary inter yer system" were those just +before and just after sundown; and now entomologists inform us that +these are precisely the hours at which the _Anopheles_ mosquito, the +only genus that carries malaria, flies abroad. + +Of course, a number of popular causes, such as bad drainage, the +drinking of water from shallow surface wells, damp subsoils under the +houses, and especially that peculiarly widespread and firmly held +article of belief that new settlements, where large areas of prairie sod +were being freshly upturned by the plough, were peculiarly liable to +the attack and spread of malaria, had to go by the board,--with this +important reservation, however, that almost every one of these alleged +causes either implied or was pretty safe to be associated with pools or +swamps of stagnant water in the neighborhood, which would furnish +breeding-spots for the mosquitoes. + +The discovery explains at once a score of hitherto puzzling facts as to +the distribution of malaria. Why, for instance, in all tropical or other +malarious countries, those who slept in second and third story bedrooms +were less likely to contract the disease, supposedly because "bad air +didn't rise to that height," is clearly seen to be due to the fact that +the mosquito seldom flies more than ten or twelve feet above the level +of the ground or marsh in which he breeds, except when swept by +prevailing winds. It also explained why in our Western and Southwestern +states the inhabitants of the houses situated on the south bank of a +river, though but a short distance back from the stream, would suffer +very slightly from malaria, while those living upon the north bank, half +a mile back, or even upon bluffs fifteen or twenty feet above the water +level, were simply plagued with it. The prevailing winds during the +summer are from the south and mosquitoes cannot fly a foot against the +wind, but will fly hundreds of yards, and even the best part of a mile, +with it. The well-known seasonal preference of the disease for warm +spring and summer months, and its prompt subsidence after a killing +frost, were seen simply to be due to the influence of the weather upon +the flight of mosquitoes. Shakespeare's favorite reference to "the sun +of March that breedeth agues" has been placed upon a solid entomological +basis by the discovery that, like his pious little brother insect, the +bee, the one converted and church-going member of a large criminal +family, the mosquito hies himself abroad on his affairs at the very +first gleam of spring sunshine, and will even reappear upon a warm, +sunny day in November or December. Perhaps even some of the popular +prejudice against "unseasonable weather" in winter may be traceable to +this fact. + +Granted that mosquitoes do cause and are the only cause of malaria, what +are you going to do about it? At first sight any campaign against +malaria which involves the extermination of the mosquito would appear +about as hopeless as Mrs. Partington's attempt to sweep back the rising +Atlantic tide with her broom. But a little further investigation showed +that it is not only within the limits of possibility, but perfectly +feasible, to exterminate malaria absolutely from the mosquito end. In +the first place, it was quickly found that by a most merciful +squeamishness on the part of the plasmodium, it could live only in the +juices of one particular genus of mosquito, the _Anopheles_; and as +nowhere, not even in the most benighted regions of Jersey, has this +genus been found to form more than about four or five per cent of the +total mosquito population, this cuts down our problem to one-twentieth +of its apparent original dimensions at once. The ordinary mosquito of +commerce (known as _Culex_) is any number of different kinds of a +nuisance, but she does not carry malaria. + +Here the trails of the extermination party fork, one of them taking the +perfectly obvious but rather troublesome direction of protecting houses +and particularly bedrooms with suitable screens and keeping the +inhabitants safely behind them from about an hour before sundown on. By +this simple method alone, parties of explorers, of campers, of +railroad-builders going through swamps, of the laborers on our Panama +Canal, have been enabled to live for weeks and months in the most +malarious regions with perfect impunity, so long as these precautions +were strictly observed. The first experiment of this sort was carried +out by Bignami upon a group of laborers in the famous, or rather +infamous, Roman Campagna, whose deadly malarial fevers have a classic +reputation, and has achieved its latest triumphs in the superb success +of Colonel Gorgas at Panama. While this procedure should never be +neglected, it is obvious that it involves a good deal of irksome +confinement and interferes with freedom of movement, and it will +probably be carried out completely only under military or official +discipline, or in tropical regions where the risks are so great that its +observance is literally a matter of life or death. + +The other division of malaria-hunters pursued the trail of the +_Anopheles_ to her lair. There they discovered facts which give us +practically the whip-hand over malarial and other tropical fevers +whenever we choose to exercise it. It had long been known that the +breeding-place of mosquitoes was in water; that their eggs when +deposited in water floated upon the surface like tiny boats, usually +glued together into a raft; that they then turned into larvae, of which +the well-known "wigglers" in the water-butt or the rain-barrel are +familiar examples; and that they finally hatched into the complete +insect and rose into the air. + +Obviously, there were two points at which the destroyers might strike, +the egg and the larvae. It was first found that, while the eggs required +no air for their development, the larvae wiggled up to the surface and +inhaled it through curious little tubes developed for this purpose, +oddly enough from their tail-ends. If some kind of film could be spread +over the surface of the water, through which the larvae could not obtain +air, they would suffocate. The well-known property of oil in "scumming +over" water was recalled, two or three stagnant pools were treated with +it, and to the delight of the experimenters, not a single larva was able +to develop under the circumstances. Here was insecticide number one. The +cheapest of oils, crude petroleum, if applied to the pool or marsh in +which mosquitoes breed, will almost completely exterminate them. Scores +of regions and areas to-day, which were once almost uninhabitable on +account of the plague of mosquitoes, are now nearly completely free from +these pests by this simple means. An ounce to each fifteen square feet +of water-surface is all that is required, though the oiling needs to be +repeated carefully several times during the season. + +But what of the eggs? They require no air, and it was found impossible +to poison them without simply saturating the water with powerful +poisons; but an unexpected ally was at our hand. It was early noted that +mosquitoes would not breed freely in open rivers or in large ponds or +lakes, but why this should be the case was a puzzle. One day an +enthusiastic mosquito-student brought home a number of eggs of different +species, which he had collected from the neighboring marshes, and put +them into his laboratory aquarium for the sake of watching them develop +and identifying their species. The next morning, when he went to look at +them, they had totally disappeared. Thinking that perhaps the laboratory +cat had taken them, and overlooking a most contented twinkle in the +corner of the eyes of the minnows that inhabited the aquarium, he went +out and collected another series. This time the minnows were ready for +him, and before his astonished eyes promptly pounced on the raft of eggs +and swallowed them whole. Here was the answer at once: mosquitoes would +not develop freely where fish had free access; and this fact is our +second most important weapon in the crusade for their extermination. If +the pond be large enough, all that is necessary is simply to stock it +with any of the local fish, minnows, killies, perch, dace, bass,--and +presto! the mosquitoes practically disappear. If it be near some larger +lake or river containing fish, then a channel connecting the two, to +allow of its stocking, is all that is required. + +On the Hackensack marshes to-day trenches are cut to let the water out +of the tidal pools; while in low-lying areas, which cannot be thus +drained, the central lowest spot is selected, a barrel is sunk at this +spot, and four or five "killie" fish are placed in it. Trenches are cut +converging into this barrel from the whole of the area to be drained, +and behold, no more mosquitoes can breed in that area, and, in the +language of the day, "get away with it." + +Finally, most consoling of all, it was discovered that, while the +ordinary _Culex_ mosquito can breed, going through all the stages from +the egg to the complete insect, in about fourteen days, so that any +puddle which will remain wet for that length of time, or even such +exceedingly temporary collections of water as the rain caught in a +tomato-can, in an old rubber boot, in broken crockery, etc., will serve +her for a breeding-place, the _Anopheles_ on the other hand takes nearly +three months for the completion of her development. So that, while a +region might be simply swarming with ordinary mosquitoes, it would +frequently be found that the only places which fulfilled all the +requirements for breeding-homes for the _Anopheles_, that is, isolation +from running water or larger streams, absence of fish, and persistence +for at least three months continuously, would not exceed five or six to +the square mile. Drain, fill up, or kerosene these puddles,--for they +are often little more than that,--and you put a stop to the malarial +infection of that particular region. Incredible as it may seem, places +in such a hotbed of fevers as the west coast of Africa, which have been +thoroughly investigated, drained, and cleaned up by mosquito-brigades, +have actually been freed from further attacks of fever by draining and +filling not to exceed twenty or thirty of these breeding-pools. + +In short, science is prepared to say to the community: "I have done my +part in the problem of malaria. It is for you to do the rest." There is +literally no neighborhood in the temperate zone, and exceedingly few in +the tropics, which cannot, by intelligent cooeperation and a moderate +expense, be absolutely rid first of malaria, and second of all +mosquito-pests. It is only a question of intelligence, cooeperation, and +money. The range of flight of the ordinary mosquito is seldom over two +or three hundred yards, save when blown by the wind, and more commonly +not more than as many feet, and thorough investigation of the ground +within the radius of a quarter of a mile of your house will practically +disclose all the danger you have to apprehend from mosquitoes. It is a +good thing to begin with your own back yard, including the water-butt, +any puddles or open cesspools or cisterns, and any ornamental water +gardens or lily-ponds. These latter should be stocked with fish or +slightly oiled occasionally. If there be any accumulations of water, +like rain-barrels or cisterns, which cannot be abolished, they should +either be kept closely covered or well screened with mosquito netting. + +It might be remarked incidentally in passing, that the only really +dangerous sex in mosquitodom, as elsewhere, is the female. The male +mosquito, if he were taxed with transmitting malaria, would have a +chance to reecho Adam's cowardly evasion in the Garden of Eden, "It was +the woman that thou gavest me." Both sexes of mosquitoes under ordinary +conditions are vegetable feeders, living upon the juices of plants. But +when the female has thrown upon her the tremendous task of ripening and +preparing her eggs for deposition, she requires a meal of blood--which +may be a comfort to our vegetarian friends, or it may not. Either she +requires a meal of blood to nerve her up to her criminal deed, or, when +she has some real work to do, she has to have some real food. + +The mosquito-brigade have still another method of checking the spread of +malaria, at first sight almost a whimsical one,--no less than screening +the patient. The mosquito, of course, criminal as she is, does not hatch +the parasites _de novo_ in her own body, but simply sucks them up in a +meal of blood from some previous victim. Hence by careful screening of +every known case of malaria, mosquitoes are prevented from becoming +infected and transmitting the disease. Instead of the screens protecting +the victims from the mosquitoes, they protect the mosquitoes against the +victim. + +This explains why hunters, trappers, and Indians may range a region for +years, without once suffering from malaria, while as soon as settlers +begin to come in in considerable numbers, it becomes highly malarious. +It had to be infected by the coming of a case of the disease. + +The notorious prevalence of malaria on the frontier is due to the +introduction of the plasmodium into a region swarming with mosquitoes, +where there are few window-screens or two-story houses. + +No known race has any real immunity against malaria. The negro and other +colored races, it is true, are far less susceptible; but this we now +know applies only to adults, as the studies of Koch in Africa showed +that a large percentage of negro children had the plasmodium in their +blood. No small percentage of them die of malaria, but those who recover +acquire a certain degree of immunity. Possibly they may be able to +acquire this immunity more easily and with less fatality than the white +race, but this is the extent of their superiority in this regard. The +negro races probably represent the survivors of primitive men, who were +too unenterprising to get away from the tropics, and have had to adjust +themselves as best they might. + +The serious injury wrought in the body by malaria is a household word, +and a matter of painfully familiar experience. Scarcely an organ in the +body escapes damage, though this may not be discovered till long after +the "fever-and-ague" has been recovered from. + +As the parasite breeds in the red cells of the blood, naturally its +first effect is to destroy huge numbers of these, producing the typical +malarial _anaemia_, or bloodlessness. Instead of 5,000,000 to the cubic +centimetre of blood the red cells may be reduced to 2,000,000 or even +1,500,000. The breaking down of these red cells throws their pigment or +coloring-matter afloat in the blood; and soaking through all the tissues +of the body, this turns a greenish-yellow and gives the well-known +sallow skin and yellowish whites of the eyes of swamp-dwellers and +"river-rats." + +The broken-down scraps of the red blood-cells, together with the toxins +of the parasite, are carried to the liver and spleen to be burned up or +purified in such quantities that both become congested and diseased, +causing the familiar "biliousness," so characteristic of malaria. + +The spleen often becomes so enormously enlarged that it can be readily +felt with the hand in the left side below the ribs, so that it is not +only relied upon as a sign of malaria in doubtful cases, but has even +received the popular name of the "ague-cake" in malarious districts. + +So full is the blood of the parasites, that they may actually choke up +the tiny blood-vessels and capillaries in various organs, so as to block +the circulation and cause serious and even fatal congestions. +Obstructions of this sort may occur in the brain, the liver, the coats +of the stomach, or intestines, and the kidneys; and they are the chief +cause of the deadly "congestive chills," or pernicious malarial +paroxysms, which we have alluded to. + +The kidneys are particularly liable to be attacked in this way; indeed, +one of their involvements is so serious and fatal in the tropics as to +have been given a separate name, "Blackwater fever," from the quantities +of broken-down blood which appear in and blacken the urine. + +The vast majority of attacks of malaria are completely recovered from, +like any other infection, but it can easily be seen what an injurious +effect upon the system may be produced by successive attacks, keeping +the entire body saturated with the poison; while there is serious risk +of the parasite sooner or later finding some weak spot in the +body,--kidney, liver, nervous system,--where its incessant battering +works permanent damage. + +How long the infection may lurk in the body is uncertain; certainly for +months, and possibly for years. Many cases are on record which had +typical chills and fever, with abundance of plasmodia in the blood, +years after leaving the tropics or other malarious districts; but there +is often the possibility of a recent re-infection. + +Altogether, malaria is a remarkably bad citizen in any community, and +its stamping-out is well worth all it costs. + + + + +CHAPTER XIV + +RHEUMATISM: WHAT IT IS, AND PARTICULARLY WHAT IT ISN'T + + +What's in a name? All the aches and pains that came out of Pandora's +box, if the name happens to be rheumatism. It is a term of wondrous +elasticity. It will cover every imaginable twinge in any and every +region of the body--and explain none of them. It is a name that means +just nothing, and yet it is in every man's vocabulary, from proudest +prince to dullest peasant. Its derivative meaning is little short of an +absurdity in its inappropriateness, from the Greek _reuma_ (a flowing), +hence, a cold or catarrh. It is still preserved for us in the familiar +"salt rheum" (eczema) and "rheum of the eyes" of our rural districts. +But this very indefiniteness, absurdity if you will, is a comfort both +to the sufferer and to the physician. Moreover, incidentally, to +paraphrase Portia's famous plea,-- + + It blesseth him that _has_ and him that _treats_; + 'T is mightier than the mightiest. + It doth _fit_ the throned monarch _closer_ than his crown. + +To the patient it is a satisfying diagnosis and satisfactory explanation +in one; to the doctor, a great saving of brain-fag. When we call a +disease rheumatism, we know what to give for it--even if we don't know +what it is. As the old German distich runs,-- + + Was man kann nicht erkennen, + Muss er Rheumatismus nennen.[2] + +[Footnote 2: What one cannot recognize he must call rheumatism.] + +However, in spite of the confusion produced by this wholesale and +indiscriminate application of the term to a host of widely different, +painful conditions, many of which have little else in common save that +they hurt and can be covered by this charitable name-blanket, a few +definite facts are crystallizing here and there out of the chaos. The +first is, that out of this swarm of different conditions there can be +isolated one large and important central group which has the characters +of a well-defined and constant disease-entity. This is the disease known +popularly as rheumatic fever, and technically as acute rheumatism or +acute articular rheumatism. In fact, the commonest division is to +separate the "rheumatisms" into two great groups: acute, covering the +"fever" form, and chronic, containing all the others. From a purely +scientific point of view, this classification has rather an undesirable +degree of resemblance to General Grant's famous division of all music +into two tunes: one of which was Old Hundred, and the other wasn't. But +for practical purposes it has certain merits and may pass. + +Every one has seen, or known, or had, the acute articular form of +rheumatism, and when once seen there is no difficulty in recognizing it +again. It is one of the most striking and most abominable of +disease-pictures, beginning with high fever and headache, then +tenderness, quickly increasing to extreme sensitiveness in one or more +of the larger joints, followed by drenching sweats of penetrating acid +odor. The joint attacked becomes red, swollen, and glossy, so tender +that merely pointing a finger at it will send a twinge of agony through +the entire body, and the patient lies rigid and cramped for fear of the +agony caused by the slightest movement. The tongue becomes coated and +foul, the blood-cells are rapidly broken down, and the victim becomes +ashy pale. He is worn out with pain and fever, yet afraid to fall asleep +for fear of unconsciously moving the inflamed joint and waking in +tortures; and altogether is about as acutely uncomfortable and +completely miserable as any human being can well be made in so short a +time. + +Fortunately, as with its twin brother, the grip, the bark of rheumatism +is far worse than its bite; and a striking feature of the disease is its +low fatality, especially when contrasted with the fury of its onslaught +and the profoundness of the prostration which it produces. Though it +will torture its victim almost to the limits of his endurance for days +and even weeks at a stretch, it seldom kills directly. Its chief danger +lies in the legacies which it bequeaths. Though, like nearly all fevers, +it is self-limited, tends to run its course and subside when the body +has manufactured an antitoxin in sufficient amounts, it is unique in +another respect, and that is in the extraordinary variability of the +length of its "course." This may range anywhere from ten days to as many +weeks, the "average expectation of life" being about six weeks. The +agonizing intensity of the pain and acute edge of the discomfort usually +subside in from five to fifteen days, especially under competent care. +When the temperature falls, the drenching sweats cease, the joints +become less exquisitely painful, and the patient gradually begins to +pull himself together and to feel as if life were once more worth +living. He is not yet out of the woods, however, for while the pain is +subsiding in the joints which have been first attacked, another joint +may suddenly flare up within ten or twelve hours, and the whole +distressing process be repeated, though usually on a somewhat milder and +shorter scale. This uncertainty as to how many joints in the body may be +attacked, is, in fact, one of the chief elements in making the duration +of the disease so irregular and incalculable. + +Even when the frank and open progress of the disease through the joints +of the body has come to an end, the enemy is still lying in wait and +reserving his most deadly assault. Distressing and crippling as are the +effects of rheumatism upon the joints and tendons, its most deadly and +permanent damage is wrought upon the heart. Fortunately, this vital +organ is not attacked in more than about half the cases of acute +rheumatism, and in probably not more than one-third of these are the +changes produced either serious or permanent, especially if the case be +carefully watched and managed. But it is not too much to say that, of +all cases of serious or "organic" heart disease, rheumatism is probably +responsible for from fifty to seventy per cent. The same germ or toxin +which produces the striking inflammatory changes in the joints may be +carried in the blood to the heart, and there attack either the lining +and valves of the heart (endocardium), which is commonest, or the +covering of the heart (pericardium), or the heart-muscle. So intense is +the inflammation, that parts of the valves may be literally eaten away +by ulceration, and when these ulcers heal with formation of scar-tissue +as everywhere else in the body, the flaps of the valves may be either +tied together or pulled out of shape, so that they can no longer +properly close the openings of the heart-pump. This condition, or some +modification of it, is what we usually mean when we speak of "heart +disease," or "organic heart disease." The effect upon the heart-pump is +similar to that which would be produced by cutting or twisting the valve +in the "bucket" of a pump or in a bulb syringe. + +In severe cases of rheumatism the heart may be attacked within the first +few days of the disease, but usually it is not involved until after the +trouble in the joints has begun to subside; and no patient should be +considered safe from this danger until at least six weeks have elapsed +from the beginning of the fever. The few cases (not to exceed one or two +per cent) of rheumatic fever which go rapidly on to a fatal termination, +usually die from this inflammation of the heart, technically known as +endocarditis. The best way of preventing this serious complication and +of keeping it within moderate limits, if it occurs, is absolute rest in +bed, until the danger period is completely passed. + +Now comes another redeeming feature of this troublesome disease, and +that is the comparatively small permanent effects which it produces upon +the joints in the way of crippling, or even stiffening. To gaze upon a +rheumatic knee-joint, for instance, in the height of the +attack,--swollen to the size of a hornet's nest, hot, red, throbbing +with agony, and looking as if it were on the point of bursting,--one +would almost despair of saving the joint, and the best one would feel +entitled to expect would be a roughening of its surfaces and a permanent +stiffening of its movements. + +On the contrary, when once the fury of the attack has passed its climax, +especially if another joint should become involved, the whole picture +changes as if by magic. The pain fades away to one-fifth of its former +intensity within twenty-four, or even within twelve hours; three-fourths +of the swelling follows suit in forty-eight hours; and within three or +four days' time the patient is moving the joint with comparative ease +and comfort. After he gets up at the end of his six weeks, the knee, +though still weak and stiff and sore, within a few weeks' time "limbers +up" completely, and usually becomes practically as good as ever. In +short, the violence and swiftness of the onset are only matched by the +rapidity and completeness of the retreat. It would probably be safe to +say that not more than one joint in fifty, attacked by rheumatism, is +left in any way permanently the worse. + +But, alas! to counterbalance this mercifulness in the matter of +permanent damage, unlike most other infections, one attack of rheumatic +fever, so far from protecting against another, renders both the +individual and the joint more liable to other attacks. The historic +motto of the British in the War of 1812 might be paraphrased into, +"Once rheumatic, always rheumatic." The disease appears to be lost to +all sense of decency and reason; and to such unprincipled lengths may it +go, that I have actually known one luckless individual who had the +unenviable record of seventeen separate and successive attacks of +rheumatic fever. As he expressed it, he had "had rheumatism every spring +but two for nineteen years past." Yet only one ankle-joint was +appreciably the worse for this terrific experience. + +Obviously, the picture of acute rheumatism carries upon its face a +strong suggestion of its real nature and causation. The high +temperature, the headache, the sweats, the fierce attack and rapid +decline, the self-limited course, the tendency to spread from one joint +to another, from the joints to the heart, from the heart to the lungs +and the kidneys, all stamp it unmistakably as an infection, a fever. On +the other hand, there are two rather important elements lacking in the +infection-picture: one, that, although it does at times occur in +epidemics, it is very seldom transmitted to others; the other, that one +attack does not produce immunity or protect against another. The +majority of experts are now practically agreed that _acute_ rheumatism, +or _rheumatic fever_, is probably due to the invasion of the system by +some microoerganism or germ. When, however, we come to fixing upon the +particular bacillus, or micrococcus, there is a wide divergence of +opinion, some six or seven different eminent investigators having each +his favorite candidate for the doubtful honor. In fact, it is our +inability as yet positively to identify and agree upon the causal germ +that makes our knowledge of the entire subject still so regrettably +vague, and renders either a definite classification or successful +treatment so difficult. + +The attitude of the most careful and experienced physicians and +broad-minded bacteriologists may be roughly summed up in the statement +that acute rheumatism is probably due to some germ or germs, but that +the question is still open which particular germ is at fault, and even +whether the group of symptoms which we call rheumatism may not possibly +be produced by a number of different organisms, acting upon a particular +type of constitution or susceptibility. There is no difficulty in +finding germs of all sorts, principally micrococci, in the blood, in the +tissues about the joints, and on the heart-valves of patients with +rheumatism, and these germs, when injected into animals, will not +infrequently produce fever and inflammatory changes in the joints, +roughly resembling rheumatism. But the difficulty so far has been, +first, that these organisms are of several different kinds and distinct +species; and second, and even more important, that almost any of the +organisms of the common infectious diseases are capable at times of +producing inflammation of the joints and tendons. For instance, the +third commonest point of attack of the tubercle bacillus, after the +lungs and the glands, is the bones and joints, as illustrated in the +sadly familiar "white-swelling of the knee" and hip-joint disease. All +the so-called septic organisms, which produce suppuration and +blood-poisoning in wounds and surgery, may, and very frequently do, +attack the joints; while nearly all the common infections, such as +typhoid, scarlet fever, pneumonia, and even measles, influenza, and +tonsillitis, may be followed by severe joint symptoms. + +In fact, we are coming to recognize that diseases of the joints, like +diseases of the nervous system, are among the frequent results of any +and all of the acute infectious diseases or fevers; and we now trace +from fifty to seventy-five per cent of both joint troubles and +degenerations of the nervous system to this cause. Two-thirds, for +instance, of our cases of hip-joint disease and of spinal disease +(_caries_) are due to tuberculosis. + +The puzzling problem now before pathologists is the sorting out of these +innumerable forms of joint inflammations and the splitting off of those +which are clearly due to certain specific diseases, from the great, +central group of true rheumatism. Most of these joint inflammations +which are due to recognized germs, such as the pus-organisms of surgical +fevers, tuberculosis, and typhoid, differ from true rheumatism in that +they go on to suppuration (formation of "matter") and permanently +cripple the joint to a greater or less degree. So that there is probably +a germ or group of germs which produces the swift attack and rapid +subsidence and other characteristic features of true rheumatism, even +though we have not yet succeeded in sorting them out of the swarm. So +confident do we feel of this, that although, as will be shown, there are +probably other factors involved, such as exposure, housing, occupation, +food, and heredity, yet the best thought of the profession is +practically agreed that none of these would alone produce the disease, +but that they are only accessory causes plus the micrococcus. In +practically all our modern textbooks of medicine, rheumatism is +included under the head of infections. + +This theory of causation, confessedly provisional and imperfect as it +is, helps us to harmonize the other known facts about the disease; it +has already greatly improved our treatment and given us a foothold for +attacking the problem of prevention. For instance, it has long been +known that rheumatism was very apt to follow tonsillitis or other forms +of sore throat; indeed, many of the earlier authorities put down +tonsillitis as one of the great group of "rheumatic" disturbances, and +persons of rheumatic family tendency were supposed to have tonsillitis +in childhood and rheumatism in later life. Not more than ten or fifteen +per cent of all cases gave a history of tonsillitis; but since we have +broadened our conception of infection and begun to inquire, not merely +for symptoms of tonsillitis, but also for those of influenza, "common +colds," measles, whooping-cough, and the like, we reach the most +significant result of finding that forty to sixty per cent of our cases +of rheumatism have been preceded, anywhere from one to three weeks +before, by an attack of some sort of "cold," sore throat, catarrhal +fever, cough, bronchitis, or other group of disturbances due to a mild +infection. Further, it has long been notorious that when a rheumatic +individual "catches cold" it is exceedingly apt to "settle in the +joints," and, if these cases happen to come under the eye of a +physician, they are recognized as secondary attacks of true rheumatism. +In other words, the "cold" may simply be a second dose of the same germ +which caused the primary attack of rheumatism. + +This brings us to the widespread article of popular belief that +rheumatism is most commonly due to cold, exposure, chill, or damp. Much +of this is found on investigation to be due to the well-known historic +confusion between "cold," in the sense of exposure to cold air, and +"cold," in the sense of a catarrh or influenza, with running at the +nose, coughing, sore throat, and fever, a group of symptoms now clearly +recognized to be due to an infection. In short, the vast majority of +common colds are unmistakably infections, and spread from one victim to +another, and this is the type of "cold" which causes the majority of +rheumatic attacks. + +The chill, which any one who is "coming down" with a cold experiences, +and usually refers to a draft or a cold room, is, in nine cases out of +ten, the rigor which precedes the fever, and has nothing whatever to do +with the external temperature. The large majority of our cases of +rheumatism can give no clear or convincing history of exposure to wet, +cold, or damp. But popular impression is seldom entirely mistaken, and +there can be no question that, given the presence of the infectious +germ, a prolonged exposure to cold, and particularly to wet, will often +prove to be the last straw which will break down the patient's power of +resistance, and determine an attack of rheumatism. + +This climatic influence, however, is probably not responsible for more +than fifteen or twenty per cent of all cases, and, popular impression to +the contrary notwithstanding, the liability of outdoor workers who are +subject to severe exposure, such as lumbermen, fishermen, and sailors, +is only slightly greater than that of indoor workers. The highest +susceptibility, in fact, not merely to the disease, but also to the +development of serious heart involvements, is found among domestic +servants, particularly servant girls, agricultural laborers and their +families (in districts where wages are low and cottages bad), and +slum-dwellers; in fact, those classes which are underfed, overworked, +badly housed, and crowded together. Diet has exceeding little to do with +the disease, and, so far from meat or high living of any sort +predisposing to it, it is most common and most serious in precisely +those classes which get least meat or luxuries of any sort, and are from +stern necessity compelled to live upon a diet of cereals, potatoes, +cheap fats, and coarse vegetables. + +Even its relations to the weather and seasons support the infection +theory. Its seasonal occurrence is very similar to that of +pneumonia,--rarest in summer, commonest in winter, the highest +percentage of cases occurring in the late fall and in the early spring; +in other words, just at those times when people are first beginning to +shut themselves up for the winter, light fires, and close windows, and +at the end of their long period of winter imprisonment, when both their +resisting power has been reduced to the lowest ebb in the year and +infections of all sorts have had their most favorable conditions of +growth for months. + +The epidemics of rheumatism, which occasionally occur, probably follow +epidemics of influenza, tonsillitis, or other mild infections, and +instances of two or more cases of rheumatism in one family or household +are most rationally explained as due to the spread of the precedent +infection from one member of the family to the other. Instances of the +direct transmission of the disease from one patient to another are +exceedingly rare. + +Our view of the infectious causation of rheumatism, vague as it is, has +given us already our first intelligent prospect of prevention. Whatever +may be the character of a germ or germs, the vast majority of them agree +in making the nose and throat their first point of attack and of entry +into the system. Hence, vigorous antiseptic and other rational treatment +of all acute disturbances of the nose and throat, however slight, will +prove a valuable preventive and diminisher of the percentage of +rheumatism. This simply emphasizes again the truth and importance of the +dictum of modern medicine, "Never neglect a cold," since we are already +able to trace, not merely rheumatism, but from two-thirds to +three-fourths of our cases of heart disease, of kidney trouble, and of +inflammations of the nervous system, to those mild infections which we +term "colds," or to other definite infectious diseases. + +Not only is this good _a priori_ reasoning, but it has been demonstrated +in practice. One of our largest United States army posts had acquired an +unenviable reputation from the amount of rheumatism occurring in the +troops stationed there. A new surgeon coming to take charge of the post +set about investigating the cause of this state of affairs, and came to +the conclusion that the disease began as, or closely followed, +tonsillitis and other forms of sore throat. He accordingly saw to it +that every case of tonsillitis, of cold in the head, or sore throat was +vigorously treated with local germicides and with intestinal +antiseptics and laxatives, until it was completely cured; with the +result that in less than a year he succeeded in lowering the percentage +of cases of rheumatism per company nearly sixty per cent. + +At some of our large health-resorts, where great numbers of cases of +rheumatism are treated, it has been discovered that if a case of common +cold, or tonsillitis, happens to come into the establishment, and runs +through the inmates, nearly half of the rheumatic patients attacked will +have a relapse or new seizure of their rheumatism. Accordingly, a +rigorous and hawk-like watch is kept for every possible case of cold, +tonsillitis, or sore throat entering the house; the patient is promptly +isolated and treated on rigidly antiseptic principles, with the result +that epidemics of relapses of rheumatism in the inmates have greatly +diminished in frequency. + +If every case of cold or sore throat were promptly and thoroughly +treated with antiseptic sprays and washes such as any competent +physician can direct his patients to keep in the house, in readiness for +such an emergency, combined with laxatives and intestinal antiseptic +treatment, and, above all, with rest in bed as long as any rise of +temperature is present, there would be a marked diminution in both the +frequency and the severity of rheumatism. If to this were added an +abundant and nutritious dietary, good ventilation and pure air, an +avoidance of overwork and overstrain, we should soon begin to get the +better of this distressing disease. In fact, while positive data are +lacking, on account of the small fatality of rheumatism and its +consequent infrequent appearance among the causes of death in our vital +statistics, yet it is the almost unanimous opinion of physicians of +experience that the disease is distinctly diminishing, as a result of +the marked improvement in food, housing, wages, and living conditions +generally, which modern civilization has already brought about. + +So much for acute rheumatism. Vague and unsatisfactory as is our +knowledge of it, it is, unfortunately, clearness and precision itself +when contrasted with the welter of confusion and fog which covers our +ideas about the _chronic_ variety. The catholicity of the term is +something incredible. Every chronic pain and twinge, from corns to +locomotor ataxia, and from stone-in-the-kidney to tic-douloureux, has +been put down as "rheumatism." It is little better than a diagnostic +garbage-dump or dust-heap, where can be shot down all kinds of vague and +wandering pains in joints, bones, muscles, and nerves, which have no +visible or readily ascertainable cause. Probably at least half of all +the discomforts which are put down as "rheumatism" of the ankle, the +elbow, the shoulder, are not rheumatism at all, in any true or +reasonable sense of the term, but merely painful symptoms due to other +perfectly definite disease conditions of every imaginable sort. The +remaining half may be divided into two great groups of nearly equal +size. One of these, like acute rheumatism, is closely related to, and +probably caused by, the attack of acute infections of milder character, +falling upon less favorable soil. The other is of a vaguer type and is +due, probably, to the accumulation of poisonous waste-products in the +tissues, setting up irritative and even inflammatory changes in nerve, +muscle, and joint. Either of these may be made worse by exposure to cold +or changes in the weather. In fact, this is the type of rheumatism which +has such a wide reputation as a barometer and weather prophet, second +only to that of the United States Signal Service. When you "feel it in +your bones," you know it is going to snow, or to rain, or to clear up, +or become cloudy, or whatever else may happen to follow the sensation, +merely because all poisoned and irritated nerves are more sensitive to +changes in temperature, wind-direction, moisture, and electric tension, +than sound and normal ones. The change in the weather does not cause the +rheumatism. It is the rheumatism that enables us to predict the change +in the weather, though we have no clear idea what that change will be. + +Probably the only statement of wide application that can be made in +regard to the nature of chronic rheumatism is that a very considerable +percentage of it is due to the accumulation of poisons (toxins) in the +nerves supplying joints and muscles, setting up an irritation +(neurotoxis), or, in extreme cases, an inflammation of the nerve +(neuritis), which may even go on to partial paralysis, with wasting of +the muscles supplied. The same broad principles of causation and +prevention, therefore, apply here as in acute rheumatism. + +The most important single fact for rheumatics of all sorts, whether +acute or chronic, to remember is that they must _avoid exposure to +colds_, in the sense of infections of all sorts, as they would a +pestilence; that they must eat plenty of rich, sound, nourishing food; +live in well-ventilated rooms; take plenty of exercise in the open air, +to burn up any waste poisons that may be accumulating in the tissues; +dress lightly but warmly (there is no special virtue in flannels), and +treat every cold or mild infection which they may be unfortunate enough +to catch, according to the strictest rigor of the antiseptic law. + +The influence of diet in chronic rheumatism is almost as slight as in +the acute form. Persons past middle age who can afford to indulge their +appetites and are inclined to eat and drink more than is good for them, +and, what is far more important, to exercise much less, may so embarrass +their liver and kidneys as to create accumulations of waste products in +the blood sufficient to cause rheumatic twinges. The vast majority, +however, of the sufferers from chronic rheumatism, like those from the +acute form, are underfed rather than overfed, and a liberal and abundant +dietary, including plenty of red meats, eggs, fresh butter, green +vegetables, and fresh fruits, will improve their nutrition and diminish +their tendency to the attacks. + +There appears to be absolutely no rational foundation for the popular +belief that red meats cause rheumatism, either from the point of view of +practical experience, or from that of chemical composition. We now know +that white meats of all sorts are quite as rich in those elements known +as the purin bodies, or uric-acid group, as red meats, and many of them +much richer. It may be said in passing, that this last-mentioned bugbear +of our diet-reformers is now believed to have nothing whatever to do +with rheumatism, and probably very little with gout, and that the +ravings of Haig and the Uric-Acid School generally are now thoroughly +discredited. Certainly, whenever you see any remedy or any method of +treatment vaunted as a cure for rheumatism, by neutralizing or washing +out uric acid, you may safely set it down as a fraud. + +One rather curious and unexpected fact should, however, be mentioned in +regard to the relation of diet to rheumatism, and that is that many +rheumatic patients have a peculiar susceptibility to some one article of +food. This may be a perfectly harmless and wholesome thing for the vast +majority of the species, but to this individual it acts as a poison and +will promptly produce pains in the joints, redness, and even swelling, +sometimes accompanied by a rash and severe disturbances of the digestive +tract. The commonest offenders form a curious group in their apparent +harmlessness, headed as they are by strawberries, followed by +raspberries, cherries, bananas, oranges; then clams, crabs, and oysters; +then cheese, especially overripe kinds; and finally, but very rarely, +certain meats, like mutton and beef. What is the cause of this curious +susceptibility we do not know, but it not infrequently occurs with this +group of foods in rheumatics and also in asthmatics. + +Both rheumatics and asthmatics are also subject to attacks of urticaria +or "hives" (nettle-rash), from these and other special articles of diet. + +As to principles of treatment in a disease of so varied and indefinite a +character, due to such a multitude of causes, obviously nothing can be +said except in the broadest and sketchiest of outline. The prevailing +tendency is, for the acute form, rest in bed, the first and most +important, also the second, the third, and the last element in the +treatment. This will do more to diminish the severity of the attack and +prevent the occurrence of heart and other complications than any other +single procedure. + +After this has been secured, the usual plan is to assist nature in the +elimination of the toxins by alkalies, alkaline mineral waters, and +other laxatives; to relieve the pain, promote the comfort, and improve +the rest of the patient by a variety of harmless nerve-deadeners or +pain-relievers, chief among which are the salicylates, aspirin, and the +milder coal-tar products. By a judicious use of these in competent hands +the pain and distress of the disease can be very greatly relieved, but +it has not been found that its duration is much shortened thereby, or +even that the danger of heart and other complication is greatly +lessened. The agony of the inflamed joints may be much diminished by +swathing in cotton-wool and flannel bandages, or in cloths wrung out of +hot alkalies covered with oiled silk, or by light bandages kept +saturated with some evaporating lotion containing alcohol. As soon as +the fever has subsided, then hot baths and gentle massage of the +affected joints give great relief and hasten the cure. But, when all is +said and done, the most important curative element, as has already been +intimated, is six weeks in bed. + +In the chronic form the same remedies to relieve the pain are sometimes +useful, but very much less effective, and often of little or no value. +Dry heat, moist heat, gentle massage, and prolonged baking in special +metal ovens, will often give much relief. Liniments of all sorts, from +spavin cures to skunk oil, are chiefly of value in proportion to the +amount of friction and massage administered when they are rubbed in. + +In short, there is no disease under heaven in which so much depends upon +a careful study of each individual case and adaptation of treatment to +it personally, according to its cause and the patient in whom it occurs. +Rheumatism, unfortunately, does tend to "run in families." Apparently +some peculiar susceptibility of the nervous system to influences which +would be comparatively harmless to normal nerves and cells is capable of +being inherited. But this inheritance is almost invariably "recessive," +in Mendelian terms, and a majority of the children of even the most +rheumatic parent may entirely escape the disease, especially if they +live rationally and vigorously, feed themselves abundantly, and avoid +overwork and overcrowding. + + + + +CHAPTER XV + +GERM-FOES THAT FOLLOW THE KNIFE, OR DEATH UNDER THE FINGER-NAIL + + +Our principal dread of a wound is from fear that it may fester instead +of healing quickly. We don't exactly enjoy being shot, or stabbed, or +scratched, though, as a matter of fact, in what Mulvaney calls the "fog +av fightin'" we hardly notice such trifles unless immediately disabling. +But our greatest fear after the bleeding has stopped is lest +blood-poisoning may set in. And we do well to dread it, for in the olden +days,--that is, barely fifty years ago,--in wounds of any size or +seriousness, two-thirds of the risk remained to be run after the +bleeding had been stopped and the bandages put on. Nowadays the danger +is only a fraction of one per cent, but till half a century ago every +wound was expected to form "matter" or _pus_ in the process of healing, +as a matter of course. Most of us can recall the favorite and brilliant +repartee of our boyhood days in answer to the inquisitive query, "What's +the matter?" "Nuthin': it hasn't come to matter yet. It's only a fresh +cut!" + +Even surgeons thought it a necessary part of the process of healing, and +the approving term "laudable pus" was applied to a soft, creamy +discharge, without either offensive odor or tinge of blood, upon the +surfaces of the healing wound; and the hospital records of that day +noted with satisfaction that, after an operation, "suppuration was +established." So strongly was this idea intrenched, that a free +discharge or outpouring of some sort was necessary to the proper healing +of the wound, that in the Middle Ages it was regarded as exceedingly +dangerous to permit wounds to close too quickly. Wounds that had +partially united were actually torn apart, and liquids like oil and wine +and strong acids, which tended to keep them from closing and to set up +suppuration, were actually poured into them; and in some instances their +sides were actually burned with hot irons. There was a solid basis of +reason underlying even these extraordinary methods, viz., the "rule of +thumb" observation, handed down from one generation to another, that +wounds that discharged freely and "sweetly," while they were slow in +healing and left disfiguring scars, usually did not give rise to serious +or fatal attacks of blood-poison or wound-fever. And of two evils they +chose the less. Plenty of pus and a big ugly scar in preference to an +attack of dangerous blood-poisoning. Even if it didn't kill you, it +might easily cripple you for life by involving a joint. The trouble was +with their logic, or rather with their premises. They were firmly +convinced that the danger came from within, that there was a sort of +morbid humor which must be allowed to escape, or it would be dammed up +in the system with disastrous results. + +One day a brilliant skeptic by the name of Lister (who is still living) +took it into his head that perhaps the fathers of surgery and their +generations of imitators might have been wrong. He tried the experiment, +shut germs out of his wounds, and behold, antiseptic surgery, with all +its magnificent line of triumphs, was born! + +Now a single drop of pus in an operation wound is as deep a disgrace as +a bedbug on the pillow of a model housekeeper, and calls for as vigorous +an overhauling of equipment, from cellar to skylight; while a second +drop means a commission of inquiry and a drumhead court-martial. This is +the secret of the advances of modern surgery,--not that our surgeons are +any more skillful with the knife, but that they can enter cavities like +those of the skull, the spinal cord, the abdomen, and the chest, remove +what is necessary, and get out again with almost perfect safety; whereas +these cavities were absolutely forbidden ground to their forefathers, on +account of the twenty, forty, yes, seventy per cent death risk from +suppuration and blood-poison. + +The triumphs of antisepsis and asepsis, or keeping the "bugs" out of the +cuts, have been illustrated scores of times already by abler pens, and +are a household word, but certain of its practical appliances in the +wounds and scratches and trifling injuries of every-day life are not yet +so thoroughly familiar as they should be. When once we know who our +wound-enemies are, whence they came, and how they are carried, the fate +of the battle is practically in our own hands. + +Like most disease-germs our wound-infection foes are literally "they of +our own household." They don't pounce down upon us from the trees, or +lie in wait for us in the thickets, or creep in the grass, or grow in +the soil, or swarm in our food. They live and can live only within the +shelter of our own bodies, where it is warm and moist and comfortable. +This is one great (in the expressive vernacular) "cinch" that we have on +the vast majority of disease-germs, whether medical or surgical, that +they do not flourish and breed outside of the body, or of houses closed +and warm; and this grip can be improved, with skill and determination, +into a veritable strangle-hold on most of them. In the language of +biology, most of them have become "adapted to their environment" so +closely that they can scarcely flourish and breed anywhere outside of +the warm, moist, fertile soil of a living body, and many of them cannot +even live long at temperatures more than ten degrees above or fifteen +degrees below that of the body. At all events, so poorly are these +pus-germs able to preserve their vigor and power of attack, not merely +outside of the human body, but outside of some wound or sore spot, that +it is practically certain that eight-tenths of all cases of +wound-infection or blood-poisoning come directly from some previous +festering wound, sore, ulcer, scab, boil, or pimple, in or on some other +human being or animal. Practically whenever we get pus in a wound in a +hospital, we insist upon finding the precise previous case of pus from +which that originated, and seldom is our search unsuccessful. If we kept +not only our wounds surgically clean, but our gums, noses, throats, +skins, and fingernails, and burned and sterilized everything that came +in contact with a sore, pustule, or scab, we should wipe out nine-tenths +of our cases of wound-infection and suppuration; in fact, practically +all of them, except such small percentage as may come from contact with +infections in animals. This is the reason why, up to half a century ago, +by a strange paradox hospitals were among the most dangerous places to +perform operations in, on account of the abundance of wounds or sores +always present for the pus-germs to breed in, and the fact that out of +fifty or more wound-cases, there was practically certain to be one or +two infected ones to poison the whole lot. + +Surgeons, ignorant of antisepsis, and careless nurses, spread the +infection along, until in some instances it reached a virulence which +burst into the dreaded "hospital gangrene." This dread disease was the +scourge of all hospitals, especially military ones, all over the +civilized world, as recently as our War of Secession. In some wards of +our military hospitals, from thirty to fifty per cent of all the wounded +received were attacked, and over five thousand cases were formally +reported during the war, of which nearly fifty per cent died. This +plague was born solely of those two great mothers of evils, ignorance +and dirt, and is to-day, in civilized lands, as extinct as the dodo. +Then the dread that the community had of hospitals, as places that "help +the poor to die," in Browning's phrase, had a certain amount of +foundation; and cases operated upon in a farmhouse kitchen, where no one +in the family happened to have had a boil or a catarrh or a festering +cut within a month or so, and where the knife happened to be clean or +new, would recover with less suppuration than hospital cases. Nowadays, +from incessant and eternal vigilance, a hospital is surgically the +cleanest and safest place in the world for an operation, so that most +surgeons decline to operate outside of one, except in emergencies; and +some will not even operate except in one with which they are personally +connected, so that they know every step in the process of protection. + +It was this terrible risk of the surgeon carrying infection from one +case to another, that made the coroner of London declare, barely sixty +years ago, that he would hold an inquest upon the next case of death +after ovariotomy that was reported to him, on account of the fearful +pus-mortality that followed this serious operation, which now has a +possible death-rate from all causes connected with the operation of only +a fraction of one per cent. + +The brusque reply is still remembered of Lawson Tait, the great English +ovariotomist, to a distinguished German colleague, who had inquired the +secret of his then marvelously low death-rate: after a glance at the +bands of mourning on the ends of the other's fingers, he said, "I keep +my fingernails clean, sir!" There was sadly too much truth in the saying +of another eminent surgeon, that in the pre-Listerian days many a poor +woman's death warrant was written under the fingernails of her surgeon. +This reproach has been wiped out, thank Heaven! but the labor, pains, +and persistence after heart-breaking failures which it took to do it! +Never was there a more vivid illustration of the declaration that genius +is the capacity for taking pains, than antiseptic surgery! Not a +loophole must be left unstopped, not a possibility unconsidered, not a +thing in, or about, or connected with, the operating-room left +unsterilized, except the patient and the surgeon; and these are brought +as near to it as is possible without danger to life. + +In the first place, the operating-room itself must be like a bath room, +or, more accurately, the inside of a cistern. Walls, floor, and ceiling +are all waterproof and capable of being washed down with a hose. There +must be no casings or cornices of any sort to catch dust; and in the +best appointed hospitals no one is permitted to enter, under any +pretext, whose hands and garments have not been sterilized. + +In the second place, everything that is brought into the room for use +in, or during, the operation, is first thoroughly sterilized. The +knives, instruments, and other operative objects are sterilized by +boiling, or by the use of superheated steam; and the towels, dressings, +bandages, sheets, etc., by boiling, baking, or superheated steam. Then +begins the preparation of the surgeon and the nurse. Dressing-rooms are +provided, in which the outer garments are removed, and the hands given +an ordinary wash. Then the scrubbing-room is entered, where, at a series +of basins provided with running hot and cold water, whose faucets are +turned by pressure with the foot so as to avoid any necessity for +touching them with the hand, the hands are thoroughly scrubbed with hot +water, boiled soap, and a boiled nail-brush. Then they are plunged into, +and thoroughly soaked in, some strong antiseptic solution, then washed +again; then plunged into another antiseptic solution, containing some +fat solvent like ether or alcohol, to wash off any dirt that may have +been protected by the natural oil of the skin. Then they are thoroughly +scrubbed with soap and hot water again, to remove all traces of the +antiseptics, most of which are irritating to wounded tissues; then +washed in absolute alcohol, then in boiled or distilled water. Then the +nurse, whose hands are already sterilized, takes out of the original +package in which it came from the sterilizing oven, a linen surgical +gown or suit which covers the operator from neck to toes. A sterilized +linen or cotton cap is placed upon his head and pulled down so that the +scales or germs of any sort may not fall into the wound. Some surgeons +of stout and comfortable habit, who are apt to perspire in the high +temperature of an operating-room, will tie a band of gauze around their +foreheads, to prevent any unexpected drops of perspiration from falling +into the wound; while some purists muffle up the mouth and lower part of +the face lightly in a similar comforter. + +You would think that by this time the hands were clean enough to go +anywhere with safety, but no risks are going to be taken. A pair of +rubber or cotton gloves, the former taken right out of a strong +antiseptic solution, the latter out of the sterilizing oven, are pulled +carefully on by the nurse. Holding his sacred hands spread out rigidly +before him, like the front paws of a kangaroo, the surgeon carefully +edges his way into the operating-room, waiting for any doors that he may +have to pass through to be opened by the nurse, or awkwardly pushing +them with his elbow. In that attitude of benediction, the hands are +maintained until the operation is ready to begin. + +Then comes the patient! If his condition will in any wise permit, he has +been given a boiling hot bath and scrub the night before, and put to bed +in a sterilized nightgown between sterilized sheets. The region which is +to be operated upon has, at the same time, been scrubbed and rubbed and +flushed with hot water, germicides, alcohol, soap,--in fact, has gone +through the same sacred ceremonial of cleansing through which the +surgeons' hands have passed; and a large, closely fitting antiseptic +dressing, covering the whole field, has been applied and tightly bound. +He is brought into a waiting-room and put under ether by an anaesthetist, +through a sterilized mask; he is then wheeled into the operating-room, +the dressing is removed, a thorough double scrub is again given, for +"good measure," to the whole area in which the wound is to be made. A +big sheet is thrown over the lower part of his body, another over the +upper part, a third, with an oval opening in the centre of it, thrown +over the region to be operated upon. The instrument nurse takes a boiled +knife out of a sterilized dish of distilled water, hands it to the +surgeon, who takes it in his gloved hand, and the operation begins. + +Now, if you can think of any possible chink through which a wandering +streptococcus can, by any possibility, sneak into that wound, please +suggest it, and it shall be closed immediately! + +The intruders against whom all these preparations are made are two in +number: _Streptococcus pyogenes_ and _Staphylococcus pyogenes_--cousins, +as you see, by their names. Their last (not family) name really means +something, and is not half so alarming as it sounds, as it is Greek for +"pus-making." Their real family name, _Coccus_, which means a berry, was +suggested, by their rounded shape under the microscope, to some +poetically minded microscopist. Undesirable citizens, both of them! But +the older, or _Strepto_, cousin is by far the more dangerous character +and desperate individual, giving rise to and being concerned in nearly +all the civilized and dangerous wound-fevers--septicaemia, erysipelas, +etc. _Staphylococcus_ is a milder and less harmful individual, seldom +going farther than to produce the milder forms of festering, +discharging, refusing to heal, pustules, etc. He is not to be given a +yard of leeway, however, for if he can get a sufficient number of dirty +wounds to run through, he can work himself up to a high degree of +virulence and poisoning power. Indeed, this faculty of his may possibly +furnish a clew as to how these pus-makers developed their power of +living in wounds, and almost nowhere else. There is another cousin also, +in the group, called _Staphylococcus pyogenes albus_, to distinguish him +(_albus_, "white") from the other two, who have the tag name aureus +(golden). He is an almost harmless denizen of the surfaces of our +bodies, particularly the mouths of the sweat-ducts, and the openings of +the hair follicles. Under peculiarly favorable circumstances, such as a +very big wound, an aggravated chafe, or the application of that +champion "bug-breeder," a poultice, he may summon up courage enough +to attack some half-dead skin-cells and make a few drops of pus on +his own account. He is the criminal concerned in the so-called +stitch-abscesses, or tiny points of pus which form around the stitches +of a big wound and in some of the smaller pimples which turn to +"matter." It is conceivable that this feeble and harmless white coccus +may at some time have been accelerated under favorable circumstances to +where he was endowed with "yellow" powers, and even, upon another turn +of the screw, with strepto-virulence. But this is a mere academic +question. Practically the only thing needful is to keep all the rascals +out of every wound. + +Now comes the question, how is this to be done? Fortunately it is not +necessary to hunt out and destroy the pus-germs in their breeding-places +outside of the human body. As we have seen, they do not long retain +their vitality out of doors, or as a rule even in the dust of rooms and +dirt of houses, unless the latter have been recently contaminated with +the dressings of, or discharges from, wounds. There are two main things +to be watched: first, the wound itself, and second, any unwashed or +unsterilized part of your own or some other living body. Dirt of all +sorts is a mighty good thing to keep absolutely out of the wound, but +practically a whole handful of ordinary soil or dust rubbed into a wound +might not, unless it happened to contain fertilizer of some sort, be +half so dangerous as a single touch with a finger which had been +dressing a wound, picking a scab out of the nose, rubbing an ulcerated +gum, or scratching an itching scalp. If it be a cut on the finger, or +scratch on the hand, for instance, don't suck it, or lick it, unless you +can give an absolutely clean bill of health to your gums and teeth. If +not thoroughly brushed three or four times a day, they are sure to be +swarming with germs of twenty or thirty different species, which not +infrequently include one or both of the pus-germs. Indeed, the real +reason why the bite of certain animals, and above all of a man, +particularly of a "blue-gum nigger," is regarded as so dangerous is on +account of the swarms of germs that breed in any remnants of food left +between the teeth or in the pockets of ulcerating gums. Many a human +bite is almost as dangerous as a rattlesnake's. The devoted hero who +sucks the poison of the dagger out of the wound may be conferring a +doubtful benefit, if he happens to be suffering from Rigg's disease. + +Don't try to stop the bleeding unless it comes in spurts or the flow is +serious. The loss of a few teaspoonfuls, tablespoonfuls, or, for the +matter of that, cupfuls, of blood won't do you any harm, and its free +flow will wash out the cut from the bottom, and carry out most of the +germs that may happen to be present on the knife or nail. If water and +dressings are not accessible, let the blood cake and dry over the wound +without disturbing it, even though it does look rather gory. + +A slight cut with a clean knife, or other instrument, into which no dirt +has been rubbed, will often require no other dressing than its own +blood-scab. If, however, as oftener happens, you cannot be sure of the +cleanness of the knife, tool, or nail, hold the wound under running +water from a pump or tap (this is not germ-free, but practically never +contains pus-germs), until the wound has been thoroughly washed out, +wiping any gravel or dirt out of the cut with soft rags which have been +recently washed, or baked in the oven; then dry with a small piece of +linen, or white goods, put on a dressing of absorbent cotton such as can +be purchased for a few cents an ounce at any drug store. Absorbent or +surgical cotton makes a good dressing, because it both sucks up any +fluids which might leak out of the wound, and forms a mesh-filter +through which no germs can penetrate. + +It is not advisable to use sticking-plaster for any but the most trivial +wounds, and seldom even for these, for several reasons. First, because +its application usually involves licking it to make it stick; second, +because it must cover a sufficient amount of skin on either side of the +wound to give it firm grip, and this area of skin contains a +considerable number of both sweat-ducts and hair-follicles, which will +keep on discharging under the plaster, producing a moist and unhealthy +condition of the lips of the wound. Moreover, these sweat-ducts and +hair-follicles will, as we have seen, frequently contain white +staphylococci, which are at times capable of setting up a low grade of +inflammation in the wound. A wound always heals better if its surfaces +and coverings can be kept dry. This is why cotton makes such an ideal +dressing, since it permits the free evaporation of moisture, a moderate +access of air, and yet keeps out all germs. + +If the cut or scratch is of any depth or seriousness whatever, or the +knife, tool, or other instrument be dirty, or if any considerable amount +of street-dust or garden-soil has got into the wound, then it is, by +all means, advisable to go to a physician, have the wound thoroughly +cleaned on antiseptic principles, and put up in antiseptic dressing. A +single treatment of this sort, in a comparatively trifling wound which +has become in any way contaminated, may save weeks of suffering and +disability, and often danger of life, and will in eight cases out of ten +shorten the time of healing from forty to sixty per cent. The rapidity +with which a wound in a reasonably healthy individual, cleaned and +dressed on modern surgical principles, will heal, is almost incredible, +until it has actually been seen. + +The principal danger of garden-soil or street-dust in a wound is not so +much from pus-germs, though these may be present, as from another +"bug"--the tetanus or lockjaw bacillus. This deadly organism lives in +the alimentary canal of the horse, and hence is to be found in any dirt +or soil which contains horse manure. It is, fortunately, not very +common, or widely spread, but enough so to make it the part of prudence +to have thoroughly asepticized and dressed any wound into which +considerable amounts of garden-soil, or street-dust, have been rubbed. +The reason why wounds of the feet and hands have had such a bad +reputation, both for festering and giving rise to lockjaw, is that it is +precisely in these situations that they are most likely to get +garden-soil, or stable manure, into them. The classic rusty nail does +not deserve the bad reputation as a wound-maker which it enjoys, its bad +odor being chiefly due to the fact already referred to, that injuries +inflicted by it are most apt to be in the palm of the hand, or in the +sole of the foot, and hence peculiarly liable to contamination by the +tetanus and other soil bacilli. + +For some reason or other which we don't as yet thoroughly understand, +burns from a toy pistol in particular, and Fourth of July fireworks in +general, seem to be peculiarly liable to be followed by tetanus. The +fulminate used in the cap of a toy pistol, and the paper and explosives +of several of the brands of firecrackers, have been thoroughly examined +bacteriologically, but without finding any tetanus germs in them. So +many cases of lockjaw used to follow the Fourth of July celebrations a +few years ago, that Boards of Health became alarmed, and not only +forbade outright the sale of deadly toy pistols, but provided supplies +of the tetanus antitoxin at various depots throughout the cities, so +that all patriotic wounds of this description could have it dropped into +them when they were dressed. Since then, the lockjaw penalty which we +pay for our highly intelligent method of celebrating the Fourth, has +diminished considerably. It is probable that the mortality was chiefly +due to infection of the ugly, slow-healing, dirty little wounds with +city-dust, a large percentage of which, of course, is dried horse +manure. What with the tetanus bacillus and the swarms of flies which +breed chiefly in stable manure, and carry summer diseases, typhoid, +diphtheria, and tuberculosis in every direction, it will not be long +before the keeping of horses within city limits will be as strictly +forbidden as pigpens now are. + +So definite is the connection between the tetanus bacilli and the soil, +that tetanus fields or lockjaw gardens are now recognized and listed by +the health authorities, on account of their having given rise to several +successive cases of the disease. Workers in such fields or gardens, who +scratch or cut themselves, are warned to report themselves promptly for +treatment with the tetanus antitoxin. + +Apart from the tetanus germ, however, the problem of the treatment of +wounds--while there should be perfect cleanliness, the spotlessness of +the model housekeeper multiplied fivefold--is yet not so much a matter +of keeping dirt in general out of the wound, as of keeping out that +_particular form of dirt which consists of or contains, discharges from +some previous wound, sore, ulcer, or boil!_ + +While both these pus-organisms can breed and flourish freely only in +wounds or sores, this is but their starting-point where they gather +strength to invade the entire organism. We used to make a distinction +between those cases in which their toxins or poison-products got into +the blood, with the production of fever, headache, backache, delirium, +sweats, etc., which we term _septicaemia_, and other cases in which the +cocci themselves were carried into the blood and swept all over the body +by forming fresh foci, or breeding-places, which resulted in abscesses +all over the body, which we call _pyaemia_. But now we know that there is +no hard and fast line to be drawn, and that the germs get into the blood +much more easily than we supposed; and the degree and dangerousness of +the fever which they set up depend, first, upon their virulence, or +poisonousness, and, second, upon the resisting power of the patient at +the time. Anything which lowers the general health and strength and +weakens the resisting power of the body will make it much easier for +pus-germs to get an entrance into it, and overwhelm it; so that, after +prolonged famines for instance, or among the population of besieged +cities, or in armies or exploring expeditions which have been deprived +of food and exposed to great hardship, the merest scratch will fester +and inflame, and give rise to a serious and even fatal attack of +blood-poisoning, erysipelas, hospital gangrene, etc. Famines and sieges +in fact are not infrequently followed by positive epidemics of +blood-poisoning, often in exceedingly severe and fatal forms. + +It was long ago noted by the chroniclers that the death-rate from +wound-fever among the soldiers of a defeated army was apt to be much +greater than among those of the victorious one, and this was quoted as +one of the stock evidences of the influence of mind over body. But we +now know that armies are not beaten without some physical cause, that +the defeated soldiers are apt to be in poorer physical condition to +begin with; that they have often been cut off from their base of +supplies, have made desperate forced marches without food or shelter in +the course of their retreat; and, until within comparatively recent +years, were never half so well treated or well fed as their captors. + +As the invading germs pass into the body, they travel most commonly +through the lymph-channels and skin; are arrested and threatened with +destruction by the so-called lymphatic glands, or lymph-nodes. This is +why, if you have a festering wound or boil on your hand or wrist, the +"kernels" or lymph-nodes up in your armpit will swell and become +painful. If the lymph-nodes can conquer the germs and eat them up, the +swelling goes down and the pain disappears. But if the germs, on the +other hand, succeed in poisoning and killing the cells of the body, +these latter melt down and turn to pus, and we get what we call a +"secondary abscess." + +The next commonest point of attack of these pus-germs, if they once get +into the body, and by far the most dangerous, is the heart, as in +rheumatism and other fevers. Some will also attack the kidneys, giving +rise to albumin in the urine, while others attack the membranes of the +joints (_synovia_) and cause suppuration of one or more joints in the +body, which is very apt to be followed by very serious stiffening or +crippling. So that, common, and, in many instances, comparatively mild +as they are, the pus-germs in the aggregate are responsible for a very +large amount of damage to the human body. + +This is the way the _streptococcus_ and _staphylococcus_ behave in an +open wound, or sore; but they have two other methods of operating which +are somewhat special and peculiar. One of these is where the germ digs +and burrows, as it were, underground, in a limited space, resulting in +that charming product known as a boil, or a carbuncle. The other, where +it spreads rapidly over the surface just under the skin, after the +fashion of the prairie fire, producing _erysipelas_. In the first of +these he behaves like the famous burrowing owl of our Western plains, +who forms, with the prairie-dog, the so-called "happy family." He never +makes his own burrow, he simply uses one which is already provided for +him by nature, and that is the little close-fitting pouch surrounding +the root of a hair. Whether the criminal is a harmless native white +coccus which has suddenly developed anti-social tendencies, or a +Mongolian immigrant who has been accidentally introduced, is still an +open question. The probabilities are that it is more frequently the +latter, as, while boils are absolutely no respecters, either of persons +or places, and may rear their horrid heads in every possible region of +the human form divine, yet they display a very decided tendency to +appear most frequently in regions like the back of the neck, the wrist, +the hips, and the nose. One thing that these areas have in common is +that they are liable to a considerable amount of chafing and scratching +as by collars and stocks on the neck, and cuffs on the wrists, or of +friction from belts, or pressure or chafing from chairs or saddles. When +the tissues have been bruised or chafed after such fashion, especially +if the surface of the skin has been at the same time broken, and any +pus-organism is either present in the hair-follicle, like the white +coccus, or rubbed into it by a finger or finger-nail which has just been +sucked in the mouth, used to pick the nose, or possibly engaged in +dressing some wound, or cutting meat, or handling fertilizer, then all +the materials for an explosion are at hand. + + + + +CHAPTER XVI + +CANCER, OR TREASON IN THE BODY-STATE + + +The imagination of the race has ever endowed Cancer with a peculiar +individuality of its own. Although it has vaguely personified in darkest +ages other diseases, like the Plague, the Pestilence, and _Maya_ (the +Smallpox), these have rapidly faded away in even the earliest light of +civilization, and have never approached in concreteness and definiteness +the malevolent personality of Cancer. Its sudden appearance, the utter +absence of any discoverable cause, the twinges of agonizing pain that +shoot out from it in all directions, its stone-like hardness in the +soft, elastic flesh of the body, the ruthless way in which it eats into +and destroys every organ and tissue that come in its way, make this +impression, not merely of personality, but of positive malevolence, +almost unescapable. + +Its very name is instinct and bristling with this idea: _Krebs_, in +German, _Cancer_, in Latin, French, and English, _Carcinoma_, in Greek, +all alike mean "Crab," a ghastly, flesh-eating parasite, gnawing its way +into the body. The simile is sufficiently obvious. The hard mass is the +body of the beast; the pain of the growth is due to his bite; the hard +ridges of scar tissue which radiate in all directions into the +surrounding skin are his claws. + +The singular thing is that, while brushing aside, of course, all these +grotesque similes, the most advanced researches of science are +developing more and more clearly the conception of the independent +individuality--as they term it, the _autonomy_--of cancer. + +More and more decidedly are they drifting toward the unwelcome +conclusion that in cancer we have to deal with a process of revolt of a +part of the body against the remainder, "a rebellion of the cells," as +an eminent surgeon-philosopher terms it. Unwelcome, because a man's +worst foes are "they of his own household." Successful and even +invigorating warfare can be waged against enemies without, but a contest +with traitors within dulls the spear and paralyzes the arm. Against the +frankly foreign epidemic enemies of the race a sturdy and, of late +years, a highly successful battle has been fought. We have banished the +plague, drawn the teeth of smallpox, riddled the armor of diphtheria, +and robbed consumption of half its terrors. In spite of the ravings and +gallery-play of the Lombroso school anent "degeneracy," our bills of +mortality show a marked diminution in the fatality of almost every +important disease of external origin which afflicts humanity. + +The world-riddle of pathology the past twenty years has been: Is cancer +due to the invasion of a parasite, a veritable microscopic crab, or is +it due to alterations in the communal relations, or, to speak +metaphorically, the allegiance of the cells? Disappointing as it may be, +the balance of proof and the opinion of the ablest and broadest-minded +experts are against the parasitic theory, so far, and becoming more +decidedly so. In other words, cancer appears to be an evil which the +body breeds within itself. + +There is absolutely no adequate ground for the tone of lamentation and +the Cassandra-like prophecy which pervade all popular, and a +considerable part of medical, discussion of the race aspects of the +cancer problem. The reasoning of most of these Jeremiahs is something on +this wise: That, inasmuch as the deaths from cancer have apparently +nearly trebled in proportion to the population within the last thirty +years, it only needs a piece of paper and a pencil to be able to figure +out with absolute certainty that in a certain number of decades, at this +geometric ratio, there will be more deaths from cancer than there are +human beings living. + +There could be no more striking illustration, both of the dangerousness +of "a little knowledge" and of the absurdity of applying rigid logic to +premises which contain a large percentage of error. Too blind a +confidence in the inerrancy of logic is almost as dangerous as +superstition. Space will not permit us to enter into details, but +suffice it to say:-- + +First, that expert statisticians are in grave doubt whether this +increase is real or only apparent, due to more accurate diagnosis and +more complete recording of all cases occurring. Certainly a large +proportion of it is due to the gross imperfection of our records thirty +years ago. + +Second, that the apparent increase is little greater than that of deaths +due to other diseases of later life, such as nervous, kidney, and heart +diseases. Our heaviest saving of life so far is in the first five-year +period, and more children are surviving to reach the cancer and Bright's +disease age. + +Third, that a disease, eighty per cent of whose death-rate occurs after +forty-five years of age, is scarcely likely to threaten the continued +existence of the race. + +The nature of the process is a revolt of a group of cells. The cause of +it is legion, for it embraces any influence which may detach the cell +from its normal surroundings,--"isolate it," as one pathologist +expresses it. The cure is early and complete amputation of not only the +rebellious cells, but of the entire organ or region in which they occur. + +A cancer is a biologic anomaly. Everywhere else in the cell-state we +find each organ, each part, strictly subordinated, both in form and +function, to the interests of the whole. + +Here this relation is utterly disregarded. In the body-republic, where +we have come to regard harmony and loyalty as the invariable rule, we +find ourselves suddenly confronted by anarchy and revolt. + +The process begins in one great class of cells, the epithelium of the +secreting glands. This is a group of cell-citizens of the highest rank, +descended originally from the great primitive skin-sheet, which have +formed themselves into chemical laboratories, ferment-factories for the +production of the various secretions required by the body, from the +simplest watery mucus, as in the mouth, or the mere lubricant, as in the +fat-glands of the hair-follicles, to the most complex gastric or +pancreatic juice. They form one of the most active and important groups +in the body, and their revolt is dangerous in proportion. + +The movement of the process is usually somewhat upon this order: After +forty, fifty, or even sixty years of loyal service, the cells lining one +of the tubules of a gland--for instance, of the lip, or tongue, or +stomach--begin to grow and increase in number. Soon they block up the +gland-tube, then begin to push out in the form of finger-or root-like +columns of cells into the surrounding tissues. + +These columns appear to have the curious power of either turning their +natural digestive ferments against the surrounding tissues, or secreting +new ferments for the purpose, closely resembling pepsin, and thus +literally eating their way into them. So rapidly do these cells continue +to breed and grow and spread resistlessly in every direction, that soon +the entire gland, and next the neighboring tissues, become packed and +swollen, so that a hard lump is formed, the pressure upon the +nerve-trunks gives rise to shooting pains, and the first act of the +drama is complete. + +But these new columns and masses, like most other results of such rapid +cell-breeding in the body, are literally a mushroom growth. Scarcely are +they formed before they begin to break down, with various results. If +they lie near a surface, either external or internal, they crumble under +the slightest pressure or irritation, and an ulcer is formed, which may +either spread slowly over the surface, from the size of a shilling to +that of a dinner-plate, or deepen so rapidly as to destroy the entire +organ, or perforate a blood-vessel and cause death by hemorrhage. The +cancer is breaking down in its centre, while it continues to grow and +spread at its edge. Truly a "magnificent scheme of decay." + +Then comes the last and strangest act of this weird tragedy. In the +course of the resistless onward march of these rebel cell-columns some +of their skirmishers push through the wall of a lymph-channel, or even, +by some rare chance, a vein, and are swept away by the stream. Surely +now the regular leucocyte cavalry have them at their mercy, and can cut +them down at leisure. We little realize the fiendish resourcefulness of +the cancer-cell. One such adrift in the body is like a ferret in a +rabbit warren; no other cell can face it for an instant. It simply +floats unmolested along the lymph-channels until its progress is +arrested in some way, when it promptly settles down wherever it may +happen to have landed, begins to multiply and push out columns in every +direction, into and at the expense of the surrounding tissues, and +behold, a new cancer, or "secondary nodule," is born (_metastasis_). + +In fact, it is a genuine "animal spore," or seed-cell, capable of taking +root and reproducing its kind in any favorable soil; and, unfortunately, +almost every inch of a cancer patient's body seems to be such. It is +merely a question of where the spore-cells happen to drift and lodge. +The lymph-nodes or "settling basins" of the drainage area of the primary +cancer are the first to become infected, probably in an attempt to check +the invaders; but the spores soon force their way past them toward the +central citadels of the body, and, one after another, the great, vital +organs--the liver, the lungs, the spleen, the brain--are riddled by the +deadly columns and choked by decaying masses of new cells, until the +functions of one of them are so seriously interfered with that death +results. + +Obviously, this is a totally different process, not merely in degree, +but in kind, from anything that takes place as a result of the invasion +of the body by an infectious germ or parasite of any sort. There is a +certain delusive similarity between the cancer process and an infection. +But the more closely and carefully this similarity is examined the more +superficial and unreal does it become. The invading germ may multiply +chiefly at one point or focus, like cancer, and from this spread +throughout the body and form new foci, and may even produce swarms of +masses of cells resembling tumors, as, for instance, in tuberculosis and +syphilis. But here the analogy ends. + +The great fundamental difference between cancer and any infection lies +in the fact that, in an infection, the inflammations and poisonings and +local swellings are due solely and invariably to the presence and +multiplication of the invading germs, which may be recovered in millions +from every organ and region affected, while swellings or new masses +produced are merely the outpouring of the body-cells in an attempt to +attack and overwhelm these invaders. In cancer, on the contrary, the +destroying organism is a group of perverted body-cells. The invasion of +other parts of the body is carried out by transference of their bastard +and abortive offspring. Most significant of all, the new growths and +swellings that are formed in other parts of the body are composed, not +of the outpourings of the local tissues, but of _the descendants of +these pirate cells_. This is one of the most singular and incredible +things about the cancer process: that a cancer starting, say, in the +pancreas, and spreading to the brain, will there pile up a mass--not of +brain-cells, or even of connective tissue-cells--but of gland-cells, +resembling crudely the organ in which it was born. So far will this +resemblance go that a secondary cancer of the pancreas found in the lung +will yield on analysis large amounts of trypsin, the digestive ferment +of the pancreas. Similarly a cancer of the rectum, invading the liver, +will there pile up in the midst of the liver-tissue abortive attempts at +building up glands of intestinal mucous membrane. + +This fundamental and vital difference between the two processes is +further illustrated by this fact: While an ordinary infection may be +transferred from one individual to another, not merely of the same +species, but of half a dozen different species, with perfect certainty, +and for any number of successive generations, no case of cancer has ever +yet been known to be transferred from one human being to another. In +other words, the cancer-cell appears utterly unable to live in any other +body except the one in which it originated. + +So confident have surgeons and pathologists become of this that a score +of instances are on record where physicians and pathologists, among them +the famous surgeon-pathologist, Senn, of Chicago, only a few years ago, +have voluntarily ingrafted portions of cancerous tissue from patients +into their own arms, with absolutely no resulting growth. In fact, the +cancer-cell behaves like every other cell of the normal body, in that, +though portions of it can be grafted into appropriate places in the +bodies of other human beings and live for a period of days, or even +months, they ultimately are completely absorbed and disappear. The only +apparent exception is the epithelium of the skin, which can be used in +grafting or skinning over a wide raw surface in another individual. +However, even here the probability appears to be that the taking root of +the foreign cells is only temporary, and makes a preliminary covering or +protection for the surface until the patient's own skin-cells can +multiply fast and far enough to take its place. + +A similarly reassuring result has been obtained in animals. Not a single +authenticated case is on record of the transference of a human cancer to +one of the lower animals; and of all the thousands and thousands of +experiments that have been made in attempting to transfer cancers from +one animal to another, only one variety of tumor with the microscopic +appearance of cancer--the so-called Jensen's tumor of mice--has yet been +found which can be transferred from one animal to another. + +So we may absolutely disabuse our minds of the fear which some of our +enthusiastic believers in the parasitic theory of cancer have done much +to foster, that there is any danger of cancer "spreading," like an +infectious disease. Disastrous and gruesome as are the conditions +produced by this disease, they are absolutely free from danger to those +living with or caring for the unfortunate victim. In the hundreds of +thousands of cases of cancers which have been treated, in private +practice, in general hospitals, and in hospitals devoted exclusively to +their care, not a single case is on record of the transference of the +disease to a husband, wife, or child, nurse or medical attendant. So +that the cancer problem, like the Kingdom of Heaven, is within us. + +This conclusion is further supported by the disappointing result of the +magnificent crusade of research for the discovery of the cancer +"parasite," whether vegetable or animal, which has been pursued with a +splendid enthusiasm, industry, and ability by the best blood and brains +of the pathological world for twenty years past. I say disappointing, +because a positive result--the discovery and identification of a +parasite which causes cancer--would be one of the greatest boons that +could be granted to humanity; not so much on account of the actual loss +of life produced by the disease as for the agonies of apprehension +engendered by the fact of the absolute remorselessness and blindness +with which it may strike, and our comparative powerlessness to cure. So +far the results have been distressingly uniform and hopelessly negative. + +Scores, yes, hundreds, of different organisms have been discovered in +and about cancerous growths, and announced by the proud discoverer as +the cause of cancer. Not one of these, however, has stood the test of +being able to produce a similiar growth by inoculation into another +body; and all which have been deemed worthy of a test-research by other +investigators besides the paternal one have been found to be mere +accidental contaminations, and present in a score of other diseases, or +even in normal conditions. Many of them have been shown to be abnormal +products of the cells of the body in the course of the cancer process, +and some even such ludicrous misfits as impurities in the chemical +reagents used, scrapings from the corks of bottles, dust from the air, +or even air-bubbles. These "discoveries" have ranged the whole realm of +unicellular life,--bacilli, bacteria, spirilla, yeasts, moulds, +protozoa,--yet the overwhelming judgment of broad-minded and reputable +experts the world over is the Scotch verdict of "not proven"; and we are +more and more coming to turn our attention to the other aspect of the +problem, the factors which cause or condition this isolation and +assumption of autonomy on the part of the cells. + +This is not by any means to say that there is no causative organism, and +that this will not some day be discovered. Human knowledge is a blind +and short-sighted thing at best, and it may be that some invading cell, +which, from its very similarity to the body-cells, has escaped our +search, will one day be discovered. Nor will the investigators diminish +one whit of their vigor and enthusiasm on account of their failure thus +far. + +The most strikingly suggestive proof of the native-born character of +cancer comes from two of its biologic characters. The first is that its +habit of beginning with a mass formation, rapidly deploying into columns +and driving its way into the tissues in a ghastly flying wedge, is +simply a perfect imitation and repetition of the method by which glands +are formed during the development of the body. The flat, or epithelial, +cells of the lining of the stomach, for instance, begin to pile up in a +little swarm, or mass, elongate into a column, push their way down into +the deeper tissue, and then hollow out in their interior to form a +tubular gland. The only thing that cancer lacks is the last step of +forming a tube, and thereby becoming a servant of the body instead of a +parasite upon it. + +Nor is this process confined to our embryonic or prenatal existence. +Take any gland which has cause to increase in size during adult life, +as, for instance, the mammary gland, in preparation for lactation, and +you will find massing columns and nests of cells pushing out into the +surrounding tissue in all directions, in a way that is absolutely +undistinguishable in its earlier stages from the formation of cancer. It +is a fact of gruesome significance that the two organs--the mammary +gland and the uterus--in which this process habitually takes place in +adult life are the two most fatally liable to the attack of cancer. + +Another biologic character is even more striking and significant. A +couple of years ago it was discovered by Murray and Bashford, of the +English Imperial Cancer Research Commission, that the cells of cancer, +in their swift and irregular reproduction, showed an unexpected +peculiarity. In the simplest form of reproduction, one cell cutting +itself in two to make two new ones, known as mitosis, the change begins +in the nucleus, or kernel. This kernel splits itself up into a series of +threads or loops, known as the chromosomes, half of which go into each +of the daughter cells. When, however, sex is born and a male germ-cell +unites with a female germ-cell to form a new organism, each cell +proceeds, as the first step in the process, to get rid of half of these +chromosomes, so that the new organism has precisely the normal number of +chromosomes, half of which are derived from the father and the other +half from the mother germ-cell. This, by the way, is the mechanical +basis of heredity. + +It has been long known that the mitotic processes of cancer and the +forming and dividing of the chromosomes were riotous and irregular, like +the rest of its growth. But it was reserved for these investigators to +discover the extraordinary fact that the majority of dividing and +multiplying cancer-cells had, instead of the normal number of +chromosomes, exactly half the quota. In other words, they had resumed +the powers of the germ, or sexual, cells from which the entire body was +originally built up, and were, like them, capable of an indefinite +amount of multiplication and reproduction. How extraordinary and +limitless this power is may be seen from the fact that a little group of +cancer-cells grafted into a mouse to produce a Jensen tumor, from which +a graft is again taken and transplanted into another mouse, and so on, +is capable, in a comparatively few generations, of producing cancerous +masses a thousand times the weight of the original mouse in which the +tumor started! + +In short, cancer-cells are obviously a small, isolated group of the +body-cells, which in a ghastly fashion have found the fountain of +perpetual youth, and can ride through and over the law-abiding citizens +of the body-state with the primitive vigor of the dawn of life. + +This brings us to the most practical and important questions of the +problem: What are the influences which condition this isolation and +outlawry of the cells? What can we do to prevent or suppress the +rebellion? To the first of these science can only return a tentative and +approximate answer. The subject is beset with difficulties, chief among +which is the fact that we are unable to produce the disease with +certainty in animals, with the single exception of the Jensen's tumors +in mice referred to, nor is it transferred from one human being to +another, so that we can make even an approximate guess at the precise +time at, or conditions under, which the process began. + +Many theories have been advanced, but most investigators who have +studied the problem in a broad-minded spirit are coming gradually to +agree to this extent:-- + +First of all, that one of the most powerful influences conditioning this +isolation and revolt of the cells is age, both of the individual and of +the organ concerned. Not only does far the heaviest cancer mortality +fall between the ages of forty-five and sixty, but the organs most +frequently and severely attacked are those which between these years are +beginning to lose their function and waste away. First and most +striking, the mammary gland and the uterus in women, and the shriveling +lips and tongue of elderly men. To put it metaphorically, the mammary +gland and the uterus, after the change of life, the lip, after the decay +of the teeth, have done their work, outlived their usefulness, and are +being placed upon a starvation pension by a grateful country. Nineteen +out of twenty accept the situation without protest and sink slowly to a +mere vegetative state of existence, but, in the twentieth, some little +knot of cells rebel, revert to an ancestral power of breeding rapidly to +escape extinction, begin to make ravages, and cancer is born. + +The age-preferences are well marked. Cancer is emphatically a disease of +senility, of age; but, as Roger Williams has pointed out in his +admirable monograph, not of "completed" senility. + +To express it in percentages, barely twenty per cent of the cases occur +before forty years of age, sixty per cent between forty and sixty, and +twenty per cent between sixty and eighty. Thus the early period of +decline, the transition stage between full functional vigor and declared +atrophy (wasting) of the glands, is clearly the period of greatest +danger; precisely the period in which the gland-cells, though losing +their function,--and income,--have still the strength to inaugurate a +rebellion, and a sufficient supply of the sinews of war, either in their +own possession or within easy striking distance in the tissues about +them, to make it successful. Not less than sixty-five to seventy-five +per cent of all cancers in women occur in atrophying organs, the uterus +and mammary glands. + +A rather alluring suggestion was made by Cohnheim, years ago, that +cancers might be due to the sudden resumption of growth on the part of +islands or _rests_ of embryonic tissue, left scattered about in various +parts of the body. But these are now believed to play but a small part, +if indeed any, in the production of true cancer. + +Finally, what can be done to prevent or cure this grotesque yet deadly +process? So far as it is conditioned by age, it is, of course, obvious +that little can be done, for not even the most radical vivisector would +propose preventing in any way as large a proportion as possible of the +human race from reaching fifty or sixty, or even seventy years, to avoid +the barely six per cent liability to cancer after forty-five. + +As regards the influence of chronic inflammations and irritation, much +can be done, and here is our most hopeful field for prevention. Warts +and birthmarks that are in any way subject to pressure or friction from +clothing or movements should be promptly removed, as both show a +distinctly greater tendency than normal tissue to develop into cancer. +Cracks, fissures, chafes, and ulcers of all sorts, especially about the +lips, tongue, mammary gland, uterus, and rectum, should be early and +aseptically dealt with. Jagged remnants of teeth should be removed, all +suppurative processes of the gums antiseptically treated, and the whole +mouth-parts kept in a thoroughly aseptic condition. + +Thorough and conscientious attention to this sort of surgical toilet +work is valuable, not only for its preventive effect,--which is +considerable,--but also because it will insure the bringing under +competent observation at the earliest possible moment the beginnings of +true cancer. + +For the disease itself, after it has once started, there is, like +treason in the body-politic, but one remedy--capital punishment. +Parleying with the rebels is worse than useless. Pastes, caustics, +X-rays, trypsin, radium,--all are fatally defective, because they +suppress a symptom only and leave the cause untouched. Only in one form +of surface-cancer, the so-called flat-celled or rodent ulcer, which has +little or no tendency to form spore-cells and attack the deeper organs, +are they effective. + +Nothing is easier and nothing more idle than to destroy and break down +cells which have actually become cancerous; but so long as there remains +in the body a single nest, or even cell, of the organ in which the +revolt started, so long the life of the patient is in danger. + +Absolutely the only remedy which is of the slightest value is complete +removal with the knife. The one superiority of the knife, shudder as we +may at the name of it, over every other means of removal lies solely in +this fact, that with it can be removed not merely the actual cancer, but +the entire gland or group of surrounding cells in which this malignant, +parricidal change has begun to occur. + +The modern radical operations for cancer take not merely the tumor, but +the entire diseased breast, for instance, and all the lymph-glands into +which it drains, clear up into the armpit, with the muscles beneath it +down to the ribs. Where this is done early enough, the disease does not +recur. Such radical and complete amputation of an organ or region as +this is possible in from two-thirds to three-fourths of all cases if +seen reasonably early. + +With watchfulness and courage, our attitude toward the cancer problem is +one of hopeful confidence. + + + + +CHAPTER XVII + +HEADACHE: THE MOST USEFUL PAIN IN THE WORLD + + +Greatness always has its penalties. Other ills besides death love a +shining mark. Pain is one of them, and headache its best exemplar. If +there be one thing about our bodies of which we are peculiarly and +inordinately proud it is that expanded brain-bulb which we call the +head. Yet it aches oftener than all the rest of us put together. +Headache is the commonest of all pains, which fact gives the slight +consolation that everybody can sympathize with you when you have it. One +touch of headache makes the whole world kin, and the man or woman who +has never had it would be looked upon as a creature abnormal and "a +thing apart." It has even become incorporated into our social fabric as +one of the sacred institutions of the game of polite society. How could +we possibly protect ourselves against our instructors in youth and our +would-be friends in later life if there were no such words as "a severe +headache"? + +What is a headache, and why does it ache the head? This is a wide and +hotly disputed problem. But one fact, which is obvious at the first +intelligent glance, becomes clearer and more important with deeper +study, and that is that it _is not the fault of the head_. When the head +aches, it is, nine times out of ten, simply doing a combination of +scapegoat and fire-alarm duty for the rest of the body. Just as the +brain is the servant of the body, rather than its master, so the devoted +head meekly offers itself as a sort of vicarious atonement for the sins +of the entire body. It is the eloquent spokesman of such "mute, +inglorious Miltons" as the stomach, the liver, the muscles, and the +heart. The humblest and least distinguished of all the organs of the +body can order the lordly head to ache for it, and the head has no +alternative but to obey. + +To discuss the cause of headaches is like discussing the cause of the +human species. It is one of the commonest facts of every-day +observation, and can be demonstrated almost at will, that any one of a +hundred different causes,--a stuffy room, a broken night's sleep, a +troublesome letter, a few extra hours of work, eating something that +disagrees, a cold, a glare of light in the eyes,--any and all of these +may bring on a headache. The problem of avoiding headaches is the +problem of the whole conduct of life. + +Two or three broad generalizations, however, can be made from the +confused and enormous mass of data at our disposal, which are of both +philosophic interest and practical value. One of these is that, while +headache is felt in the head, and particularly in those regions that lie +over the brain, the brain has comparatively little to do with the pain. +Headache is neither a mark of intellectuality, nor, with rare +exceptions, a sign of cerebral disturbance. Indeed, it is far more a +matter of the digestion, the muscles, and the ductless glands, than it +is of the brain, or even of the nervous system. It is, therefore, idle +to endeavor either to treat or try to prevent it by measures directed +to the head, the brain, or even the nervous system as such. + +Secondly, it is coming to be more and more clearly recognized that, +while its causes are legion, a very large percentage of these +practically and eventually operate by producing a toxic, or poisoned, +condition of the blood, which, circulating through certain delicate and +sensitive nerve-strands in the head and face, give rise to the sensation +of pain. + +Thirdly, the tissues which give out this pain-cry under the torture of +the toxins in the blood are, in a large majority of cases, neither the +brain, nor the nerves of the eye, nor other special senses, but the +nerves of common sensation which supply the face, the scalp, and the +structures of the head generally, most of them derived from one great +pair of nerve-trunks, the so-called _Trigeminus_, or fifth pair of +cranial nerves. Strange as it may seem, the brain substance is +comparatively insensitive to pain, and the acutest pain of an operation +upon it, such as for the removal of a tumor, is over when the skin and +scalp have been cut through. These poisons, of course, go all over the +body, wherever the circulation goes, but they produce their promptest +and loudest pain outcry, so to speak, in the region where the nerves are +most exquisitely sensitive. When your head aches, nine times out of ten +your whole body is suffering, but other regions of it are not able to +express themselves so promptly and so clearly. + +These newer and clearer views of the nature of headache dispose at once +of some of the most time-honored controversies in regard to its nature. +In my student-days one of the most hotly debated problems in medicine +was as to whether headaches were due to lack of blood (anaemia) or excess +of blood (hyperaemia) in the brain. Few things could have been more +natural for both the sufferer in, and the observer of, a case of +throbbing, bursting headache, where every pulse-beat is registered as a +thrill of agony, than to draw the conclusion that the pain was due to a +huge engorgement and swelling of the brain with blood, resulting in +agonizing pressure against its rigid, bony skull-walls. + +One of the most naive and vivid illustrations of this conception of +headache is the remedy adopted for generations past, in this all too +familiar and distressing condition, by the Irish peasantry. It consists +of a band or strip of tough cloth, or better, of twisted or plaited +straw, which is tied around the head and then tightened vigorously by +means of a stick inserted tourniquet fashion. This is believed to +prevent the head, which is aching "fit to split," from actually bursting +open, and is considered a cure of wondrous merit through many a +countryside. Ludicrous as is the reason which is gravely assigned for +its use, it does, in some cases, greatly relieve the pain, a fact which +we were entirely at a loss to account for until our later knowledge +showed us that the pain, instead of being inside the skull, was outside +of it in the sensitive nerves supplying the scalp. By steady pressure of +this sort upon the trunks of these nerves, pressing them against the +bone, they can be gradually numbed into a condition of anaesthesia, when +naturally the pain would diminish. + +In politer circles a similar misapprehension has also given rise to a +favorite form of treatment. That is the application of cold in the form +of the classic wet cloth sprinkled with _eau de Cologne_. The mere +mention of headache calls up in the minds of most of us memories of a +darkened room, a pale face on the pillow with a ghastly bandage over the +eyes, and a pervading smell of _eau de Cologne_. It was a perfectly +natural conclusion that, because the head throbbed and felt hot and +bursting, there must be some inflammation, or at least congestion, +present, and that the application of cold would relieve this. The +results seemed to justify this belief, for in many cases the sense of +coolness to the aching head gives great relief; but this is apt to be +only temporary, and in really severe cases makes the situation worse by +adding another depressing influence--cold--to the toxin-burdens that are +weighing upon the tortured nerves. The chief virtue in these cold cloths +and handkerchiefs soaked in cologne was that you were compelled to lie +down and keep perfectly still in order to keep them on, while at the +same time they mechanically blindfolded you. Few better devices for +automatically insuring that absolute rest, which is the best and only +rational cure for a headache, have ever been invented. + +We were not long in discovering that headaches, both of the mildest and +the severest types, might be accompanied either by a rush of blood to +the head, with flushing of the skin, reddening of the eyes, and a +bursting sense of oppression in the head, or, on the other hand, by an +absolute draining of the whole floating surplus of the blood into the +so-called "abdominal pool," the huge network of vessels supplying the +digestive organs, which, when distended, will contain nearly two-thirds +of the entire blood of the body, leaving the face blanched, the eyes +white and staring, and the brain so nearly emptied of blood as to cause +loss of consciousness or swooning. Other headaches, again, will be +accompanied by a fresh, natural color and a perfectly normal and healthy +distribution of the blood-supply. In short, the amount of blood in the +head, whether plus or minus, has practically nothing to do with the +pain, but depends solely upon the effect of the poisons producing it +upon the heart and great blood-vessels. + +A good illustration of the full-blooded type of headache is that which +so very frequently, indeed almost invariably, occurs in the early stage +of a fever or other acute infection, such as typhoid, pneumonia, or +blood-poisoning, Here the face is red, the eyes are bloodshot and +abnormally bright, the pulse is rapid and full, the headache so severe +as to become the first disabling symptom in the disease,--all because +this is the effect of the poison (toxin) of the disease upon the heart, +the temperature, and the surface blood-vessels. Fortunately for the +sufferer, this head-pain, like most others in the course of severe +infections, is only preliminary, for as soon as the tissues of the body +have become thoroughly saturated with the toxins, the nerves become +dulled and semi-narcotized, so that they no longer respond with the +pain-cry. As the patient settles down into the depression and dullness +of the regular course of the fever, the headache usually subsides into +little more than a sense of heaviness, or oppression and vague +discomfort. + +Moral: It is a sign of health to be able to feel a headache, an +indication that your body is still fighting vigorously against the +enemy, whether traitor within or foe without. + +On the other hand, many of our most agonizing, and particularly our most +persistent and obstinate headaches, occur in individuals who are +markedly anaemic, with a low, weak pulse, poor circulation, blanched +lips, and dull, lackluster eyes. The one and only thing in common +between these two classes of "head-achers" is that their blood and +tissues are loaded with poisons. Whether produced by invading germs or +by starvation and malnutrition of the body-tissues makes no difference +to the headache nerves. Their business, like good watchdogs, is to bark +every time they smell danger of any sort, whether it be bears or +book-agents. One of the most valuable services rendered us by our +priceless heads is aching. + +This view of the nature of headache explains at once why it is so +extraordinarily frequent and so extraordinarily varied in causation. It +is not too much to say that _any_ influence that injuriously affects the +body may cause a headache. It would, of course, be idle even to attempt +to enumerate the different causes and kinds of this pain, as it would +involve a review of the entire environment of the human species, +internal and external. It makes not the slightest difference how the +poison gets into the blood, or where it starts. A piece of tainted meat +or a salad made from spoiled tomatoes will produce a headache just as +promptly and effectively as an over-exposure to the July sun or an +attack of influenza. It is even practically impossible to pick out from +such a wealth of origins two or three, or even a score of, conditions +which are the most frequent, most important, or the most interesting +causes. The most exasperating thing about dealing with a headache is +that we never know, until its history has been most carefully examined, +whether we have to do with a mere temporary expression of discomfort and +unbalance, due to overfatigue, errors in diet, a stuffy room, lack of +exercise, or what-not, which can be promptly relieved by removing the +cause; or whether we have to deal with the first symptoms of a dangerous +fever, the beginning of a nervous breakdown, or an early warning of some +grave trouble in kidneys, liver, or heart. + +The one thing, however, that stands out clearly is that _headache always +means something_; that it should be promptly and thoroughly investigated +with a view to finding and removing the cause,--never as something which +is to be cured as quickly as possible, as the police cure social +discontent, by clubbing it over the head, with some narcotic or other +symptom-smotherer. Nor should it be regarded as a malady so trifling +that it is best treated with contempt, and still less as a mere "thorn +in the flesh," whose ignoring is to be counted a virtue, or whose +patient endurance without sign a mark of saintship. Martyrdom is +magnificent when it is necessary, but many forms of it are sheer +stupidity. Don't either gulp down some capsule, or "grin and bear it." +Look for the cause. The more trivial it is, the easier it will be to +discover and remove before serious harm has been done. The less easy you +find it to put your finger upon it, the more likely it is to be serious +or chronic, and the more necessary it is to remove it. + +Once, however, we have clearly recognized that no headache should be +treated too lightly or indifferently, it may be frankly admitted that +practically the vast majority of headaches in which we are keenly +interested--that is, the kind that we individually or the members of our +family habitually indulge in--do form a moderately uniform class among +the hundreds of varieties, and are in the main due to some six or seven +great groups of causes. We have learned by repeated and unpleasant +experience that they are very apt to "come on" in about a certain way, +after a certain set of circumstances; that they last about so long, that +they are made worse by such and such things, that they are helped by +other things, and that they generally get better after a good night's +sleep. + +One of the commonest causes of this group of recurrent and self-limited +headaches is fatigue, whether bodily, mental, or emotional. This was +long an apparent stumbling-block in the way of a poison theory of +headache, but now it is one of its best illustrations. Physiologists +years ago discovered that what produced not merely the sensation but +also the fact of fatigue, or tiredness, was the accumulation in the +muscles or nerves of the waste-products of their own activities. Simply +washing these out with a salt solution would start the utterly fatigued +muscle contracting again, without any fresh nourishment or even period +for rest. It has become an axiom with physiologists that fatigue is +simply a form of self-poisoning, or, as they sonorously phrase it, +autointoxication. One of the reasons why we are so easily fatigued when +we are already ill, or, as we say, "out of sorts," is that our tissues +are already so saturated with waste-products or other poisons that the +slightest addition of the fatigue poisons is enough to overwhelm them. +This also explains why our pet variety of headache, which we may have +clearly recognized to be due to overwork or overstrain of some sort, +whether with eye, brain, or muscles, is so much more easily brought on +by such comparatively small amounts of over-exertion whenever we are +already below par and out of sorts. People who are "born tired," who are +neurasthenic and easily fatigued and "ached," are probably in a chronic +state of self-poisoning due to some defect in their body-chemistry. +Further, the somewhat greater frequency and acuteness of headache in +brain workers--although the difference between them and muscle workers +in this regard has been exaggerated--is probably due in part to the +greater sensitiveness of their nerves; but more so to the curious fact, +discovered in careful experiments upon the nervous system, that the +fatigue products of the nerve-cells are the deadliest and most powerful +poisons produced in the body. Hence some brain workers can work only a +few half-hours a day, or even minutes at a time; for instance, Darwin, +Spencer, and Descartes. + +A very frequent cause of these habitual headaches, really a subdivision +of the great fatigue group, is eye-strain. This is due to an abnormal or +imperfect shape of the eye, which is usually present from birth. Hence, +the only possible way of correcting it is by the addition to the +imperfect eye of carefully fitted lenses or spectacles which will +neutralize this mechanical defect. To put it very roughly, if the eye is +too flat to bring the light-rays to a focus upon the retina, which is +far the commonest condition (the well-known "long sight," or hyperopia), +we put a plus or bulging glass before the eye and thus correct its +shape. But if the eye is too round and bulging, producing the familiar +"short sight," or myopia, we put a minus or concave lens before the eye, +and thus bring it back to the normal. By a curious paradox, however, it +often happens that the headache due to eye-strain is caused not by the +grosser defects, such as interfere with vision so seriously as +absolutely to demand the wearing of glasses to see decently, but from +slighter and more irregular degrees and kinds of misshapenness in the +eye, most of which fall under the well-known heading of astigmatism. +These interfere only slightly with vision, but keep the eye perpetually +on the strain, on a twist, as it were, rasping the entire nervous system +into a state of chronic irritation. Our motto now, in all cases of +chronic headache, is, first examine the patient's habits of life, next +his eyes. + +Many forms of headache are really stomach-ache in disguise, due to +digestive disturbances, the absorption of poisons from the food-tube, +whether from tainted, spoiled, or decayed foods, as in the now familiar +ptomaine poisoning, or from imperfect processes of digestion. The +immediate effect, however, of diet in the causation of headache is not +so great as we once believed. We have no adequate basis for believing +that any particular kinds or amounts of food are especially likely to +produce either headache or what we might call the headache habit, except +in so far as they upset the digestion. In a certain number of +susceptible individuals, however, it will be found that some particular +kind of food, often perfectly wholesome and harmless in itself, will +bring on an attack of headache whenever it is indulged in. Very +frequently the disturbances of digestion which are put down as the +_cause_ of a headache are only _symptoms_ of some general constitutional +lack of balance, as eye-strain or neurasthenia, which is the cause of +both these discomforts. Far fewer headaches can be cured by dieting than +we at one time believed, and underfeeding is a more frequent cause than +overeating. + +By an odd _bouleversement_ the one type of headache which we have almost +unanimously in the past attributed to digestive disturbances, the +famous, or, rather, infamous, "sick headache," is now known to have +little or nothing to do with the stomach in its origin. In fact, +incredible as it may seem at first sight, it is the headache that causes +the sickness, not the sickness the headache. Stop the pain of a sick +headache in the early stage, and the sickness will never develop at all. +The vomiting of sick headache is an interesting illustration of vomiting +due to disturbances of the brain and nervous system, technically known +as central vomiting. Another illustration is the vomiting of +seasickness, due solely to dizziness from the gross contradiction +between the testimony of our eyes and of the balancing canals in the +inner ear. The stomach or its contents has no more to do with +seasickness than the water in a pump has with the plunger. Injuries to +the head will bring on severe and uncontrollable vomiting, and the +severer type of fevers is very frequently ushered in by this curious +sign. As to what it means, we are as yet utterly in the dark, for in +none of these conditions does the process do the slightest good, but +simply adds to the discomfort of the situation. It would appear to be a +curious echo of ancestral times, when the animal was pretty much all +stomach, and hence emptying that organ would probably relieve two-thirds +of his discomforts. Whatever the explanation, the fact remains that +whenever our nervous system gets about so panic-stricken, it promptly +begins throwing its cargo overboard, in the blind hope that this may +somehow relieve the situation. The bile that we bring up at the end of +these interesting acrobatic performances and which makes us feel so much +better,--because we have now got the cause of the trouble out of our +system,--is simply due to the prolonged vomiting, which has reversed the +normal current and caused the perfectly healthy bile from our +unoffending liver to pass upward into the stomach, instead of downward +into the bowels. + +In another great group of headaches natural poisons or waste-products +are not burned up or got rid of through the body-sewers and pores as +rapidly as they should be; for instance, the familiar headache from +sitting too long in a stuffy room. Your well-known and well-earned +discomfort is, of course, due in part to the irritating and often +poisonous gases, dust, and bacteria, which are present in the air of an +unventilated room; but it is also due to the steady piling up of the +waste products of your own tissues. These poisons are normally oxidized +in the muscles, burned up and exhaled through the lungs, and sweated out +through the skin,--all three of which relief agencies are, of course, +practically paralyzed, or working at lowest possible level, while you +are sitting at your desk. + +The well-known headache of sluggish bowels is an obvious case in point; +and one of the early signs of beginning failure of the kidneys, as in +Bright's disease, is a headache of a peculiar type due to accumulation +in the system of the poisons which it is their duty to get rid of. + +There are few things the head resents more keenly than loss of sleep. +The pillow is the best headache medicine. If this loss of sleep be due +to the encroachments of work or of amusements, then the mechanism of its +production is obvious. The fatigue poisons produced during the day and +normally completely neutralized and burned up during sleep are not +entirely disposed of and remain in the tissues to torture the nerves. +The headache of insomnia, or habitual sleeplessness, on the other hand, +is not, strictly speaking, caused by loss of sleep. Paradoxical as it +may sound, the fatigue poisons, which in moderate amounts will produce +drowsiness and promote sleep, in excessive amounts will cause +wakefulness and inability to sleep. Insomnia and headache are usually +symptoms of this overfatigued, or poisoned, condition, and should both +be regarded and treated as symptoms by the removal of their causes, +_not_ by the use of coal-tar products and hypnotics. + +Another common cause of headache is nasal obstruction, such as may be +due to adenoids or deformities of the septum, or chronic catarrhal +conditions. These probably act by their interference with breathing and +consequent imperfect ventilation of the blood, as well as by obstruction +and inflammation of the great air-spaces in the bones of the skull, +closely underlying the brain, which open and drain into the nose. + +It may be remarked in passing that "sick headache," or _migraine_, +though long and painfully familiar to us, is still a puzzle as to its +cause. But the view which seems to come nearest to explaining its many +eccentricities is that it is usually due to a congenital defect, not so +much of the nervous system as of the entire body, by which the poisons +normally produced in its processes fail to be neutralized and got rid +of, and gradually accumulate until they saturate the system to such a +degree as to produce a furious explosion of pain. This defect may quite +possibly be in one of the ductless glands or in some of the internal +secretions, rather than in the nervous system. + +Obviously, after what has been said of the world-wide causation of +headache, to attempt to discuss its treatment would be as absurd as to +undertake to advise what should be done for the relief of hunger, for +"that tired feeling," or for a pain in the knee. The treatment for a +headache due to an inflammation or tumor of the brain would, of course, +be wide as the poles from that which would relieve an ordinary fatigue +or indigestion pain. Besides, it is utterly irrational and often harmful +to attempt _to treat any headache as such_. That is the open road to the +morphine habit and drug addictions of all sorts. Remedies--and there are +plenty of them--which simply relieve the pain without doing anything to +remove its cause, merely make the latter state of that individual worse +than the first. Headache is always and everywhere nature's vivid warning +that something is going wrong, like the shrieking of a wagon-axle or the +clatter of a broken cog in machinery. + +There is, however, fortunately one remedy which alone will cure +ninety-nine per cent of all headaches, and that is rest. The first thing +an intelligent machinist does when squeaking or rattling begins is to +stop the machinery. This has the double advantage of preventing the +damage from going any further and of enabling him to get at the cause. +Headache, like pain anywhere, is nature's imperative order _to Halt_, at +least long enough to find out what you are doing to yourself that you +shouldn't. It makes little difference what you take for your headache, +so long as you follow it up by lying down for an hour or two, or, better +still, by going to bed for the remainder of the day and sleeping through +until the next morning. If more headaches were treated in this way there +would not only be fewer headaches, but two-thirds of the risks of +nervous breakdown, collapse, insomnia, and chronic degenerative changes +in the liver, kidneys, and blood-vessels would be avoided. + +This, of course, is a counsel of perfection, and incapable of general +application for the sternest of reasons; but it does indicate the +rational attitude toward headache and its treatment, and one which is +coming to be more and more adopted. No motorist would dream of pushing +ahead with a shrieking axle or a scorching hot box, unless his journey +were one of most momentous importance or a matter of life and death. +Pain is nature's automatic speed regulator. It is often necessary to +disregard it, to get the work of the world done and to discharge our +sacred obligations to others; but this disregarding should not be +exalted to too high a pinnacle of virtue, and least of all worshiped as +inherently and everywhere a mark of piety and one of the insignia of +saintship. + +A business firm or a factory, for instance, which would send home for +the day each of its employees who reported a genuine case of bad +headache, would, in the long run, save money by avoiding accidents, +mistakes, muddles, and confusions, often involving a whole department, +due to the kind of work that is done by a man or woman who is physically +unfit to attempt it. And the higher the type of work that has to be +done, the more the elements of insight, grasp, and sound judgment enter +into it, the graver and costlier are the mistakes that are likely to be +made under such circumstances. + +Of course, it will probably be objected at this point: "What is the use +of wasting a day, or even half a day, when by taking two or three +capsules of So-and-So's Headache Cure I can get rid of the pain and go +right on with my work?" It is perfectly true that there are a number of +remedies which will relieve the average headache; but there are two +important things to be borne in mind. The first is that all of these are +simply weaker or stronger nerve-deadeners; most of them actual +narcotics. All that they do is to stop the pain and thus cheat you into +the impression that you are better. You are just as tired and as unfit +for work as you were before. Your nervous system is just as saturated +with poisons, and the chances are ten to one that the quality of the +work that you do will be just as bad as if you had taken no medicine. +Further, like alcohol, when used as a "pick-me-up" under somewhat +similar conditions, the remedy which you have taken, while producing a +false sense of comfort and even exhilaration by deadening your pain and +discomfort, in that very process itself takes off the finer edge of your +judgment, the best keenness of your insight, and the highest balance of +your control. In short, your nervous system has to struggle with all the +poisons that were present before, with another one added to them! + +After you have taken nature's wise advice, and obeyed her orders, and +put yourself at rest, then there are a number of mild sedatives, with +which every physician is familiar, one of which, according to the +special circumstances of your case, it may be perfectly legitimate to +take in moderate doses, with the approval of a physician, as a means of +relieving the pain and helping to get that sleep which will complete the +cure. + +One other measure of relief, which, like rest, is also indicated by +instinct, is worth mentioning, and that is gentle friction of the head. +One of the most instinctive tendencies of most of us when suffering from +a severe headache is to put the hands to the head, either for the +purpose of frantically clutching at it, rubbing as if our lives depended +upon it, or pressing hard over the aching region. The mere picture of a +man with his head in his hands instantly suggests the idea of headache. +Part of this is, of course, little more than a blind impulse to do +something to or with the offending member. We would sometimes like to +throw it away if we could, or at others to bang it against the wall. But +part of it is due to the discovery, ages ago, that pressure and friction +would give a certain amount of relief. + +For some curious reason the nerves most frequently involved are those +which are most readily accessible for this kind of treatment, namely, +the long nerve-threads which run from the inner third of the eyebrow up +the forehead and over the crown of the head (the so-called supraorbital +or frontal branches). A corresponding pair run up the back of the neck, +about half-way between the back of the ear and the spinal column, +supplying the back of the head and the crown (these form the cervical +plexus); and a smaller pair run up just in front of the ear into the +temple, and from there on upward to join the other two pairs at the top +of the head. + +Broadly speaking, the position of the pain depends upon which pair of +these nerves is lifting up its voice most vigorously in protest. If it +be the front pair (supraorbitals) then we get the well-known frontal or +forehead headache; if the back pair (known as the occipitals) then we +have the deadly, constricting, band-around-the-head pain which clutches +us across the back of the neck and base of the brain. If the lateral +pair are chiefly affected then we get the classic throbbing temples. +Practically all of these aches, however, are of the "fire-alarm" +character; and while certain of these nerve-gongs show some tendency to +respond more readily to calls coming in from certain regions of the +body, as, for instance, the forehead nerves to eye-strain, the +back-of-the-head nerves (occipital) to grave toxic states of the system, +the tips of any of the nerves in the crown of the head to pelvic +disturbances and anaemic conditions, the lateral branches in the temples +to diseases of the teeth and throat, yet there is little fixed +uniformity in these relations. Eye-strain, for instance, may cause +either frontal or occipital headache; and, as every one knows from +experience, the pain may be felt in all parts of the head at once. + +Gentle and intelligent massage over the course of these nerves of the +scalp, according to the location of the pain, will often do much to +relieve the severity of the suffering. + +Treat headache as a danger signal, by rest and the removal of its cause, +and it will prevent at least ten times as much suffering and disability +as it causes. + + + + +CHAPTER XVIII + +NERVES AND NERVOUSNESS + + +Nerves are real things. In spite of their connection with imaginary +diseases and mental disturbances, there is nothing imaginary or +unsubstantial about them. There is no more genuine and obstinate malady +on earth than a nervous disease. Because nerves lie in that twilight +borderland between mind and matter, body and soul, the real and the +ideal, the impression has got abroad that they are little better than +figures of speech. Though their disturbances give rise to visions of all +sorts there is nothing visionary about them; they are just as genuine +and substantial a part of our bodily structure as our bones, muscles, +and blood-vessels. In fact, it was this very substantiality that at the +beginning prevented their proper recognition, and handicapped them with +their present absurd and inappropriate name. + +"Nerve" is from the Greek _neuron_, meaning tendon, or sinew, and was +originally applied indiscriminately to all the different shining cords +which run down the limbs and among the muscles. In fact the first +recognition of nerves was an utter failure to recognize. The tendon +cords, which are the ropes with which the muscles work the joint +pulleys, were actually included under one head with the less numerous +but almost equally large and tough cords of grayer color, flatter +outline, and less glistening hue, which were afterwards found to be +nerve-trunks. Cutting either paralyzed the limb below the cut,--and what +more proof could you ask of their having the same function? + +Such is the persistence of ancient memories, that any physician could +tell you of scores of cases in which he has heard the naive remark, in +reference most frequently to a deep gash across the wrist, that the +"nerves" were cut, and the hand was paralyzed, when what had happened +was simply that the tendons had been cut across. When, after centuries +of blundering in every possible direction until the right one was +finally stumbled upon (which is the mechanism of progress), it was +realized that some of these "nerves," the grayer and flatter ones, +carried messages instead of pulling ropes, they were still far from +being properly understood. + +It is an amusing illustration of the blissful ignorance and charming +naivete which marked their study and discussion at this time, that +nerves were for centuries regarded as hollow tubes, carrying a supply of +"animal spirits" from the central reservoir of the brain to the +different limbs. So seriously was this believed, that, in amputations, +the cut nerve-trunks were carefully sought out and tied, for fear the +vital spirits would leak out and the patient thus literally bleed to +death. One can imagine how this must have added to the comfort of the +luckless patient. + +The term "nerves" still persists, in the old sense, in both botany and +entomology, which speak of the "nerves" of a butterfly's wing, or the +"nervation" of a leaf, meaning simply the branching, fibrous framework +of each. + +It comes in the nature of a surprise to most of us to learn that +"nerves" are real things. I shall never forget the shock of my own first +convincing demonstration of this fact. It was in one of the first +surgical clinics that I attended as a medical student. A woman patient +was brought in, with a history of suffering the tortures of the damned +for a year past, from an uncontrollable sciatica. + +It was a recognized procedure in those days (and is resorted to still), +when all medical, electrical, and other remedial measures had failed to +relieve a furious neuralgia, for the surgeon to cut down upon the +nerve-trunk, free it from its surrounding attachments, and, slipping his +tenaculum or finger under it, stretch the nerve with a considerable +degree of force. Whether it acts by merely setting up some trophic +change in the nerve-tissue, or by tearing loose inflammatory adhesions +which are binding down the nerve-trunk, the procedure gives excellent +results, nearly always temporary relief, and sometimes a permanent cure. + +The patient was placed upon the table and anaesthetized, and the surgeon +made a free, sweeping incision down the back of the thigh, exposing the +sciatic nerve. He thrust his finger into the wound, loosened up the +adhesions about the nerve, hooked two fingers underneath it, and, to my +wide-eyed astonishment, heaved upward upon it, until he brought into +view through the gaping wound a flattened, bluish-gray cord about twice +the size of a clothesline, with which he proceeded to lift the hips of +the patient clear of the table. In my ignorant horror, I expected every +moment to see the thing snap and the patient go down with a bump, +paralyzed for life; but I never doubted after that that nerves were real +things. Though it has nothing to do with this discussion, for the +benefit of those of my readers who cannot bear to have a story left +unfinished, I will add that the operation was as successful as it was +dramatic, and the patient left the hospital completely relieved of her +sciatica. + +When at last it was clearly recognized that the nerves were concerned in +the sending of messages from the centre to the brain, known as +_sensory_, or centripetal, and carrying back messages from the brain to +the muscles and surface, known as _motor_, or centrifugal,--in other +words that they were the organs of the mind,--still another source of +confusion sprang up, and that was the determination on the part of some +to regard them from a purely mental and, so to speak, spiritual point of +view, and on the part of others to regard them from a physical and +anatomical point of view. This confusion is of course in full riot at +the present time. + +The term "nerves," and its adjective, "nervous," are used in two totally +distinct senses: one, that which is vague and unsubstantial, purely +mental or subjective, and, in the realm of disease at least, imaginary; +the other, purely anatomical, referring to certain strands of tissue +devoted to the purpose of transmitting impulses, and the condition +affecting these strands. I am not so rash as to raise the question +here,--still less to attempt to settle it,--which of these two views is +the right and rational one. Whether the brain secretes thought as the +liver does bile, or whether the mind created the brain and nervous +system, or, as it has been epigrammatically put in a recent work on +psychology, "whether the mind has a body, or the body has a mind," I +merely call attention to the fact that this confusion of meanings +exists, and that its injection into the field of medicine and pathology, +at least, has done an enormous amount of harm in the way of confusing +problems and preventing a proper recognition of the actual facts. + +The more carefully and exhaustively and dispassionately we study the +disorders of the nervous system which come in the field of medicine, the +more irresistibly we are drawn to the conclusion that from neurasthenia +and hysteria to insanity and paralysis they are every one of them the +result of some definite morbid change in some cell or strand of the +nervous system. The man or woman who is nervous has poisoned +nerve-cells, either from hereditary defect, or direct saturation of the +tissues with toxic substances. The patient who has an imaginary disease +is suffering from some kind of a hallucination produced by poison-soaked +nerve-cells, such as in highest degree give rise to the delirium of +fevers, and the horrid spectres of delirium tremens. + +Even the man who is suffering from a "mind diseased," and confined in +one of our merciful asylums for the insane, is in that condition and +position on account of physical disease, not merely of his brain, but of +his entire body. The lunatic is insane, in the for once correct +derivative sense of unhealthy, to the very tips of his fingers. Not +merely his mind and his brain, but his liver, his stomach, his skin, his +hair and fingernails, the very sweat-glands of his surface which control +his bodily odor, are diseased and have been so usually for years before +his mind breaks down. + +Tell a competent expert to pick out of a crowd of a thousand men and +women the ten who are likely to become insane, and his selection will be +found almost invariably to include the two or three who will actually +become so. + +In fact, from even the crudest and scantiest knowledge of the actual +growth of our own bodies from the ovum to the adult, it will be +difficult to conceive how this relation could be otherwise, The +nerve-cells and their long processes, which form the nerve-trunks, are +simply one of a score of different specialized cells which exist side by +side in the body. Primarily all our body-cells had the power of +responding to stimuli, of digesting and elaborating food, of moving by +contraction, of reproducing their kind. The nerve-cells are simply a +group which have specialized exclusively upon the power of receiving and +transmitting impulses. They still take food, but it has to be prepared +for them by the other cells; and here, as we shall see later, is one of +the dangers to which they are exposed. They still reproduce their kind, +but in very much smaller and more limited degree. They still, incredible +as it may seem, probably have slight powers of movement or contraction, +and can draw in their processes. But they have surrendered many of their +rights and neglected some of their primitive accomplishments, in order +to devote themselves more exclusively and perfectly to the carrying out +of one or two things. + +In spite of all this, however, they still remain blood-brothers and +comrades to every other cell in the body. In the language of Shylock, +"If you cut them, they will bleed; if you tickle them, they will laugh; +if you starve them, they will die." In all this development, which +continued up to a late hour last night, and is still going on, the +nerve-tissue has lain side by side with every other tissue in the body, +fed by the same blood, supplied with the same oxygen, saturated with the +same body-lymph. + +It is of course perfectly clear that any influence, whether beneficial +or injurious, affecting the body, will also be likely to affect the +nervous system, as a part of it; and this is precisely the fact, as we +find it. If the body be well fed, well warmed, sufficiently exercised, +without being overworked, and allowed a liberal allowance of that +recharging of the human battery which we call sleep, then the nervous +system will work smoothly and easily, at peace with itself and with all +mankind. Its sense-organs will receive external impressions promptly and +accurately. Its conducting fibres will transmit them to the centre with +neither delay nor friction. The brain clearing-house will receive and +dispose of them with ease and good judgment. And then, just because his +nervous system is working to perfection, we say that such an individual +"has no nerves." + +If the triumph of art be to conceal art, then the nerves have achieved +this. They have literally effaced themselves in the well-being of the +body. + +If on the other hand, the food-supply is inadequate, if the sleep +allowance has been cut short, whether by the demands of work or by those +of fashion, if the body has been starved of oxygen and deprived of +sunlight, if the whole system has been kept on the rack, whether in the +sweatshop, or in the furnace of affliction, what is the effect on the +nervous system? Just what might have been expected. The sense-organs +shy, like a frightened horse, at every shadow or fluttering leaf. The +conducting wires break, and cross, and tangle in every imaginable +fashion. The central exchange, half wild with hunger, or crazed with +fatigue-toxins, shrieks out as each distorted message comes in, or sulks +because it can't understand them. And then, with charming logicality, we +declare that such an one is "all nerves." + +The brain, by which we mean the biggest one near the mouth,--we have +little brains, or _ganglia_ all over our bodies,--so far from being an +absolute monarch, is not even a constitutional one, or a president of a +republic, but a mere house of congress of the modern type, which can do +little but register and obey the demands of its constituents. The brain +originates nothing. Impulses are brought to it from the sense-organs by +the nerves. They set up in it certain vibrations, or chemical +disturbances. It responds to these much as blue litmus paper turns red +when a weak acid is dropped on it, or as lemonade fizzes when you put +soda in it. If more than one of these vibrations are set up +simultaneously, it "chooses" between them, by responding to the +strongest. If the response differs from the stimulus, it is because of +its huge deference to precedent as established by the records of +previous stimuli with which its tissues are stored. + +This brings us to the interesting and important question, What are the +causes of these disturbances of the nerve-tissues? Probably the most +important single result that has been reached in our study of nervous +diseases in the last fifteen years, is that the cause of them in easily +eighty per cent of all cases _lies entirely outside of the nervous +system_. + +The stomach burns, the nerve-tissues send in the fire alarm and order +out the engines. The liver goes on a strike, and the body-garbage, which +it has failed to burn to clean ashes and clear smoke, poisons the +nerve-cells, and they remonstrate accordingly, on behalf of the other +tissues. The heart, or blood-vessels, fails to supply a certain muscle +with its due rations of blood and the nerves of the region cry out in +the agony of cramp. + +We have discovered, by half a century of careful study in the hospital +and in the sick-room, not only that the nerve-tissues are usually +poisoned by defect of other tissues of the body, but that they are among +the very last of the body-stuffs to succumb to an intoxication. The +complications of a given disease involving the nervous system are almost +invariably the last of all to appear. This is one of the things that has +given nervous diseases such a bad name for unmanageableness and +incurableness, and that for years made us regard their study as so +nearly hopeless, so far as any helpful results were concerned. + +When a disease has, so to speak, soaked into the inmost core of the +nerve-fibre, it has got a hold which it will take months and even years +to dislodge. And before your remedies can reach it, it will often have +done irreparable damage. An illustration of the care taken to spare the +nervous system is furnished by its behavior in starvation. If a man or +an animal has almost died of starvation, the tissues of the body will be +found to have been wasted in very varying degrees, the fat, of course, +most of all; in fact this will have almost entirely disappeared, all but +three per cent. Then come the liver and great glands, which will have +shrunk about sixty per cent; then the muscles, thirty per cent; then the +heart and blood-vessels. Last of all, the nervous system, which will +scarcely have wasted to any appreciable degree. In fact, it is an +obvious instance of jettison on the part of the body, throwing overboard +those tissues which it could most easily spare, and hanging on like grim +death to those which were absolutely essential to its continued +existence, viz., the heart and the nervous system. To use a +cannibalistic and more correct illustration, it is killing and eating +the less useful and valuable members of its family, in order that their +flesh may keep alive the two or three most indispensable. + +Another illustration is the actual behavior of the nerve-stuff in +disease. This is most clearly shown in those clear-cut disturbances +which are definitely known to be due to a specific infection; in other +words, invasion of the body by a disease-organism, or germ. + +First of all, it may be stated that physicians are now substantially +agreed that two-thirds of the general diseases of the nervous system are +due to the extension of one of these acute infections to the +nerve-tissue; and this extension almost invariably comes late in the +disease. The only exceptions to this rule in the whole list of +infectious diseases are two, epidemic cerebro-spinal meningitis (spotted +fever), and tetanus (lockjaw). Both of these have an extraordinary and +deadly preference for the nervous system from the very start, and this +is what gives them their frightful mortality and discouraging outlook. +Even of this small number of exceptions, we are not altogether certain +as to epidemic meningitis, inasmuch as we do not know how long the germ +may have existed in the other tissues of the body before it succeeded in +working its way to and attacking the brain and spinal cord. + +The case of tetanus, however, is perfectly clear in this regard, and +exceedingly interesting, inasmuch as it explains why a disease specially +involving the nervous system from the start is so excessively hard to +check or cure. The germ of the disease, long ago identified as one +having its habitat in farm or garden soils,--particularly those which +have been heavily fertilized with horse manure,--gets into the system +through a cut or scratch upon the surface, into which the soil is +rubbed. These infected cuts, for obvious reasons, are most frequently +upon the hands or feet. + +Small doses of the organism have been injected into animals; then, when +they have recovered, larger ones, and so on, after the manner of the +bacillus of diphtheria, until a powerful antitoxin can be obtained from +their blood, very minute quantities of which will promptly kill the +bacilli in a test-tube. For seven or eight years past we have been +injecting this into every patient with tetanus that came under our +observation, but so far with very limited benefit, even though the +injections were made directly into the spinal cord, or brain substance. +The problem puzzled us for years, until finally Cattani stumbled upon +the explanation. While we had been supposing that the poison was +carried, as almost every other known poison is, through the +blood-vessels, or lymph-channels, to the heart and thence to the brain, +he clearly proved that it ran up the central axis of the nerve-trunks, +and consequently, when it had got once fairly started up this channel, +was as safe from the attack of any antitoxin merely present in the +general circulation and fluids of the body, as the copper of the +Atlantic cable is from the eroding action of the sea-water. If, in his +experimental animals, he carefully sought for the cut end of the +nerve-trunk in the wound that had been infected, and injected the +antitoxin directly into that, the disease was stopped. Or it might even +be "headed off" by the crude method of cutting directly across the +nerve-trunk at a point above that yet reached by the infection. + +The commonest and most fatal of all forms of general diseases of the +nervous system are those which are due to the later extensions of +general infections. + +First and foremost stands syphilis, due to the invasion of the blood by +a clearly defined _spirillum_, the _Treponema pallida_ of Schaudinn. +This first attacks the mucous membranes of the throat and mouth, then +the skin, then the great internal organs like the liver and stomach, +then the bones, and, last of all, the nervous system. The length of time +which the poison takes to reach the nervous system is something which at +first sight is almost incredible, viz., from one and a half to fifteen +years. It is true that in rare instances brain symptoms will manifest +themselves within six or eight months; but these are usually due to +pressure by inflammatory growths on the bones of the skull and its +lining membrane (_dura mater_). It is not too much to say that this +disease plays the greatest single role in nervous pathology. Three of +the commonest and most fatal diseases of the spinal cord and brain, +_paresis_ (general paralysis of the insane), _locomotor ataxia_, and +_lateral sclerosis_, are due to it. + +Naturally, when a poison has taken a decade or a decade and a half to +penetrate to the nerve-tissues, it does irreparable damage long before +it can be dislodged or neutralized. + +A similar aftermath may occur in almost all of the acute infectious +diseases. Every year adds a new one to the list capable of causing +cerebral complications. Tuberculosis, diphtheria, scarlet fever, +typhoid, smallpox, influenza, have now well-recognized cerebral and +nervous complications, some temporary, some permanent. A form of +tuberculosis attacking the coverings (_meninges_) of the brain--hence +known as meningitis--is far the commonest fatal brain-disease of +infancy and childhood. + +Perhaps the most striking illustration of just how acute affections +attack the nervous system, is that furnished by diphtheria. A child +develops an attack of this disease, passes the crisis safely, and begins +to recover. A few days later, it is allowed to sit up in bed. Suddenly, +after some slight exertion, or often without any apparent cause, the +face blanches, the eyes stare widely, the child gasps two or three +times, and is dead: sudden heart failure, due to the poisoning either of +the heart muscle itself, or of the nerves supplying the heart, by the +toxin of the disease. Moral: Keep diphtheria patients strictly at rest +in bed for at least a week after the crisis is past. Another case will +pass this period safely, though perhaps with a rapid and weak heart, for +days or weeks; then one morning the child will choke when swallowing +milk. The next time it is attempted, the milk, instead of going down the +throat, comes back through the nostrils. Paralysis of the soft palate +has developed, apparently from a local saturation of the nerves with the +poison. This may go no further, or it may extend, as it commonly does, +to the nerves of the eye, and the child squints and can no longer read, +if old enough, because the muscle of accommodation also is paralyzed. +The arms and limbs may be affected, and in extreme cases the nerves of +respiration supplying the diaphragm may be involved, and the child dies +of suffocation. In the majority of cases, however, fortunately, after +this paralysis has lasted from three to six weeks, it gradually +subsides, and may clear up completely, though not at all infrequently +one or more muscles may remain permanently damaged by the attack, +giving, for instance, a palatal tone to the voice, or interfering with +the production of singing tones. Occasionally a permanent squint may +follow. + +It might be said in passing, that, with one of the charming logicalities +of popular reasoning, these nerve complications have been said to be +_caused by_ antitoxin, simply because the use of the antitoxin saves +more children alive to develop them. + +The next group of nervous diseases may be roughly described as due to +the failure of some part of the digestive system, like the stomach and +intestines, properly to elaborate its food; or of one of the great +glands, like the liver, thyroid, or suprarenal, properly to supply its +secretion, which is needed to neutralize the poisons normally produced +in the body. This class is very large and very important. It has long +been known how surely a disordered liver "predicts damnation"; +melancholia, or "black bilious condition," hypochondria, or "under the +rib-cartilages" (where the liver lies), are every-day figures of speech. +A thorough house-cleaning of the alimentary canal, together with proper +stimulation of the skin and kidneys, and an intelligent regulation of +diet, are our most important measures in the treatment of diseases of +the nervous system, even in those extreme forms known as insanity. + +Closely allied to these are those disturbances of the nervous system +lumped together under the soul-satisfying designation of "neurasthenia," +which are chiefly due to the accumulation in the system of the fatigue +poisons, or substances due to prolonged overstrain, under-rest, or +underfeeding of the system. Neurasthenia is the "fatigue neurosis," as a +leading expert terms it. It may be due to any morbid condition under +heaven. It is "that blessed word Mesopotamia" of the slipshod +diagnostician. Nearly one-fourth of the cases which come into our +sanatoria for tuberculosis have been diagnosed and treated for months +and even years as "neurasthenia." It satisfies the patient--and it means +nothing; though some experts contend for a distinct disease entity of +this name but admit its rarity. + +The intelligent neurologist, nowadays, has practically no known specific +for any form of nervous disease, no remedy which acts directly and +curatively upon the nervous system itself. He relies chiefly--and this +applies to the asylum physician also--upon intestinal antisepsis, upon +rest, upon baths, upon regulation diet, and habits of life. + +A number of the more sudden and fatal disturbances of the nervous +system, as for instance, the familiar "stroke of paralysis," or +apoplexy, of later middle life, are due to a defect, not in the nervous +system at all, but in the blood-vessels supplying the brain; rupture of +a vessel, and consequent escape of blood, destroys so much of the +surrounding brain-tissue as to produce paralysis, and, in extreme cases, +death. Just why the blood-vessels of the brain in general, and of one +part of the basal ganglia in particular (the _Lenticulostriate_ artery +in the internal capsule of the _corpus striatum_, the old jaw +ganglion), are so liable to rupture we do not know; but it certainly is +chiefly from a defect of the blood-vessels, and not of the brain. All of +which brings us to the following important practical conclusions. + +First of all, that every attack or touch, however light, of +"nervousness," "nerves," "imagination," "neurasthenia," yes, hysteria, +_means_ something. It is the cry of protest of a smaller or larger part +of the nervous system against underfed blood, under-ventilated muscles, +lack of sunlight, lack of exercise, lack of sleep, excess of work, or +bad habits. In other words, it is the danger signal, the red light +showing the open switch, and we will disregard it at our peril. +Unfortunately, by that power of _esprit de corps_ of the entire system, +known as "pluck" or "grit," or the veto-power, physiologically termed +inhibition, we may ignore and for a time suppress the symptom, but this +in the long run is just as rational as cutting the wire that rings a +fire alarm, or blowing out the red light without closing the switch. + +Nervousness is a _symptom_ which should always have _something done for +it_, especially in children. In fact, it has passed into an axiom both +with intelligent teachers and with physicians who have much to do with +the little ones, that crossness, fretfulness, laziness, lack of +initiative, and readiness to weep, in children, are almost invariably +the signs of physical disease. And this doctrine will apply to a +considerable percentage of children of larger growth. + +Unfortunately, one of the first and most decided tendencies on the part +of the badly fed or poisoned nervous system, is to exaggerate the +difficulties of the situation, and to minimize its good features. The +individual "has lost his nerve," is afraid to undertake things, shrinks +from responsibility, exaggerates the difficulties that may be in the +way; hence the floods of tears, or outbursts of temper, with which +nervous children will greet the suggestion of any task or duty, however +trifling. If the nervous individual has reached that stage of maturity +when she realizes that she is not merely "naughty," but sick, then this +same process applies itself to her disease. She is sure that she is +going to die, that another attack like that will end in paralysis; as a +patient of mine once expressed it to me, "My heart jumps up in my mouth, +I bite a couple of pieces off it, and it falls back again." In short, +she so obviously and grossly exaggerates every symptom and phase of her +disease, that the impression irresistibly arises that the disease itself +is a fabrication. This view of her condition by her family or her +physician is the tragedy of the neurasthenic. + +Broadly speaking, _no_ disease, even of the nervous system, is ever +purely imaginary. Some part of the patient's nervous system is poisoned, +or he would not imagine himself to be sick. We can all of us find +trouble enough in some part of our complex bodily machinery, if we go +around hunting for it; but this is precisely what the healthy man, or +woman, _never_ does. They have other things to occupy them, and are far +more liable to run into danger by pushing ahead at full steam, and +neglecting small creakings and jarrings until something important in the +gear jams, or goes snap, and brings them to a halt, than they are to be +wasting time and energy worrying over things that may never happen. + +Worry, in fact, is a sign of disease instead of a cause. To put it very +crudely, whenever the blood and fluids of a body become impoverished +below a certain degree, or become loaded with fatigue poisons, or other +waste products above a certain point, then the nervous system proceeds +to make itself felt. Either the perceptive end-organs become color-blind +and read yellow for blue, or are astigmatic and report oval for round; +or the conducting nerve-strands tangle up the messages, or deliver them +to the wrong centre; or the central clearing-house, puzzled by the +crooked messages, loses its head, and begins to throw the inkstands +about, or goes down in a sulk. In other words, the nervous system goes +on a strike. But it is perfectly idle to endeavor to treat it with +cheering words, or kindly meant falsehoods, to the effect that "nothing +is really the matter." Like any other strike, it can be rationally dealt +with only by improving the conditions under which the operatives have to +work, and meeting their demands for higher wages, or shorter hours. + +We were accustomed at one time to divide diseases into two great +classes, organic and functional. By the former, we meant those in which +there was some positive defect of structure, which could be recognized +by the eye or the microscope; by the latter, those diseases in which +this could not be discovered, in which, so to speak, the machine was all +right, but simply wouldn't work. It goes without saying that the latter +class was simply a confession of our ignorance, and one which is +steadily and rapidly diminishing as science progresses. + +If the machine won't work, there is a reason for it somewhere, and our +business is to find it out, and not loftily to assure our patients that +there is nothing much the matter, and all they need is rest, or a little +cheerful occupation. Furthermore, the most inane thing that a +sympathizing friend or kindly physician can do to a neurasthenic, is to +advise him to take his mind off himself or his symptoms. The utter +inability to do that very thing is one of the chief symptoms of the +disease, which will not disappear until the underlying cause has been +carefully studied out and removed. + +"Nerves," "neurasthenia," "psychasthenia," and "hysteria," are all the +names of _symptoms_ of _definite bodily disease_. The modern physician +regards it as his duty to study out and discover the nature of this +disease, and, if possible, remove it, rather than to give high-sounding, +soul-satisfying names to the symptoms, and advise the patient to "cheer +up"; which advice costs nothing--and is worth just what it costs. + +"But," some one will say at once, "if nervous diseases are simply the +reflection of general bodily states, as sanitary conditions improve +under civilization, should they not become less frequent? And yet, any +newspaper will tell you that nervous diseases are rapidly on the +increase." This is a widespread belief, not only on the part of the +public, but of many scientists and a considerable number of physicians; +but it is, I believe, unfounded. + +In the first place, we have no reliable statistical basis for a positive +statement, either one way or another. Our ignorance of the precise +prevalence of disease in savagery, in barbarism, and even under +civilization up to fifty years ago, is absolute and profound. It is only +since 1840 that vital statistics of any value, except as to gross deaths +and births, began to be kept. So far as we are able to judge from our +study of savage tribes by the explorer, the army surgeon, and the +medical missionary, the savage nervous system is far less well balanced +and adjustable than that of civilized man. Hysteria, instead of +occurring only in individual instances, attacks whole villages and +tribes. In fact, the average savage lives in a state alternating between +naive and childish self-satisfaction and panic-stricken terror, with +their resultant cowardice and cruelty on the one hand, and unbridled +lust and delusions of grandeur on the other. The much-vaunted strain of +civilization upon the nervous system is not one-fifth that of savagery. + +Think of living in a state when any night might see your village raided, +your hut burned, yourself killed or tortured at the stake, and your wife +and children carried into slavery. Read the old hymns and see how +devoutly thankful our pious ancestors _were every day_ at finding +themselves alive in the morning,--"Safely through another night,"--and +fancy the nerve-strain of never knowing, when you lay down to sleep, +whether some one of the djinns, or voodoos, or vampires would swoop down +upon you before morning. Think of facing death by famine every winter, +by drought or cyclone every summer, and by open war or secret +scalp-raid every month in the year; and then say that the racking +nerve-strain of the commuter's time-table, the deadly clash of the +wheat-pit, or the rasping grind of office-hours, would be ruinous to the +uncivilized nervous system. Certainly, in those belated savages, the +dwellers in our slums, hysteria, diseases of the imagination, enjoyment +of ill health, and the whole brood of functional nervous disturbances +are just as common as they are on Fifth Avenue. + +It is not even certain that insanity is increasing. Insanity is quite +common among savages; just how common is difficult to say, on account of +their peculiar methods of treating it. The stupid and the dangerous +forms are very apt to be simply knocked on the head, while the more +harmless and fantastic varieties are turned into priests and prophets +and become the founders of the earlier religions. A somewhat similar +state of affairs of course prevailed among civilized races up to within +the last three-quarters of a century. The idiot and the harmless lunatic +were permitted to run at large, and the latter, as court and village +fools, furnished no small part of popular entertainment, since organized +into vaudeville. Only the dangerous or violent maniacs were actually +shut up; consequently, the number of insane in a community a century ago +refers solely to this class. Hence, in every country where statistics +have been kept, as larger and larger percentages of these unfortunates +have been gathered into hospitals, where they can be kindly cared for +and intelligently treated, the number of the registered insane has +steadily increased up to a certain point. This was reached some fifteen +years ago in Great Britain, in Germany, in Sweden, and in other +countries which have taken the lead in asylum reform, and has remained +practically stationary since, at the comparatively low rate of from two +to three per thousand living. This limit shows signs of having been +reached in the United States already; and this gradual increase of +recognition and registration is the only basis for the alleged increase +of insanity under modern conditions. + +It is also a significant fact that the lower and less favorably situated +stratum of our population furnishes not only the largest number of +inmates, but the largest percentage of insanity in proportion to their +numbers, while the most highly educated and highly civilized classes +furnish the lowest. Immigrants furnish nearly three times as many +inmates per thousand to our American asylums as the native born. + +It is, however, true that in each succeeding census a steadily +increasing number and percentage of the deaths is attributed to diseases +of the nervous system. This, however, does not yet exceed fifteen or +twenty per cent of the whole, which would be, so to speak, the natural +probable percentage of deaths due to failure of one of the five great +systems of the body: the digestive, the respiratory, the circulatory, +the glandular, the nervous. Two elements may certainly be counted upon +as contributing in very large degree to this apparent increase. One is +the enormous saving of life which has been accomplished by sanitation +and medical progress during the first five years of life, infant +mortality having been reduced in many instances fifty to sixty per +cent, thus of course leaving a larger number of individuals to die later +in life by the diseases especially of the blood-vessels, kidneys, and +nervous system, which are most apt to occur after middle life. The other +is the great increase in medical knowledge, resulting in the more +accurate discovery of the causes of death, and a more correct reporting +and classifying of the same. + +In short, a careful review of all the facts available to date leads us +decidedly to the conclusion that the nervous system is the toughest and +most resisting tissue of the body, and that its highest function, the +mind, has the greatest stability of any of our bodily powers. Only one +man in six dies of disease of the nervous system, as contrasted with +nearly one in three from diseases of the lungs; and only one individual +in four hundred becomes insane, as contrasted with from three to ten +times that number whose digestive systems, whose locomotor apparatus, +whose heart and blood-vessels become hopelessly deranged without +actually killing them. + + + + +CHAPTER XIX + +MENTAL INFLUENCE IN DISEASE, OR HOW THE MIND AFFECTS THE BODY + + +One of the dearest delusions of man through all the ages has been that +his body is under the control of his mind. Even if he didn't quite +believe it in his heart of hearts, he has always wanted to. The reason +is obvious. The one thing that he felt absolutely sure he could control +was his own mind. If he couldn't control that, what could he control? +Ergo, if man could control his mind and his mind could control his body, +man is master of his fate. Unfortunately, almost in proportion as he +becomes confident of one link in the chain he becomes doubtful of the +other. Nowadays he has quite as many qualms of uncertainty as to whether +he can control his mind as about the power of his mind over his body. By +a strange paradox we are discovering that our most genuine and lasting +control over our minds is to be obtained by modifying the conditions of +our bodies, while the field in which we modify bodily conditions by +mental influence is steadily shrinking. + +For centuries we punished the sick in mind, the insane, loading them +with chains, shutting them up in prison-cells, starving, yes, even +flogging them. We exorcised their demons, we prayed over them, we argued +with them,--without the record of a single cure. Now we treat their +sick and ailing bodies just as we would any other class of chronic +patients, with rest, comfortable surroundings, good food, baths, and +fresh air, correction of bad habits, gentleness, and kindness, leaving +their minds and souls practically without treatment, excepting in so far +as ordinary, decent humanity and consideration may be regarded as mental +remedies,--and we cure from thirty to fifty per cent, and make all but +five per cent comfortable, contented, comparatively happy. + +We are still treating the inebriate, the habitual drunkard, as a minor +criminal, by mental and moral means--with what hopeful results let the +disgraceful records of our police courts testify. We are now treating +truancy by the removal of adenoids and the fitting of glasses; juvenile +crime by the establishment of playgrounds; poverty and pauperism by +good food, living wages, and decent surroundings; and all for the first +time with success. + +In short, not only have all our substantial and permanent victories over +bodily ills been won by physical means, but a large majority of our +successes in mental and moral diseases as well. Yet the obsession +persists, and we long to extend the realm of mental treatment in bodily +disease. + +That the mind does exert an influence over the body, and a powerful one, +in both health and disease, is obvious. But what we are apt to forget is +that the whole history of the progress of medicine has been a record of +diminishing resort to this power as a means of cure. The measure of our +success and of our control over disease has been, and is yet, in exact +proportion to the extent to which we can relegate this resource to the +background and avoid resorting to it. Instead of mental influence being +the newest method of treatment it is the oldest. Two-thirds of the +methods of the shaman, the witch-doctor, the medicine-man, were psychic. +Instead of being an untried remedy, it is the most thoroughly tested, +most universal, most ubiquitous remedy listed anywhere upon the pages of +history, and, it may be frankly stated, in civilized countries, as +widely discredited as tested. The proportion to which it survives in the +medicine of any race is the measure of that race's barbarism and +backwardness. To-day two of the most significant criteria of the measure +of enlightenment and of control over disease of either the medical +profession of a nation or of an individual physician are the extent to +which they resort to and rely upon mental influence and opium. +Psychotherapy and narcotics are, and ever have been, the sheet-anchors +of the charlatan and the miracle-worker. + +The attitude of the medical profession toward mental influence in the +treatment of disease is neither friendly nor hostile. It simply regards +it as it would any other remedial agency, a given drug, for instance, a +bath, or a form of electricity or light. It is opposed to it, if at all, +only in so far as it has tested it and found it inferior to other +remedies. Its distrust of it, so far as this exists, is simply the +feeling that it has toward half a hundred ancient drugs and remedial +agencies which it has dropped from its list of working remedies as +obsolete, many of which still survive in household and folk medicine. My +purpose is neither to champion it nor to discredit it, and least of all +to antagonize or throw doubt upon any of the systems of philosophy or of +religion with which it has been frequently associated, but merely to +attempt to present a brief outline of its advantages, its character, and +its limitations, exactly as one might of, say, calomel, quinine, or +belladonna. + +As in the study of a drug, the chief points to be considered are: What +are its actual powers? What effects can be produced with it, both in +health and sickness? What are the diseases in which such effects may be +useful, and how frequent are they? In what way does it produce its +effects, directly or indirectly? + +The first and most striking claim that is made for mental influence in +disease is based upon the allegation that it has the power of producing +disease and even death; the presumption, of course, being that, if able +to produce these conditions, it would certainly have some influence in +removing or preventing them. Upon this point the average man is +surprisingly positive and confident in his convictions. Popular +literature and legend are full of historic instances where individuals +have not merely been made seriously ill but have even been killed by +powerful impressions upon their imaginations. Most men are ready to +relate to you instances that have been directly reported to them of +persons who were literally frightened to death. But the moment that we +come to investigate these widely quoted and universally accepted +instances, we find ourselves in a curious position. On the one hand, +merely a series of vague tales and stories, without date, locality, +name, or any earmark by which they can be identified or tested. On the +other, a collection of rare and extraordinary instances of sudden death +which have happened to be preceded by a powerful mental impression, many +of which bear clearly upon their face the imprint of death by rupture of +a blood-vessel, heart failure, or paralysis, in the course of some +well-marked and clearly defined chronic disease, like valvular +heart-mischief, diabetes, or Bright's disease. + +Upon investigation most of these cases which have been seen by a +physician previous to death have been recognized as subject to a disease +likely to terminate in sudden death; and practically all in which a +post-mortem examination has been made have shown a definite physical +cause of death. The fright, anger, or other mental impression, was +merely the last straw, which, throwing a sudden strain upon already +weakened vessels, heart, or brain, precipitated the final catastrophe. +In some cases, even the sense of fright and the premonition of +approaching death were merely the first symptoms of impending +dissolution. + +The stories of death from purely imaginative impressions, such as the +victims being told that they were seriously ill, that they would die on +or about such and such a date, fall into two great classes. The first of +these--involving death at a definite date, after it had been prophesied +either by the victim or some physician or priest--may be dismissed in a +few words, as they lead at once into the realm of prophecy, witchcraft, +and voodoo. Most of them are little better than after-echoes of the +ethnic stories of the "evil eye," and of bewitched individuals fading +away and dying after their wax image has been stuck full of pins or +otherwise mutilated. There have occurred instances of individuals dying +upon the date at which some one in whose powers of prophecy they had +confidence declared they would, or even upon a date on which they had +settled in their own minds, and announced accordingly; but these are so +rare as readily to come within the percentage probabilities of pure +coincidence. Most such prophecies fail utterly; but the failures are not +recorded, only the chance successes. + +The second group of these alleged instances of death by mental +impression is in most singular case. Practically every one with whom you +converse, every popular volume of curiosities which you pick up, is +ready to relate one or more instances of such an event. But the more you +listen to these relations, the more familiar do they become, until +finally they practically simmer down to two stock legends, which we have +all heard related in some form. + +First, and most famous, is the story of a vigorous, healthy man accosted +by a series of doctors at successive corners of the street down which he +is walking, with the greeting:-- + +"Why, my dear Mr. So-and-So, what is the matter? How ill you look!" + +He becomes alarmed, takes to his bed, falls into a state of collapse, +and dies within a few days. + +The other story is even more familiar and dramatic. Again it is a group +of morbidly curious and spiteful doctors who desire to see whether a +human being can be killed by the power of his imagination. A condemned +criminal is accordingly turned over to them. He is first allowed to see +a dog bled to death, one of the physicians holding a watch and timing +the process with, "Now he is growing weaker! Now his heart is failing! +Now he dies!" Then, after having been informed that he is to be bled to +death instead of guillotined, his eyes are bandaged and a small, +insignificant vein in his arm is opened. A basin is held beneath his +arm, into which is allowed to drip and gurgle water from a tube so as to +imitate the sounds made by the departing life-blood. Again the +death-watch is set and the stages of his decline are called off: "Now he +weakens! Now his heart is failing!" until finally, with the solemn +pronouncement, "Now he dies!" he falls over, gasps a few times and is +dead, though the total amount of blood lost by him does not exceed a few +teaspoonfuls. + +A variant of the story is that the trick was played for pure mischief in +the initiation ceremonies of some lodge or college fraternity, with the +horrifying result that death promptly resulted. + +The stories seem to be little more than pure creatures of the same force +whose power they are supposed to illustrate, amusing and dramatic +fairy-tales, handed down from generation to generation from Heaven knows +what antiquity. Death under such circumstances as these _may_ have +occurred, but the proofs are totally lacking. One of our leading +neurologists, who had extensively experimented in hypnotism and +suggestion, declared a short time ago: "I don't believe that death was +ever caused solely by the imagination." + +Now as to the scope of this remedy, the extent of the field in which it +can reasonably be expected to prove useful. This discussion is, of +course, from a purely physical point of view. But it is, I think, now +generally admitted, even by most believers in mental healing, that it is +only, at best, in rarest instances that mental influence can be relied +upon to cure organic disease, namely, disease attended by actual +destruction of tissue or loss of organs, limbs, or other portions of the +body. This limits its field of probable usefulness to the so-called +"functional diseases," in which--to put it crudely--the body-machine is +in apparently perfect or nearly perfect condition, but will not work; +and particularly that group of functional diseases which is believed to +be due largely to the influence of the imagination. + +Nowhere can the curious exaggeration and over-estimation of the real +state of affairs in this field be better illustrated than in the popular +impression as to the frequency in actual practice of "imaginary" +diseases. Take the incidental testimony of literature, for instance, +which is supposed to hold the mirror up to nature, to be a transcript of +life. The pages of the novel are full, the scenes of the drama are +crowded with imaginary invalids. Not merely are they one of the most +valuable stock properties for the humorist, but whole stories and +comedies have been devoted to their exploitation, like Moliere's classic +"Le Malade Imaginaire," and "Le Medecin Malgre Lui." Generation after +generation has shaken its sides until they ached over these pompous old +hypochondriacs and fussy old dowagers, whose one amusement in life is to +enjoy ill health and discuss their symptoms. They are as indispensable +members of the _dramatis personae_ of the stock company of fiction as the +wealthy uncle, the crusty old bachelor, and the unprotected orphan. Even +where they are only referred to incidentally in the course of the story, +you are given to understand that they and their kind furnish the +principal source of income for the doctor; that if he hasn't the tact to +humor or the skilled duplicity to plunder and humbug these self-made +sufferers, he might as well retire from practice. In short, the entire +atmosphere of the drama gives the strong impression that if +people--particularly the wealthy classes--would shake themselves and go +about their business, two-thirds of the illness in the world would +disappear at once. + +Much of this may, of course, be accounted for by the delicious and +irresistible attractiveness, for literary purposes, of this type of +invalid. Genuine, serious illness, inseparable from suffering and ending +in death, is neither a cheerful, an interesting, nor a dramatic episode, +except in very small doses, like a well-staged death-bed or a stroke of +apoplexy, and does not furnish much valuable material for the novelist +or the play-writer. Battle, murder, and sudden death, while horrible +and repulsive, can be contemplated with vivid, gruesome interest, and +hence are perfectly available as interest producers. But much as we +delight to talk about our symptoms, we are never particularly interested +in listening to those of others, still less in seeing them portrayed +upon the stage. On account of their slow course, utter absence of +picturesqueness, and depressing character, the vast majority of diseases +are quite unsuitable for artistic material. In fact, the literary worker +is almost limited to a mere handful, at one extreme, which will produce +sudden and dramatic effects, like heart failure, apoplexy, or the +ghastly introduction of a "slow decline" for a particularly pathetic +effect; and at the other extreme, those imaginary diseases, migraines +and vapors, which furnish amusement by their sheer absurdity. + +Be that as it may, such dramatic and literary tendencies have produced +their effect, and the popular impression of the doctor is that of a man +who spends his time between rushing at breakneck speed to save the lives +of those who suddenly find themselves _in articulo mortis_ and will +perish unless he gets there within fifteen minutes, and dancing +attendance upon a swarm of old hypochondriacs, neurotics, and nervous +dyspeptics, of both sexes. As a matter of fact, these two supposed +principal occupations of the doctor are the smallest and rarest elements +in his experience. + +A few years ago a writer of world-wide fame deliberately stated, in the +course of a carefully considered and critical discussion of various +forms of mental healing, that it was no wonder that these methods +excited huge interest and wide attention in the community, because, if +valid, they would have such an enormous field of usefulness, seeing that +at least seven-tenths of all the suffering which presented itself for +relief to the doctor was imaginary. + +This, perhaps, is an extreme case, but is not far from representing the +general impression. If a poll were to be taken of five hundred +intelligent men and women selected at random, as to how much of the +sufferings of all invalids, or sick people who are not actually +obviously "sick unto death" or ill of a fever, was real and how much +imaginary, the estimate would come pretty close to an equal division. +But when one comes to try to get at the actual facts, an astonishingly +different state of affairs is revealed. I frankly confess that my own +awakening was a matter of comparatively recent date. + +A friend of mine was offered a position as consulting physician to a +large and fashionable sanatorium. He hesitated because he was afraid +that much of his time would be wasted in listening to the imaginary +pains, and soothing the baseless terrors, of wealthy and fashionable +invalids, who had nothing the matter with them except--in the language +of the resort--"nervous prosperity." His experience was a surprise. At +the end of two years he told me that he had had under his care between +six and seven hundred invalids, a large percentage of whom were drawn +from the wealthier classes; and out of this number there were _only +five_ whose sufferings were chiefly attributable to their imagination. +Many of them, of course, had comparatively trivial ailments, and others +exaggerated the degree or mistook the cause of their sufferings; but the +vast majority of them were, as he naively expressed it, "really sick +enough to be interesting." + +This set me to thinking, and I began by making a list of all the +"imaginary invalids" I had personally known, and to my astonishment +raked up, from over twenty years' medical experience, barely a baker's +dozen. Inquiries among my colleagues resulted in a surprisingly similar +state of affairs. While most of them were under the general impression +that at least ten to twenty per cent of the illnesses presenting +themselves were without substantial physical basis and largely imaginary +in character, when they came actually to cudgel their memories for +well-marked cases and to consult their records, they discovered that +their memories had been playing the same sort of tricks with them that +the dramatists and novelists had with popular impressions. + +Within the past few months one of the leading neurologists of New York, +a man whose practice is confined exclusively to mental and nervous +diseases, stated in a public address that purely or even chiefly +imaginary diseases were among the rarer conditions that the physician +was called upon to treat. Shortly after, two of the leading neurologists +of Philadelphia, one of them a man of international reputation, +practically repeated this statement; and they put themselves on record +to the effect that the vast majority of those who imagined themselves to +be ill were ill, though often not to the degree or in precisely the +manner that they imagined themselves to be. + +Obviously, then, this possible realm of suffering in which the mind can +operate is very much more limited than was at one time believed. In +fact, imaginary diseases might be swept out of existence, and humanity +would scarcely know the difference, so little would the total sum of its +suffering be reduced. + +Another field in which there has been much general misunderstanding and +looseness of both thought and statement, which has again led to +exaggerated ideas of the direct influence of the mind over the body, is +the well-known effect of emotional states, such as fright or anger, upon +the ordinary processes of the body. Instances of this relation are, of +course, household words,--the man whose "hair turned white in a single +night" from grief or terror; the nursing mother who flew into a furious +fit of passion and whose child was promptly seized with convulsions and +died the next time it was put to the breast; the father who is +prostrated by the death or disgrace of a favorite son, and dies within a +few weeks of a broken heart. The first thing that is revealed by even a +brief study of this subject is that these instances are exceedingly +rare, and owe their familiarity in our minds to their striking and +dramatic character and the excellent "material" which they make for the +dramatist and the gossip. It is even difficult to secure clear and valid +proof of the actual occurrence of that sudden blanching of the hair, +which has in the minds of most of us been accepted from our earliest +recollection. + +More fundamental, however, and vital, is the extent to which we have +overlooked the precise method in which these violent emotional +impressions alter bodily activities, like the secretions. Granting, for +the sake of argument, that states of mind, especially of great tension, +have some direct and mysterious influence as such, and through means +which defy physical recognition and study, it must be remembered that +they have a perfectly definite physiological sphere of influence upon +vital activities. Indeed, we are already in a position to explain at +least two-thirds of these so-called "mental influences" upon purely +physical and physiological grounds. + +First of all, we must remember that these emotions which we are pleased +to term "states of mind" are also states of body. If any man were to +stand up before you, for instance, either upon the stage or in private, +and inform you that he was "scared within an inch of his life," without +tremor in his voice, or paling of his countenance, or widening eyes, or +twitching muscles, or preparations either to escape or to fight, you +would simply laugh at him. You would readily conclude, either that he +was making fun of you and felt no such emotion, or that he was +repressing it by an act of miraculous self-control. The man who is +frightened and doesn't do anything or look as if he were going to do +anything, the man who is angry and makes no movement or even twitching +suggesting that fact, is neither angry nor frightened. + +An emotional state is, of course, a peculiarly complex affair. First, +there is the reception of the sensation, sight, sound, touch, or smell, +which terrifies. This terror is a secondary reaction, and in ninety-nine +cases out of a hundred is conditioned upon our memory of previous +similar objects and their dangerousness, or our recollection of what we +have been told about their deadliness. Then instantly, irrepressibly, +comes the lightning-flash of horror to our heart, to our muscles, to +our lungs, to get ready to meet this emergency. Then, and not till then, +do we really feel the emotion. In fact, our most pragmatic philosopher, +William James, has gone so far as to declare that emotions are the +after-echoes of muscular contractions. By the time an emotion has fairly +got us in its grip so that we are really conscious of it, the +blood-supply of half the organs in our body has been powerfully altered, +and often completely reversed. + +To what extent muscular contractions condition emotions, as Professor +James has suggested, may be easily tested by a quaint and simple little +experiment upon a group of the smallest voluntary muscles in the body, +those that move the eyeball. Choose some time when you are sitting +quietly in your room, free from all disturbing thoughts and influences. +Then stand up and, assuming an easy position, cast the eyes upward and +hold them in that position for thirty seconds. Instantly and +involuntarily you will be conscious of a tendency toward reverential, +devotional, contemplative ideas and thoughts. Then turn the eyes +sideways, glancing directly to the right or to the left, through +half-closed lids. Within thirty seconds images of suspicion, of +uneasiness, or of dislike, will rise unbidden in the mind. Turn the eyes +to one side and slightly downward, and suggestions of jealousy or +coquetry will be apt to spring unbidden. Direct your gaze downward +toward the floor, and you are likely to go off into a fit of reverie or +of abstraction. + +In fact, as Darwin long ago remarked, quoting in part from Bain: "Most +of our emotions [he should have said all] are so closely connected with +their expression that they hardly exist if the body remains passive. As +Louis XVI, facing a mob, exclaimed, 'Afraid? Feel my pulse!' so a man +may intensely hate another, but until his bodily frame is affected he +can hardly be said to be enraged." + +And, a little later, from Maudsley:-- + +"The specific muscular action is not merely an exponent of passion, but +truly an essential part of it. If we try, while the features are fixed +in the expression of one passion, to call up in the mind a different +one, we shall find it impossible to do so." + +It will also be recollected what an important part in the production of +hypnosis and the trance state, fixed and strained positions of these +same ocular muscles have always been made to play. Many hypnotists can +bring their subjects under their influence solely by having them gaze +fixedly at some bright object like a mirror, or into a crystal sphere, +for a few minutes or even seconds. + +A graphic illustration of the importance of muscular action in emotional +states is the art of the actor. Not only would it be impossible for an +actor to make an audience believe in the genuineness of his supposed +emotion if he stood glassy-eyed and wooden-limbed declaiming his lines +in a monotone, without gestures or play of expression of any sort, but +it would also be impossible for him to feel even the counterfeit +sensation which he is supposed to represent. So definite and so well +recognized is this connection, that many actors take some little time, +as they express it, to "warm up" to their part, and can be visibly seen +working themselves up to the pitch of emotion desired for expression by +twitching muscles, contractions of the countenance, and catchings of the +breath. This last performance, by the way, is not by any means confined +to the stage, but may be seen in operation in clashes and disagreements +in real life. An individual who knows his case to be weak, or himself to +be lacking in determination, can be seen working himself up to the +necessary pitch of passion or of obstinacy. There is even a lovely old +fairy-tale of our schoolboy days, which is still to be found in ancient +works on natural history, to the effect that the King of Beasts himself +was provided with a small, horny hook or spur at the end of his tail, +with which he lashed himself into a fury before springing upon his +enemy! + +What, then, will be the physical effect of a shock or fright or furious +outburst of anger upon the vital secretions? Obviously, that any +processes which require a full or unusually large share of blood-supply +for their carrying out will be instantly stopped by the diversion of +this from their secreting cells, in the wall of the stomach, in the +liver, or in the capillaries of the brain, to the great muscular masses +of the body, or by some strange, atavistic reflex into the so-called +"abdominal pool," the portal circulation. The familiar results are just +what might have been expected. The brain is so suddenly emptied of blood +that connected thought becomes impossible, and in extreme cases we stand +as one paralyzed, until the terror that we would flee from crashes down +upon us, or we lose consciousness and swoon away. If the process of +digestion happens to be going on, it is instantly stopped, leaving the +food to ferment and putrefy and poison the body-tissues which it would +otherwise have nourished. The cells of the liver may be so completely +deprived of blood as to stop forming bile out of broken-down blood +pigment, and the latter will gorge every vessel of the body and escape +into the tissues, producing jaundice. + +Every one knows how the hearing of bad news or the cropping up of +disagreeable subjects in conversation at dinner-time will tend to +promote indigestion instead of digestion. The mechanism is precisely +similar. The disagreeable news, if it concern a financial or executive +difficulty, will cause a rush of blood to the brain for the purpose of +deciding what is to be done. But this diminishes the proper supply of +blood to the stomach and to the digestive glands, just as really as the +paralysis of violent fright or an explosion of furious anger. If the +unpleasant subject is yet a little more irritating and personal, it will +lead to a corresponding set of muscular actions, as evidenced in +heightened color, loud tones, more or less violent gesticulation, with +marked interruption of both mastication and the secretion of saliva and +all other digestive juices. In short, fully two-thirds of the influences +of emotional mental states upon the body are produced by their calling +away from the normal vital processes the blood which is needed for their +muscular and circulatory accompaniments. No matter how bad the news or +how serious the danger, if they fail to worry us or to frighten us,--in +other words, to set up this complicated train of muscular and +blood-supply changes,--then they have little or no effect upon our +digestions or the metabolism of our liver and kidneys. + +The classic "preying upon the damask cheek" of grief, and the carking +effect of the Black Care that rides behind the horseman, have a +perfectly similar physical mechanism. While the primary disturbance of +the banking balances of the body is less, this is continued over weeks +and months, and in addition introduces another factor hardly less +potent, by interfering with all the healthful, normal, regular habits of +the body,--appetite, meal-times, sleep, recreation. These wastings and +pinings and fadings away are produced by mental influence, in the sense +that they cannot be cured by medicines or relieved at once by the best +of hygienic advice; but it is idle to deny that they have also a broad +and substantial physical basis, in the extent to which states of +emotional agony, despair, or worry interfere with appetite, sleep, and +proper exercise and recreation in the open air. Just as soon as they +cease to interfere with this normal regularity of bodily functions, the +sufferer begins to recover his health. + +We even meet with the curious paradox of individuals who, though +suffering the keenest grief or anxiety over the loss or serious illness +of those nearest or dearest to them, are positively mortified and +ashamed because their countenances show so little of the pallid hues and +the haggard lines supposed to be inseparably associated with grief. So +long as the body-surplus is abundant enough to stand the heavy +overdrafts made on it by grief and mental distress, without robbing the +stomach of its power to digest and the brain of its ability to sleep, +the physical effects of grief, and even of remorse, will be slight. + +It must be remembered that loss of appetite is not in itself a cause of +trouble, but a symptom of the stomach's inability to digest food; in +this instance, because it finds that it can no longer draw upon the +natural resources of the body in sufficient abundance to carry out its +operations. The state is exactly like a tightness of the money market, +when, on account of unnatural retention or hoarding in some parts of the +financial field, the accumulation of sufficient amounts of floating +capital at the banks for moving the crop or paying import duties cannot +be carried out as usual. The vital system is, in fact, in a state of +panic, so that the stomach cannot get the temporary credit or capital +which it requires. + +A similar condition of temporary panic, call it mental or bodily, as you +will, occurs in disease and is not confined to the so-called imaginary +diseases, or even to the diseases of the nervous system, but is apt to +be present in a large number of acute affections, especially those +attended by pain. Sudden invasion of the system by the germs of +infectious diseases, with their explosions of toxin-shells all through +the redoubts of the body, often induces a disturbance of the bodily +balance akin to panic. This is usually accompanied and aggravated by an +emotional dread and terror of corresponding intensity. The relief of the +latter, by the confident assurance of an expert and trusted physician +that the chances are ten to one that the disease will run its course in +a few days and the patient completely recover,--especially if coupled +with the administration of some drug which relieves pain or diminishes +congestion in the affected organs,--will often do much toward restoring +balance and putting the patient in a condition where the natural +recuperative powers of the system can begin their work. The historic +popularity of opium, and of late of the coal-tar products (phenacetine +and acetanilide), in the beginning of an acute illness, is largely based +on the power which they possess of dulling pain, relieving disturbances +of the blood-balance, and soothing bodily and mental excitement. +Fever-panic or pain-panic, like a banking panic, though it has a genuine +and substantial basis, can be dealt with and relieved much more readily +after checking excessive degrees of distrust and excitement. An opiate +will relieve this physical pain-panic, just as a strong mental +impression will relieve the fright-paralysis and emotional panic which +often accompany it, and thus give a clearer field and a breathing space +for the more slowly acting recuperative powers of nature to assert their +influence and get control of the situation. + +_But neither of them will cure._ The utmost that they can do is to give +a breathing spell, a lull in the storm, which the rallying powers of the +body, if present, can take advantage of. If the latter, however, be not +adequate to the situation, the disease will progress to serious or even +fatal termination, just as certainly as if no such influence had been +exerted, and often at an accelerated rate. In fact, our dependence upon +opiates and mental influence have been both a characteristic and a +cause of the Dark Ages of medicine. The more we depended upon these, the +more content we were to remain in ignorance of the real causes of +disease, whether bodily or mental. + +The second physical effect produced by mental influence is probably the +most important of all, and that is _the extent to which it induces the +patient to follow good advice_. We as physicians would be the last to +underestimate the importance of the confidence of our patients. But we +know perfectly well that our retention of that confidence will depend +almost entirely upon the extent to which we can justify it; that its +principal value to us lies in the extent to which it will insure prompt +obedience to our orders, and intelligent and loyal cooeperation with us +in our fight against disease. The man who would depend upon the +confidence of his patients as a means of healing, would soon find +himself without practice. We know by the bitterest of experience that no +matter how absolute and boundless the confidence of our patients may be +in our ability to heal them, no matter how much they may express +themselves as cheered and encouraged by our presence, ninety-nine per +cent of the chance of their recovery depends upon the gravity of the +disease, the vigor of their powers of resistance, and our skill and +intelligence in combating the one and assisting the other. + +Valuable and helpful as courage and confidence in the sick-room are, +they are but a broken reed which will pierce the hand of him who leans +upon it too heavily, be he patient or physician. We can all recall, as +among our saddest and most heart-breaking experiences, the cases of +fatal disease, which were well-nigh hopeless from the start, and yet in +which the sufferers expressed, and maintained to the last moments of +conscious speech, a bright and pathetically absolute confidence in our +powers of healing, based upon our success in some previous case, or upon +their own irrepressible hopefulness. + +Even the deadliest and most serious of infectious diseases, consumption, +has--as is well known--as one of its prominent symptoms an irrepressible +hopefulness and confidence that they will get well, on the part of a +considerable percentage of its victims. This has even been formally +designated in the classical medical treatises as the "_Spes Phthisica_," +or "Consumptive Hope." But these hopeful consumptives die just as surely +as the depressed ones; in fact, if anything, in a little larger +proportion. It well illustrates the other side of the shield of hope and +confidence, the danger of unwavering expectancy, in that it is chiefly +those who are early alarmed and turn vigorously to fight the disease +under intelligent medical direction, who make the recoveries. Too serene +a courage, too profound a confidence in occult forces, is only a form of +fatalism and a very dangerous one. + +Broadly speaking, mental states in the sick-room are a pretty fair +index--I don't mind saying, product--of bodily states. Hopefulness and +confidence are usually favorable signs, for the reason that they are +most likely to be displayed by individuals who, although they may be +seriously ill, are of good physique, have high resisting power, and +will make a successful fight against the disease. So, roughly speaking, +courage and hopefulness are good omens, on purely physical grounds. + +But these are only rough indications of probabilities, not reliable +signs; and as a rule we are but little affected by either the hopes or +the fears of our patients in making up our estimate of their chances. +The only mental symptom that weighs heavily with us is indifference. +This puts us on the lookout at once. So long as our patients have a +sufficiently vivid and lively fear of impending death, we feel pretty +sure that they are not seriously ill; but when they assure us dreamily +that they "feel first-rate," forget to ask us how they are getting +along, or become drowsily indifferent to the outlook for the future, +then we redouble our vigilance, for we fear that we recognize the +gradual approach of the Great Restbringer, the merciful drowsiness which +in nine cases out of ten precedes and heralds the coming of the Long +Sleep. + +Lastly, the cases in which the sufferings of the patient are due chiefly +to a morbid action of his or her imagination, are a small percentage of +the total of the ills which come before us for relief. But, even of this +small percentage, _only a very few are in perfect or even reasonably +good physical health_. A large majority of even these neurasthenics, +psychasthenics, imaginary invalids, and bodily or mental neurotics, have +some physical disturbance, organic or functional, which is the chief +cause of their troubles. And the important point is that our success in +relieving these sufferers will depend upon our skill in ferreting out +this physical basis, and the extent to which we can succeed in +correcting or relieving it. We no longer ridicule or laugh at these +unfortunates. On the contrary we pity them from the bottom of our +hearts, because we know that their sufferings, however polarly remote +they may be from endangering their lives in any way, and however +imaginary in a purely material sense, are _to them_ real. Their +happiness is destroyed and their efficiency is crippled just as +genuinely and effectively as if they had a broken limb or a diseased +heart. + +We are now more and more firmly convinced that these patients, however +ludicrously absurd their forebodings, are _really sick_, either bodily +or mentally, and probably both. A perfectly healthy individual seldom +imagines himself or herself to be ill. And as the list of so-called +functional diseases--that is to say, those diseases in which no +definite, objective mark of degeneration or decay in any tissue or organ +can be discovered--are steadily and swiftly diminishing under the +scrutiny of the microscope and the methods of the laboratory, so these +purely imaginary diseases, these "depressed mental states," these +"essential morbid tendencies," are also rapidly diminishing in number, +as cases are more conscientiously and personally studied and worked out. + +Even hysteria is no longer looked upon as sheer perversity on the part +of the patient, but is patiently traced back, stage by stage, until if +possible the primary "strangulated emotion" which caused it is +discovered; and where this can be found the whole morbid tendency can +often be relieved and reversed almost as if by magic. + +To sum up: My contention is, that the direct influence of emotional +states upon bodily organs and functions has been greatly exaggerated; +that it is exceedingly doubtful whether, for instance, any individual in +a reasonable condition of health was ever killed by an imaginary or even +an emotional shock; that there is surprisingly little valid evidence +that the hair of any human being turned white in a single night, or was +completely shed within a few hours, under the influence of fright, +terror, or grief; that the effects upon bodily functions and secretions, +digestion, etc., produced by emotion, are due to secondary effects of +the latter, diverting the energy of the body into other channels and +disturbing the general balance of its forces and blood-supply; that the +actual percentage of cases in which the imagination plays the chief, or +even a dominant part, is small, probably not to exceed five or ten per +cent; that a very considerable share of the influence of mental +impressions in the cure of disease is due to the relief of mental panic, +permitting the rallying of the recuperative powers of the body, and to +the extent to which they produce the reform of bad physical habits or +surroundings or conditions. + +The most important element in the cure of disease by mental +impression is _time_ plus the _vis medicatrix naturae_. The mental +impression--suggestion, scolding, securing of confidence--diverts the +attention of the patient until his own recuperative power and the +intelligent correction of bad physical habits remedy his defect. Pure +mental impression, however vivid, which is not followed up by +improvement of the environment, or correction of bad physical habits, +will be almost absolutely sterile. Faith without works is as dead in +medicine as in religion. Mental influence is little more than an +introduction committee to real treatment. Even the means used for +producing mental impressions are physical,--impressions made upon some +one of the five senses of the individual. In short, as Barker aptly puts +it, "Every psychotherapy is also a physical therapy." + +Furthermore, even mental worry, distress, or depression, in nine cases +out of ten has a physical cause. To remedy conditions of mental stress +by correcting the underpay, overwork, bad ventilation, or underfeeding +on account of illness or death of the wage-earner of the family, is, of +course, nothing but the most admirable common sense; but to call it the +_mental_ treatment of disease is a mere juggling with words. "Take care +of the body and the mind will take care of itself," is a maxim which +will prove valid in actual practice nine times out of ten. + + + + +INDEX + + + Abernethy, Dr. John, 80. + + Acne, 38. + + Acromegaly, 119. + + Adenoids, 105-122. + + Air, foul, 97. + + Alimentary canal, 274-279. + + Allbutt, Sir Clifford, 134. + + Allen, Dr. Harrison, 120. + + Animals, immune to certain diseases, 255. + + Anti-bodies. _See_ Antitoxins. + + Antisepsis, 333, 336-339. + + Antitoxins, or anti-bodies, 9, 93, 94, 199, 200; + discovery and use of the diphtheria antitoxin, 230-233, 236, 242, 401; + tetanus antitoxin, 345, 346, 398. + + Apoplexy, 40, 402. + + Appendicitis, 269-288. + + Appendix, vermiform, 35, 36, 268-270, 273-279. + + Asepsis, 333. + + Asthmatics, 328. + + Attitude, the upright, 76. + + Autointoxication, 376. + + + Bacilli. _See_ Bacteria. + + Bacteria, abundance of, in the body, 10, 99. + + Bang, Professor, 148. + + Bath, the cold, 98. + + Bile, in vomiting, 379. + + Bites, danger from, 342. + + Blood, coagulation of, 39, 40. + + Blood-corpuscles, 24-29. + + Blood-poisoning, 331-349. + + Bloodgood, Dr. J. C., 272. + + Bones, nature of, 20, 21. + + Boswell, James, 88. + + Bridge, Dr. Norman, 95. + + + Caecum, 274-278. + + Cancer, a rebellion of the cells, 42, 351; + heredity and, 50, 51; + individuality of, 350; + probable nature of, 351; + death-rate from, 352, 353; + natural history of, 353-364; + not communicable, 357, 358; + vain search for a parasite, 359, 360; + a disease of senility, 363, 364; + problems of prevention and cure, 365, 366. + + Carriage, in illness, 76. + + Cattani, 398. + + Cellular theory of disease, 18, 19. + + Cerebro-spinal meningitis, 397. + + Chantemesse, 221. + + Children's diseases, importance of, 243-245; + prevention of, 245; + dangerous results of, 245, 246; + effect on growth and development, 247; + reasons for, 248-250; + occasional severity of, 251-254; + taming of, 253, 254; + causes of, 254, 255; + treatment of, 255, 256; + symptoms of, 256, 257; + the three chief, 257-266. + + Cities, disease and death-rate in, 159-165. + + Civilization, and nervousness, 406-408. + + Cleanliness, 98. + + Cohnheim, 364. + + Colds, treatment of, 11, 12, 93-101; + cause of, 85-93; + how to catch, 101, 102; + their relation to rheumatism, 320, 321, 323, 324, 326, 327. + + Colic, 4. + + Color, in diagnosis, 70-74. + + Congenital disease, 44, 45. + + Coughing, use of, 11, 12. + + + Darwin, Charles, quoted, 425, 426. + + Diagnosis, 55-82. + + Diarrh[oe]a, use of, 5; + treatment of, 5. + + Diphtheria, 222-242; + attacking the nervous system, 400, 401. + + Disease, causes of, 3; + not absolute but relative, 14; + former conceptions of, 15-18; + organic and functional, 405, 406; + mental influence in, 411-437. + + Drafts, 94, 95, 99. + + + Earache, 110. + + Edison, Thomas A., 286. + + Epilepsy, heredity and, 52, 53. + + Erysipelas, 348. + + Eustachian tubes, 109, 110. + + Expectoration, 142, 143. + + Eye-strain, 377. + + + Facial expression, in diagnosis, 62-70. + + Fever, meaning of, 7, 8; + treatment of, 8-11. + + Flick, Dr. Laurence, 96. + + Fly, house, and typhoid, 210, 211. + + Food-tube, the, 274-279. + + + Gait, in illness, 76-78. + + Gall-bladder, 37. + + Grip, the, 90. + + Guinea-pig, a burnt offering, 222; + used in the discovery of the diphtheria antitoxin, 229-231. + + + Hand, the, in diagnosis, 73-75. + + Harelip, 37. + + Headache, purpose and meaning of, 12, 13, 367-376; + treatment of, 370, 371, 381-386; + from eye-strain, 377, 386; + from digestive disturbances, 377, 378; + sick headache, 378, 379, 381; + from stuffy rooms, 380; + from sluggish bowels and kidney trouble, 380; + from loss of sleep, 380, 381; + from nasal obstruction, 381; + rest the cure for, 382-384; + massage for the relief of, 385, 386; + the nerves affected in, 385, 386. + + Heart, effect of rheumatism on, 314, 315. + + Heredity, in health and disease, 32-54. + + Hernia, 36. + + Holmes, Oliver Wendell, 125. + + Horses, and disease, 344, 345. + + Hospitals, blood-poisoning and antisepsis in, 335-339. + + Humoral theory of disease, 17, 18. + + Huxley, Thomas Henry, quoted, 1, 112, 201. + + Hysteria, 403, 406, 407, 435. + + + Imaginary illness, 415-422, 436. + + Immunity, 93. + + Indians, epidemics among, 251, 252. + + Indifference of the dying, 434. + + Infants, diagnosis in the case of, 81, 82. + + Influenza, 90. + + Insanity, heredity and, 52-54; + among savages and in civilization, 408, 409; + treatment of, 411, 412. + + Intestines, 274. + + + James, William, 425. + + Johnson, Samuel, 89. + + Joints, diseases of, 318, 319. + + + King, Dr. Albert F. A., 298. + + Koch, Robert, 126, 152, 153, 155, 156, 228, 308. + + + Laveran, 295. + + Lister, Lord, 332. + + Liver, functions of, 6, 7. + + Lockjaw, 344-346, 397, 398. + + Locomotor ataxia, 399; diagnosis of, 77, 78. + + Lungs, their liability to disease, 175-178. + + Lupus, 126. + + + Malaria, 289-310. + + Measles, 243, 246, 248-252, 260-263. + + Medicines, repulsive, 17. + + Meningitis, 399, 400. + _See also_ Cerebro-spinal meningitis. + + Mental influence in disease, 411-437. + + Metschnikoff, Elie, 214. + + Meyer, William, 105. + + Mind, its relation to the body, 390, 391, 411-437. + + Mosquitoes, and malaria, 297-307. + + Mouth-breathing, 103-119. + + Moxon, the pathologist, 187. + + Mumps, 252. + + + Nails, the, in disease, 74, 75; + pus-germs lurking under, 334, 336, 349. + + Nature, as a physician, 2, 3; + not to be trusted too blindly, 7; + cooeperating with, 9. + + Nerves, affected in headache, 385, 386; + old notions of, 387, 388; + reality of, 389, 390; + function of, 390; + their diseases due to morbid changes in their tissues, 391, 392; + affected by the bodily condition, 393-395; + causes of disturbances in, 395-397; + diseases that attack them directly, 397, 398; + late effects of other diseases on, 398-401; + nervousness and, 401-408; + death-rate from diseases of, 409, 410. + + Nervousness, 403-408. + + Neurasthenia, 401, 402. + + Nocard, the veterinary pathologist, 157. + + Northrup, Dr. William, 196. + + Noses, narrow, 118, 119. + + + Operations. _See_ Surgery. + + Opiates, 431, 432. + + Osler, Dr. William, 160, 282. + + Ovariotomy, 336. + + + Pain, nature's command to halt, 13, 382; + nature's automatic speed regulator, 383. + + Paresis, 399. + + Pimples, 38. + + Pituitary body, 119. + + Pneumonia, cause of, 84, 85, 88, 178-183, 185, 186; + easily recognized, 174, 175; + recent increase of, 184, 186; + habits of the pneumococcus, 186-191; + its relations to age and to other diseases, 192-194; + symptoms of, 194, 195; + treatment of, 195, 196; + outlook as to, 196, 197. + + Poisons in the body, elimination of, 3-13; + from fatigue, 373-376. + + Psychotherapy, 413. + + Pus, 331-336; + germs of, 339-344, 346-349. + + Pyaemia, 346. + + + Quinine, 293, 294. + + + Repair of the body in the lower animals, 41, 42. + + Rheumatism, 311-330. + + Ross, Dr. Ronald, 247. + + + Savages, nervousness among, 407, 408. + + Scarlet fever, 243, 247, 257-260. + + Sciatica, cure of a case of, 389, 390. + + Sclerosis, lateral, 399. + + Scrofula, 126. + + Seasickness, 379. + + Senn, Dr. Nicholas, 357. + + Septicaemia, 346. + + Sleeping porches, 96, 97. + + Smallpox, 125, 255. + + Smell, 111. + + Spitting, 142, 143. + + Staphylococcus, 339, 340, 343, 348. + _See also_ Pus. + + Sticking-plaster, 343. + + Stomach, 274. + + Streptococcus, 339-341, 348. _See also_ Pus. + + Surgery, and blood-poisoning, 331-339. + + Syphilis congenital, 44; + organism of, 255, 399; + attacking the nervous system, 399. + + Tait, Lawson, 336. + + Taste, 111. + + Teeth, crowded, 114, 115. + + Tetanus, 344-346, 397, 398. + + Tonsillitis, 320, 323, 324. + + Tonsils, 107-109, 116-118. + + Tooth, wisdom, 36, 37. + + Tuberculosis, congenital, 45; + seeming inheritance of, 46-50; + diagnosis of, 68, 72; + discovery of the bacterial nature of, 123-126; + means of fighting, 127, 128; + treatment of, 129-132; + prevention of, 132, 135-139; + universality of, 133, 134; + prevention of transmission of, 140-145; + in cattle and other animals, 146, 158; + encouraging outlook as to, 159-166; + civilization and, 166-173; + cerebral complications from, 399; + hopefulness in, 433. + + Tumor, Jensen's, 358, 362. + + Typhoid fever, 199-221. + + Typhus, 203, 204. + + + Uric acid, 327, 328. + + + Vestigia, 35-39, 268, 269. + + Virchow, Rudolf, 18. + + Vis medicatrix naturae, 2. + + Voice, in diagnosis, 78. + + Voltaire, on doctors, 14. + + Vomiting, use of, 4, 5; + from headache and seasickness, 378, 379; + bile in, 379. + + + Waters, mineral, 17. + + Whooping-cough, 244, 246, 249, 263-266. + + Williams, Dr. Leonard, 93. + + Williams, Dr. Roger, 364. + + Wound-fever, among soldiers, 347. + + Wounds, healing of, 40, 41; + blood-poisoning in, 331-335, 341-344; + treatment of, 342-344, 346. + + Wright, Dr., 221. + + +The Riverside Press +CAMBRIDGE, MASSACHUSETTS + + + + + + +End of Project Gutenberg's Preventable Diseases, by Woods Hutchinson + +*** END OF THIS PROJECT GUTENBERG EBOOK PREVENTABLE DISEASES *** + +***** This file should be named 21965.txt or 21965.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/2/1/9/6/21965/ + +Produced by Audrey Longhurst, Janet Blenkinship and the +Online Distributed Proofreading Team at http://www.pgdp.net +(This file was produced from images from the Home Economics +Archive: Research, Tradition and History, Albert R. 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