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

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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 orsurpassed at almost every point by some product of the machine-shop orsome animal. It does almost nothing perfectly or with absoluteprecision. As Huxley most unexpectedly remarked a score of years ago, "If a manufacturer of optical instruments were to hand us for laboratoryuse 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, " ashe went on to say, "while the eye is inaccurate as a microscope, imperfect as a telescope, crude as a photographic camera, it is all ofthese in one. " In other words, like the body, while it does nothingaccurately and perfectly, it does a dozen different things well enoughfor practical purposes. It has the crowning merit, which overbalancesall these minor defects, of being able to adapt itself to almost everyconceivable change of circumstances. 

This is the keynote of the surviving power of the human species. It isnot enough that the body should be prepared to do good work underordinary conditions, but it must be capable, if needs be, of meetingextraordinary ones. It is not enough for the body to be able to takecare of itself, and preserve a fair degree of efficiency in health, under what might be termed favorable or average circumstances, but itmust also be prepared to protect itself and regain its balance indisease. 

The human automobile in its million-year endurance-run has had to learnto 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 underthe sun, " but in at least eight cases out of ten that remedy will befound within the body itself. Generations ago this self-balancing, self-repairing power was recognized by the more thoughtful fathers inmedicine and even dignified by a name in their pompous Latinity--the_vis medicatrix naturæ_, the healing power of nature. 

In the new conception of disease, our drugs, our tonics, ourprescriptions and treatments, are simply means of rousing this forceinto activity, assisting its operations, or removing obstacles in itsway. This remedial power does not imply any gift of prophecy on nature'spart, nor is it proof of design, or beneficent intention. It is ratherone of those blind reactions to certain stimuli, tending to restore thebalance of the organism, much as that interesting, new scientific toy, the gyroscope car, will respond to pressure exerted or weight placedupon one side by rising on that side, instead of tipping over. Let theonslaught of disease be sufficiently violent and unexpected, and naturewill fail to respond in any way. 

Moreover, we and our intelligences are a product of nature and a partof her remedial powers. So there is nothing in the slightest degreeirrational or inconsistent in our attempting to assist in the process. 

However, a great, broad, consoling and fundamental fact remains: that ina vast majority of diseases which attack humanity, under ninety per centof the unfavorable influences which affect us, nature will effect a cureif not too much interfered with. As the old proverb has it, "A man atforty is either a fool or a physician"; and nature is a good deal overforty and has never been accused of lacking intelligence. 

In the first place, nature must have acquired a fair knowledge ofpractical medicine, or at least a good working basis for it, from thefact that the body, in the natural processes of growth and activity, isperpetually manufacturing poisons for its own tissues. 

In this age of sanitary reform, we are painfully aware that the mostfrequent causes of human disease are the accumulations about us of thewaste 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 beengoing on within the body for millions of years. No sooner did three orfour cells begin to cling together, to form an organism, a body, thanthe waste products of the cells in the interior of the group began toform a source of danger for the others. If some means of getting rid ofthese could not be devised, the group would destroy itself, and theexperiment of coöperation, of colony-formation, of organization in fact, would be a failure. 

Hence, at a very early period we find the development of the rudimentsof systems of body-sewerage, providing for the escape of waste poisonsthrough the food-tube, through the kidneys, through the gills and lungs, through the sweat glands of the skin. So that when the body isconfronted by actual disease, it has all ready to its hand a remarkablyeffective and resourceful system of sanitary appliances--sewer-flushing, garbage-burning, filtration. In fact, this is precisely what it doeswhen attacked by poisons from without: it neutralizes and eliminatesthem by the same methods which it has been practicing for millions ofyears against poisons from within. 

Take, for instance, such a painfully familiar and unheroic episode as anattack of colic. It makes little difference whether the attack is due tothe swallowing of some mineral poison, like lead or arsenic, or theirritating juice of some poisonous plant or herb, or to the every-dayaccident of including in the menu some article of diet which wasbeginning to spoil or decay, and which contained the bacteria ofputrefaction or their poisonous products. The reaction of defense ispractically the same, varying only with the violence and the characterof the poison. If the dose of poisonous substances be unusually large orvirulent, nature may short-circuit the whole attack by causing theoutraged stomach to reject its contents. The power of "playing Jonah" isa wonderful safety-valve. 

If the poison be not sufficiently irritating thus to short-circuit itsown career, it may get on into the intestines before the body thoroughlywakes up to its presence. This part of the food-tube being naturallygeared to discharge its contents downward, the simplest and easiestthing is to turn in a hurry call and cut down the normal schedule fromhours 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 andtreating them as if they were diseases in themselves. Nothing could bemore irrational than to stop a diarrh[oe]a before it has accomplishedits purpose. Intelligent physicians now assist it instead of trying tocheck it in its early stages; and paradoxical as it may sound, laxativesare often the best means of stopping it. It is only the excess of thisform of nature's house-cleaning which needs to be checked. Many of thepopular Colic Cures, Pain-Relievers, and "Summer Cordials" contain opiumwhich, while it relieves the pain and stops the discharge, simply locksup in the system the very poisons which it was trying to get rid of. Laxatives, intestinal antiseptics, and bowel irrigations have almosttaken the place of opiates in the treatment of these conditions inmodern medicine. We try to help nature instead of thwarting her. 

Supposing that the poison be of more insidious form, a germ or aptomaine, for instance, which slips past these outer "firing-out"defenses of the food-tube and arouses no suspicion of its presence untilit has been partially digested and absorbed into the blood. Again, resourceful nature is ready with another line of defense. It was for along time a puzzle why every drop of the blood containing food and itsproducts absorbed from the alimentary food-canal had to be carried, often by a most roundabout course, to and through the liver, before itcould reach any part of the general system. Here was the largest andmost 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 thefood-products for use by the body-cells, and that it secreted the bile;but this latter secretion had little real digestive value, and the otherchanges seemed hardly important enough to demand that every drop of theblood coming from the food-tube should pass through this custom-house. Now, however, we know that in addition to its other actions, the liveris a great poison-sponge or toxin-filter, for straining out of the bloodpoisonous or injurious materials absorbed from the food, and convertingthem into harmless substances. It is astonishing what a quantity ofthese 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 generalsystem. But sometimes it is overwhelmed by appalling odds; some of theinvaders slip through its lines into the general circulation, producingheadache, backache, fever, and a "dark-brown taste in the mouth"; and, behold, we are bilious, and proceed to blame the poor liver. We used topour in remedies to "stir it up, " to "work on it"--which was about asrational as whipping a horse when he is down, instead of cutting hisharness or taking his load off. Nowadays we stop the supply of furtherfood-poisons by stopping eating, assist nature in sweeping out orneutralizing the enemies that are still in the alimentary canal, flushthe 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 atall, we shouldn't be bilious: we should be dead, or in a state ofcollapse. 

Moral: Don't rush for some remedy with which to club into insensibilityevery symptom of disease as soon as it puts in an appearance. Givenature a little chance to show what she intends to do before attemptingto 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 inextremes, and the body may become so panic-stricken as to keep onthrowing overboard, not merely the poisons, but its necessary dailyfood, if the process be allowed to continue too long. 

This is where the doctor comes in. This is the point at which it takesbrains to succeed in the treatment of disease--to decide just how farnature knows what she is doing, even in her most violent expulsivemethods, and is to be helped; and just when she has lost her head, orgot 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 alarge majority of the symptoms of disease are really nature's attemptsto cure it. 

This is admirably shown in our modern treatment of fevers. These we nowknow to be due to the infection of the body by more or less definitelyrecognized disease-germs or organisms. Fever is a complicated process, and we are still in the dark upon many points in regard to it, but weare coming more and more firmly to the conclusion that most of itssymptoms are a part of, or at least incidents in, the fight of the bodyagainst the invading army. The flushed and reddened skin is due to thepumping of large quantities of blood through its mesh, in order that thepoisons may be got rid of through the perspiration. The rapid pulseshows the vigor with which the heart is driving the blood around thebody, to have its poisons neutralized in the liver, burned up in thelungs, poured out by the kidneys and the skin. The quickened breathingis the putting on of more blast in the lung poison-crematory. It ispossible that even the rise of temperature has an injurious effect uponthe invading germs or assists the body in their destruction. 

In the past we have blindly fought all of these symptoms. We shut ourpatients up in stove-heated rooms with windows absolutely closed, forfear that they would "catch cold. " We took off the sheets and piledblankets upon the bed, setting a special watch to see that the wretchedsufferer did not kick them off. We discouraged the drinking of water andinsisted on all drinks that were taken being hot or lukewarm. Nowadaysall this is changed. We throw all the windows wide-open, and even putour patients out of doors to sleep in the open air, whether it betyphoid, tuberculosis, or pneumonia; knowing that not only they will not"catch cold, " but that, as their hurried breathing indicates, they needall the oxygen they can possibly get, to burn up the poison poured outin the lungs and from the skin. We encourage the patient to drink allthe cool, pure water he will take, sometimes gallons in a day, knowingthat his thirst is an indication for flushing and flooding all the greatsystems of the body sewers. Instead of smothering him in blankets, weput him into cold packs, or put him to soak in cool water. 

In short, we trust nature instead of defying her, coöperate with her inplace of fighting her, --and we have cut down the death-rate of mostfevers fifty to seventy-five per cent already. Plenty of pure, coolwater internally, externally, and eternally, rest, fresh air, andcareful feeding, are the best febrifuges and antipyretics known tomodern medicine. All others are frauds and simply smother a symptomwithout relieving its cause, with the exception of quinine in malaria, mercury, and the various antitoxins in their appropriate diseases, whichact directly upon the invading organism. 

Underneath all this storm and stress of the fever paroxysm, nature isquietly at work elaborating her antidote. In some marvelous fashion, which we do not even yet fully understand, the cells of the body areproducing in ever-increasing quantities an _anti-body_, or _antitoxin_, which will unite with the toxin or poison produced by the hostile germsand render it entirely harmless. By a curious paradox of the process, itdoes not kill the germs themselves. It may not even stop their furthermultiplication. Indeed, it utilizes part of their products in theformation of the antitoxin; but it domesticates them, as it were--turnsthem 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 ofthe family escape and enter the body of another human being, and theywill attack it as virulently as ever. 

Now, where and how did nature ever succeed in getting the rehearsal andthe practice necessary to build up such an extraordinary and complicatedsystem of defense as this? Take your microscope and look at a drop offluid from the mouth, the gums, the throat, the stomach, the bowels, andyou will find it simply swarming with bacteria, bacilli, and cocci, eachspecies of which numbers its billions. There are thirty-three specieswhich inhabit the mouth and gums alone! We are literally alive withthem; but most of them are absolutely harmless, and some of themprobably slightly helpful in the processes of digestion. In fevers andinfections the body merely applies to disease-germs the tricks which ithas learned in domesticating these millions of harmless vegetableinhabitants. 

Still more curious--there is a distinct parallel between the method inwhich food-materials are split up and prepared for assimilation by thebody, and the method adopted in breaking up and neutralizing the toxinsof disease-germs. It is now known that poisons are formed in the processof digesting and absorbing the simplest and most wholesome foods; andthe 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 infectionsdo, within periods ranging from three or four days to as many weeks, itsimply means that it has taken the liver and the other police-cells thislength of time to handle the rioters and turn them into peaceable andlaw-abiding, even though not well-disposed citizens. In this process theforces of law and order can be materially helped by skillful andintelligent coöperation. But it takes brains to do it and avoid doingmore harm than good. It requires far more intelligence on the part ofthe doctor, the nurse, or the mother, skillfully to help nature than itdid blindly to fight her. 

This is what doctors and nurses are trained for nowadays, and they areof use in the sick-room simply because they have devoted more time andmoney to the study of these complicated processes than you have. Don'timagine that calling in the doctor is going to interfere with thenatural course of the disease, or rob the patient of some chance hemight have had of recovering by himself. On the contrary, it will simplygive nature and the constitution of the patient a better chance in thestruggle, probably shorten it, and certainly make it less painful anddistressing. 

If these symptoms of the summer fevers and fluxes are indicative ofnature's attempts to cure, those of the winter's coughs and colds are noless clearly so. As we walk down the streets, we see staring at us inlarge 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 thebody to expel and get rid of irritating materials in the upperair-passages. As long as your larynx and windpipe are inflamed ortickled by disease-germs or other poisons, your body will do its best toget rid of them by coughing, or, if they swarm on the mucous membrane ofthe nose, by sneezing. To attempt to stop either coughing or sneezingwithout removing the cause is as irrational as putting out aswitch-light without closing the switch. Though this, like otherremedial processes, may go to extremes and interfere with sleep, orupset the stomach, within reasonable limits one of the best things to dowhen you have a cold is to cough. When patients with severeinflammations of the lungs become too weak or too deeply narcotized tocough, then attacks of suffocation from the accumulation of mucus in theair-tubes are likely to occur at any time. Young children who cannotcough properly, not having got the mechanism properly organized as yet, have much greater difficulty in keeping their bronchial tubes clear inbronchitis or pneumonia than have grown-ups. Most colds are infectious, like the fevers, and like them run their course, after which the coughwill subside along with the rest of the symptoms. But simply stoppingthe cough won't hasten the recovery. Most popular "Cough-Cures" benumbthe upper throat and stop the tickling; smother the symptoms withouttouching the cause. Many contain opium and thus load the system with twopoisons instead of one. 

Lastly, in the realm of the nervous system, take that commonest of allills that afflict humanity--headache. Surely, this is not a curativesymptom or a blessing in disguise, or, if so, it is exceedingly welldisguised. And yet it unquestionably has a preventive purpose andmeaning. Pain, wherever found, is nature's abrupt command, "Halt!" herimperative order to stop. When you have obeyed that command, you havetaken the most important single step towards the cure. _A headachealways means something_--overwork, under-ventilation, eye-strain, underfeeding, infection. Some error is being committed, some badphysical habit is being dropped into. There are a dozen differentremedies that will stop the pain, from opium and chloroform down to thecoal-tar remedies (phenacetin, acetanilid, etc. ) and the bromides. Butnot one of them "cures, " in the sense of doing anything toward removingthe cause. In fact, on the contrary they make the situation worse byenabling the sufferer to keep right on repeating the bad habit, deprivedof nature's warning of the harm that he is doing to himself. As thepenalties of this continued law-breaking pile up, he requires larger andlarger doses of the deadening drug, until finally he collapses, poisonedeither by his own fatigue-products or by the drugs which he has beentaking to deaden him against their effect. 

In fine, follow nature's hints whenever she gives them: treat pain byrest, infections by fresh air and cleanliness, the digestivedisturbances by avoiding their cause and helping the food-tube to flushitself clean; keep the skin clean, the muscles hard, and the stomachwell filled--and you will avoid nine-tenths of the evils which threatenthe race. 

The essence of disease consists, not in either the kind or the degree ofthe process concerned, but only in its relations to the general balanceof 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 singletissue-change, no group even of changes or of symptoms, of which we cansay, "This is essentially morbid, this is everywhere and at all timesdisease. "

Our attainment of any clear view of the essential nature of disease wasfor a long time hindered, and is even still to some degree clogged, bythe standpoint from which we necessarily approached and still approachit, not for the study of the disease itself, but for the relief of itsurgent symptoms. Disease presents itself as an enemy to attack, in theconcrete form of a patient to be cured; and our best efforts were forcenturies almost wasted in blind, and often irrational, attempts toremove symptoms in the shortest possible time, with the most powerfulremedies at our disposal, often without any adequate knowledge whateverof the nature of the underlying condition whose symptoms we werecombating, or any suspicion that these might be nature's means ofrelief, or that "haply we should be found to fight against God. " Therewas sadly too much truth in Voltaire's bitter sneer, "Doctors pour drugsof which they know little, into bodies of which they know less"; and Ifear the sting has not entirely gone out of it even in this day ofgrace. 

And yet, relative and non-essential as all our definitions now recognizedisease to be, it is far enough (God knows) from being a mere negativeabstraction, a colorless "error by defect. " It has a ghastlyindividuality and deadly concreteness, --nay, even a vindictiveaggressiveness, which have both fascinated and terrorized theimagination of the race in all ages. From the days of "the angel of thepestilence" to the coming of the famine and the fever as unbidden guestsinto the tent of Minnehaha; from "the pestilence that walketh indarkness" to the plague that still "stalks abroad" in even the prosaiccolumns 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 rationalconceptions of disease without at least a statement of the earlierconceptions growing out of this personifying tendency. Absurd as it mayseem now, it was the legitimate ancestor of modern pathogeny, and stillholds well-nigh undisputed sway over the popular mind, and much morethan could be desired over that of the profession. 

The earliest conception of disease of which we have any record is, ofcourse, the familiar Demon Theory. This is simply a mental magnificationof the painfully personal, and even vindictive, impression produced uponthe mind of the savage by the ravages of disease. And certainly we ofthe profession would be the last to blame him for jumping to such aconclusion. Who that has seen a fellow being quivering and chattering inthe chill-stage of a pernicious malarial seizure, or tossing and ravingin the delirium of fever, or threatening to rupture his muscles andburst his eyes from their sockets in the convulsions of tetanus oruræmia, can wonder for a moment that the impression instinctively arosein the untutored mind of the Ojibwa that the sufferer was actually inthe grasp, and trying to escape from the clutch, of some malicious butinvisible power? And from this conception the treatment logicallyfollowed. The spirits which possessed the patient, although invisible, were supposed to be of like passions with ourselves, and to be affectedby very similar influences; hence dances, terrific noises, beatings andshakings of the unfortunate victim, and the administration of bitter andnauseous messes, with the hope of disgusting the demon with hisquarters, were the chief remedies resorted to. And while to-day suchconceptions and their resultant methods are simply grounds for laughter, and we should probably resent the very suggestion that there was anyconnection whatever between the Demon Theory and our present practice, yet, unfortunately for our pride, the latter is not only the directlineal, historic descendant of the former, but bears still abundanttraces of its lowly origin. It will, of course, be admitted at once thatthe ancestors of our profession, historically, the earliest physicians, were the priest, the Shaman, and the conjurer, who even to this day incertain tribes bear the suggestive name of "medicine men. " Indeed, thisgrotesque individual was neither priest nor physician, but the commonancestor of both, and of the scientist as well. And, even if the historyof this actual ancestry were unknown, there are scores of curioussurvivals in the medical practice of this century, even of to-day, whichtestify to the powerful influence of this conception. The extraordinaryand disgraceful prevalence of bleeding scarcely fifty years ago, forinstance; the murderous doses of calomel and other violent purges; theindiscriminate use of powerful emetics like tartar emetic and ipecac;the universal practice of starving or "reducing" fevers by a diet ofslops, were all obvious survivals of the expulsion-of-the-demon theoryof treatment. Their chief virtue lay in their violence andrepulsiveness. Even to-day the tendency to regard mere bitterness ordistastefulness as a medicinal property in itself has not entirely diedout. This is the chief claim of quassia, gentian, calumbo, and the"simple bitters" generally, to a place in our official lists ofremedies. Even the great mineral-water fad, which continues to flourishso vigorously, owed its origin to the superstition that springs whichbubbled or seethed were inhabited by spirits (of which the "troubling ofthe waters" in the Pool of Bethesda is a familiar illustration). Thebubble and (in both senses) "infernal" taste gave them their reputation, the abundant use of pure spring water both internally and externallyworks the cure, assisted by the mountain air of the "_Bad_, " and wesapiently ascribe the credit to the salts. Nine-tenths of our cells arestill submarine organisms, and water is our greatest panacea. 

Then came the great "humoral" or "vital fluid" theory of disease whichruled during the Middle Ages. According to this, all disease was due tothe undue predominance in the body of one of the four great vitalfluids, --the bile, the blood, the nervous "fluid, " and the lymph, --andmust be treated by administering the remedy which will get rid of orcounteract the excess of the particular vital fluid in the system. Theprincipal 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 anyobscure condition. 

Last of all, in the fullness of time, --and an incredibly late fullnessit was, --under the great pioneer Virchow, who died less than a decadeago, was developed the great cellular theory, a theory which has donemore to put disease upon a rational basis, to substitute logic forfancy, and accurate reasoning for wild speculation, than almost anydiscovery since the dawn of history. Its keynote simply is, that everydisturbance to which the body is liable can be ultimately traced to somedisturbance or disease of the vital activities of the individual cellsof which it is made up. The body is conceived of as a cell-state orcell-republic, composed of innumerable plastid citizens, and itsgovernment, both in health and disease, is emphatically a government "ofthe cells, by the cells, for the cells. " At first these cell-units wereregarded simply as geographic sections, as it were, sub-divisions of thetissues, bearing much the same relation to the whole body as the bricksof the wall do to the building, or, from a little broader view, as theHessians of a given regiment to the entire army. They were merely thecreatures of the organism as a whole, its servants who lived but to obeyits commands and carry out its purposes, directed in purely arbitraryand despotic fashion by the lordly brain and nerve-ganglia, which againare directed by the mind, and that again by a still higher power. Infact, they were regarded as, so to speak, individuals withoutpersonality, mere slaves and helots under the ganglion-oligarchy whichwas controlled by the tyrant mind, and he but the mouthpiece of one ofthe Olympians. But time has changed all that, and already the triumphsof democracy have been as signal in biology as they have been inpolitics, and far more rapid. The sturdy little citizen-cells havesteadily but surely fought their way to recognition as the controllingpower of the entire body-politic, have forced the ganglion-oligarchy toadmit that they are but delegates, and even the tyrant mind to concedethat he rules by their sufferance alone. His power is mainly a veto, andeven that may be overruled by the usual two-thirds vote. 

In fact, if we dared to presume to criticise this magnificent theory ofdisease, we would simply say that it is not "cellular" enough, that ithardly as yet sufficiently recognizes the individuality, theindependence, the power of initiative, of the single constituent cell. It is still a little too apt to assume, because a cell has donned auniform and fallen into line with thousands of its fellows to form atissue in most respects of somewhat lower rank than that originallypossessed by it in its free condition, that it has therefore surrenderedall of its rights and become a mere thing, a lever or a cog in the greatmachine. Nothing could be further from the truth, and I firmly believethat our clearest insight into and firmest grasp upon the problems ofpathology will come from a recognition of the fact that, no matter howstereotyped, or toil-worn, or even degraded, the individual cells of anytissue may have become, they still retain most of the rights andprivileges which they originally possessed in their free and untrammeledam[oe]boid stage, just as in the industrial community of the world aboutus. And, although their industry in behalf of and devotion to thewelfare of the entire organism is ever to be relied upon, and almostpathetic in its intensity, yet it has its limits, and when these havebeen transgressed they are as ready to "fight for their own hand, "regardless of previous conventional allegiance, as ever were any oftheir ancestors on seashore or rivulet-marge. And such rebellions areour most terrible disease-processes, cancer and sarcoma. More than this:while, perhaps, in the majority of cases the cell does yeoman servicefor the benefit of the body, in consideration of the rations and fuelissued to it by the latter, yet in many cases we have the curious, andat first sight almost humiliating, position of the cell absorbing anddigesting whatever is brought to it, and only turning over the surplusor waste to the body. It would almost seem as if our lordly _Ego_ wasliving upon the waste-products, or leavings, of the cells lining itsfood-tube. 

Let us take a brief glance at the various specializations and tradedevelopments, which have taken place in the different groups of cells, and see to what extent the profound modifications which many of themhave undergone are consistent with their individuality and independence, and also whether such specialization can be paralleled by actuallyseparate and independent organisms existing in animal communitiesoutside of the body. First of all, because furthest from the type anddegraded to the lowest level, we find the great masses of tissue weldedtogether by lime-salts, which form the foundation masses, leverage-bars, and protection plates for the higher tissues of the body. Here thecells, in consideration of food, warmth, and protection guaranteed tothemselves and their heirs for ever by the body-state, have, as it were, deliberately surrendered their rights of volition, of movement, andhigher liberties generally, and transformed themselves into masses ofinorganic material by soaking every thread of their tissues inlime-salts and burying themselves in a marble tomb. Like Esau, they havesold their birthright for a mess of "potash, " or rather lime; and ifsuch a class or caste could be invented in the external industrialcommunity, the labor problem and the ever-occurring puzzle of theunemployed would be much simplified. And yet, petrified and mummified asthey have become, they are still emphatically alive, and upon thepreservation of a fair degree of vigor in them depends entirely thestrength and resisting power of the mass in which they are embedded, andof which they form scarcely a third. Destroy the vitality of its cells, and the rock-like bone will waste away before the attack of thebody-fluids like soft sandstone under the elements. Shatter it, or twistit out of place, and it will promptly repair itself, and to a remarkabledegree resume its original directions and proportions. 

So little is this form of change inconsistent with the preservation ofindividualism, that we actually find outside of the body an exactlysimilar process, occurring in individual and independent animals, in thefamiliar drama of coral-building. The coral polyp saturates itself withthe lime-salts of the sea-water, much as the bone-corpuscles with thoseof the blood and lymph, and thus protects itself in life and becomes theflying buttress of a continent in death. 

In the familiar connective-tissue, or "binding-stuff, " we find a processsimilar in kind but differing in the degree, so to speak, of itsdegradation. 

The quivering responsiveness of the protoplasm of the am[oe]boidancestral cell has transformed itself into tough, stringy bands and websfor the purpose of binding together the more delicate tissues of thebody. It has retained more of its rights and privileges, andconsequently possesses a greater amount of both biological andpathological initiative. In many respects purely mechanical in itsfunction, fastening the muscles to the bones, the bones to each other, giving toughness to the great skin-sheet, and swinging in hammock-likemesh the precious brain-cell or potent liver-lobule, it still possessesand exercises for the benefit of the body considerable powers ofdiscretion and aggressive vital action. Through its activity chiefly iscarried out that miracle of human physiology, the process of repair. Bythe transformation of its protoplasm the surplus food-materials of thetimes of plenty are stored away within its cell-wall against the time ofstress. 

Whatever emergency may arise, nature, whatever other forces she may beunable to send to the rescue, can always depend upon theconnective-tissues to meet it; and, of course, as everywhere the medalof honor has its reverse side, their power for evil is as distinguishedas their power for good. From their ranks are recruited a whole army ofthose secessions from and rebellions against the body at large--thetumors, from the treacherous and deadly sarcoma, or "soft cancer, " tothe harmless fatty tumor, as well as the tubercle, the gumma ofsyphilis, the interstitial fibrosis of Bright's disease. They are thesturdy farmers and ever ready "minute-men" of the cell-republic, and wefind their prototype and parallel in the external world, both inmaterial structure and degree of vitality, in the well-known sponge andits colonies. 

Next in order, and, in fact, really forming a branch of the last, wefind the great group of storage-tissues, the granaries or bankers of thebody-politic, distinguished primarily, like the capitalist classelsewhere, by an inordinate appetite, not to say greed. They sweep intotheir interior all the food-materials which are not absolutely necessaryfor the performance of the vital function of the other cells. These theyform first into protoplasm, and then by a simple degenerative process itis transformed, "boiled down" as it were, into a yellow hydrocarbonwhich is capable of storage for practically an indefinite period. Not avery exalted function, and yet one of great importance to the welfare ofthe entire body, for, like the Jews of the Middle Ages, the fat-cells, possessing an extraordinary appetite for and faculty of acquiringsurplus wealth in times of plenty, can easily be robbed of it andliterally sucked dry in times of scarcity by any other body-cell whichhappens to need it, especially by the belligerent military class ofmuscle-cells. In fever or famine, fat is the first element of ourbody-mass to disappear; so that Proudhon would seem to have somebiological basis for his demand for the _per capita_ division of thefortunes of millionaires. And yet, rid the fat-cell of the weight of hissordid gains, gaunt him down, as it were, like a hound for thewolf-trail, and he becomes at once an active and aggressive member ofthe binding-stuff group, ready for the repair of a wound or the barringout of a tubercle-bacillus. 

And this form of specialization has also its parallel outside of thebody in one of the classes in a community of Mexican ants, whose mostdistinguishing feature is an enormously distended [oe]sophagus, capableof containing nearly double the weight of the entire remainder of thebody. They are neither soldiers nor laborers, but accompany the latterin their honey-gathering excursions, and as the spoils are collectedthey are literally packed full of the sweets by the workers. Whendistended to their utmost capacity they fall apparently into asemi-comatose condition, are carried into the ant-hill, and hung up bythe hind legs in a specially prepared chamber, in which (we trust)enjoyable position and state they are left until their contents areneeded for the purposes of the community, when they are waked up, compelled to disgorge, and resume their ordinary life activities untilthe next season's honey-gathering begins. It scarcely need be pointedout what an unspeakable boon to the easily discouraged and unlucky theintroduction of such a class as this into the human industrial communitywould be, especially if this method of storage could be employed forcertain liquids. 

Another most important class in the cell-community is the great groupof the blood-corpuscles, which in some respects appear to maintain theirindependence and freedom to a greater degree than almost any other classwhich can be found in the body. While nearly all other cells have becomepacked or felted together so as to form a fixed and solid tissue, thesestill remain entirely free and unattached. They float at large in theblood-current, much as their original ancestor, the am[oe]ba, did in thewater of the stagnant ditch. And, curiously enough, the less numerous ofthe 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 theblood-corpuscles and the rest of the body, not even by the tiniestbranch of the great nerve-telegraph system, and yet they are the mostloyal and devoted class among all the citizens of the cell-republic. They are called hither and thither partly by messenger-substances throwninto the blood, known as _hormones_, partly by the "smell of the battleafar off, " the toxins of inflammation and infection as they pour throughthe blood. 

The red ones lose their nuclei, their individuality, in order to becomesponges, capable of saturating themselves with oxygen and carrying it tothe gasping tissues. The white are the great mounted police, thesanitary patrol of the body. The moment that the alarm of injury issounded in a part, all the vessels leading to it dilate, and theirchannels are crowded by swarms of the red and white hurrying to thescene. The major part of the activity of the red cells can be accountedfor by the mechanism of the heart and blood-vessels. They are simplythrown there by the handful and the shovelful, as it were, like so manypebbles or bits of chalk. 

But the behavior of the white cells goes far beyond this. We are almosttempted to endow them with volition, though they are of course drawn ordriven by chemical and physical attractions, like iron-filings by amagnet, or an acid by a base. Not only do all those normally circulatingin the blood flowing through the injured part promptly stop and begin toscatter themselves through the underbrush and attack the foe at closequarters, but, as has been shown by Cabot's studies in leucocytosis, themoment that the red flag of fever is hoisted, or the inflammation alarmis sounded, the leucocytes come rushing out from their feeding-groundsin the tissue-interspaces, in the lymph-channels, in the great serouscavities, and pour themselves into the blood-stream, like minute-menleaving the plough and thronging the highways leading towards thefrontier fortress which has been attacked. Arrived at the spot, if therebe little of the pomp and pageantry of war in their movements, theirpractical devotion and heroism are simply unsurpassed anywhere, even insong and story. They never think of waiting for reinforcements or fororders from headquarters. They know only one thing, and that is tofight; and when the body has brought them to the spot, it has done allthat is needed, like the Turkish Government when once it has got itssturdy peasantry upon the battlefield: they have not even the sense toretreat. And whether they be present in tens, or in scores, or inmillions, each one hurls himself upon the toxin or bacillus which standsdirectly in front of him. If he can destroy the bacillus and survive, somuch the better; but if not, he will simply overwhelm him by the weightof his body-mass, and be swept on through the blood-stream into thegreat body-sewers, with the still living bacillus literally buried inhis dead body. Like Arnold Winkelried, he will make his body a sheathfor a score of the enemy's spears, so that his fellows can rush inthrough the gap that he has made. And it makes no difference whatever ifthe first ten or hundred or thousand are instantly mowed down by thebacillus or its deadly toxins, the rear ranks sweep forward without aninstant's hesitation, and pour on in a living torrent, like the Zulu_impis_ at Rorke's Drift, until the bacilli are battered down by thesheer impact of the bodies of their assailants, or smothered under thepile of their corpses. When this has happened, in the language of theold surgeon-philosophers, "suppuration is established, " and the patientis saved. 

Or if, as often happens, an antitoxin is formed, which protects thewhole body, this is largely built out of substances set free from thebodies of slain leucocytes. And the only thing that dims our vision tothe wonder and beauty of this drama, is that it happens every day, andwe term it prosaically "the process of repair, " and expect it as amatter of course. Every wound-healing is worthy of an epic, if we couldonly look at it from the point of view of these citizens of our greatcell-republic. And if we were to ask the question, "Upon what doestheir peculiar value to the body-politic depend?" we should find that itwas largely the extent to which they retained their ancestralcharacteristics. They are born in the lymph-nodes, which are simplylittle islands of tissue of embryonic type, preserved in the bodylargely for the purpose of breeding this primitive type of cells. Theyare literally the Indian police, the scavengers, the Hibernians, as itwere, of the entire body. They have the roving habits and fightinginstincts of the savage. They cruise about continually through thewaterways and marshes of the body, looking for trouble, and, like theirHibernian descendants, wherever they see a head they hit it. They arethe incarnation of the fighting spirit of our ancestors, and if it werenot for their retention of this characteristic in so high a degree, manyclasses of our fixed cells would not have been able to subside into suchburgher like habits. 

Although even here, as we shall see, it is only a question of quicknessof response, for while the first bands of the enemy may be held at bayby the leucocyte cavalry, and a light attack repelled by theirskirmish-line, yet when it comes to the heavy fighting of afever-invasion, it is the slow but substantial burgher-like fixed cellsof the body which form the real infantry masses of the campaign. And Ibelieve that upon the proportional relation between these primitive andcivilized cells of our body-politic will depend many of the singulardifferences, not only in degree but also in kind, in the immunitypossessed by various individuals. While some surgeons and anatomistswill show a temperature from the merest scratch, and yet either neverdevelop any serious infection or display very high resisting power inthe later stages, others, again, will stand forty slight inoculationswith absolute impunity, and yet, when once the leucocyte-barrier isbroken down, will make apparently little resistance to a fatal systemicinfection. And this, of course, is only one of a score of ways in whichthe leucocytes literally _pro patria moriuntur_. Our whole alimentarycanal is continually patrolled by their squadrons, poured into it by thetonsils above and Peyer's patches below; if it were not for them weshould probably be poisoned by the products of our own digestiveprocesses. 

If, then, the cells of the body-republic retain so much of theirindependence and individuality in health, does it not seem highlyprobable that they do also in disease? This is known to be the casealready in many morbid processes, and their number is being added toevery day. The normal activities of any cell carried to excess mayconstitute disease, by disturbing the balance of the organism. Nay, mostdisease-processes on careful examination are found to be at bottomvital, often normal to the cells concerned in them. The great normaldivisions of labor are paralleled by the great processes of degenerationinto fat, fibrous tissue, and bone or chalk. A vital chemical changewhich would be perfectly healthy in one tissue or organ, in another maybe fatal. 

Ninety-nine times out of a hundred any group of cells acts loyally inthe interests of the body; once in a hundred some group acts againstthem, and for its own, and disease is the result. There is a perpetualstruggle for survival going on between the different tissues and organsof the body. Like all other free competition, as a rule, it inuresenormously to the benefit of the body-whole. Exceptionally, however, itfails to do so, and behold disease. This struggle and turmoil is notonly necessary to life--it is life. Out of the varying chances of itswarfare is born that incessant ebb and flow of chemical change, thatinability to reach an equilibrium, which we term "vitality. " The courseof life, like that of a flying express train, is not a perfectlystraight line, but an oscillating series of concentric curves. Withoutthese 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 flyingshuttle keeps moving in its restless course to and fro, life is. Asingle stop is death. The very same blow which, rightly placed, sends itlike an arrow to the safe centre of the opposing racket, if it fallobliquely, or even with too great or too little force, drives itperilously wide of its mark. It can recover the safe track only by asudden and often violent lunge of the opposing racket. The straightcourse 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 merecoincidence that the earliest gods of a race are invariably demons. Ourfirst conception of the great forces of nature is that they are ourenemies. This misconception is not only natural, but even necessary onthe sternest of physical bases. The old darky, Jim, in Huckleberry Finn, hit upon a profound and far-reaching truth when he replied in answer toHuck's question whether among all the signs and portents with which hismind was crammed--like black cats and seeing the moon over your leftshoulder and "harnts"--some were not indications of good luck instead ofall being of evil omen:--

"Mighty few--an' _dey_ ain't no use to a body. What fur you want to knowwhen 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 inall 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 makea more lasting impression upon our memories than a thousand benefitsconferred by these same forces. Besides, evil has to be sharply lookedout for and guarded against. Well enough can be safely let alone. 

The conviction is steadily growing, among both physicians andbiologists, that this attitude has caused a serious, if not vital, misconception of the influence of that great conservative andpreservative force of nature--heredity. We hear a great deal ofhereditary disease, hereditary defect, hereditary insanity, but verylittle of hereditary powers of recovery, of inherited vigor, and thefact that ninety-nine and seven-tenths per cent of us are sane. 

One instance of hereditary defect, of inherited degeneracy, fills uswith horror and stirs us to move Heaven and earth to prevent anothersuch. The inheritance of vigor, of healthfulness, and of sanity weplacidly accept as a matter of course and bank upon it in our plans forthe future, without so much as a thank you to the force that underliesit. 

When once we clear away these inherited misconceptions and look thefacts of the situation squarely in the face, we find that heredity is atleast ten times as potent and as frequently concerned in thetransmission and securing of health and vigor as of disease andweakness; that its influence on the perpetuation of bodily and mentaldefects has been enormously exaggerated and that there are exceedinglyfew hereditary diseases. 

It is not necessary for our present purpose to enter into a discussionof the innumerable theories of that inevitable tendency of like to begetlike, of child to resemble parent, which we call heredity. Onereference, however, may be permitted to the controversy that hasdivided the scientific world: whether _acquired_ characters, changesoccurring during the lifetime of the individual, can be inherited. Disease is nine times out of ten an acquired character; hence, insteadof the probabilities being that it would be inherited, the balance ofevidence to date points in exactly the opposite direction. The burden ofproof as to the inheritance of disease is absolutely upon those whobelieve in its possibility. 

Another fundamental fact which renders the inheritance of disease upon a_priori_ grounds improbable and upon practical grounds obviouslydifficult, is that characters or peculiarities, in order to be inheritedcertainly for more than a few generations, must be beneficial andhelpful in the struggle. A moment's reflection will show this to bemathematically necessary, in that any family or race which tended toinherit defects and injurious characters would rapidly go down in thestruggle for survival and become extinct. An inherited disease of anyseriousness could not run for more than two or three generations in anyfamily, simply for the reason that by the end of that time there wouldbe no family left for it to run in. A slight defect or small peculiarityof undesirable character might run for a somewhat longer period, buteven this would tend toward disappearance and elimination by the stern, selective influence of environment. 

Naturally, this great conservative tendency of nature has, like allother influences, "the defects of its virtues, " as the French say. Ithas no gifts of prophecy, and in the process of handing down tosuccessive generations those mechanisms and powers which have beenfound useful in the long, stern struggle of the past, it will also handdown some which, by reason of changes in the environment, are not onlyno longer useful, but even injurious. As the new light of biology hasbeen turned on the human body and its diseases, it has revealed so manyof these "left-overs, " or remnants in the body-machine--some of mostdramatic interest--that they at first sight have done much to justifythe popular belief in the malignant tendencies of heredity. 

Yet, broadly considered, the overwhelming majority of them should reallybe regarded as honorable scars, memorials of ancient victories, monuments to difficulties overcome, significant and encouragingindications of what our body-machine is still capable of accomplishingin the way of further adjustment to conditions in the future. The reallysurprising thing is not their number, but the infrequency with whichthey give rise to serious trouble. 

The human automobile is not only astonishingly well built, with all theimprovements that hundreds of thousands of generations of experiencehave been able to suggest, but it is self-repairing, self-cleaning, andself-improving. It never lets itself get out of date. If only given anadequate supply of fuel and water and not driven too hard, it will standan astonishing amount of knocking about in all kinds of weather, repairing itself and recharging its batteries every night, supplying itsown oil, its own paint and polish, and even regulating its own changesof gear, according to the nature of the work it has to do. Simply as anendurance racer it is the toughest and longest-winded thing on earthand can run down and tire out every paw, pad, or hoof that strikes theground--wolf, deer, horse, antelope, wild goat. This is only a sample ofits toughness and resisting power all along the line. 

These wide powers of self-support and adjustment overbalance a hundredtimes any little remnant defects in its machinery or gearing. Easilyninety-nine per cent of all our troubles through life are due toinevitable wear and tear, scarcity of food-fuel, of water, of rest, andexternal accidents--injuries and infectious diseases. Still, itoccasionally happens that these little defects may furnish the point ofleast resistance at which external stresses and strains will cause themachine to break down. They are often the things which prevent us fromliving 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. Itis just as well that they should, for, of all deaths to die, theloneliest and the most to be dreaded is that by extreme old age. 

These _vestigia_ or remnants--instances of apparently hideboundconservatism on nature's part--are very much in the public eye atpresent, partly on account of their novelty and of their exceptional andextraordinary character. Easily first among these trouble-breedingremnants 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 andrequired a longer and more complicated food-tube, with larger sidepouches in the course of it, to dissolve and absorb our food. Itspresent 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 causestrouble, but the surprisingly small amount of actual damage that arisesfrom it. Never yet in even the most appendicitis-ridden community has itbeen found responsible for more than one half of one per cent of thedeaths. 

Then there is that curious and by no means uncommon tendency for a loopof the intestine to escape from the abdominal cavity, which we callhernia. This is one of a fair-sized group of dangers clearly due to theassumption of the erect position and our incomplete adjustment thereto. In the quadrupedal position this necessary weak spot--a partial openingthrough the abdominal wall--was developed in that region which washighest from the point of view of gravity and least exposed to strain. In the bipedal position it becomes lowest and most exposed; hence themuch greater frequency of hernia in the human species as compared withany of the animals. 

Another fragment, of the impertinence of whose presence many of us havehad painful proof, is the third or last molar, so absurdly misnamed thewisdom tooth. If there be any wisdom involved in its appearance it is ofthe sort characterized by William Allen White's delicious definition:"That type of ponderous folly of the middle-aged which we term 'maturejudgment. '" The last is sometimes worst as well as best, and thisbelated remnant is not only the last to appear, but the first todisappear. In a considerable percentage of cases it is situated so farback in the jaw that there is no room for it to erupt properly, and itproduces inflammatory disturbances and painful pressure upon the nervesof the face and the jaw. 

Even when it does appear it is often imperfectly developed, has fewercusps and fewer roots than the other molars, is imperfectly covered withenamel and badly calcified. In no small percentage of cases it does notmeet its fellow of the jaw below and hence is almost useless forpurposes of mastication. But it comes in every child born into theworld, simply because at an earlier day, when our jaws were longer--togive our canine teeth the swing they needed as our chief weapons ofdefense--there was plenty of room for it in the jaw and it was of someservice to the organism. If the Indiana State Legislature would onlypass a law prohibiting the eruption of wisdom teeth in future, andenforce 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 thegall-bladder, that curious little pouch budded out from the bile ducts, which has so little known utility as compared with its possibility as astarting-point for inflammations, gall-stones, and cancer. 

Then there is that disfiguring facial defect, hare-lip, due to a failureof the three parts of which our upper jaw is built to uniteproperly, --this triple construction of the jaw being an echo ofancestral fishlike and reptilian times when our jaws were built in fivepieces to permit of wide distention in the act of swallowing our preyalive. All over the surface of the body are to be found innumerablelittle sebaceous glands originally intended to lubricate hairs, whichhave now atrophied and disappeared. These useless scraps, under variousforms of irritation, both external and internal, become inflamed andgive rise to pimples, acne, or "a bad complexion. "

And so the list might be drawn out to most impressive length. But thislength would be no indication of its real importance, inasmuch as thevast majority of entries upon it would come under the head ofpathological curiosities, or conditions which were chiefly interestingon account of their rareness and unusual character. With the exceptionof the appendix, the gall-bladder, and hernia, these vestigialconditions may be practically disregarded as factors in the death-rate. 

In the main, when the fullest possible study and recognition have beenmade of all the traces of experimentation and even of ancient failurethat are to be found in this Twentieth Century body-machine of ours, theresulting impression is one of enormously increased respect for andconfidence in the machine and its capabilities. While they are of greatinterest as indicating what the past history and experiences of theengine have been, and of highest value as enabling us to interpret andeven anticipate certain weak spots in its construction and joints in itsarmor, their most striking influence is in the direction of emphasizingthe enormous elasticity and resourcefulness of the creature. 

Not only has it met and survived all these difficulties, but it iscontinuing the selfsame processes to-day. So far as we are able tojudge, it is as young and as adaptable as it ever was, and just as readyto "with a frolic welcome greet the thunder and the sunshine" as it everwas in the dawn of history. 

These ancestral and experimental flaws, even when unrecognized andunguarded against, have probably not at any time been responsible formore than one or two per cent of the body's breakdowns; while, on theother hand, every process with which it fights disease, every trick ofstrategy which it uses against invading organisms, every step in theprocess of repair after wounds or injury, is a trick which it haslearned in its million-year battle with its surroundings. 

Take such a simple thing as the mere apparently blind habit possessed bythe blood of coagulating as soon as it comes in contact with the edgesof a cut or torn blood-vessel, and think what an enormous safeguard thishas been and is against the possibility of death by hemorrhage. So wellis it developed and so rapidly does it act that it is practicallyimpossible to bleed some animals to death by cutting across any vesselsmaller than one of the great aortic trunks. The rapidity and toughnessof the clotting, combined with the other ancestral tricks of loweringthe blood pressure and weakening down the heart, are so immenselyeffective that a slash across the great artery of the thigh in thegroin of a dog will be closed completely before he can bleed to death. So delicate and so purposeful is this adjustment that the blood willcontinue as fluid as milk for ten, twenty, forty, eighty years--as longas it remains in contact with healthy blood-vessels. But the instant itis 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 itgives rise to some of the sudden forms of death by bloodclot in thebrain or lung (apoplexy, "stroke"), the clot having formed upon theroughened inner surface of the heart or of one of the blood-vessels andthen 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 thedeeper details of its study. First, the quick outpouring and clotting ofthe blood after enough has escaped to wash most poisonous or offendingsubstances out of the wound. This living, surgical cement, elastic, self-moulding, soothing, not only plugs the cut or torn mouths of theblood-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 theanimal it forms a tough, firm, protective coating or scab, completelyshutting out cold, heat, irritants, or infectious germs. 

Into the wedge-shaped, elastic clot which now fills the wound frombottom to top like jelly in a mould, the leucocytes or white blood-cellspromptly migrate and convert it into a mesh of living cells. They aremerely the cavalry and skirmishers of the repair brigade and arequickly followed by the heavy infantry of the line in the shape of cellsborn of the injured tissues on either side of the wound. These joinhands across the gap, the engineer corps and the commissariat departmentmove up promptly to their support in the form of littlevein-construction switches, which bud out from the woundedblood-vessels. The clot is transformed into what we term granulationtissue and begins to organize. A few days later this granulation tissuebegins to contract and pull the lips of the wound together. If the gaphas not been too wide the wound will be completely closed, its lips anddeeper parts drawn together in nearly perfect line, separated only by athin scar on the surface with a vertical keel of scar tissue descendingfrom it. If the lips cannot be drawn together and there be no surgicalskill at hand to assist them with stitches or bandages, then the gapwill be filled up by the fibrous transformation of this granulationtissue and a thick, heavy scar result. Meanwhile, the skin-cells of thesurface have not been idle, but are budding out on either side of thehealing wound, pushing a little line of colonists forward across the rawsurface. 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 hasleft is perfectly coated over with a layer of healthy skin. This dramahas occurred so many score of times in every one of us that custom hasblinded our eyes to its ingenious perfection, but it took a millionyears to bring it to its present finish. 

It may be a healthy corrective to our overweening conceit to remindourselves that, remarkable and valuable as it is, it is a mere infantin arms compared to the superb powers of replacement and repairpossessed by our more remote ancestors. Most invertebrates and many ofthe lowest two classes of backboned animals, the fishes and theamphibians, 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 halfwill grow a new head and the front half a new tail. It may even be cutin four or five segments, each of which will proceed to form a head atone end and a tail at the other. The lobster can regrow a complete gilland any number of claws or an eye. A salamander will reproduce a footand part of a limb. Take out the crystalline lens in the eye of asalamander and the edge of the iris, or colored part of the eye, willgrow another lens. Take out both the lens and the iris and the choroidcoat of the eye will reproduce both. 

We are in the A, B, C class in powers of repair by comparison with theangleworm, the lobster, or the salamander. Yet we are not withoutgruesome echoes of this lost power of regeneration in that our wholebrood of tumors, including the deadly cancer and sarcoma, are due to astrange resumption, on the part of some little knot of our body-cells, of the power of reproducing themselves or the organ in which they aresituated, without any regard to the welfare of the rest of the body. Cancer is, in one sense, a throwing off of the allegiance to thebody-state and a resumption of amphibian powers of independent growth onthe part of certain groups of our body-cells--literally, a "rebellion ofthe 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 incombating disease and preserving life are the result of the hereditaryexperiences of our cells. Intelligent physicians are receding completelyfrom that curiously warped and jaundiced view which led us to regardheredity 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 tobe corrected. But, just as in the growth of our ethnic religions it isEvil that is worshiped first as strongest and most aggressive, and therecognition of the greater power of good comes only at a later stage, soit has been in pathology. 

Not only do we regard heredity as a comparatively small and steadilyreceding factor in the production of disease, but we fully and franklyrecognize it as the strongest and most important single force in itsprevention. All our processes of repair, all the reactions of the bodyagainst the attack of accident or of disease, are hereditary endowments, worked out with infinite pains and labor through tens of thousands ofgenerations. The utmost that we can do with our drugs and remedies is toappeal to and rouse into action the great healing power of nature, theclassic "_Vis medicatrix Naturæ_, " an incarnation of our pastexperiences handed down by heredity. Enormously valuable and importantas are the services to human welfare, health, and happiness which can berendered by the destruction of the living external causes of disease andthe prevention of contagion, our most permanent and substantialvictories are won by appealing to and increasing this long-descended andhard-won power of individual resistance. 

"But, " says some one at once, "I thought there were a large number ofhereditary diseases. " Fifty years ago there were a score of such, twentyyears ago the score had sunk to five or six. Now there is scarcely oneleft. There is no known disease which is directly inherited as such. There is scarcely even a disease in which we now regard heredity asplaying a dominant or controlling part. Among the few diseases in whichthere 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 thepossibility of their inheritance, but which have now resolved themselvesclearly into instances of the fact that a mother who happens to contractan acute infectious disease of any sort may communicate that disease tothe unborn child. If this occurs at an early stage of development thechild will naturally be promptly killed. In fact, this is the almostinvariable result in smallpox and yellow fever. If, on the other hand, development be further advanced or the infection be of a mildercharacter, like scarlet fever or syphilis, the child may be bornsuffering with the disease or with the virus in its blood, which willcause the disease to develop within a few days after birth. This, however, is clearly not inheritance at all, but direct infection. We nolonger use the term _hereditary_ syphilis but have substituted for itthe word _congenital_, which simply means that a child is born with thedisease. 

There is no such thing as this disease extending "unto the third andfourth generation, " like the wrath of Jehovah. One fact must, of course, be remembered, which has probably proved a source of confusion in thepopular mind, and that is its extraordinary "long-windedness. " It takesnot 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 achild to be born with the taint in its blood and yet not exhibit to thenon-expert eye any sign of the disease until its eighth, twelfth, oreven fifteenth year. 

The case of tuberculosis is almost equally clear-cut. In all thethousands of post-mortem examinations which have been held upon newbornchildren and upon mothers dying in or shortly after childbirth, thenumber of instances of the actual transference of the bacilli oftuberculosis from mother to child could be counted upon the fingers oftwo hands. It is one of the rarest of pathologic curiosities and, forpractical purposes, may be entirely disregarded. When tuberculosisappears in several members of a family, in eight cases out of ten it isdue to direct infection from parents or older children. This isstrikingly brought out in the admirable work done by the AssociatedDispensaries for Tuberculosis of the Charity Organization Society of NewYork. 

One of the first steps in advance which they took was to establish inconnection with every clinic for tuberculosis an attendant nurse, whoseduty it was to visit the patients at their homes and advise and instructthem 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 backreports of other cases in the same family. Now the procedure isregularly adopted, whenever a case presents itself, of rounding up theremainder of the family group for examination, with the astoundingresult that where a mother or father is tuberculous, from twenty tosixty per cent of the children will be found to be suffering from someform of the infection. Instances of three infected children out of fiveliving in the same room with a tuberculous mother are actually onrecord. 

No one can practice long in any of our great climatic health resorts fortuberculosis, like Colorado or the Pacific Slope, without coming acrossscores of painful and distressing instances of children of tuberculousparents dying suddenly in convulsions from tuberculous meningitis, or bya wasting diarrh[oe]a from tuberculosis of the bowels, or from a violentattack of distention of the bowels due to tuberculous peritonitis. Thefavorite breeding-place of the tubercle bacillus is unfortunately in thehome. 

On the other hand, while the vast majority of cases of so-calledhereditary tuberculosis are due to direct infection, and may beprevented by proper disposal of the sputum and other methods foravoiding contagion, there is probably a hereditary element in the spreadof tuberculosis to this degree: that, inasmuch as all of us have beenexposed to the attack and invasion of the tubercle bacillus, not merelyscores, but hundreds of times, and have been able to resist or throwoff that attack without apparent injury, the development of an invasionof the tubercle bacillus sufficiently extensive to endanger life is, innine cases out of ten, in itself a proof of lowered resisting power onthe part of the patient. This may be, and often is, only temporary, dueto overwork, underfeeding, overconfinement, or that form of gradualsuffocation which we politely term inadequate ventilation. 

In a certain percentage of cases, however, it is due to a chronic lackof vigor and vitality; a lowering of the whole systemic tone, which mayhave existed from birth. In that case it is hardly to be expected thatsuch an individual, becoming a parent, will be able to transmit to hisor her offspring more vigor than he originally possessed. It istherefore probable that the children of a considerable percentage oftuberculous parents would not possess the same degree of resisting poweragainst tuberculosis, or any other infection, as the average individual. 

It is doubtful whether this factor of inherited lowered resistance playsany very important part in the propagation of tuberculosis, partlybecause it is comparatively seldom that consumptive marries consumptive, and such tendencies to lowered vigor and vitality as may be transmittedby one parent will be neutralized by the other; partly also because, bythe superb and beneficent logic of nature, the pedigree of any diseaseis of the most mushroom and insignificant length, while the pedigree ofhealth stretches back to the very dawn of time. In the struggle fordominance which takes place between the germ cells of the father andthose of the mother, the chances are at least ten to one in favor ofthe old ancestral traits of vigor, of resisting power, and of survival. How deeply this idea is implanted in the convictions of the scientificworld, the bitterly and widely debated biologic question whetheracquired characters or peculiarities can under any circumstances beinherited clearly shows. Victory for the present rests with those whodeny the possibility of such inheritance, and disease is emphatically anacquired character. 

Truth here, as everywhere, probably lies between the extremes, and bothbiologists and the students of disease have arrived at practically thesame working compromise, namely, that while no gross defect, such as amutilation, nor definite disease factor, such as a germ, nor even acancer, can possibly be inherited, yet, inasmuch as the two cells, whichby their development form the new individual, are nourished by the bloodof the maternal body, influences which affect the nutritiousness orhealthfulness of that blood may unfavorably influence the development ofthe offspring. 

Disease cannot be inherited any more than a mutilating defect, but theresults of both, in so far as they affect the nutrition of the offspringin the process of formation, may be transmitted, though to a very muchsmaller extent than we formerly believed. In the case of tuberculosis, if the mother, during the months that she is building up the body andframework of a child, is in a state of reduced or lowered nutrition onaccount of consumption or any other disease, or has her tissuessaturated with the toxins of this disease, it is hardly to be expectedthat the development of the child will proceed with the same perfectionas it would under perfectly normal maternal surroundings. 

However, even this influence is comparatively small; for one of the mostmarvelous things in nature is the perfection of the barrier which shehas erected between the child before birth and any injurious conditionswhich 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 anadequate supply of nutrition, as, for instance, in cases of underfeedingor of famine, it is the mother who will suffer in her nutrition ratherthan the child. The unborn child, biologically considered, feeds uponthe best she has to offer, rejecting all that is inferior, doing nothingand giving nothing in return. 

How perfectly the coming generation is protected under the mostunfavorable circumstances we have been given a striking object-lesson inone family of the lower animals. In the effective crusade againsttuberculosis in dairy cattle waged by the sanitary authorities inDenmark, it was early discovered that the greatest practical obstacle tothe extermination of tuberculosis in cattle was the enormous financialsacrifice involved in killing all animals infected. The disease was atthat time particularly rife among the high-bred Jersey, Holstein, andother milking breeds. It was determined as a working compromise to testthe truth of the modern belief that tuberculosis was transmitted only bydirect infection, by permitting the more valuable cows to be saved alivefor breeding purposes. They were isolated from the rest of the herd andgiven the best of care and feeding. The moment that their calves wereborn they were removed from them altogether and brought up on the milkof perfectly healthy cows. The milk of the infected cows was eitherdestroyed or sterilized and used for feeding pigs. 

The results were brilliantly successful. Scarcely one of the calves thusisolated developed tuberculosis in spite of their highly infectedancestry. And not only were they not inferior in vigor and perfection oftype to the remainder of their breed, but some of them have since becomeprize-winners. The additional care and more abundant feeding that theyreceived more than compensated for any problematic defect in theirheredity. 

As to the heredity of cancer, all that can be said is that the burden ofproof rests upon those who assert it. It is really curious howwidespread the belief is that cancer "runs in families, " and howexceedingly slender is the basis of evidence for such a belief. Thereare so many things that we do not know about cancer that any positivestatement of any kind would be unbecoming. It would be absurd to declarethat a disease, of which the cause is still unknown, either is or is notinherited. And this is our position in regard to cancer. An overwhelmingmajority of the evidence so far indicates that it is not a parasite; ifit were, of course, we could say positively that it is not inherited. Although we are getting a discouraging degree of familiarity with theprocess and clearly recognize that it consists chiefly in the suddenrevolt or rebellion of some group of cells, a tendency which quiteconceivably might be transmitted to future generations, yet it is highlyimprobable, on both biological and pathological grounds, that such isthe case. If this rebellious tendency were transmitted we should atleast have the right to expect that it would appear in the cells of thesame organ or region of the body. It is a singular fact that in all thehundreds of cases in which cancer has appeared in the child of acancerous parent it has almost invariably appeared in some differentorgan from that affected in the parent. 

For instance, cancer of the lip in the father may be followed by cancerof the liver in the son or daughter, while cancer of the breast in themother will be followed by cancer of the lip in a son. Further thanthis, the percentage of instances in which cancer appears in more thanone member of a family is decidedly small, considering the frequency ofthe disease. 

I took occasion to look into the matter carefully from a statisticalpoint of view some ten or twelve years ago, and out of a collection ofsome fifty thousand cases of cancer less than six per cent were found togive any history of cancer in the family. And this, of course, simplymeans that some one of the relatives of the patient had at one timedeveloped the disease. 

In fact, the consensus of intelligent expert opinion upon the subject ofheredity of cancer is, that though it may occur, we have comparativelylittle proof of the fact; that the percentage of cases in which there iscancer in the family is but little larger than might be expected on thedoctrine of probabilities from the average distribution. Though possiblythe offspring of a cancerous individual may display a slightly greatertendency toward the development of that strange, curious process of"autonomy" than the offspring of the average individual, this tendencyis so small and occurs so infrequently as to be a factor of smallpractical importance in the propagation and spread of the disease. 

In insanity and epilepsy we have probably the last refuge and almostonly valid instance of the old belief in the remorseless heredity ofdisease. But even here the part played by heredity is probably only afraction of that which it is popularly, and even professionally, believed to play. It is, of course, obvious that diseases which tendquickly to destroy the life of the patient, especially those which killor seriously cripple him before he has reached the age of reproduction, or prevent his long surviving that epoch, will not, for mechanicalreasons, become hereditary. The Black Death, or the cholera, forinstance, could not "run in a family. " Supposing that children were bornwith a special susceptibility to this disease, there would obviouslysoon 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 wholeprogress of civilization has been a continuous process of the weedingout of those who were most susceptible and the survival of those whowere least so. 

But when we come to deal with certain conditions, fortunately rare, suchas functional disturbances of the nervous system, which neitherseriously unfit their possessor for the struggle of life nor preventhim from reproducing his kind, then it becomes possible that a tendencyto such disease may be transmitted through several successivegenerations. 

Such is the case with insanity, with epilepsy, with _hemophilia_, or"bleeders, " and with certain rare and curious disturbances of thenervous system, such as the hereditary _ataxias_ and "tics" of varioussorts. However, even here the only conditions on which these diseasescan continue to run in a family for more than one or two generations iseither that they shall be mild in form or that only a comparativelysmall percentage of the total family shall be affected by them. If, forinstance, two-thirds, one-half, or even a third of the descendants of amentally unsound individual were to become insane, it would only need afew generations for that family to be crushed to the wall. 

While the descendants of insane persons are distinctly more liable tobecome insane than the rest of the community, yet, on account of theirfewness, this tendency probably does not account for more than a smallfraction of the total insanity. We should, by all means, prevent themarriage of the insane and discourage that of their children, and thedevelopment 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, ofcourse, as usually happens, that the other parent--husband or wife--issound and sane, not more than ten or fifteen per cent would probablybecome insane. In other words, insanity is acquired and the result ofindividual stress and strain at least five times as frequently as it isinherited. We have absolutely no rational or statistical basis forgloomy predictions that, at present rates, within a couple of centuriesmore, we shall all be shut up in asylums with nobody left to support usand pay the taxes. The apparent increase of insanity of recent decadesis probably only "on paper, " due to better registration. 

To put it very roughly, probably ninety-eight per cent of us are soborn, thanks to heredity, that the possibility of our becoming insane, even under the severest stress, is almost infinitesimal. Of the two percent born with this taint, this possible tendency to mental unbalance, only about one-tenth now become completely insane, [1] and thispercentage might be greatly diminished by general sanitary improvements. Our alienists now claim that, by checking the reproduction of theobviously unstable, and careful hygienic treatment and training of thepredisposed two per cent, insanity is almost as preventable astuberculosis. 

[Footnote 1: The proportion of registered insane in civilized countriesto-day ranges from two to three per 1000 of the population. ]

In fine, from all the broad field of pathology, the mists of traditionwhich have dimmed the fair name and reputation of heredity are slowlybut surely lifting, until we now behold it, not as our worst enemy, butas our best friend in the prevention of disease and the upbuilding ofthe 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 atthat, originally, is becoming a science. And the most powerful factor inthis development, its indispensable basis, in fact, has been theinvention of instruments of precision--the microscope, the feverthermometer, the stethoscope, the ophthalmoscope, the test-tube, theculture medium, the triumphs of the bacteriologist and of the chemist. Any man who makes a final diagnosis in a serious case without resortingto some or all of these means is regarded--and justly--as careless andderelict in his duty to his patient. 

At the same time, priceless and indispensable as are these laboratorymethods of investigation, they should not be allowed to make us tooscornful and neglectful of the evidence gained by the direct use of ourfive senses. We should still avail ourselves of every particle ofinformation that can be gained by the trained eye, the educated ear, theexpert touch, --the _tactus eruditus_ of the medical classics, --and eventhe sense of smell. There is, in fact, a general complaint among theolder members of the profession that the rising generation is beingtrained 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 themicroscope or demonstrated by a reaction in the test-tube. As one of ourkeenest observers and most philosophic thinkers expressed it a fewmonths ago:--

"I fear that certain physicians on their rounds are most careful to takewith 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 halfmagic, possessed in such a wonderful degree by the older physicians ofthe passing and past generations, has been almost lost by the new. 

A healthful reaction has, however, set in; and while we certainly do notlove the Cæsar of laboratory methods and accuracy the less, we arebeginning to have a juster affection for the Rome of the rich harvestthat may be gained from the careful, painstaking, detective-likeexercise of our eye, ear, and hand. 

As a matter of fact, the conflict between the two methods is onlyapparent. Not only is each in its proper sphere indispensable, but theyare enormously helpful one to the other. Instead of our being able totell less by the careful, direct eye-and-hand examination of ourpatients than the doctor of a century ago, we can tell three to fivetimes as much. Signs that he could interpret only by the slow andpainful method of two-thirds of a lifetime of plodding experience, or byoccasional flashes of half-inspired insight, we are now able tointerpret absolutely upon a physiological--yes, a chemical--basis fromthe revelations of the microscope, the test-tube, and the culturemedium. His only way of determining the meaning of a particular tint ofthe complexion, or line about the mouth, or eruption on the skin, was byslowly and laboriously accumulating a long series of similar cases inwhich that particular symptom was found always to occur, and deducingits meaning. Now, we simply take a drop of our patient's blood, ascraping from his throat, a portion of some one of his secretions, alittle slice of a tumor or growth, submit them to direct examination inthe laboratory, and get a prompt and decisive answer. 

The observant physician begins to gather information about a patientfrom the moment he enters the sick-room or the patient steps into hisconsulting-room; and the value of the information obtained in the firstthirty seconds, before a word has been spoken, is sometimesastonishingly great. While no intelligent man would dream of dependingupon this first _coup d'[oe]il_, "stroke of the eye" as the French sographically call it, for his final diagnosis, or accept its findingsuntil he had submitted them to the most ruthless cross-examination withthe stethoscope and in the laboratory, yet it will sometimes give him aclew of almost priceless value. It is positively uncanny to see theswift, intuitive manner in which an old, experienced, and thoughtfulphysician will grasp the probable nature of a case in one keen look at apatient. Often he can hardly explain to you himself how he does it, whatare the data that determine it; yet not infrequently, three times outof five, your most elaborate and painstaking study of the case with allthe modern methods will bring you to the same conclusion as that sensedwithin forty-five seconds by this keen-eyed old sleuth-hound of thefever trails. Time and again, in my interne days, have I gone the roundsof the wards or the out-patient departments with some kindly-faced, keen-eyed old Sherlock Holmes of the profession, and seen him point to anew case across the ward with the question: "When did that pneumoniacome in?" or pick out a pain-drawn, ashy mask in the waiting line, withan 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 positivelypainful to walk down a crowded street, from the gruesome habit that theyhad of picking out, and condemning to lingering deaths, the cases ofcancer, of Bright's disease, or of locomotor ataxia, that we happened tomeet. Of course, they would be the first to admit that this was onlywhat they would term a "long shot, " a guess; but it was a guess basedupon significant changes in the patient's countenance or gait, whichtheir trained eye picked out at once, and it was surprising how oftenthis snapshot diagnosis turned out to be correct. 

The first thing that a medical student has to learn is that appearancesare _not_ deceptive--except to fools. Every line of the human figure, every proportion of a limb, every detail of size, shape, or relation inan organ, _means_ something. Not a line upon any bone in the skeletonwhich was not made by the hand-grip or thumbprint of some muscle, tendon, or ligament; no bump or knuckle which is not a lever orhand-hold for the grip of some muscle; not a line or a curve or anopening in that Chinese puzzle, the skull, which was not made to protectthe brain, to accommodate an eye, to transmit a blood-vessel, or toallow the escape of a nerve. Every minutest detail of structure meanssomething to the man who will take the pains to puzzle it out. And ifthis is true of the foundation structure of the body, is it to beexpected 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 exquisitelyresponsive surface--half mirror, half sensitive plate--the humancountenance. The place where the moving finger of disease writes itsclearest and most unmistakable message is the one to which we mustnaturally turn, the face; not merely for the infantile tenth part of areason which we often hear alleged, that it is the only part of thebody, except the hand, which is habitually exposed, and hence open toobservation, but because here are grouped the indicators and registersof almost every important organ and system in the body. 

What, of course, originally made the face the face, and, for the matterof that, the head the head, was the intake opening of the food-canal, the mouth. Around this necessarily grouped themselves the outlookdepartments, the special senses, the nose, the eyes, and ears; whilelater, by an exceedingly clumsy device of nature, part of the mouth wassplit off for the intake of a new ventilating system. So that when weglance at the face we are looking first at the automatically controlledintake openings of the two most important systems in the body, thealimentary and the respiratory, whose muscles contract and relax, ripplein comfort or knot in agony, in response to every important change thattakes place throughout the entire extent of both. 

Second, at the apertures of the two most important members of theoutlook corps, the senses of sight and of smell. These are not onlysharply alert to every external indication of danger, but by a curiousreversal, which we will consider more carefully later, reflect signalsof distress or discomfort from within. Last, but not least, thetranslucent tissues, the semi-transparent skin, barely veiling thepulsating mesh of myriad blood-vessels, is a superb color index, painting in vivid tints--"yellow, and ashy pale, and hectic red"--theliving, ever changing, moving picture of the vigor of the life-centre, the blood-pump, and the richness of its crimson stream. Small wonderthat the shrewd advice of a veteran physician to the medical studentshould be: "The first step in the examination is to look at yourpatient; the second is to look again, and the third to take another lookat him; and keep on looking all through the examination. "

It is no uncommon thing for an expert diagnostician deliberately to leadthe patient into conversation upon some utterly irrelevant subjects, like the weather, the crops, or the incidents of his journey to thecity, simply for the purpose of taking his mind off himself, puttinghim at his ease, and meanwhile quietly deciphering the unmistakablecuneiform inscription, often twice palimpsest, written by the finger ofdisease upon his face. It takes time and infinite pains. In no otherrealm does genius come nearer to Buffon's famous description, "thecapacity for taking pains, " but it is well worth the while. And with allour boasted and really marvelous progress in precise knowledge ofdisease, accomplished through the microscope in the laboratory, itremains a fact of experience that so careful and so trustworthy is thisface-picture when analyzed, that our best and most depended uponimpressions as to the actual condition of patients, are still obtainedfrom this source. Many and many a time have I heard the expression froma grizzled consultant in a desperate case, "Well, the last blood-countwas better, " or, "The fever is lower, " or, "There is less albumen, --butI don't like the look of him a bit"; and within twenty-four hours youmight be called in haste to find your patient down with a hemorrhage, orin a fatal chill, or sinking into the last coma. 

It would really be difficult to say just what that careful and lovingstudent of the _genus humanum_ known as a doctor looks at first in theface 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 sucha second nature, such a matter of instinct with him, that he will oftenput together all the signs at once, note their relations, and come to aconclusion almost in the "stroke of an eye, " as if by instinct, just asa weather-wise old salt will tell you by a single glance at the skywhen 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 oftypical locomotor ataxia, gave me a brief but significant history, putthe patient through his paces, and asked for a diagnosis. I hesitated, blundered through a number of further unnecessary questions, and finallystumbled upon it. After the patient had left the room, I, feeling ratherproud of myself, expected his commendation, but I didn't get it. "Myboy, " he said, "you are not up to the mark yet. You should be able torecognize a disease like that just as you know the face of anacquaintance on the street. " A positive and full-blown diagnosis of thissort can, of course, only be made in two or three cases out of ten. Butthe method is both logical and scientific, and will give information ofpriceless value in ninety-nine cases out of a hundred. 

Probably the first, if not the most important, character that catchesthe physician's eye when it first falls upon a patient is hisexpression. This, of course, is a complex of a number of differentmarkings, but chiefly determined by certain lines and alterations ofposition of the skin of the face, which give to it, as we frequentlyhear it expressed, an air of cheerfulness or depression, comfort ordiscomfort, hope or despair. These lines, whether temporary orpermanent, are made by the contractions of certain muscles passing fromone part of the skin to another or from the underlying bones to theskin. These are known in our anatomical textbooks by the natural butabsurd name of "muscles of expression. "

Their play, it is true, does make up about two-thirds of the wonderfulshifting of relations, which makes the human countenance the mostexpressive thing in the world; but their original business is somethingtotally different. Primarily considered, they are solely for the purposeof opening or closing, contracting or expanding, the different orificeswhich, as we have seen, appear upon the surface of the face. Thisnaturally throws them into three great groups: those about andcontrolling the orifice of the alimentary canal, the mouth; thosesurrounding the joint openings of the air-tube and organ of smell, andthose surrounding the eyes. 

As there are some twenty-four pairs of these in an area only slightlygreater than that of the outspread hand, and as they are capable ofacting with every imaginable grade of vigor and in every possiblecombination, it can readily be seen what an infinite and complicatedseries of expressions--or, in other words, indications of the state ofaffairs within those different orifices--they are capable of. Only thebarest and rudest outlines of their meaning and principles ofinterpretation can be attempted. To put it very roughly, the mainunderlying principle of interpretation is that we make our firstinstinctive judgment of the site of the disease from noting which of thethree great orifices is distorted furthest from its normal condition. Then by constructing a parallel upon the similarity or the difference ofthe lines about the other two openings, we get what a surveyor wouldcall our "lines of triangulation, " and by following these to theirconverging point can often arrive at a fairly accurate localization. 

The greatest difficulty in the method, though at times our greatesthelp, is the extraordinary and intimate sympathy which exists betweenall three of these groups. If pain, no matter where located, oncebecomes intense enough, its manifestations will travel over theface-dial, overflowing the organ or system in which it occurs, and eyes, nostrils, and mouth will alike reveal its presence. Here, of course, iswhere 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 itvery roughly--has he cancer of the stomach? Pneumonia? Brain tumor? Ifthere be no play of the muscles distending and contracting the nostrilswith each expiration, no increased rapidity of breathing, no gasp when afull breath is drawn, and no deep red fever blush on the cheeks, wementally eliminate pneumonia. The absence of these nasal signs throws usback toward cancer or some other painful affection of the alimentarycanal. If the pain-lines about the mouth are of recent formation, andhave not graved themselves into the furrows of the forehead above andbetween the eyebrows; if the color, instead of ashy, be clear and red, we throw out cancer and think of colic, ulcer, hyperacidity, or somemilder form of alimentary disease. 

If, on the other hand, the pain-lines are heaviest about the brows, theeyes, and the forehead, with only a sympathetic droop or twist of thecorners of the mouth, if the nostrils are not at all distorted or toomovable, if there is no fever flush and little wasting, and on turningto the eyes we find a difference between the pupils, or a widedistention or pin-point-like contraction of both or a slight squint, thepicture of brain tumor would rise in the mind. Once started upon any oneof these clews, then a hundred other data would be quickly looked forand asked after, and ultimately, assisted by a thorough and exhaustiveexamination with the instruments of precision and the tests in thelaboratory, a conclusion is arrived at. This, of course, is but theroughest and crudest outline suggestive of the method of procedure. 

Probably not more than once in three times will the first clew that westart on prove to be the right one; but the moment that we find thisbarred, we take up the next most probable, and in this manner hit uponthe true scent. 

As to the cause and rationale of these pain-lines, only the barestoutlines can be given. Take the mouth for an example. When all is goingwell in the alimentary canal, without pain, without hunger, and bothabsorption of food and elimination of waste are proceeding normally, thetissues about the mouth, like those of the rest of the body, are apt tobe plump and full; the muscles which open the aperture, having fulfilledtheir duty and received their regular wages, are quietly at rest; thosethat close the opening, having neither anticipation of an early call forthe admission of necessary nutriment, nor an instinctive desire to shutout anything that may be indigestible or undesirable, are now in theirnormal condition of peaceful, moderate contraction; the face has acomfortable, well-fed, wholesome look. On the other hand, let thedigestive juices fail to do their duty properly, or the swarms ofbacteria pets which we keep in our food-canals get beyond control; or iffor any other reason the tissues be kept from getting their propersupply of nourishment from the food-canal, the state of affairs isquickly revealed in the mouth mirror. Those muscles which open themouth, instead of resting peacefully in the consciousness of duty welldone, are in a state of perpetual fidget, twitching, pulling, wonderingwhether they ought not to open the portal for the entrance of newsupplies of material, since the tissues are crying for food. 

As the strongest of these are those which pull the corners of the mouthoutward and downward, the resultant expression is one of depression, with downward-curving angles to the mouth. The eyes, and even thenostrils, sympathetically follow suit, and we have that countenancewhich, by the cartoonist's well-known trick, can be produced by thealteration of one pair of lines, those at the angles of the mouth, turning a smiling countenance into a weeping one. On the other hand, ifall these processes of nutrition and absorption are proceeding as theyshould, they are accompanied by mild sensations of comfort which, although they no longer reach our consciousness, reveal themselves inthe mouth-opening muscles, and they gently contract upward and outward, in pleasurable anticipation of the next intake, and we get the grin orthe smile. 

If, on the other hand, these digestive disturbances be accompanied bypain, then another shading appears on our magic mirror, and that is acurious contraction of the mouth, with distortion of the linessurrounding it, so violent in some cases as positively to whiten thelips or produce lines of paleness along the course of the muscles. Thisis the set or twisted mouth of agony, and is due to a curioustransference and reflex on this order: that inasmuch as the last foodwhich entered the alimentary canal seems to have caused this disturbanceand pain, no more will be allowed to enter it at present under anyconditions. And as our alimentary instincts are the most fundamental ofall, by a due process of transference, mental agony calls into actionthis same set of muscles, to shut out any possible addition to the agonyalready present. 

The lines of determination, similarly, about the mouth, are those of theindividual who has the courage to say "No" to the tempting morsel whenhe doesn't need it; and the lines of weakness and irresolution are thoseof the nature which cannot resist either gastronomic or othertemptation. Similarly, the well-known lines of disgust or of discontentabout the corners of the mouth are the unconscious contractionsaccompanying nausea, and preparations to expel the offending morselwhether from stomach or mouth. 

If, on the other hand, our first glance shows us that the deepestpain-lines are those about the nostrils and upper lip, especially if thewings of the nostrils can be seen to dilate with each breath, andbreathing be faster than normal, our clew points in the direction ofsome disease of the great organs above the diaphragm--that is, thelungs or heart. 

Signs in this region might refer to either of these, for the reasonthat, although a sufficient intake of air is one of the necessaryconditions of proper oxygenation, a free and abundant circulation of theblood through the air-cells is equally essential. In fact, that commonphenomenon known as "shortness of breath" is more frequently due todisturbances of the heart and circulation than it is to the lungs, especially in patients who are able to be up and about. If, in additionto the danger signal of the rise and fall of the nostrils with eachbreath, we have a pale, translucent skin, with a light, hectic flushshowing just below the knife-like lower edge of the cheekbone, a widelyopen, shining eye, and a clustering abundance of hair of a glossinessbordering on dampness, red lips slightly parted, showing the teethbetween, a painfully strong suspicion of consumption would ariseunbidden. 

This pathetic type of face has that fatal gift which the Frenchclinicians, with their usual happiness of phrase, term _La beauté dudiable_. The eager eyes, dilated nostrils, parted lips, give that weirdair of exaltation which, when it occurs, as it occasionally does in thedying, is interpreted as the result of glimpses into a spirit world. When to this is added the mild delirium of fever, when memories ofhappier days and of those who have passed before rise unbidden andbabble themselves from the tongue, one can hardly wonder at thisinterpretation. 

The last group of lines to be noted is that about the eyes andforehead. These are less reliable than either of the other two, for thereason that they are so sympathetic as almost invariably to be presentin addition, whenever the lower dial-plates of the face are disturbed. It is only when they appear alone that they are significant; then theymay be interpreted as one of three things: first, and commonest, eyestrain; second, disease in some part of the nervous system or muscularsystem, not connected with the organs of the chest or abdomen; andthird, mental disturbances. 

This last relation, of course, makes them in many respects the leastreliable of all the face indices, because--as is householdknowledge--they indicate mental conditions and operations, as well asbodily. "The wrinkled brow of thought, " the "deep lines of perplexity, "etc. , are in the vocabulary of the grammar grades. They are, however, avaluable check upon the other two groups. They are not apt to be presentin 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 oftyphoid. 

One of the most singular transformations in the sick-room, especially inserious disease marked by lethargy or stupor, is that in which thepatient's countenance will appear like a sponged-off slate, socompletely have the lines of worry and of thought been obliterated. 

One distinct value of the pain-lines about the eyes and brow is that youcan often test their genuineness. Just engage your hypochondriac orhysterical patient in lively conversation; or, on the reverse principle, wound his vanity, so as to produce an outburst of temper, and see howthe lines of undying agony will fade away and be replaced by the curvesof 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, whilea pale, sallow complexion suggests disease. But our color signals, whilemore vivid, are much less reliable and more apt to deceive than ourline-markings. 

Surprising as it may sound, careful analyses have shown, first, that thekind of pigment present in the human skin of every race is absolutelyone and the same. The only difference between the negro and the whiteman 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 aconsiderable, amount of this pigment present in it. 

"The red hue of health" is even more apt to mislead us, because, beingdue to the abundance of blood in the meshes of the skin, many fevers, byincreasing the rapidity of the heart-beat and dilating the vessels inthe skin, give a ruddiness of hue equal to or in excess of the normal. 

However, a little careful checking up will eliminate most of thepossible mistakes and enable us to obtain information of the greatestvalue from color. For instance, if our patient be of Southern blood, ortanned from the seashore, the good red blood in his arteries is prettysafe to show through at the normal blush area on the cheeks; or, failingthat, through the translucent epithelium of the lips and gums. If, onthe other hand, this yellow tint be due to the escape of broken-downblood-pigments into the tissues, or a damming up of the bile, and asimilar escape of its coloring matter, as in jaundice, then we turn tothe whites of the eyes, and if a similar, but more delicate, yellowishtint confronts us there, we know we have to deal with a severe form ofanæmia or jaundice, according to the tint. In extreme cases of thelatter, the mucous membrane of the lips and of the gums will even show adistinctly yellowish hue. The frightful color of yellow fever, and theyellow "death mask, " which appears just before the end of several fatalforms of blood poisoning, is due to the tremendous breaking down of thered cells of the blood under the attack of the fever toxins, and theirleaking out into the tissues. A similar process of a milder and lessserious extent occurs in those temporary anæmias of young girls, knownfor centuries past in the vernacular as "the green sickness. " And adelicate lemon tint of this same origin, accompanied by a waxy pallor, is significant of the deadly, pernicious anæmia and the later stages ofcancer. 

The most significant single thing about the red flush, supposed to beindicative of health, is its location. If this be the normal "blusharea, " about the middle of each cheek, --which is one of nature's sexualornaments, placed, like a good advertisement, where it will attract mostattention and add most beauty to the countenance, --and it fades offgradually at the edges into the clear whiteness or brownness of thehealthy skin, it is probably both healthy and genuine. If the work ofeither fever or of art, it will generally reveal itself as a baseimitation. In eight cases out of ten of fever, the flush, instead ofbeing confined to this definite area, extends all over the face, even upto 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 increasedrapidity of respiration, and a general air of discomfort and unrest, youare fairly safe in making a diagnosis of fever. If the first touch ofthe 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. Thefirst of these is consumption; for here the flush, both in position andin delicacy and gentle fading away at the proper margins, is an almostperfect imitation of health. It, however, usually appears, not as thenormal flush of health does, upon a plump and rounded cheek, but upon ahollow and wasted one. It rises somewhat higher upon the cheekbones, throwing the latter out into ghastly prominence. The lips and the eyeswill give us no clew, for the former are red from fever, and the latterare bright from the gentle, half-dreamy state produced by the toxins ofthe disease, the so-called "_spes phthisica_"--the everlasting andpathetic hopefulness of the consumptive. But here we call for help uponanother 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 feelsas if you were grasping a handful of bones and nerves, and thefinger-tips are clubbed and the nails curved like claws, then you have astrong _prima facie_ case. 

The other color condition which is apt to puzzle us is that of the plumpand comfortable middle-aged gentleman with a fine rosy color, but awatery eye and loose and puffy mouth, a wheezy respiration and apparentexcess of adipose. Here the high color is often due to a paralyticdistention of the blood-vessels of the face and neck, and an examinationof his heart and blood-vessels shows that his prospects are anything butas rosy as his countenance. 

The varying expressions of the face of disease are by no means confinedto the countenance. In fact, they extend to every portion of--inTrilby's immortal phrase--"the altogether. " Disease can speak mosteloquently through the hand, the carriage, the gait, and, in a way thatthe patient may be entirely unconscious of, the voice. These forms ofexpression are naturally not so frequent as those of the face, onaccount of the extraordinary importance of the great systems whoseclock-dials and indices form what we term the human countenance. Butwhen they do occur they are fully as graphic and more definitely anddistinctively localizing. 

Next in importance to the face comes the hand, and volumes have beenwritten upon this alone. Containing, as it does, that throbbing littleblood-tube, the radial artery, which has furnished us for centuries withone of our oldest and most reliable guides to health conditions, thepulse, it has played a most important part in surface diagnoses. To thisday, in fact, Arabic and Turkish physicians in visiting their patientson the feminine side of the family are allowed to see nothing of themexcept the hand, which is thrust through an opening in a curtain. Howaccurate their diagnoses are, based upon this slender clew, I should notlike to aver, but a sharp observer might learn much even from thislimited area. 

We have--though, of course, in lesser degree--all the color and linepictures with which we have been dealing upon the face. Though not anindex of any special system, it has the great advantage of being our oneapproach to an indication of the general muscular tone of the body, asindicated both in its grasp and in the poses it assumes at rest. Thepatient with a limp and nerveless hand-clasp, whose hand is inclined tolie palm upward and open instead of palm downward and half-closed, isapt to be either seriously ill, or not in a position to make much of afight against the attack of disease. 

The nails furnish one of our best indices of the color of the blood andcondition of the circulation. Our best surface test of the vigor of thecirculation is to press upon a nail, or the back of the finger justabove it, until the blood is driven out of it, and when our thumb isremoved from the whitened area to note the rapidity with which the redfreshet of blood will rush back to reoccupy it. 

In the natural growth of the nail, traveling steadily outward from rootto free edge, its tissues, at first opaque and whitish, and thusforming the little white crescent, or _lunula_, found at the base ofmost nails, gradually become more and more transparent, and hence pinkerin color, from allowing the blood to show through. During a seriousillness, the portion of the nail which is then forming suffers in itsnutrition, and instead of going on normally to almost perfecttransparency, it remains opaque. And the patient will, in consequence, carry a white bar across two or three of his nails for from three tonine months after the illness, according to the rate of growth of hisnails. Not infrequently this white bar will enable you to ask a patientthe 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 hisfearsome astonishment, if he answers your question in the affirmative, is amusing to see. You will be lucky if, in future, he doesn't inclineto regard you as something uncanny and little less than a wizard. 

Another of the score of interesting changes in the hand, which, thoughnot very common, is exceedingly significant when found, is a curiousthickening or clubbing of the ends of the fingers, with extremecurvature of the nails, which is associated with certain forms ofconsumption. So long has it been recognized that it is known as the"Hippocratic finger, " on account of the vivid description given of it bythe Greek Father of Medicine, Hippocrates. It has lost, however, some ofits exclusive significance, as it is found to be associated also withcertain diseases of the heart. It seems to mean obstructed circulationthrough the lungs. 

Next after the face and the hand would come the carriage and gait. Whena man is seriously sick he is sick all over. Every muscle in his bodyhas lost its tone, and those concerned with the maintenance of the erectposition, being last developed, suffer first and heaviest. The bowedback, the droop of the shoulders, the hanging jaw, and the shufflinggait, tell the story of chronic, wasting disease more graphically thanwords. We have a ludicrously inverted idea of cause and effect in ourminds about "a good carriage. " We imagine that a ramrod-like stiffeningof the backbone, with the head erect, shoulders thrown back and chestprotruded, is a cause of health, instead of simply being an effect, orone of the incidental symptoms thereof. And we often proceed to drillour unfortunate patients into this really cramped and irrationalattitude, under the impression that by making them look better we shallcause them actually to become so. The head-erect, chest-out, fingers-down-the-seam-of-your trousers position of the drillmaster islittle better than a pose intended chiefly for ornament, and has to beabandoned the moment that any attempt at movement or action is begun. 

So complete is this unconscious muscular relaxation, that it isnoticeable not only in the standing and sitting position, but also whenlying down. When a patient is exceedingly ill, and in the last state ofenfeeblement, he cannot even lie straight in bed, but collapses into acurled-up heap in the middle of the bed, the head even dropping from thepillow and falling on the chest. Between this _débâcle_ and the slightdroop of shoulders and jaw indicative of beginning trouble there are athousand shades of expression significant instantly to the experiencedeye. 

Though more limited in their application, yet most significant whenfound, are the alterations of the gait itself. Even a maker of proverbscan tell at a glance that "the legs of the lame are not equal. " From thelimp, coupled with the direction in which the toe or foot is turned, thetilt of the hips, the part of the foot that strikes first, the presenceor absence of pain-lines on the face, a snap diagnosis can often be madeas to whether the trouble is paralysis, hip-joint disease, knee or anklemischief, or flatfoot, as your patient limps across the room. Even whereboth limbs are affected and there is no distinct limp, the form ofshuffle is often significant. 

Several of the forms of paralysis have each its significant gait. Forinstance, if a patient comes in with a firm, rather precise, calculatedsort of gait, "clumping" each foot upon the floor as if he had struck itan inch sooner than he had expected, and clamping it there firmly for amoment before he lifts it again, as though he were walking on ice, withmore knee action than seems necessary, you would have a strong suspicionthat you had to deal with a case of _locomotor ataxia_, in which loss ofsensation in the soles of the feet is one of the earliest symptoms. Ifso, your patient, on inquiry, will tell you that he feels as if therewere a blanket or even a board between his soles and the surface onwhich he steps. If a quick glance at the pupils shows both smaller orlarger than normal, and on turning his face to the light they fail tocontract, your suspicion is confirmed; while if, on asking him to beseated and cross his legs, a tap on the great extensor tendon of theknee-joint just below the patella fails to elicit any quick upward jerkof the foot, the so-called "knee-kick, " then you may be almost sure ofyour diagnosis, and proceed to work it out at your leisure. 

On the other hand, if an elderly gentleman enters with a curiously blankand rather melancholy expression of countenance, holding his cane outstiffly 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 todo so, he would fall on his face, while at the same time a vibratingtremor carries his head quickly from side to side, you are justified insuspecting that you have to do with a case of _paralysis agitans_, orshaking 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 itmakes. For, when all has been allowed and discounted that the mosthardened cynic or pessimistic agnostic can say about speech being givento man to conceal his thoughts, and the hopeless unreliability of humantestimony, two-thirds of what your patients tell you about theirsymptoms will be found to be literally the voice of the disease itselfspeaking through them. They may tell you much that is chiefly imaginary, but even imagination has got to have some physical basis as astarting-point. They may tell you much that is clearly and ludicrouslyirrelevant, or untrue, on account of inaccuracy of observation, confusion of cause and effect, or a mental color-blindness produced bythe disease itself. But these things can all be brushed aside like thechaff from the wheat if checked up by the picture of the disease inplain sight before you. 

In the main, the great mass of what patients tell you is of great valueand importance, and, with proper deductions, perfectly reliable. Infact, I think it would be safe to say that a sharp observer would beable to make a fairly and approximately accurate diagnosis in sevencases out of ten, simply by what his eye and his touch tell him whilelistening to symptoms recounted by the patient. Time and again have Iseen an examination made of a reasonably intelligent patient, and whenthe recital had been finished and the hawk-like gaze had traveled fromhead to foot and back again, from ear-tip to finger-nail, from eye tochest, a symptom which the patient had simply forgotten to mention wouldbe promptly supplied; and the gasp with which the patient wouldacknowledge the truth of the suggestion was worth traveling miles tosee. 

Of course, you pay no attention to any statement of the patient whichflatly contradicts the evidence of your own senses. But even wherepatients, through some preconceived notion, or from false ideas of shameor discredit attaching to some particular disease, are trying to misleadyou, the very vigor of their efforts will often reveal their secret, just as the piteous broken-winged utterings of the mother partridgereveal instantly to the eye of the bird-lover the presence of the youngwhich she is trying to lure him away from. Only let a patient talkenough about his or her symptoms, and the truth will leak out. 

The attitude of impatient incredulity toward the stories of ourpatients, typified by the story of that great surgeon, but greater bear, Dr. John Abernethy, has passed, never to return. When a lady of rankcame into his consulting-room, and, having drawn off her wraps andcomfortably settled herself in her chair, launched out into a luxuriousrecital of symptoms, including most of her family history andadventures, he, after listening about ten minutes pulled out his watchand looked at it. The lady naturally stopped, open-mouthed. "Madam, howlong do you think it will take you to complete the recital of yoursymptoms?" "Oh, well, "--the lady floundered, embarrassed, --"I hardlyknow. " "Well, do you think you could finish in three-quarters of anhour?" Well, she supposed she could, probably. "Very well, madam. I havean operation at the hospital in the next street. Pray continue with therecital of your symptoms, and I will return in three-quarters of an hourand proceed with the consideration of your case!"

When you can spare the time, --and no time is wasted which is spent ingetting a thorough and exhaustive knowledge of a serious case, --it is asgood as a play to let even your hypochondriac patients, and those whoare suffering chiefly from "nervous prosperity" in its most acute form, set forth their agonies and their afflictions in their fullest and mostluxurious length, breadth, and thickness, watching meanwhile the comeand go of the lines about the face-dials, the changes of the color, thesparkling and dulling of the eye, the droop or pain-cramp, or luxuriousloll of each group of muscles, and quietly draw your own conclusionsfrom it all. Many and many a time, in the full luxury ofself-explanation, they will reveal to you a clew which will prove to bethe master-key to your control of the situation, and their restorationto comfort, if not health, which you couldn't have got in a week offorceps-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 sightseem like a paradox, they are, of all others, the easiest in whom tomake not merely a provisional, but a final, diagnosis. They cannot yettalk with their tongues and their lips, but they speak a living languagein every line, every curve, every tint of their tiny, translucentbodies, from their little pink toes to the soft spot on the top of theirdowny heads. Not only have they all the muscle-signs about theface-dial, of pain or of comfort, but, also, these are absolutelyuncomplicated by any cross-currents of what their elders are pleased toterm "thought. "

When a baby knits his brows he is not puzzling over his politicalchances or worrying about his immortal soul. He has got a pain somewherein his little body. When his vocal organs emit sounds, whether thegurgle or coo of comfort, or the yell of dissatisfaction, they are justsqueezed out of him by the pressure of his own internal sensations, andhe is never talking just to hear himself talk. Further than this, hiscolor is so exquisitely responsive to every breath of change in hisinterior mechanism, that watching his face is almost like observing areaction in a test-tube, with its precipitate, or change of color. Inaddition, not only will he turn pale or flush, and his little musclescontract or relax, but so elastic are the tissues of his surface, and soabundant the mesh of blood-vessels just underneath, that, under thestroke of serious illness, he will literally shrivel like a green leafpicked from its stem, or wilt like a faded flower. 

A single glance at the tiny face on the cot pillow is usually enough totell you whether or not the little morsel is seriously ill. Nothingcould be further from the truth than the prevailing impression that, because babies can't talk, it is impossible, especially for a youngdoctor, 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 andnothing else. 

In fact, the popular impression of the puzzled discomfiture of thedoctor before a very small, ailing baby is about as rational as theattitude of a good Quaker lady in a little Western country town, who hadinduced her husband to subscribe liberally toward the expenses of acertain missionary on the West Coast of Africa. On his return, themissionary brought her as a mark of his gratitude a young half-grownparrot, of one of the good talking breeds. The good lady, thoughdelighted, was considerably puzzled with the gift, and explained to afriend of mine that she really didn't know what to feed it, and itwasn'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, togetherwith our titanic Big Game, the woolly rhinoceros, the mammoth, and thesabre-toothed tiger, from our hunting-grounds in Siberia and Norway, orfrom recollections of hunting parties pushing north from our tropicalbirth-lands, and getting trapped and stormbound by the advance of thestrange giant, Winter, certain it is that our subconsciousness is fullof ancestral memories which send a shiver through our very marrow at themere mention of "cold" or "sleet" or "wintry blasts. "

From the earliest dawn of legend cold has always been ranked, withhunger and pestilence and storm, as one of the demons to be dreaded andfought. And, at a little later date, the ancient songs and sayings ofevery people have been full of quaint warnings against the danger of achill, a draft, wet feet, or damp sheets. There is, of course, abitterly substantial basis for this feeling, as the dozens of stiffenedforms whose only winding-sheet was the curling snowdrift, or whosecoffin the frozen sleet, bear ghastly witness. It was, however, long agodiscovered that when we were properly fed and clothed, the Cold Demoncould be absolutely defied, even in a tiny hut made out of pressed snowand warmed by a smoky seal-blubber lamp; that the Storm King could bebaffled just by burrowing into his own snowdrifts and curling up underthe crust, like an Eskimo dog. Hence, nearly all the legends depict thehero as finally conquering the Storm King, like Shingebis in the Song ofHiawatha. 

The ancient terror, however, still clings, with a hold the moretenacious as it becomes narrowed, to one large group of these calamitiesbelieved to be produced by cold, --namely, those diseases supposed to becaused by exposure to the weather. Even here, it still has aconsiderable basis in fact; but the general trend of opinion amongthoughtful physicians is that this basis is much narrower than was atone time supposed, and is becoming still more restricted with theprogress of scientific knowledge. For instance, fifty years ago, popularopinion, and even the majority of medical belief, was that consumptionand 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 isthe best cure for the disease, and foul air and overcrowding its chiefcause. An almost equally complete about-face has been executed in regardto pneumonia. Prolonged and excessive exposure to cold may be the matchthat fires the mine, but we are absolutely certain that two other thingsare necessary, namely, the presence of the diplococcus, and a loweredand 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 civilizedvisitors, --and scarce a single death from pneumonia has ever yetoccurred in the crew of an Arctic expedition, --but it has actually beenproposed to fit up a ship for a summer trip through the Arctic regions, as a floating sanatorium for consumptives, on account of the purity ofthe air and the brilliancy of the sunlight. 

There is one realm, however, where the swing of this ancientsuperstition vibrates with fullest intensity, and that is in thosediseases which, as their name implies, are still believed to be due toexposure to a lowered temperature--"common colds. " Here again it has acertain amount of rational basis, but this is growing less and lessevery day. The present attitude of thoughtful physicians may begraphically indicated by the flippant inquiry of the riddle-maker, "Whenis a cold not a cold?" and the answer, "Two-thirds of the time. " Thismuch we are certain of already: that the majority of so-called "colds"have little or nothing to do with exposure to a low temperature, thatthey are entirely misnamed, and that a better term for them would be_fouls_. In fact, this proportion can be clearly and definitely provedand traced as infections spreading from one victim to another. The bestplace to catch them is not out-of-doors, or even in drafty hallways, butin close, stuffy, infected hotel bedrooms, sleeping-cars, churches, andtheatres. 

Two arguments in rebuttal will at once be brought forward, bothapparently conclusive. One is that colds are vastly more frequent inwinter, and the other that when you sit in a draft until you feelchilly, you inevitably have a cold afterward. Both these argumentsalike, however, are based upon a misunderstanding. The frequency ofcolds in winter is chiefly due to the fact that, at this time of theyear, we crowd into houses and rooms, shutting the doors and windows inorder to keep warm, and thus provide a ready-made hothouse for thecultivation and transmission from one to another of the influenza andother bacilli. As the brilliant young English pulmonary expert, Dr. Leonard Williams, puts it, "a constant succession of colds implies amode of life in which all aërial microbes are afforded abundantopportunities. " At the same time, we take less exercise and sit far lessin the open air, thus lowering our general vigor and resisting power andmaking us more susceptible to attack. Those who live out-of-doors winterand summer, and who ventilate their houses properly, even in coldweather, suffer comparatively little more from colds in the winter-timethan they do in summer; although, of course, the most vigorousindividual, in the best ventilated surroundings, will occasionallysuccumb to some particularly virulent infection. 

The second fact of experience, catching cold after sitting in a draft ora chilly room until you begin to cough or sneeze, is one to which amajority of us would be willing to testify personally, and yet it isbased upon something little better than an illusion. It is a well-knownpeculiarity of many fevers and infections to begin with a chill. Thepatient complains of shiverings up and down his spine, his fingernailsand his lips become blue, in extreme cases his teeth chatter, and hislimbs begin to twitch and shake, and he ends up in a typical ague fit. The best known, because most striking, illustration is malaria, or feverand ague, "chills and fever, " as it is variously termed. But this formof attack, milder and much slighter in degree, may occur in almost everyknown infection, such as pneumonia, typhoid, tuberculosis, scarletfever, measles, and influenza. It has nothing whatever to do with eitherexternal or internal temperature; for if you slip a fever-thermometerunder your chilling patient's tongue, it will usually register anywherefrom 102 to 105°. 

This method of attack is especially common, not only in influenza, butalso in all the other so-called "common colds. " In fact, when we beginto shiver and sneeze and hunt around for an imaginary draft or loweringof the temperature which has caused it, we are actually in the firststage of the development of an infection which was contracted hours, oreven 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 isbeginning to break out on you. Mere exposure to cold will never causesneezing. 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 toproduce it, it is the almost unanimous testimony of Arctic explorersthat, during their sojourn of from two to three years in the frozenNorth, they never had so much as a sneeze or a sore throat, even thoughfrequently sheltered in extemporized huts, and running short of adequatefood-supply before spring. Within a week of their return to civilizationthey would begin sneezing and coughing, and catch furious colds. 

Lumbermen, trappers, hunters, and prospectors in Alaska give similartestimony. I have talked with scores of these pioneers, visiting them, in fact, in their camps under conditions of wet, cold, and exposure thatwould have made one afraid of either pneumonia or rheumatism beforemorning, and found that, so long as they remained up in the mountains orout in the snow, and no case of influenza, sore throat, or cold happenedto be brought into the camp, they would be entirely free from coughs andcolds; but that, upon returning to civilization and sleeping in thestuffy room of a rude frontier hotel, they would frequently catch coldwithin three days. 

One unusually intelligent foreman of a lumber camp in Oregon told methat an experience of this kind had occurred to him three differenttimes that he could distinctly recollect. 

It is difficult to catch a cold or pneumonia unless the bacilli arethere to be caught. Boswell has embalmed for us, in the amber of hismatchless biography, the fact that it had been noted, even in thosedays, that the inhabitants of one of the Faroe Islands never had coldsin the head except on the rare occasions when a ship would touchthere--usually not oftener than once a year. Then, within a week, halfthe population would be blowing and sneezing. The great Samuel commentedupon the fact at length, and advanced the ingenious explanation that, asthe harbor was so difficult of entry, the ships could beat in only whenthe wind was in a certain quarter, and that quarter was the nor'east. _Hinc illæ lacrimæ!_ (Hence these weeps!) The colds were caused by thenortheast wind of unsavory reputation! How often the wind got into thenortheast without bringing a ship or colds he apparently did notspeculate. 

To come nearer yet, did you ever catch cold when camping out? I havewaked 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, andslept myself dry; and have lain out all day in a November gale, in ahollow scooped in the half-frozen ground of the duck-marsh, and feltnever a hair the worse. Scores of similar experiences will rise up inthe minds of every camper, hunter, or fisherman. You _may_ catch coldduring 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 thisrarely happens. 

How seldom one catches cold from swimming, no matter how cold the water;or from boating, or fishing, --even without the standard prophylactic; orfrom 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 oftencaught where infectious materials are absent. Now for the positive side. 

First of all, that typical cold of colds, influenza, or the grip, is nowunanimously admitted by authorities to be a pure infection, due to adefinite germ (the _bacillus influenzæ_ of Pfeiffer) and one of the mostcontagious diseases known. Each of the great epidemics of it--1830-33, 1836-37, 1847-48, and, of most vivid and unblessed memory, 1889-90--canbe 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, toRussia, Berlin, London, New York, Chicago. Moreover, its rate ofprogress is precisely that of the means of travel: camel-train, post-chaise, railway, as the case may be. The earlier epidemics took twoyears to spread from Eastern Russia to New York; the later ones, fortyto sixty days. Soon it will beat Jules Verne or George Francis Train. Sointensely "catching" is it, that letters written by sufferers have beenknown 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 adefinite infection, we have taken it out of the class of "colds"altogether, and that its bacterial origin proves nothing in regard tothe rest. But a rather interesting state of affairs developed during thesearch for the true bacillus of influenza: this was that a dozen otherbacilli and cocci were discovered, each of which seemed capable ofcausing all the symptoms of the _grip_, though in milder form. So thatthe view of the majority of pathologists now is that these"influenzoid, " or "grip-like" attacks, under which come a majority ofall _common colds_, are probably due to a number of different mildermicro-organisms. 

The next fact in favor of the infectious character of a cold is that itbegins with a chill, followed with a fever, runs a definite self-limitedcourse, and, barring complications, gets well of itself in a certaintime, just like the measles, scarlet fever, pneumonia, or any otherfrank infection. 

Colds are also followed by inflammations, or toxic attacks in otherorgans 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 onevictim to another, may "run through" households, schools, factories, mayoccur after attending church or theatre, may be checked by isolating thesufferers; and are now most effectually treated by the inhalation ofnon-poisonous germicidal or antiseptic vapors and sprays. 

One of my first experiences with this last method occurred in a mostunexpected field. An old friend, a most interesting and intelligentGerman, was the proprietor of a wild-animal depot, importing foreignanimals and birds and selling them to the zoölogical gardens andcircuses. 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 mydissecting-table supplied with interestingly diseased dead beasts andbirds. 

One day he came up in a state of great excitement, with a very dead anddilapidated parrot in his hand. 

"Choost look, Dogdor; here's one of dose measley new pollies I god infrom 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" (notin color, but training), and he had fifty or sixty in the store, thesituation was distinctly serious. Now, I was no specialist in thepeculiar diseases of parrots, but something had to be done, and, with aboldness born of long practice, I drew my bow at a venture and let flythis suggestion:--

"Try formalin; it's pretty fierce on the eyes and nose, but it won'tkill 'em; and, if you put a teaspoonful in the bottom of each cage, bythe time it evaporates no germ that gets into that cage will live longenough to do any harm. "

Five days later back he came, red-eyed but triumphant. "Dogdor, dotvormaleen iss de pest shtuff I effer saw. It mos' shteenk me out of deshtore, an' de pollies nearly sneeze dere fedders off, but it shtopt despret, 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, onlythree new cases and no more deaths. I would, however, hardly advise anyhuman "coldie" to try such heroic treatment offhand, for the pungencyand painfulness of formalin vapor is something ferocious, though theFrench physicians, with characteristic courage, are making extensive useof it for this purpose, with excellent results under carefulsupervision. 

Another curious straw pointing in the direction of the infectious natureof colds is the "annual cold, " or "yearly sore throat, " from which manyof us suffer. When we have had it we usually feel fairly safe from coldsfor some months at least, often for a year. The only explanation thatseems 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 forsix months or a year. This immunity is due to the formation in the bloodof protective substances known as _anti-bodies_, which destroy or renderharmless the invading germs. Flabby, under-ventilated individuals, whoare always "catching cold, " have such weak resisting powers that theyform hardly enough anti-bodies to terminate the first attack, withouthaving enough left to protect them from another for more than a fewweeks or months. Dr. Leonard Williams describes chronic cold-catchers as"people who wear flannel next their skins, ... Who know they are in adraft because it makes them sneeze; who, in short, live thoroughlyunwholesome, coddling lives. " Strong and vigorous individuals may formenough 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, offifteen or twenty different species. Nor can we quarantine every one whohas a cold. Fortunately, no such radical methods are necessary. All wehave to do is to take nature's hint of the anti-bodies and improve uponit. Healthy cells can grow fat on a diet of such germs, and, if we keepourselves vigorous, clean, and well ventilated, we can practically defythe "cold" devil and all his works. 

Here is the _leitmotif_ of the whole fascinating drama of infection andimmunity. We can study only one phrasing here. We shall, of course, catch cold occasionally, but will throw it off quickly, and probablyform 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 theopen air. This helps in several different ways. First, by increasing thevigor and resisting power of our bodies; second, by helping to burn up, clean, and rid our tissues of waste products which are poisons ifretained; third, by greatly reducing the risks of infection. 

You can't catch cold by sitting in a field exposed to the draft from anopen gate; though I understand that casuists of the old school of the"chill-and-damp" theory of colds are still discussing the case of thepatient who "caught his death o' cold" by having his gruel served in adamp basin. 

The first thing to do is to get the outdoor habit. This takes time toacquire, but, once formed, you wouldn't exchange it for anything else onearth. The next thing is to learn to sit or sleep in a gentle current ofair all the time you are indoors. You ought to feel uncomfortableunless you can feel air blowing across your face night and day. Then youare reasonably sure it is fresh, and it is the only way to be sure ofit. 

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 gentlebreeze, 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 ourhighest authorities on diseases of the lungs, Dr. Norman Bridge, haswell dubbed it "The Draft Fetich. " It is a fetich, and as murderous asMoloch. The draft is a friend instead of an enemy. What converted mostof us to a belief in the beneficence of drafts was the open-airtreatment of consumption! Hardly could there have been a morespectacular proof, a more dramatic defiance of the bogey. To make apoor, wasted, shivering consumptive, in a hectic one hour and adrenching sweat the next, lie out exposed to the November weather allday and sleep in a ten-knot gale at night! It looked little short ofmurder! So much so to some of us, that we decided to test it onourselves before risking our patients. 

I can still vividly recall the astonishment with which I woke one frostyDecember morning, after sleeping all night in a breeze across my headthat 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 madenew while I slept. 

Then we tried it in fear and trembling on our patients, and the delightof seeing the magic it worked! That is an old story now, but it hasnever lost its charm. To see the cough which has defied "dopes" andsyrups and cough mixtures, domestic, patent, and professional, formonths, subside and disappear in from three to ten days; the nightsweats dry up within a week; the appetite come back; the fever fall; thestrength and color return, as from the magic kiss of the free air of thewoods, the prairies, the seacoast. There's nothing else quite like it onthe 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 inseveral others. He put up a big sign at the entrance of White HavenSanatorium, "No persons suffering from colds allowed to enter, " andtraced the only epidemic of colds in the sanatorium to the visit of abutcher with the grip. I put up a similar sign at the gate of my Oregoncamp, and never had a patient catch cold from tenting out in the snowand "Oregon mists" until the small son of the cook came back from thevillage school, shivering and sneezing, when seven of the thirteenpatients "caught it" within a week. 

What will cure a consumptive will surely not kill a healthy man. I amdelighted to say that it shows signs of becoming a fad now, and sleepingporches are being put on houses all over the country. No house inCalifornia is considered complete without them. The ideal bedroom is asmall dressing-room, opening on a wide screened porch, or balcony, witha door wide enough to allow the bed to be rolled inside during storms orin severest weather. 

Sleep on a porch, or in a room with windows on two sides wide open, andthe 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 yourheadaches. It may be necessary in winter to warm the draft, but don'tlet any patent method of ventilation delude you into keeping yourwindows shut any hour of the day or night. 

On the other hand, don't fall into the widespread delusion that becauseair is cold it is necessarily pure. Some of the vilest air imaginable isthat shut up in those sepulchres known as "best bedrooms, " which chillyour very marrow. The rheumatism or snuffles you get from sleepingbetween their icy sheets comes from the crop of bacilli which has lurkedthere since they were last aired. The "no heat in a bedroom" dogma islittle better than superstition, born of those fecund parents which mateso often, stinginess and puritanism. Practically, the room which will_never_ have a window opened in it in winter is the one without anyheat. 

Similarly, the air in an underheated church, hall, or theatre is almostsure to be foul. The janitor will keep every opening closed in order toget the temperature up. Some churches are never once decently ventilatedfrom December to May. The same old air, with an ever richer crop ofgerms, is reheated and served up again every Sunday. The "odor ofsanctity" is the residue of the breaths and perspiration of successivegenerations. Cleanliness may be next to godliness, but it is sometimesan astonishingly long step behind it. 

The next important step is to keep clean, both externally andinternally: externally, by cold bathing, internally, by exercise. Theonly reason why a draft ever hurts us is because we are full ofself-poisons, or germs. The self-poisons can be best got rid of byabundant 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 likelyto form on one diet as another. In fact, they form normally and instates of perfect health, and are poisonous only if retained too long. It is simply a question of burning them up, and getting rid of themquickly enough, by exercise, with its attendant deep breathing andperspiration. The lungs are great garbage-burners. Exercise every daytill you puff and sweat. 

A blast of cold air suddenly stops the escape of these poisons throughthe skin and throws them on the lungs, liver, or kidneys. The resultingdisturbance is the second commonest form of a "cold, " and covers perhapsa third of all cases occurring. This is the cold that can be preventedby the cold bath. Keep the skin hardened and toned up to such a pitchthat 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 ofcold air. Too heavy flannels are cold-breeders, and chest-protectorsinventions of the evil one. Trust the skin; it is one of the mostimportant and toughest organs in the body, if only given half a chance. 

But the most frequent way in which drafts precipitate a cold is bytemporarily lowering the vital resistance. This gives the swarms ofgerms present almost constantly in our noses, throats, stomachs, bowels, etc. , the chance they have been looking for--to break through the cellbarrier and run riot in the body. 

So long as the pavement-cells of our mucous membranes are healthy, theycan keep them out indefinitely. Lower their tone by cold, fatigue, underfeeding, and their line is pierced in a dozen places at once. Oneof the many horrifying things which bacteriology has revealed is thatour bodies are simply alive with germs, even in perfect health. Oneenthusiastic dentist has discovered and described no less than_thirty-three_ distinct species, each one numbering its billions, whichinhabit our gums and teeth. Our noses, our stomachs, ourintestines, --each boasts a similar population. Most of them do no harmat all; indeed, some probably assist in the processes of digestion;others are camp-followers, living on our leavings; others, captiveenemies which have been clubbed into peaceful behavior by our leucocyteand anti-body police. 

For instance, not a few healthy noses and throats contain the bacillusof diphtheria and the diplococcus of pneumonia. We are beginning to findthat these last two groups will bear watching. Like camp-followerselsewhere, they carry knives, and are not above using them on thewounded after dark. In fact, they have a cheerful habit of taking ahand in any disturbance that starts in their bailiwick, and usually onthe side against the body-cells. 

Finally, while clearly realizing that the best defense is attack, andthat our chief reliance should be upon keeping ourselves in suchfighting trim that we can "eat 'em alive" at any time, there is no sensein running easily avoidable risks, and we should keep away frominfection as far as possible. If a child comes to school heavy-eyed, hoarse, and snuffling, the teacher should send him home at once. He willonly waste his time attempting to study in that trim, and may infect ascore of others. Moreover, it may be remarked, parenthetically, thatthese are also symptoms of the beginning of measles, scarlet fever, anddiphtheria, and two-thirds of all cases of these would be sent homebefore they could infect any one else if this procedure were the rule. 

If your own child develops a cold, if mild, keep him playingout-of-doors by himself; or if severe, keep him in bed, in awell-ventilated room, for three or four days. He'll get better twice asquick 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 afew days if possible, out of regard for your customers, yourfellow-clerks, or your office force, as well as yourself. If one of youremployees comes to work shivering, give him three days' vacation on fullpay. If it runs through the force, you'll lose five times as much inenforced sick-leaves, slowness, and mistakes. Above all, don't go to anypublic gatherings, --to church, the theatre, or parties, --when you aresnuffling and coughing. You are not exactly a joy to your beholders, even if you don't infect them. It is advisable, and well worth thetrifling trouble and expense, to fumigate thoroughly with formalin allchurches, theatres, and schoolrooms at least once a month. Reasonableand public-spirited precautions of this sort are advisable, not only toavoid colds themselves, which are disagreeable and dangerous enough, butbecause mild infections of this sort are far the commonest single meansof making a breach in our body-ramparts through which more seriousdiseases like consumption, pneumonia, and rheumatism may force an entry. 

Colds do not "run into" consumption or pneumonia, but they bear much thesame relation to them that good intentions are said to do to theinfernal regions. They release the lid of a perfect Pandora's box ofdistempers--tuberculosis, pneumonia, rheumatism, bronchitis, Bright'sdisease, neuritis, endocarditis. A cold is no longer a joke. Ageneration 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 andhandled, they are the least harmful of diseases; neglected, one of themost dangerous, because there are such legions of them. To sum up, ifyou wish to revel in colds, all that is necessary is to observe thefollowing 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 electricinsoles. 

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, orcold, 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 knowwho 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 mouthshut--chiefly, of course, upon moral or prudential grounds, for fear ofwhat might issue from it if opened. Then came physiology to back up themaxim, on the ground that the open mouth was also dangerous on accountof what might be inhaled into it. Oddly enough, in this instance, bothmorality and science have been beside the mark to the degree that theyhave been mistaking a symptom for a cause. This has led us to absurd andinjurious extremes in both cases. On the moral and prudential side ithas led to such outrageous exaggerations as the well-known andoft-quoted proverb, "Speech is silver, but silence is golden. "Articulate speech, the chiefest triumph and highest singleaccomplishment of the human species, the handmaid of thought and theinstrument of progress, is actually rated below silence, the attributeof the clod and of the dumb brute, the easy refuge of cowardice and ofstupidity. 

Easily eight-tenths of all speech is informing, educative, helpful insome modest degree; while fully that proportion of silence is due tolack of ideas, cowardice, or designs that can flourish only in darkness. It is not the abundance of words, but the scarcity of ideas, that makesus flee from "the plugless word-spout" and avoid the chatterbox. 

Similarly, upon the physical side, because children who breathe throughthe mouth are apt to have a vacant expression, to be stupid andinattentive, undersized, pigeon-breasted, with short upper lip andcrowded teeth, we have leaped to the conclusion that it is a fearsomeand dangerous thing to breathe through your mouth. All sorts of storiesare told about the dangerousness of breathing frosty air directly intothe lungs. Invalids shut themselves scrupulously indoors for weeks andeven months at a stretch, for fear of the terrible results of a "blastof raw air" striking into their bronchial tubes. All sorts of absurdinstruments of torture, in the form of "respirators" to tie over themouth and nose and "keep out the fog, " are invented, and those who havethe slightest tendency to bronchial or lung disturbances are warned uponpain of their life to wrap up their mouths whenever they goout-of-doors. 

As a matter of fact, there is exceedingly little evidence to show thatpure, fresh, open air at any reasonable temperature and humidity everdid harm when inhaled directly into the lungs. In fact, a considerableproportion of us, when swinging along at a lively gait on the countryroads, or playing tennis or football, or engaged in any form of activesport, will be found to keep our lips parted and to inhale from a sixthto a third of our breath in this way, and with no injurious resultswhatever. Nine-tenths of all the maladies believed to be due tobreathing even the coldest and rawest of air are now known to be due toinvading germs. 

Nevertheless, mouth-breathing in all ages has been regarded as a badhabit, and with good reason. It was only about thirty years ago that webegan to find out why. A Danish throat surgeon, William Meyer, whosedeath occurred only a few months ago, discovered, in studying a numberof children who were affected with mouth-breathing, that in all of themwere present in the roof of the throat curious spongy growths, whichblocked up the posterior opening of the nostrils. As this mass was madeup of a number of smaller lobules, and the tissue appeared to be likethat of a lymphatic gland, or "kernel, " the name "adenoids" (gland-like)was given to them. Later they were termed _post-nasal growths_, from thefact that they lay just behind the rear opening of the nostrils; andthese two names are used interchangeably. Our knowledge has spread andbroadened from this starting-point, until we now know that adenoids arethe chief, yes, almost the sole primary cause, not merely ofmouth-breathing, but of at least two-thirds of the injurious effectswhich have been attributed to this habit. 

Mouth-breathing is not simply a bad habit, a careless trick on the partof the child. We have come to realize that physical bad habits, as wellas many mental and moral ones, have a definite physical cause, and that_no child ever becomes a mouth-breather as long as he can breathecomfortably through his nose_. 

This clears the ground at once of a considerable amount of uselesslumber 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 aftertheir helpless offspring were asleep and gently but firmly pushing upthe little jaw and pressing the lips together until some sort of anattempt at respiration was made through the nostrils. Advertisementsstill appear of sling-like apparatuses for holding the jaws closedduring sleep. 

To attempt to stop mouth-breathing before providing abundant air-spacethrough the nostrils is not only irrational, but cruel. Of course, afterthe child has once become a mouth-breather, even after the nostrils havebeen made perfectly free, it will not at once abandon its habit ofmonths or years, and disciplinary measures of some sort may then beneeded for a time. But the hundred-times-repeated admonition, "Forheaven's sake, child, shut your mouth! Don't go around with it hangingopen like that!" unless preceded by proper treatment of the nostrils, will have just about as much effect upon the habit as the proverbialwater on a duck's back. No use trying to close his mouth by any amountof opening of your own. 

Fortunately, as does not always happen, with our discovery of the causehas come the knowledge of the cure; and we are able to say withconfidence that, widespread and serious as are disturbances of healthand growth associated with mouth-breathing, they can be absolutelyprevented and abolished. 

What, then, is the cause of this nasal obstruction, and when does itbegin to operate? The primary cause is catarrhal inflammation, withswelling and thickening of the secretions, and it may begin to operateanywhere from the seventh month to the seventh year. A neglectedattack, or series of attacks, of "snuffles, " colds in the head, catarrhs, in infants and young children, will set up a slow inflammationof this glandular mass at the back of the nostrils--a tonsil, by theway--and start its enlargement. 

Whether we know anything about adenoids themselves or not, we are allfamiliar with their handiwork. The open mouth, giving a vacantexpression to the countenance, the short upper lip, the pinched andcontracted nostrils, the prominent and irregular teeth, the listlessexpression of the eyes, the slow response to request or demand, we haveseen a score of times in every schoolroom. Coupled with these facialfeatures are apt to be found on closer investigation a lack of interestin both work and play, an impaired appetite, restless sleep, and acurious general backwardness of development, both bodily and mental, sothat the child may be from one to four inches below the normal heightfor his years, from five to fifteen pounds under weight, and from one tothree grades behind his proper school position. Very often, also, hischest 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 themere inhaling of air directly into the lungs, even though it beimperfectly warmed, moistened, and filtered, as compared with what itwould be if drawn through the elaborate "steam-coils" in the nostrilsfor this purpose, can have produced this array of defects? It isincredible on the face of it and unfounded in fact. Fully two-thirds ofthese can be traced to the direct influence of the adenoids. 

These adenoids, it may briefly be stated, are the result of anenlargement of a _tonsil_, or group of small tonsils, identical instructure with the well-known bodies of the same name which can be seenon either side of the throat. They have the same unfortunate faculty asthe other tonsils for getting into hot water, flaring up, inflaming, andswelling on the slightest irritation. And, unfortunately, they are sosituated that their capacity for harm is far greater than that of theother tonsils. They seem painfully like the chip on the shoulder of afighting man, ready to be knocked off at the lightest touch and plungethe whole body into a scrimmage. Their position is a little difficult todescribe to one not familiar with the anatomy of the throat, especiallyas they cannot be seen except with a laryngeal mirror; but it may beroughly stated as in the middle of the roof of the throat, just at theback of the nostrils, and above the soft palate. From this coign ofvantage they are in position to produce serious disturbances of two ofour most important functions, --respiration and digestion, --and three outof the five senses, --smell, taste, and hearing. 

We will begin with their most frequent and most serious injuriouseffect, though not the earliest, --the impairment of the child's power ofattention and intelligence. So well known is their effect in thisrespect that there is scarcely an intelligent and progressive teachernowadays who is not thoroughly posted on adenoids. Some of them willmake a snap diagnosis as promptly and almost as accurately as aphysician; and when once they suspect their presence, they will leaveno stone unturned to secure an examination of the child by a competentphysician, and the removal of the growths, if present. They consider ita waste of time to endeavor to teach a child weighted with thishandicap. How keenly awake they are to their importance is typified bythe remark of a prominent educator five or six years ago:--

"When I hear a teacher say that a child is stupid, my first instinctiveconclusion is either that the child has adenoids, or that the teacher isincompetent. "

The lion's share of their influence upon the child's intelligence isbrought about in a somewhat unexpected and even surprising manner, andthat is by the _effects of the growths upon his hearing_. You willrecall that this third tonsil was situated at the highest point in theroof of the pharynx, or back of the throat. The first effect of itsenlargement is naturally to block the posterior opening of the nostrils. But it has another most serious vantage-ground for harm in its peculiarposition. Only about three-fourths of an inch below it upon either sideopen the mouths of the Eustachian tubes, the little funnels which carryair from the throat out into the drum-cavity of the ear. You havefrequently had practical demonstrations of their existence, by thewell-known sensation, when blowing your nose vigorously, of feelingsomething go "pop" in the ear. This sensation was simply due to a bubbleof air being driven out through this tube from the back of the throat, under pressure brought to bear in blowing the nose. The lucklessposition of the third tonsil could hardly have been better planned if ithad been devised for the special purpose of setting up trouble in themouths of these Eustachian tubes. 

Just as soon as the enlargements become chronic, they pour out a thickmucous secretion, which quickly becomes purulent, or, in the vernacular, "matter. " This trickles down on both sides of the throat, and drainsright into the open mouth of the Eustachian tube. Not only so, but theseEustachian tubes are the remains of the first gill-slits of embryoniclife, and, like all other gill-slits, have a little mass of this samelymphoid or tonsilar tissue surrounding them. This also becomes infectedand inflamed, clogs the opening, and one fatal day the inflammationshoots 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 ofall cases of deafness in children, are due to adenoids. 

Earache is simply the pain due to acute inflammation in the smalldrum-cavity of the ear. This in the large majority of cases will subsideand drain back again into the throat through the Eustachian tube. In afair percentage of instances, however, it will break in the oppositedirection, and we have the familiar ruptured drum and discharge from theear. In either case the drum becomes thickened, so that it can no longervibrate properly; the delicate little chain of bones behind it, like thelevers of a piano, becomes clogged, and the child becomes deaf, whethera chronic discharge be present or not. 

This is the secret of his "inattention, " his "indifference, "--even ofhis apparent disobedience and rebelliousness. What other children hearwithout an effort he has to strain every nerve to catch. Hemisunderstands the question that is asked of him, makes an absurdanswer, and is either scolded or laughed at. It isn't long before hefalls into the attitude: "Well, I can't get it right, anyhow, no matterhow I try, so I don't care. " Up to five or ten years ago the puzzled anddistracted teacher would simply report the child for stupidity, indifference, and even insubordination. In nine cases out of ten, whenchildren are naughty or stupid, they are really sick. 

Not content with dulling one of the child's senses, these thugs of thebody-politic proceed to throttle two others--smell and taste. Obviouslythe 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 delicatemucous membranes coated with a thick, ropy discharge, you will not beable to distinguish anything but the crudest and rankest of odors. Butwhat 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 chalkfrom cheese, " not even a cube of apple from a cube of onion, as scoresof experiments have shown. We all know how flat tea, coffee, and evenour own favorite dishes taste when we have a bad cold, and this, remember, is the permanent condition of the palate of the poor littlemouth-breather. No wonder his appetite is apt to be poor, and that evenwhat food he eats will not produce a flow of "appetite juice" in thestomach, which Pavloff has shown to be so necessary to digestion. Nowonder his digestion is apt to go wrong, ably assisted by the continualdrip of the chronic discharge down the back of his throat; his bowels tobecome 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 unexpectedone. We have all heard much of "the struggle for existence" among plantsand animals, and have had painful demonstrations of its reality in ourown personal experience. But we hardly suspected that it was going on inour own interior. Such, however, is the case; and when once one organ orstructure falls behind the others in the race of growth, its neighborspromptly begin to encroach upon and take advantage of it. Emerson wasright when he said, "I am the Cosmos, " the universe. 

Now, the mouth and the nose were originally one cavity. As Huxley longago remarked, "When Nature undertook to build the skull of a land animalshe was too lazy to start on new lines, and simply took the oldfish-skull and made it over, for air-breathing purposes. " And a clumsyjob she made of it!

It may be remarked, in passing, that mouth-breathing, as a matter ofhistory, is an exceedingly old and respectable habit, a reversion, infact, to the method of breathing of the fish and the frog. "To drinklike a fish" is a shameful and utterly unfounded aspersion upon ablameless creature of most correct habits and model deportment. What thepoor 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 individualexistence. A horizontal ridge begins to grow out on either side of ourmouth-nose cavity, just above the roots of the teeth. This thickens andwidens into a pair of shelves, which finally, about the third month ofembryonic life, meet in the middle line to form the hard palate or roofof the mouth, which forms also the floor of the nose. Failure of the twoshelves to meet properly causes the well-known "cleft-palate, " and, ifthis failure extends forward to the jaw, "hare-lip. " In the growth of ahealthy child a balance is preserved between these lower and uppercompartments of the original mouth-nose cavity, and the nose abovegrowing as rapidly in depth and in breadth as the mouth below, thehorizontal partition between--the floor of the nose and the roof of themouth--is kept comparatively flat and level. In adenoids, however, thenostrils no longer being adequately used, and consequently failing togrow, and the mouth cavity below growing at the full normal rate, it isnot long before the mouth begins to encroach upon the nostrils bypushing up the partition of the palate. As soon as this upward bulge ofthe roof of the mouth occurs, then there is a diminution of theresistance offered by the horizontal healthy palate to the continualpressure of the muscles of the cheeks and of mastication upon the sidesof the upper jaw, the more readily as the tongue has dropped down fromits proper resting position up in the roof of the mouth. These arepushed inward, the arch of the jaw and of the teeth is narrowed, thefront teeth are made to project, and, instead of erupting, with plentyof room, in even, regular lines, are crowded against and overlap oneanother. 

When from any cause the lower jaw habitually hangs down, as in the openmouth, it tends to be thrown slightly forward in its socket. Then, whenthe jaws close again, the arches of the upper and lower teeth no longermeet evenly. Instead of "locking" at almost every point, as they should, they overlap, or fall behind, or inside, or outside, of each other. Sothat instead of every tooth meeting its fellow of the jaw above evenlyand 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 andvigor, firm and regular pressure and exercise against its fellow in thejaw above or below, gets a twist in its socket, wears away irregularly, and becomes an easy prey to decay, while from failure of the entireupper and lower arches of the teeth to meet squarely and press evenlyand firmly against one another, the jaws fail to expand properly and thetendency to narrowing of the tooth-arches and upward vaulting of thepalate is increased. 

In short, we are coming to the conclusion that from half to two-thirdsof all cases of "crowded mouth, " irregular teeth, and high-arched palatein children are due to adenoids. Progressive dentists now are insistingupon their little patients, who come to them with these conditions, being examined for adenoids, and upon the removal of these, if found, asa preliminary measure to mechanical corrective treatment. Cases are nowon record of children with two, three, or even four generations ofcrowded teeth and narrow mouths behind them, but who, simply by beingsharply watched for nasal obstruction and the symptoms of adenoids, bythe removal of these latter as soon as they have put in an appearance, have grown up with even, regular, well-developed teeth and wide, healthymouths and jaws. Unfortunately, attention to the adenoids will notremove these defects of the jaws and teeth after they have beenproduced. But, if the child be under ten, or even twelve, years of age, their removal may yet do much permanently to improve the condition, andis certainly well worth while on general principles. 

Take care of the nose, and the jaws will take care of themselves. Anounce of adenoids-removal in the young child is worth a pound of_orthodontia_--teeth-straightening--in the boy or girl; though both areoften necessary. 

The dull, dead tone of the voice in these children is, of course, anobvious effect of the blocked nostrils. Similarly, the broken sleep, with dreams of suffocation and of "Things Sitting on the Chest, " arereadily explained by the desperate efforts that the little one makes tobreathe through clogging nostrils, in which the discharges, blown andsneezed out in the daytime, dry and accumulate during sleep, until, half-suffocated, it "lets go" and draws in huge gulps of air through theopen mouth. No child ever became a mouth-breather from choice, or untilafter a prolonged struggle to continue breathing through its nose. 

This brings us to the question, What are these adenoids, and how dothey come to produce such serious disturbances? This can be partiallyanswered by saying that they are tonsils and with all a tonsil'ssusceptibility to irritation and inflammation. But that only raises thefurther question, What is a tonsil? And to that no answer can be givenbut Echo's. They are one of the conundrums of physiology. All we know ofthem is that they are not true _glands_, as they have neither duct norsecretion, but masses of simple embryonic tissue called _lymphoid_, which has a habit of grouping itself about the openings of disusedcanals. This is what accounts for their position in the throat, as theyhave no known useful function. The two largest, or throat-tonsils, surround the inner openings of the second gill-slits of the embryo; thelingual tonsil, at the base of the tongue below, encircles the mouth ofthe duct of the thyroid gland (the _goitre_ gland); and our ownparticular Pandora's Box above, in the roof of the pharynx, is groupedabout the opening of another disused canal, which performs the singularand apparently most uncalled-for office of connecting the cavity of thebrain with the throat. They can all of them be removed completelywithout any injury to the general health, and they all tend to shrinkand become smaller--in the case of the topmost, or pharyngeal, almostdisappear--after the twelfth or fourteenth year. 

Not only have they an abundant crop of troubles of their own, as most ofus can testify from painful experience, but they serve as a port ofentry for the germs of many serious diseases, such as tuberculosis, rheumatism, diphtheria, and possibly scarlet fever. They appear to be astrange sort of survival or remnant, --not even suitable for thebargain-counter, --a hereditary leisure class in the modern democracy ofthe body, a fertile soil for all sorts of trouble. 

Here, then, we have this little bunch of idle tissue, about the size ofa small hazelnut, ready for any mischief which our Satan-bacilli mayfind for its hands to do. A child kept in a badly ventilated roominhales into his nostrils irritating dust or gases, or, more commonlyyet, the floating germs of some one or more of those dozen mildinfections which we term "a common cold. " Instantly irritation andswelling are set up in the exquisitely elastic tissues of the nostrils, thick, sticky mucous, instead of the normal watery secretion, is pouredout, the child begins to sneeze and snuffle and "run at the nose, " andeither the bacteria are carried directly to this danger sponge, right atthe back of the nostrils, or the inflammation gradually spreads to it. The mucous membrane and tissues of the nose have an abundance ofvitality, --like most hard workers, --and usually react, overwhelm, anddestroy the invading germs, and recover from the attack; but the uselessand half-dead tissue of the pharyngeal tonsil has much less power ofrecuperation, and it smoulders and inflames, though ultimately, perhaps, it may swing round to recovery. Often, however, a new cold will becaught before this has fully occurred, and then another one a month orso later, until finally we get a chronically thickened, inflamed, andenlarged condition of this interesting, but troublesome, body. What itscapabilities are in this respect may be gathered from the fact that, while normally of the size of a small hazelnut, it is no uncommon thingto find a mass which absolutely blocks up the whole of the upper part ofthe pharynx, and may vary from the size of a robin's egg to that of alarge English walnut, or even a small hen's egg, according to the age ofthe child and the size of the throat. 

Dirt has been defined as "matter out of place, " and the pharyngealtonsil is an excellent illustration. Nature is said never to makemistakes, but she is apt to be absent-minded at times, and we aretracing now not a few of the troubles that our flesh is heir to, tolittle oversights of hers--scraps of inflammable material left lyingabout among the cogs of the body-machine, such as the appendix, thegall-bladder, the wisdom teeth, and the tonsils. One day a spark dropson 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, andparticularly in a baby. Have it treated at once antiseptically, bycompetent hands, and learn exactly what to do for it on the appearanceof the earliest symptoms in the future, and you will not only save thelittle ones a great deal of temporary discomfort and distress, --for itis perfect torment to a child to breathe through its mouth atfirst, --but you will ward off many of the most serious troubles ofinfancy and childhood. We can hardly expect to prevent all developmentof adenoids by these prompt and painless stitches in time, for somechildren seem to be born peculiarly subject to them, either from theinheritance of a particular shape of nose and throat, --"the familynose, " as it has been called, --or from some peculiar sponginess andliability to inflammation and enlargement of all these tonsilar orlymphoid "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_ ineach 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 whohave on that account been sharply watched for the possible developmentof adenoids in early life, and these removed as soon as they appeared, and they have grown up with well-developed, wide nostrils, broad, flatpalates, and regular teeth, overcoming "hereditary defect" in a singlegeneration. 

Curiously enough, their origin and ancestral relations may have animportant practical bearing, even in the twentieth century. At the upperend of this curious _throat-brain_ canal lies another mass, theso-called _pituitary body_. This has been found to exert a profoundinfluence over development and growth. Its enlargement is attended bygiantism and another curious giant disease in which the hands, feet, andjaws enlarge enormously, known as _acromegaly_. It also pours into theblood a secretion which has a powerful effect upon both the circulationand the respiration. It is found shrunken and wasted in dwarfs. Someyears ago it was suggested by my distinguished friend, the late Dr. Harrison Allen, and myself, that some of the extraordinary dwarfing andgrowth-retarding effects of adenoids might be due to a reflex influenceexerted on their old colleague, the pituitary body. This view has foundits way into several of the textbooks. Blood is thicker than water, andold ancestral vibrations will sometimes be set up in most unexpectedplaces. 

Now comes the cheerful side of the picture. I should have hesitated todraw at such full length and in such lugubrious detail the direfulpossibilities and injurious effects of adenoids if its only result couldhave been to arouse apprehensions which could not be relieved. 

Fortunately, just the reverse is the case, and there are few conditionsaffecting the child, so common and such a fertile source of all kinds ofmischief, and at the same time so completely curable, and whose curewill be attended by such gratifying improvement on the part of thelittle sufferer. In the first place, as has been said, their formationmay usually be prevented altogether by intelligent and up-to-datehygienic care of the nose and the throat. In the second place, evenafter they have occurred and developed to a considerable degree, theycan be removed by a trifling and almost painless operation, and, iftaken early enough, all their injurious effects overcome. If, however, they have been neglected too long, so that the child has passed theeighth or ninth year before any interference has been attempted, andstill more, of course, if it has passed the twelfth or thirteenth year, then only a part of the disturbances that have been caused can beremedied by their removal. So soft and pulpy are these growths, sopoorly supplied with blood-vessels or nerves, and so slightly connectedwith the healthy tissues below them, that they may, in skilled hands, becompletely removed by simply scraping with a dull surgical spoon(curette) or curved forceps, but never anything more knife-like thanthis. In fact, in the first seven years of life, when their removal isboth easiest and will do most good, it is hardly proper to dignify theprocedure by the name of an operation. It is attended by about the samedegree of risk and of hemorrhage as the extraction of a tooth, and byless than half the amount of pain. 

But, trifling and free from danger as is the operation, there is nothingin the entire realm of surgery which is followed by more brilliant andgratifying results. It seems almost incredible until one has seen it inhalf a dozen successive cases. Not merely doctors, but teachers andnurses, develop a positive enthusiasm for it. This was the operationthat led to the comical, but pathetic, "Mothers' Riots" in the New Yorkschools. The word went forth, "The Krishts are cutting the throats ofyour children"; and, with the shameful echoes of Kishineff ringing intheir ears, the Yiddish mothers swarmed forth to battle for the lives oftheir offspring. 

It is no uncommon thing to have a child of seven jump three to fiveinches in height, six to twelve pounds in weight, and one to threegrades in his schooling, within the year following the operation. Tenyears more of intelligence and hygienic teaching should see this scourgeof childhood completely wiped out, or at least robbed of itspossibilities for harm. When this is done, at least two-thirds of allcases 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 facinga crisis. One could safely offer a large prize for a group of tencommencement orations, or political platforms, at least a third of whichdid not announce this momentous fact. Either we are facing it or itconfronts us, and unutterable things will happen unless we "gird up ourloins, " and vote the right ticket. An interesting feature about theseloudly heralded crises is that they hardly ever "crise. " The real crisiseither strikes us so hard that we never know what hit us, or is overbefore we recognize that anything was going to happen. And most of ourreflections about it are after ones--trying to explain what caused it. In fact, in public affairs, as in medicine, a crisis is a sign ofrecovery. Its occurrence is an indication that nature is preparing tothrow off the disease. Nowhere is this truth more vividly illustratedthan in the tuberculosis situation. When, about thirty years ago, theworld began to awake from its stupor of centuries, and to realize thatthis one great disease alone was _killing one-seventh of all people bornunder civilization_, and crippling as many more; that its killed andwounded every year cast in the shade the bloodiest wars ever waged, andthat it was apparently caused by the civilization which it ravaged, --nowonder that we were appalled at the outlook. 

Here was a disease of civilization, caused by the conditions of thatcivilization. Could it be cured without destroying its cause andreverting to barbarism? Yet this very apprehension was a sign of hope, apromise of improvement. That we were able to feel it was a sign that wewere shaking off the old fatalistic attitude toward disease, --asinevitable or an act of Providence. It was brought about by the moreaccurate and systematic study of disease. We had long been sadlyfamiliar with the fact that death by consumption, by "slow decline, " by"wasting" or "slow fever, " was frightfully common. "To fall into adecline" and die was one of the standard commonplaces of romanticliterature. But that was quite different from knowing in cold, hardfigures and inescapable percentages exactly how many of the race werekilled by it. It is one of the striking illustrations of the advantagesof good bookkeeping. Boards and departments of health had just fairlygot on their feet and started an accurate system of state accounts inmatters of deaths and births. We were beginning to recognize nationalhealth as an asset, and to scrutinize its fluctuations with keeninterest accordingly. 

We may decry statistics as much as we like, but when we see the effectsof a disease set down in cold columns of black and white we have nolonger any idea of submitting to it as inevitable. We are going to getright up and do some fighting. "One-seventh of all the deaths" hasliterally become the war cry of our new Holy War against tuberculosis. Still another stirring phrase of inestimable value in rousing us fromour torpor was that coined by the brilliant and lovablephysician-philosopher, Oliver Wendell Holmes: "The Great White Plague ofthe North. " This vivid epithet, abused as it may have been in lateryears, was of enormous service in fixing the public mind on consumptionas a definite, individual disease, something to be fought and guardedagainst. Before that, we had been inclined to look upon it as just anatural failing of the vital forces, a thing that came from within, andwas in no sense caused from without. The fair young girl, or thedelicate boy whose vitality was hardly sufficient to carry him throughthe stern battle of life, under some slight shock, or even mentaldisappointment, would sink into a decline, gradually waste away, anddie. What could be done in such a case, except to bow in submission tothe inscrutable ways of Providence?

It seems incredible now, but such was the light in which smallpox wasregarded by physicians of the Arabian and mediæval schools: a naturaloozing forth of "peccant humors" in the blood of the young, adisagreeable, but perfectly natural, and even necessary, process. For ifthe patient did not get rid of these humors either he would die or hisgrowth would be seriously impaired. Now smallpox has become little morethan a memory in civilization, and consumption is due to follow itsexample. 

Sanitary pioneers had already begun casting about eagerly for light uponthe influence of housing, of drainage, of food, in the causation oftuberculosis, when a new and powerful weapon was suddenly placed intheir hands by the infant science of bacteriology. This was the nowworld-famous discovery by Robert Koch that consumption and other formsof tuberculosis were due to the attack of a definite bacillus. Notubercle 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 morehopeless. And when within a few years it was further demonstrated inrapid succession that most of the diseases of the spine in children, ofthe group of symptoms associated with enlarged glands or kernels in theneck and known as "scrofula" or struma, most cases of hip-joint disease, of white swelling of the knee, a large percentage of chronic ulcerationsof the skin known as _lupus_, a common form of fatal bowel disease inchildren, and many instances of peritonitis in adults, together withfully half of the fatal cases of convulsions in children, were due tothe activity of this same ubiquitous bacillus, it looked as if the enemywere hopelessly entrenched against attack. And when it was further foundthat a similar bacillus was almost as common a cause of death anddisease in cattle, particularly dairy cattle, and another in domesticfowls, it looked as if the heavens above and the earth beneath were sothickly strewn and so hopelessly infested with the germs that to waragainst them, or hope to escape from them, was like fighting back theAtlantic tides with a broom. 

But this chill of discouragement quickly passed. Our foe had come downout of the clouds, and was spread out in battle array before us, inplain sight on the level earth. We were ready for the conflict, andproposed to "fight it out on this line if it takes all summer. " It wasnot long before we began to see joints in the enemy's armor andweaknesses in his positions. Then, when we lowered our field-glasses andturned to count our forces and prepare for the defense, we discoveredwith a shock of delighted relief that whole regiments of unexpectedreinforcements had come up while we were studying the enemy's position. These new allies of ours were three of the great, silent forces ofnature, which had fallen into line on either side and behind us, withouthurry and without excitement, without even a bugle-blast to announcetheir coming. 

The first was the great resisting power and vigor of the human organism, which we had gravely underestimated. The second, that power ofadaptation to new circumstances, including even the attack of infectiousdiseases, which we call "survival of the fittest. " The third, thatgreat, sustaining, conservative power of nature--heredity. More cheeringyet, these forces came, not merely fully armed, but bearing new weaponsfitted for our hands. The vigor and unconquerable toughness of the humananimal presented us with three glittering weapons, sunshine, food, andfresh 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 enemywill never break the line. "

The survival of the fittest held out to us two weapons of strange andcurious make, one of them labeled "immunity, " the other "quarantine. ""Give me a little time, " she said, "and with the first of these I willmake seven-tenths of the soldiers in your army proof against the spearsof 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 thesunlight. Hold him in the open for forty-eight hours, and he will die oflight-stroke and starvation. Divide and conquer!"

These reinforcements of ours have proved no mere figure of speech. Theyhave won many a battle for us already upon the tented field. They havenot merely made good their promises, but gone beyond them, and we areonly just beginning to appreciate their true worth, and how absolutelywe can rely upon them. 

The first outpost of the enemy was captured with the sunshine-food-airweapons, and a glorious victory it was, --great in itself, and even moreimportant for its moral effect and its encouragement for the future. Topronounce an illness "consumption" had been from time immemorialequivalent to signing a death-warrant. Even the doctors could hardlybelieve it, when the first open-air enthusiasts began to claim that theyhad actually cured cases of genuine consumption. For long there was atendency 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 patientsremained cured for years afterward. Our first claims were barely fortwenty-five or thirty per cent of the threatened victims. Then we wereable to increase it to fifty per cent; sixty, seventy, and finallyeighty were successively reached. But with the increase of our powerover the cure of this disease came a realization of our knowledge of itslimitations. It quickly proved itself to be no sovereign and universalpanacea, which would cure all cases, however desperate, or howeverindiscriminately it was applied. And emphatically it had to be mixedwith brains, on the part both of the physician and of the patient. 

In the first place, the likelihood of a cure depended, with almostmathematical certainty, upon the earliness of the stage at which it wasbegun. Eight or ten years ago the outlook crystallized itself into theform which it has practically retained since: of cases put undertreatment in the very early stage, from seventy to ninety per cent werepractical cures; of ordinary so-called "first-stage" cases, sixty toseventy per cent; second-stage cases, or those in whom the disease waswell developed, thirty to sixty per cent; and well-advanced cases, fifteen to thirty per cent of apparent cures. _The crux of the wholeproposition lies in the early recognition of the disease by thephysician_, and the prompt acceptance of the diagnosis by the patient, and his willingness to drop everything and fight intelligently andvigorously for his life. Physicians are now thoroughly awake on thispoint, and are concentrating their most careful attention and study uponmethods of recognition at the earliest possible stages. At the same timethose magnificent associations for the study and prevention oftuberculosis, international, national, state, and local, --the greatestof which, the International Tuberculosis Congress, has just honoredAmerica, by meeting in Washington, --are straining every nerve to educatethe public to understand the importance of recognizing the earliestpossible symptoms of this disease, no matter how trivial they mayappear, and making every other consideration bend to the fight. 

This new Word of Power, the open-air treatment, alone has transformedone of the most hopeless, most pathetic, and painful fields of diseaseinto one of the most cheerful and hopeful. The vantage-ground won issomething enormous. No longer need the family physician hang back, indread and horror, from allowing himself even to recognize that the slowloss of weight, the increasing weakness, the flushed evening cheek, andthe restless sleep, are signs of this dread malady. Instead of shrinkingfrom pronouncing the patient's doom, he knows now that he has everythingto gain and nothing to lose by promptly warning him of his danger, evenwhile it is still problematical. On the other hand, the patient need nolonger recoil in horror when told that he has consumption, and either gohome to set his house in order and make his will, or hunt up anothermedical adviser who will take a more cheerful view of his case. All thathe has to do is to turn and fight the disease vigorously, intelligently, persistently, with the certain knowledge that the chances are five toone in his favor; and that's a good fighting chance for any one. 

Even should there be reasonable ground for doubt as to the positivenature of the disease, he has nothing to lose and everything to gain bytaking the steps required to cure it. There is nothing magical orirrational, least of all injurious, in any way about them. Simply rest, abundant feeding, and plenty of fresh air. Even if the bacillus has notyet lodged in his tissues, this treatment will relieve the conditions ofdepression from which he is suffering, and which would sooner or laterrender 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 generalefficiency will more than pay him for the time lost from his business orhis study. It always pays to take time to put yourself back into acondition of good health and highest efficiency. 

It was early recognized that the campaign could not be won with thisweapon alone. Inexpressibly valuable and cheering as it was, it hadobvious limitations. The first of these was the obvious reflection thatit was idle to cure even eighty per cent of all who actually developedtuberculosis, unless something were done to stop the disease fromdeveloping at all. "Eighty per cent of cures, " of course, sounds veryencouraging, especially by contrast with the almost unbroken successionof deaths before. But even a twenty per cent mortality from such acommon disease, if it were to proceed unchecked, would make enormousinroads every year upon our national vigor. 

Secondly, it was quickly seen that those who recovered from the diseasestill bore the scars; that while they might recover a fair degree ofhealth and vigor, yet they were always handicapped by the time lost andthe damage inflicted by this slow and obstinate malady; that many ofthem, while able to preserve good health under ideal conditions, weremarkedly and often distressingly limited in the range of their businessactivities for years after, and even for life. Finally, that as thesecases were followed further and further, it was found that even afterbecoming cured they were sadly liable to relapse under some unexpectedstrain, or to slacken their vigilance and drop back into their formerbad physical habits; while the conviction began to grow steadily uponmen who had devoted one, two, or more decades to the study of thisdisease in the localities most resorted to for its cure, that thegeneral vigor and vitality of these cured consumptives were apt to benot of the best; that their duration of life was not equal to theaverage; and that, even if they escaped a return of the disease, theywere apt to go down before their normal time under the attack of someother malady. In short, _cure_ was a poor weapon against the disease ascompared with _prevention_. 

But before this, a careful study of the enemy's position andinvestigation of our own resources had brought another most importantand reassuring fact to light, and that is, that while a distressinglylarge number of persons died of tuberculosis, these represented only acomparatively small percentage of all who had actually been attacked bythe disease. One of the reasons why consumption had come to be regardedas such a deadly disease was that the milder cases of it were neverrecognized. It was, and is yet, a common phrase in the mouths of boththe laity and of the medical profession: "He was seriously threatenedwith 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 oppositeextreme, of declaring with the German experts, "_Jeder Mann ist am endeein bischen tuberkulöse_. " (Every one is some time or another a littlebit tuberculous. ) This sounds appalling at first hearing, but as amatter of fact it is immensely encouraging. Our first suspicion of itcame from the records of that gruesome, but pricelessly valuable, treasure-house of solid facts in pathology--the post-mortem room, thedead-house. Systematic examinations of all the bodies brought to autopsyin our great hospitals and elsewhere revealed at first thirty, then, asthe investigation became more minute and skillful, forty, sixty, seventy-five per cent of scars in the apices of the lungs, remains ofhealed cavities, infected glands, or other signs of an invasion by thetubercle bacillus. Of course, the skeptic challenged very properly atonce:--

"But how do you know that these masses of chalky-material, theseenlarged glands, are the result of tuberculosis? They may be due to somehalf-dozen other infections. "

Almost before the question was asked a test was made by the troublesomebut convincing method of cutting open these scars, dividing theseenlarged glands, scraping materials out of their centre, and injectingthem into guinea pigs. Result: from thirty to seventy per cent of theguinea pigs died of tuberculosis. In other cases it was not necessary toinoculate, as scrapings or sections from these scar-masses showedtubercle bacilli, clearly recognizable by their staining reaction. 

Here, then, we have indisputable evidence of the fact that the tuberclebacillus may not only enter some of the openings of the body, --thenostrils, the mouth, the lungs, --but may actually form a lodgment and agrowth-colony in the lungs themselves, and yet be completely defeated bythe antitoxic powers of the blood and other tissues of the body, prevented from spreading throughout the rest of the lung, most of theinvaders destroyed, and the crippled remnants imprisoned for life in theinterior of a fibroid or chalky mass. 

It gave one a distinct shock at the meeting of the British MedicalAssociation devoted to tuberculosis, some ten years ago, to hear SirClifford Allbutt, one of the most brilliant and eminent physicians ofthe English-speaking world, remark, on opening his address, "Probablymost of us here have had tuberculosis and recovered from it. "

Here is evidently an asset of greatest and most practical value, whichchanges 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 theupper hand and begin to overrun their entire systems, it places beforeus the far more cheering task of building up and increasing this naturalresisting power of the human body, until not merely seventy per cent ofall 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--suchas could be produced by but a slight improvement in the abundance of thefood-supply, the lighting and ventilating of the houses, the length and"fatiguingness" of the daily toil--might be the straw which would besufficient to turn the scale and prevent the tuberculous individual frombecoming consumptive. 

Here comes in one of the most important and valuable features of oursplendid sanatorium campaign for the cure of tuberculosis, and that isthe nature of the methods employed. If we relied for the cure of thedisease upon some drug, or antitoxin, even though we might save as manylives, the general reflex or secondary effect upon the community mightnot be in any way beneficial; at best it would probably be onlynegative. But when the only "drugs" that we use are fresh air, sunshine, and abundant food, and the only antitoxins those which are bred in thepatient's own body; when, in fact, we are using for the cure ofconsumption _precisely those agencies and influences which will preventthe well from ever contracting it_, then the whole curative side of themovement becomes of enormous racial value. The very same measures thatwe rely upon for the cure of the sick are those which we would recommendto the well, in order to make them stronger, happier, and more vigorous. 

If the whole civilized community could be placed upon a moderate form ofthe open-air treatment, it would be so vastly improved in health, vigor, and efficiency, and saved the expenditure of such enormous sumsupon hospitals, poor relief, and sick benefits, that it would be wellworth all that it would cost, even if there were no such disease astuberculosis on earth. 

This is coming to be the real goal, the ultimate hope of the far-sightedleaders in our tuberculosis campaign, --to use the cure of consumption asa lever to raise to a higher plane the health, vigor, and happiness ofthe entire community. 

Enormously valuable as is the open-air sanatorium as a means of savingthousands of valuable and beloved lives, its richest promise lies in itsfunction as a school of education for the living demonstration ofmethods by which the health and happiness of the ninety-five per cent ofthe 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 anenthusiastic missionary in the fresh-air campaign. The ultimate aim ofthe sanatorium will be to turn every farmhouse, every village, everycity, into an open-air resort. When it shall have done this it will havefulfilled its mission. 

Our plan of campaign is growing broader and more ambitious, but morehopeful, every day. All we have to do is to keep on fighting and use ourbrains, and victory is certain. Our Teutonic fellow soldiers havealready 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-tuberculosisarmy, upon which we depend for the heavy, mass fighting and the greatfrontal attacks. But what of the right and the left wings, and the cloudof skirmishers and cavalry which is continually feeling the enemy'sposition and cutting off his outposts? Upon the right stretch theintrenchments of the bacteriologic brigade, with the complicated butmarvelously effective weapons of precision given us by the discovery ofthe definite and living cause of the disease, the _Bacillustuberculosis_. Upon the left wing lie camp after camp of nativeregiments, whose loyalty until of very recent years was more thandoubtful, --heredity, acquired immunity, and the so-called improvementsof modern civilization, steam, electricity, and their kinsmen. 

To the artillerymen of the bacteriologic batteries appears to have beenintrusted the most hopeless task, the forlorn hope, --the totalextermination of a foe so tiny that he had to be magnified five hundredtimes before he was even visible, and of such countless myriads that hewas at least a billion times as numerous as the human race. But hereagain, as in the centre of the battle-line, when we once made up ourminds to fight, we were not long in discovering points of attack andweapons to assault him with. 

First, and most fundamental of all, came the consoling discovery thatthough there could be no consumption without the bacillus, not more thanone individual in seven, of fair or average health, who was exposed toits attack in the form of a definite infection, succumbed to it; andthat, as strongly suggested by the post-mortem findings alreadydescribed, even those who developed a serious or fatal form of thedisease had thrown off from five to fifteen previous milder or slighterinfections. So that, to put it roughly, all that would be necessarypractically to neutralize the injuriousness of the bacillus would be toprevent about one-twentieth of the exposures to its invasion whichactually occurred. The other nineteen-twentieths would take care ofthemselves. The bacilli are not the only ones who can be numbered intheir billions. If there are billions of them there are billions of us. We are not mere units--scarcely even individuals--except in a broad andfigurative sense. We are confederacies of billions upon billions oflittle, living animalcules which we call cells. These cells of ours areno 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 victorieswritten 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 millionsof years past has been eating and digesting the vegetable. And all thatour body-cells need is a little intelligent encouragement to continuethis performance, even upon disease germs; so that we needn't be afraidof being stampeded by sudden attack. 

The next cheering find was that the worst enemies of the bacillus wereour best friends. Sunlight will kill them just as certainly as it willgive us new life. The germs of tuberculosis will live for weeks and evenmonths in dark, damp, unventilated quarters, just precisely suchsurroundings as are provided for them in the inside bedrooms of ourtenements, and the dark, cellar-like rooms of many a peasant's cottageor farmhouse. In bright sunlight they will perish in from three to sixhours; in bright daylight in less than half a day. This is one of thefactors that helps to explain the apparent paradox, that the dustcollected from the floors and walls of tents and cottages in whichconsumptives were treated was almost entirely free from tuberculousbacilli, while dust taken from the walls of tenement houses, the floorsof street-cars, the walls of churches and theatres in New York City, wasfound to be simply alive with them. One of the most important elementsin the value of sunlight in the treatment of consumption is its powerfulgermicidal effect. 

CHAPTER VII

TUBERCULOSIS, A SCOTCHED SNAKE

II

Closely allied to the discovery that sunlight and fresh air are fatal tothe microörganisms of tuberculosis came the consoling fact that thesebacilli, though most horribly ubiquitous and apparently infesting boththe heavens above and the earth beneath, had neither wings nor legs, andwere absolutely incapable of propelling themselves a fraction of aninch. They do not move--_they have to be carried_. More than this, likeall other disease-germs, while incredibly tiny and infinitesimal, theyhave a definite weight of their own, and are subject to the law ofgravity. They do not flit about hither and thither in the atmosphere, thistledown fashion, but rapidly fall to the floor of whatever room orreceptacle they may be thrown in. And the problem of their transferenceis not that of direct carrying from one victim to the next, but theintermediate one of infected materials, such as are usually associatedwith 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 canbe brought to or near the mouth, and you will practically have abolishedthe possibility of the transference of tuberculosis. The consumptivehimself is not a direct source of danger. It is only his filthy orunsanitary surroundings. Put a consumptive, who is careful of his sputumand cleanly in his habits, in a well-lighted, well-ventilated room, or, better still, out of doors, and there will be exceedingly little dangerof any other member of his family or of those in the house with himcontracting the disease. Wherever there is dirt or dust there is danger, and there almost only. Thorough and effective house-reform--not merelyin tenements, alas! but in myriads of private houses as well--wouldabolish two-thirds of the spread of tuberculosis. 

It is not necessary to isolate every consumptive in order to stop thespread of the disease. All that is requisite is to prevent the bacilliin his sputum from reaching the floor or the walls, to have both thelatter well lighted and aired, and, if possible, exposed to directsunlight at some time during the day, and to see that dust from thefloor is not raised in clouds by dry sweeping so as to be inhaled intothe lungs or settle upon food, fingers, or clothing, and that childrenbe not allowed to play upon such floors as may be even possiblycontaminated. These precautions, combined with the five-to-one resistingpower of the healthy human organism, will render the risk oftransmission of the disease an exceedingly small one. To whatinfinitesimal proportions this risk can be reduced by intelligent andstrict sanitation is illustrated by the fact, already alluded to, of thealmost complete germ-freeness of the dust from walls and floors ofsanitorium cottages, and by the even more convincing and conclusivepractical result, that scarcely a single case is on record of thetransmission of this disease to a nurse, a physician, or a servant, orother employee in an institution for its cure. 

There is absolutely no rational basis for this panic-stricken dread ofan intelligent, cleanly consumptive, or for the cruel tendency to makehim an outcast and raise the cry of the leper against him: "Unclean!Unclean!"

It cannot be too strongly emphasized that consumption is transmitted _byway of the floor_; and if this relay-station be kept sterile there islittle danger of its transmission by other means. 

Practically all that is needed to break this link is the absolutesuppression of what is universally and overwhelmingly regarded as notmerely an unsanitary and indecent, but a filthy, vulgar, and disgustinghabit--promiscuous expectoration. There is nothing new or unnatural inthis repression, this _tabu_ on expectoration. In fact, we are alreadyprovided with an instinct to back it. In every race, in every age, inevery grade of civilization, the human saliva has been regarded as themost disgusting, the most dangerous and repulsive of substances, and theact of spitting as the last and deepest sign of contempt and hatred; andif directed toward an individual, the deadliest and most unbearableinsult, which can be wiped out only by blood. Primitive literature andlegend are full of stories of the poisonousness of human saliva and thedeadliness of the human bite. It was the "bugs" in it that did it. It ismost interesting to see how science has finally, thousands of yearsafterward, shown the substantial basis of, and gone far to justify, thisinstinctive horror and loathing. 

Not merely are the fluids of the human mouth liable to contain thetubercle bacillus, and that of diphtheria, of pneumonia, and half adozen other definite disorders, but they are in perfectly healthyindividuals, especially where the teeth are in poor condition, simplyswarming with millions of bacteria of every sort, some of them harmless, others capable of setting up various forms of suppuration and septicinflammation if introduced into a wound, or even if taken into thestomach. Even if there were no such disease as tuberculosis a campaignto stamp out promiscuous expectoration would be well worth all it cost. 

Of course, as a counsel of perfection, the ideal procedure would bepromptly to remove each consumptive, as soon as discovered, from hishouse and place him in a public sanatorium, provided by the state, forthe sake of removing him from the conditions which have produced hisdisease, of placing him under those conditions which alone can offer ahopeful prospect of cure, and of preventing the further infection of hissurroundings. The only valid objections to such a plan are those of theexpense, which, of course, would be very great. It would be not merelybest, but kindest, for the consumptive himself, for his immediatefamily, and for the community. And enormous as the expense would be, when we have become properly aroused and awake to the huge and almostincredible burden which this disease, with its one hundred and fiftythousand deaths a year, is now imposing upon the United States, --fivetimes as great as that of war or standing army in the most military-madstate in Christendom, --the community will ultimately assume thisexpense. So long, however, as our motto inclines to remain, "Millionsfor cure, but not one cent for prevention, " we shall dodge this issue. 

There can be no question but that each state and each municipality ofmore than ten thousand inhabitants ought to provide an open-air camp orcolony of sufficient capacity to receive all those who are willing totake the cure but unable to meet the expense of a private institution;and, also, some institution of adequate size, to which could be sent, byprocess of law, all those consumptives who, either through perversity, or the weakness and wretchedness due to their disease, or the apathy ofapproaching dissolution, fail or are unable to take proper precautions. 

When we remember that the careful investigations of the variousdispensaries for the treatment of tuberculosis in our larger cities, NewYork, Boston, Cleveland, report that on an average twenty to thirty percent of all children living in the same room or apartment with aconsumptive member of their family are found to show some form oftuberculosis, it will be seen how well worth while, from every point ofview, this provision for the removal and sanatorium treatment of thepoorer class of these unfortunates would be. These dispensaries nowhave, as a most important part of their campaign against the disease, one or more visiting nurses, who, whenever a patient with tuberculosisis brought into the dispensary, visit him in his home, show him how toventilate and light his rooms as well as may be, give practicaldemonstrations of the methods of preventing the spread of the disease, advise him as to his food, and see that he is supplied with adequateamounts of milk and eggs, and, finally, round up all the children of thefamily and any adults who are in a suspicious condition of health, andbring them to the dispensary for examination. Distressing as are thesefindings, reaching in some cases as high as fifty and sixty per cent ofthe children, they have already saved hundreds of children, andprevented hundreds of others from growing up crippled or handicapped. 

It must be remembered that the tubercle bacillus causes not merelydisease of the lungs in children but also a large majority of thecrippling diseases of the bones, joints, and spine, together with thewhole group of strumous or scrofulous disorders, and a large group ofintestinal diseases and of brain lesions, resulting in convulsions, paralysis, hydrocephalus, and death. The battle-ground of the futureagainst tuberculosis is the home. 

We speak of the churchyard as "haunted, " and we recoil in horror fromthe leper-house or the cholera-camp. Yet the deadliest known hotbed ofhorrors, the spawning ground of more deaths than cholera, smallpox, yellow fever, and the bubonic plague combined, is the dirty floor of thedark, unventilated living-room, whether in city tenement or villagecottage, where children crawl and their elders spit. 

It is scarcely to the credit of our species that for convincing, actualdemonstrations of what can be done toward stamping out tuberculosis, bymeasures directed against the bacillus alone, we are obliged to turn tothe lower animals. By a humiliating paradox we are never quite able toput ourselves under those conditions which we know to be ideal from asanitary point of view. There are too many prejudices, too many vestedinterests, too many considerations of expense to be reckoned with. Butwith 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 rosydream of the future but an accomplished fact, in some quarters even anold story. Two illustrations will suffice, one among domestic animals, the other among wild animals in captivity. The first is among pure-breddairy cattle, the pedigreed Jerseys and Holsteins. No sooner did thediscovery of the bacillus provide us with a means of identification, than the well-known "_perlsucht_" of the Germans, or "grapes" of theEnglish veterinarians--both names being derived from the curious roundedmasses or nodules of exudate found in the pleural cavity and theperitoneum (around the lungs and the bowels), and supposed to resemblepearls and grapes respectively--were identified as tuberculosis, andcows were found very widely infected with it. This unfortunately stillremains the case with the large mass of dairy cattle. But certain of themore intelligent breeders owning valuable cattle proceeded to take stepsto protect them. 

The first step was to test their cows with tuberculin, promptly weedingout and isolating all those that reacted to the disease. It was at firstthought necessary to slaughter all these at once. But it was later foundthat, if they were completely isolated and prevented from communicatingthe disease to others, this extreme measure was necessary only withthose extensively diseased. The others could be kept alive, and if theircalves were promptly removed as soon as born, and fed only uponsterilized or perfectly healthy milk, they would be free from thedisease. And thus the breeding-life of a particularly valuable andhigh-bred animal might be prolonged for a number of years. They must, however, be kept in separate buildings and fields, and preferably upon aseparate farm from the rest of the herd. 

Those cows found healthy were given the best of care, including a markeddiminution of the amount of housing or confinement in barns, and wereagain tested at intervals of six months, several times, to weed out anyothers which might still have the infection in their systems. In a shorttime all signs of the disease disappeared, and no other cases developedin these herds unless fresh infection was introduced from without. Toguard against this, each farm established a quarantine station, whereall new-bought animals, after having been tested with tuberculin andshown to be free from reaction, are kept for a period of at least ayear, for careful observation and study, before being allowed to mixwith the rest of the herd. It is now a common requirement amongintelligent breeders of pedigreed cattle to demand, as a formalcondition of sale, their submission to the tuberculin test, or thecertificate of a competent veterinarian that the animal has been sotested without reacting. Protected herds have now been in existenceunder these conditions, notably in Denmark, where the method was firstreduced to a system under the able leadership of Professor Bang, ofCopenhagen, for ten years with scarcely a single case of tuberculosisdeveloping. Only a fraction of one per cent of calves from the mostdiseased mothers are born diseased. 

Not only is the method spreading rapidly among the more intelligentclass of breeders, but many progressive countries of Europe and statesof our Union require the passing of the tuberculin test as a requisiteto the admission within their borders of cattle intended for breedingpurposes. So that, while the problem is still an enormous one, it is nowconfidently believed that complete eradication of bovine tuberculosis isonly a question of time. 

The other instance furnishes a much more crucial test, as it is carriedout upon wild animals under the unfavorable conditions of captivity in astrange climate, like our slum-dwellers from sunny Italy, and comes hometo us more closely in many respects, inasmuch as it is concerned withour nearest animal relatives on the biological side--monkeys and apes, in zoölogical gardens. 

Tuberculosis is a perfectly frightful scourge to these unfortunatecaptives, causing not infrequently thirty, fifty, and even sixty percent of the deaths. This, however, is only in keeping with theirfrightful general mortality. The collection of monkeys in the LondonZoo, for instance, some fifteen years ago, was absolutely exterminatedby disease and started over afresh _every three years_, a death-rate ofthirty-five per cent per annum as compared with our human rate of abouttwo per cent per annum. Here, it would seem, was an instance where therewas little need to call in the bacillus. Brought from a tropical climateto one of raw, damp fog and smoke, from the freedom of the air-roadsthrough the tree-tops to the confinement of dismal and often dirty cagesin a stuffy, overheated house, condemned to a diet which at best couldbe but a feeble and far-distant imitation of their natural food, itseemed 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 ofits most brilliant and successful exemplifications in our own New YorkZoölogical Gardens in the Bronx. All animals purchased or donated weretested with tuberculin, and those that reacted were either painlesslydestroyed or disposed of. Those which appeared to be immune were kept ina thoroughly healthy, sanitary quarantine station for six months or ayear, and again tested by tuberculin before being introduced into thecages. The original stock of monkeys was treated in the same manner orelse destroyed completely, and the houses and cages thoroughly cleanedand sterilized or new ones constructed. Keepers employed in themonkey-house were carefully tested for signs of tuberculosis, andrejected or excluded if any appeared. Signs were posted forbidding anyexpectoration or feeding of the animals (which latter is often donewith nuts or fruit which had been cracked or bitten before being handedto the monkeys) by the general public, and these rules were strictlyenforced. 

At the same time the houses were thoroughly ventilated and exposed tosunlight as much as possible, and the animals were turned out into openair cages whenever the weather would possibly permit. As a result themortality from tuberculosis promptly sank from thirty per cent to fiveor six per cent. In our Bronx Zoo, for instance, it has become decidedlyrare as a cause of death in monkeys, no case having occurred in themonkey-house for eighteen months past. What is even more gratifying, thegeneral mortality declined also, though in less proportion, so that, instead of losing twenty-five to thirty per cent of the animals in thehouse every year, a mortality of ten to fifteen per cent is nowconsidered large. 

And to think that we might achieve the same results in our own speciesif 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 asanitary point of view. 

"But this method, " some one will remind us, "would silence only a partof the enemy's infection batteries. " Even supposing that we couldprevent the spread of the disease from human sources, what of the animalconsumptives and their deadly bacilli? If the milk that we drink, andthe beef, pork, and poultry that we eat, are liable to convey theinfection, what hope have we of ever stopping the invasion?

The question is a serious one. But here again a thorough and carefulstudy of the enemy's position has shown the danger to be far less thanit appeared at first sight. Even bacilli have what the French call "thedefects of their virtues. " Their astonishing and most disquieting powersof adjustment, of accommodation to the surroundings in which they findthemselves, namely, the tissues and body-fluids of some particular hostwhom they attack, bring certain limitations with them. Just in so far asthey have adjusted themselves to live in and overcome the opposition ofthe body-tissues of a certain species of animals, _just to that degreethey have incapacitated themselves to live in the tissues of any otherspecies_. 

Some of the most interesting and far-reachingly important work that hasbeen done in the bacteriology of tuberculosis of late years hasconcerned itself with the changes that have taken place in differentvarieties and strains of tubercle bacilli as the result of adjustingthemselves to particular environments. The subject is so enormous thatonly the crudest outlines can be given here, and so new that it isimpossible to announce any positive conclusions. But these appear to bethe dominant tendencies of thought in the field so far. 

Though nearly all domestic animals and birds, and a majority of wildanimals under captivity, are subject to the attack of tuberculosis, practically all the infections hitherto studied are caused by one ofthree 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 thatthey were at one time regarded as identical, and we can well rememberthe wave of dismay which swept over the medical world when Robert Kochannounced that the "_perlsucht_" of cattle was a genuine andunquestioned tuberculosis due to an unmistakable tubercle bacillus. Butas these varieties were thoroughly and carefully studied, it was soonfound that they presented definite marks of differentiation, until nowthey are universally admitted to be distinct varieties, each with itsown life peculiarities, and, according to some authorities, evendistinct species. 

"But, " we fancy we hear some one inquire impatiently, "what do thoseacademic, technical distinctions matter to us? Whether the aviantuberculosis germ is a variety or a true species may be left to thetaxonomists, but it is of no earthly importance to us. "

On the contrary, it is of the greatest importance. For the distinctivefeature about a particular species of parasite is that it will live andflourish where another species will die, and, vice versa, _will die insurroundings where its sister species might live and thrive_. 

One of the first differences found to exist among these three types ofbacteria was the extraordinary variation in their power of attackingdifferent animals. For instance, while the guinea-pig and the rabbitcould be readily inoculated with _human_ bacilli, they could only beinfected with difficulty by cultures of the _bovine_ bacillus; while theonly animal that could be inoculated at all with the _avian_ or birdbacillus 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 humanbeings, so widely different were the conditions in their moist andmoderately warm tissues to those of the dry and superheated tissues ofthe bird to which it had adjusted itself for so many generations. 

And next came the bold pronunciamento of no less an authority than Kochhimself, that the bovine bacillus also was so feebly infective to humanbeings that it might be practically disregarded as a source of danger. This promptly split the bacteriologists of the world into two opposingcamps, and started a warfare which is still being waged with greatvigor. As the question is still under hot dispute by even the highestauthorities, it is, of course, impossible to pronounce any definiteconclusions. But the net result to date appears to be that while Kochmade a serious error of judgment in declaring that meat and milk as asource of danger to human beings of tuberculosis might be disregarded, yet, for practical purposes, his position is, in the main, correct: theactual danger from the bovine bacillus to human beings is relativelysmall. 

There was nothing whatever improbable, in the first place, in thecorrectness of Koch's position. 

It is one of the few consoling facts, well known to all students ofcomparative pathology or the diseases of the different species ofanimals, how peculiarly specialized they are in the choice of theirdiseases, or, perhaps, to put it more accurately, how particular andrestricted disease-germs are in their choice of a host. For instance, out of twenty-eight actually infectious diseases which are most commonamong the domestic animals and man, other than tuberculosis, onlyone--_rabies_--is readily communicable to more than three species; onlythree--_anthrax_, _tetanus_, and _foot-and-mouth disease_--arecommunicable to two species; while the remainder are almost absolutelyconfined to one species, even though this be thrown into closest contactwith half a dozen others. 

Again, we have half a dozen similar instances in the case oftuberculosis itself. The horse and the sheep, for instance, are bothmost intimately associated with cattle, pastured in the same fields, fedupon the same food, and yet tuberculosis is almost unknown in sheep anddecidedly uncommon in horses, and when it does occur in them is from ahuman source. The goat is almost equally immune from both human and_bovine_ forms, while the cat and the dog, although developing theinfection with a low degree of frequency, almost invariably trace thatinfection to a human source. 

There is, therefore, no _a priori_ reason whatever why we should be anymore susceptible to bovine tuberculosis than the remainder of thedomestic animals. It is only fair to say, however, that the animal whosediet--and appetite--most closely resembles ours, the hog, is quitefairly susceptible to bovine tuberculosis if fed upon the milk or meatof tuberculous cattle. 

Next came the particularly consoling fact that although nothing has beenmore striking than the great increase in the amounts of meat and milkconsumed by the mass of the community during our last twenty years'progress in civilization, this has been accompanied not by any increaseof tuberculosis, but by a _diminution of from thirty-five to forty-fiveper cent_. The allegation so frequently made that there has been anincrease in the amount of infantile tuberculosis has been shown, uponcareful investigation by Shennan of Edinburgh, Guthrie of London, Kosselin Germany, Comby in France, Bovaird in New York, and others, to bepractically without foundation. 

Then, while repetitions of Koch's experiment, upon which hisannouncement was based, of inoculating calves and young cattle with_human_ bacilli have proved that a certain number of them can be, underappropriate circumstances, made to develop tuberculosis, that number hasnever been a large percentage of the animals tested, and in many casesthe infection has been a local one, or of a mild type, which hasresulted in recovery. Lastly, while a number of bacilli, with _bovine_culture and other characteristics, have been recovered from the bodiesof children dying of tuberculosis, and these bacilli have provedvirulent to calves when injected into them, yet, as a matter ofhistorical fact, the actual number of instances in which children orother human beings have been definitely proved to have contracted thedisease from the milk of a tuberculous cow is still exceedingly andencouragingly small. A careful study of the entire literature of thepast twenty years, some three years ago, revealed _only thirty-sevencases_; and of these thirty-seven Koch's careful investigations havesince disproved the validity of nine. 

On the other hand, it is anything but safe to accept Koch's practicaldictum and neglect the meat and milk of cattle as a source of danger intuberculosis. First, because the degree of our immunity against thebovine bacilli is still far from settled; and, second, because, whilebacteriologists are fairly agreed that the _avian_, the _bovine_, andthe _human_ represent three distinct and different variations, if notspecies, of the bacillus, they are almost equally agreed that they areprobably the descendants of one common species, which may possibly be abacillus commonly found upon meadow grasses, particularly the well-knowntimothy, and hence very frequently in the excreta of cattle, and knownas the _grass bacillus_ or _dung bacillus_ of M[oe]ller. This bacillushas all the staining, morphological, and even growth characteristics ofthe tubercle bacillus except that it produces only local irritation andlittle nodular masses, if injected into animals. Our knowledge of itsexistence is, however, of great practical importance, inasmuch as itwarned us that in our earlier studies of the bacilli contained in milkand butter we have been mistaking this organism for a genuine tuberclebacillus. As a consequence, of late years our tests for the presence oftubercle bacilli in milk are made not only by searching for the organismwith the microscope, but also by injecting the centrifugated sediment ofthe infected milk into guinea pigs, to see if it proves infectious. Manyof our earlier statements as to the presence of tubercle bacilli in milkand butter are now invalidated on this account. 

Not only are the three varieties of tubercle bacilli probably of commonorigin, but they may, under certain peculiar conditions, be transformedinto one another, or, at least, enabled to live under the conditionsfavorable to one another. This was shown nearly fifteen years ago by theingenious experiments of Nocard, the great veterinary pathologist. Hetook a culture of bovine bacilli, which were entirely harmless to fowls, and, inclosing them in a collodion capsule, inserted them into theperitoneal cavity of a hen. The collodion capsule permitted the fluidsof the body to enter and provide food for the bacilli, but prevented theadmission of the leucocytes to attack and destroy them. After severalweeks the capsule was removed, the bacilli found still alive, andtransferred to another capsule in another fowl. When this process hadbeen repeated some five or six times, the last generation of bacilli wasinjected into another fowl, which promptly developed tuberculosis, showing that by gradually exposing the bacilli for successivegenerations to the high temperature of the bird's body (from five tofifteen degrees above that of the mammal), they had become acclimated, as it were, and capable of developing. So that it is certainly quiteconceivable that bovine bacilli introduced in milk or meat might manageto find a haven of refuge or lodgment in some out-of-the-way gland ortissue of the human body, and there avoid destruction for a sufficientlylong time to become acclimated and later infect the entire system. 

This is the method which several leaders in bacteriology, includingBehring (of antitoxin fame), believe to be the principal source andmethod of infection of the human species. The large majority, however, of bacteriologists and clinicians are of the opinion that ninety percent of all cases of human tuberculosis are contracted from some humansource. So that, while we should on no account slacken our fight againsttuberculosis in either cattle or birds, and should encourage in everyway veterinarians and breeders to aim for its total destruction, --aconsummation which would be well worth all it would cost them, purelyupon economic grounds, just as the extermination of human tuberculosiswould be to the human race, --yet we need not bear the burden of feelingthat the odds against us in the fight for the salvation of our ownspecies are so enormous as they would be, had we no natural protectionagainst infection from animals and birds. 

The more carefully we study all causes of tuberculosis in children, thelarger and larger percentage of them do we find to be clearly traceableto infection from some member of the family or household. In Berlin, forinstance, Kayserling reports that seventy per cent of all casesdiscovered can be traced to direct infection from some previous humancase. 

Lastly, what of the left wing of our army of extermination, composed ofthose light-horse auxiliaries--the general progress and new developmentsof civilization, and the net results upon the individual of theexperiences of his ancestors, which we designate by the term "heredity"?For many years we were in serious doubt how far we could depend upon theloyalty of this group of auxiliaries, and many of the faint-heartedamong us were inclined to regard their sympathies as really against usrather than with us, and prepared to see them desert to the enemy at anytime. It was pointed out, as of great apparent weight, that consumptionwas decidedly and emphatically a disease of civilization; that it wasborn of the tendency of men to gather themselves into clans and nationsand crowd themselves into villages and those hives of industry calledcities; that the percentage of deaths from tuberculosis in any communityof a nation or any ward of a city was high in direct proportion to thedensity of its population; and that the whole tendency of civilizationwas to increase this concentration, this congestion of ground space, this piling of room upon room, of story upon story. How could wepossibly, in reason, expect that the influences which had caused thedisease could help us to cure it?

But the improbable has already happened. Never has there been a morerapid and extraordinary growth of our great cities as contrasted withour rural districts, never has there been a greater concentration ofpopulation in restricted areas than during the past thirty-five years. And yet, the prevalence of tuberculosis in that time, in all civilizedcountries of the earth, has shown not only no increase, _but a decreaseof from thirty-five to fifty per cent_. To-day the world power which hasthe largest percentage of its inhabitants gathered within the limits ofits great cities, England, has the lowest death-rate in the civilizedworld from tuberculosis, although closely pressed within the last fewyears by the United States, whose percentage of urban population isalmost equally large, while England's sister island, Ireland, with oneof 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 _morecivilization_, or, better, perhaps, _higher_ civilization. Nor are theseexceptional instances. Take practically any city, state, or province inthe civilized world, which has had an adequate system of recording allbirths and deaths for more than thirty years, and you will find adecrease in the percentage of deaths from tuberculosis in that time offrom twenty to forty per cent. The city of New York's death-roll, forinstance, from tuberculosis, per one thousand living, is somethirty-five per cent less than it was thirty years ago. So that ourfight against the disease is beginning to bear fruit already. As Oslerputs it, we run barely half the risk of dying of tuberculosis that ourparents did and barely one-fourth of that of our grandparents. 

But this gratifying improvement goes deeper, and is even moresignificant than this. It is, of course, only natural to expect that ourvigorous fight against the spread of the infection of the disease wouldgive us definite results. But the interesting feature of the situationis that this diminution in England and in Germany, for instance, begannot merely twenty, but thirty, forty, even fifty years ago--two decadesbefore we even knew that tuberculosis was an infectious disease with acontagion 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 thedeath-rate from tuberculosis for the twenty years preceding thediscovery of Koch's bacillus was almost as great as it has been in thetwenty years since. In other words, the general tendency, born ofcivilization, toward sanitary reform, better housing, better drainage, higher wages and consequently more abundant food, rigid inspection offood materials, factory laws, etc. , is of itself fighting against anddiminishing the prevalence of the "great white plague" by improving theresisting 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 agiven disease within the past forty or fifty years, probably representnot merely a real decrease of the amount indicated by the figures but aneven greater one in fact; because each succeeding decade, as ourknowledge of disease and the perfection of our statistical machineryimproves and increases, is sure to show a prompter recognition and amore thorough and complete reporting of all cases of the diseaseoccurring. Statistics, for instance, showing a moderate apparent rate of_increase_ of a disease within the last thirty years are looked upon bystatisticians as really indicating that it is at a standstill. It isalmost certain that at least from ten to twenty per cent more of thecases actually occurring will be recognized during life and reportedafter death than was possible with our more limited knowledge and lesseffective methods of registration thirty years ago. So we need nothesitate to encourage ourselves to renewed effort by the reflection thatwe are enlisted in a winning campaign, one in which the battle-line isalready making steady and even rapid progress, and which can have onlyone termination so long as we retain our courage and our common-sense. 

This decline of the tuberculosis death-rate is, of course, only a partof the general improvement of physique which is taking place undercivilization. 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 onabout us! There is nothing mysterious about it. The soundest of physicalgrounds for improving health can be seen on every hand. We point withhorror, and rightly, to the slum tenement house, but forget that it is amore sanitary human habitation than even the houses of the nobility inthe Elizabethan age. We become almost hysterical over the prospect thatthe very fibre of the race is to be rotted by the adulteration of ourfood-supply, by oleomargarine in the butter, by boric acid in our cannedmeats, by glucose in our sugar, and aniline dyes in our candies, butforget that all these things represent extravagant luxuries unheard ofupon the tables of any but the nobility until within the past twohundred, and in some cases, one hundred, years. Up to three hundredyears ago even the most highly civilized countries of Europe weresubject to periodic attacks of famine; our armies and navies were sweptand decimated with scurvy, from bad and rotten food-supplies; almostevery winter saw epidemics breaking out from the use of half-putridsalted and cured foods; only forty years ago, a careful investigation ofone of our most conservative sociologists led him to the conclusionthat in Great Britain _thirty per cent of the population never in alltheir lives had quite as much as they could eat_, and for five monthsout of the year were never comfortably warm. The invention of steam, with its swift and cheap transportation of food-supplies, putting everypart of the earth under tribute for our tables, meat every day insteadof once a week for the workingman, and the introduction of sugar incheap and abundant form, with the development of the dietary in fruitsand cereals which this has made possible, have done more to improve theresisting power and build up the physique of the mass of the populationin our civilized communities, than ten centuries of congestion andnerve-worry could do to break it down. 

We shake our heads, and prate fatuously that "there were giants in thosedays, " ignorant of the thoroughly attested fact, that the averagestature of the European races has increased some four inches since thedays of the Crusaders, as shown by the fact that the common Britishsoldier of to-day--Mr. Kipling's renowned "Tommy Atkins, " who is lookedupon by the classes above him in the social scale as a short, undersizedsort of person--can neither fit his chest and shoulders into theirarmor, get his hands comfortably on the hilts of their famous two-handedswords, nor even lie down in their coffins. 

We are at last coming to acknowledge with our lips, although we scarcelydare yet to believe it in our heart of hearts, that not merely thedeath-rate from tuberculosis, but the general death-rate from all causesin civilized communities, is steadily and constantly declining; thatthe average longevity has increased nearly ten years within the memoryof most of us, chiefly by the enormous reduction in the mortality frominfant diseases; and that, though the number of individuals in thecommunity who attain a great or notable age is possibly not increasing, the percentage of those who live out their full, active life, play theirman'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 onthe work of the race, is far greater than ever before. Even in ourmuch-denounced industrial conditions, made possible by the discovery ofsteam with its machinery and transportation, the gain has far exceededthe loss. While machinery has made the laborer's task more monotonousand more confining, the net result has been that it has shortened hishours and increased his efficiency. 

Even more important, it has increased his intelligence by demanding andfurnishing a premium for higher degrees of it. Naturally, one of thefirst uses which he has made of his increased intelligence has been todemand 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 moreintelligent among employees, to recognize the commercial value ofhealth, and of sanitary surroundings, comfort, and healthy recreations, as a means of promoting this. The combined results of these forces areseen in the incontestable, living fact that the death-rate fromtuberculosis among intelligent artisans and in well-regulated factorysuburbs is already below that of many classes of outdoor and even farmlaborers, whose day is from twelve to fourteen hours, and whose childrenare worked, and often overworked, from the time that they can fairlywalk alone, with as disastrous and stunting results as can be found inany mine or factory. Child-labor is one of the oldest of our racialevils, instead of, as we often imagine, the newest. 

All over the civilized world to-day the average general death-rate ofeach city, slums included, is now below that of many rural districts inthe same country. If I were to be asked to name the one factor which haddone more than any other to check the spread and diminish the death-ratefrom tuberculosis I should unhesitatingly say, the _marked increase ofwages among the great producing masses of the country_, with theconsequent increased abundance of food, better houses, better sanitarysurroundings, and last, but not least, shorter hours of labor. 

_Underfeeding and overwork are responsible for more deaths fromtuberculosis than any other ten factors. _ Rest and abundant feeding arethe only known means for its cure. 

This is one of the reasons why the medical profession has abandoned allthought of endeavoring to fight the disease single-handed, and isstriving and straining every nerve to enlist the whole community in thefight. Its burden rests, not upon the unfortunate individual who hasbecome tuberculous, but _upon the community_ which, by its ignorance, its selfishness, and its greed, has done much to make him so. Whatcivilization has _caused_ it is under the most solemn obligation to_cure_. 

 * * * * *

One more brigade of irregular troops on the extreme left remains to bebriefly reviewed, and that is those forces resulting from the successiveexposure of generations to the physical influences of civilization, including the infectious diseases. For years we never dreamed of evenattempting to raise any levies among these border tribes of more thandoubtful loyalty. Indeed, they were supposed to be our open enemies. 

When we first attempted to take a world-view of tuberculosis, the firstgreat fact that stood out plainly was that it was emphatically a diseaseof the walled town and the city; that the savage and the nomad barbarianwere practically free from it; that range cattle and barnyard fowlsseldom fell victims to it, while their housed and confined cousins inthe dairy barn and the breeding-pens suffered frightfully. It was one ofour commonplace sayings that we must "get back to nature, " get away fromthe walled city into the open country, revert from the conditions ofcivilization in a considerable degree to those of barbarism, in order toescape. While, as for heredity, its influence was almost dead againstus. How could a race be exposed to a disease like tuberculosis, generation after generation, without having its vital resistanceimpaired?

But a marked and cheering change has come over our attitude to this wingof the battle of life. So far from regarding it as in any sensenecessary to revert to barbarism, still less to savagery, for eitherthe prevention or the cure of disease, we have discovered by the mostconvincing, practical experience, that we can, in the first place, withthe assistance of the locomotive and trolley, combined with modernbuilding skill and sanitary knowledge, put even our city-dwellers underconditions, in both home and workshop, which will render them far lesslikely to contract tuberculosis than if they were in a peasant's cottageor _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 livingin brush-shelters on what we can catch or shoot, it takes _all theresources of civilization_ to place our open-air patients in the idealconditions for their recovery. Let any consumptive be reckless enough to"go back to nature, " unencircled by the strong arm of civilizedintelligence and power, and unprotected by her sanitary shield, andnature will kill him three times out of five. There could not be a moredangerous delusion than the all-too-common one--that all that isnecessary for the cure of consumption is to turn the victim loose amongthe elements, even in the mildest and most favorable of climates. 

He must be fed upon the most abundant and nutritious of foods, even thesimplest being milk of a richness which is given by no kind of wildcattle, and which, indeed, only the most carefully bred and highlycivilized strains of domestic cattle are capable of producing; eggs suchas are laid by no wild bird or by any but the most highly specializedof domestic poultry at the season of the year when they are mostrequired; steaks and chops, hams and sides of bacon, sugar and fruitsand nuts, which simply _are not produced anywhere outside ofcivilization_, and often only in the most intelligent and progressivesections of civilized communities. 

Put him upon even the average diet of many people in this progressiveand highly civilized United States the year round, --with its thin milk, its pulpy, half-sour butter, its tough meat, its half-rancid pickledpork, its short three months of really fresh vegetables and good fruit, and six months of eternal cabbage, potatoes, dried apples, andprunes, --and he will fail to build up the vigor necessary to fight thedisease, even in the purest and best of air. 

The saddest and most pitiful tragedies which the consumptivehealth-resort physician can relate are those of wretchedsufferers, --even in a comparatively early stage of the disease, --whosemisguided but well-meaning friends have raised money enough to pay theirfare out to Colorado, California, Arizona, or New Mexico, and expectthem to get work on a ranch, so as to earn their living and take theopen-air treatment at the same time. 

Three things are absolutely necessary for a reasonable prospect of cureof 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 belacking, and your patient will die just as certainly as if all threewere. _Not one in five_ of those who go out to climates with even a highreputation as health-resorts--expecting to earn their own living or to"rough it" in shacks or tents on three or four dollars a week, doingtheir own cooking and taking care of themselves--recovers. They have afour-to-one chance of recovery in _any_ climate in which they can obtainthese three simple requisites, and a four-to-one chance of dying in anyclimate in which any one of these is lacking. 

Instead of nature being able to cure the consumptive unaided, as amatter of fact she has neither the ability nor the inclination to doanything of the sort. There is no class of patients whose recoverydepends more absolutely upon a most careful and intelligent study andregulation of their diet, of every detail of their life throughout theentire twenty-four hours, and of the most careful adjustment of air, food, heat, cold, clothing, exercise, recreation, by the combined forcesof sanitarian, nurse, and physician. So that, instead of feeling thatonly by reverting to savagery can consumption be prevented, we have nohesitation in saying that it is _only under civilization, andcivilization of the highest type, that we have any reasonable prospectof cure_. 

Finally, we are getting over our misgivings as to the intentions of thehereditary brigade. It is certainly not our enemy, and may probably turnout 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 ofsavage life were such as to discourage, if not prevent, tuberculosis, certainly, then, the race which had been exposed to these conditions forcountless generations would have a high degree of resisting power to thedisease. But what an awakening was in store for us! No sooner did thearmy surgeon and medical missionary settle down in the wake of thatextraordinary world-movement of Teutonic unrest, which has resulted inthe colonization of half the globe within the past two or three hundredyears, than it was discovered that, although the hunting or nomad savagehad not developed tuberculosis, and the disease was emphatically born ofcivilization, yet the moment that these healthy and vigorous children ofnature were exposed to its infection, instead of showing the high degreeof resisting power that might be expected, they died before it likesheep. 

From all over the world--from the Indians of our Western plains, thenegroes of our Southern States, the islanders of Polynesia, New Zealand, Hawaii, Samoa--came reports of tribes practically wiped out of existenceby the "White Plague" of civilization. To-day the death-rate fromtuberculosis among our Indian wards is from _three to six times_ that ofthe surrounding white populations. The negro population of the SouthernStates has nearly three times the death-rate of the white populations ofthe same states. Instead of centuries of civilization having made usmore susceptible to the disease than those savages who probably mostnearly parallel our ancestral conditions of a thousand to fifteenhundred years ago, we seem to have acquired from three to five timestheir resisting power against it. Not only this, but those races amongus which have been continuous city-dwellers for a score of generationspast have acquired a still higher degree of immunity. 

In every civilized land the percentage of deaths from tuberculosis amongthe Jews, who, from racial and religious prejudices, have been prisonersof the Ghetto for centuries, is about half to one-third that of theirGentile neighbors. In certain blocks of the congested districts of NewYork and Chicago, for instance, the Jewish population shows a death-rateof only one hundred and sixty-three per hundred thousand living, whilethe Gentile inhabitants of similar blocks show the appalling rate offive hundred and sixty-five. Similarly, by a strange apparent paradox, the highest mortality from tuberculosis in the United States is not inthose 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 ofTennessee, Kentucky, West Virginia, Virginia, and South Carolina, whileNew York, Pennsylvania, and Massachusetts are among the lowest. 

The subject is far too wide and complicated to admit of any detaileddiscussion here. But, explain it as we may, the consoling fact remainsthat civilized races, including slum-dwellers, have a distinctly lowerdeath-rate from tuberculosis than have savage tribes which are exposedto it even under most favorable climatic and hygienic conditions; thatthose races which have survived longest in city and even slumsurroundings have a lower death-rate than the rest of the communityunder those conditions; and that certain of our urban populations havelower death-rates than many of our rural ones. 

As for the immediate effect of heredity in the production of thedisease, the general consensus of opinion among thoughtful physiciansand sanitarians now is that direct infection is at least five times asfrequent a factor as is heredity; that at least eight-tenths of thecases occurring in the children of tuberculous parents are probably dueto the direct communication of the disease, and that if the spread ofthe infection could be prevented, the element of heredity could bepractically disregarded. 

We are inclined to regard even the well-marked tendency of tuberculosisto attack a considerable number of the members of a given family to bedue largely, in the first place, to direct infection; secondly, to thefact that that family were all submitted to the same unfavorableenvironment in the matter of food, of housing, of overwork, or of theNew England conscience, with its deadly belief that "Satan finds somemischief still for idle hands to do. "

Upon direct pathological grounds nothing is more definitely proven thanthat the actual inheritance of tuberculosis, in the sense of itstransmission from a consumptive mother to the unborn child, is one ofthe rarest of occurrences. On the other hand, the feeling is generalthat, inasmuch as probably four-fifths of us are repeatedly exposed tothe infection of tuberculosis and throw it off without developing asystemic attack of the disease, the development of a generalizedinfection, such as we term consumption, is in itself a sign of aresisting power below the average. Should such an individual as thisbecome a parent, the strong probability is that his children--unless, asfortunately often happens, their other parent should be as far above theaverage of vigor and resisting power--would not be likely to inheritmore vigor than that possessed by their ancestry. So that upon _apriori_ grounds we should expect to find that the children born oftuberculous parents would be more susceptible to the infection to whichthey are so sure to be exposed than the average of the race. So that themarriage of consumptives should, unquestionably, upon racial grounds, bediscouraged except after they have made a complete recovery and remainedwell at least five years. 

To sum up: while the earlier steps of civilization unquestionablyprovide that environment which is necessary for the development oftuberculosis, the later stages, with their greatly increased power overthe forces of nature, their higher intelligence and their broaderhumanity, not merely have it in their power to destroy it, but arealready well on the way to do so. 

CHAPTER VIII

THE GREAT SCOURGE

Not only have most diseases a living cause, and a consequent naturalhistory and course, but they have a special method of attack, whichlooks almost like a preference. It seems little wonder that theterror-stricken imagination of our Stone Age ancestors should havepersonified them as demons, "attacking" or leaping upon their victimsand "seizing" them with malevolent delight. The concrete comparison wasready to their hand in the attack of fierce beasts of prey; and as thetiger 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 theflank or the hamstring, so these different disease demons appear each tohave its favorite point of attack: smallpox, the skin; cholera, thebowels; the Black Death, the armpits and the groin; and pneumonia, thelung. 

There are probably few diseases which are so clearly recognized by everyone and about which popular impressions are in the main so clear-cut andso correct as pneumonia. The stabbing pain in the chest, the cough, therusty or blood-stained expectoration, the rapid breathing, all stamp itunmistakably as a disease of the lung. Its furious onset with ateeth-chattering chill, followed by a high fever and flushed face, andits rapid course toward recovery or death, mark it off sharply from allother lung infections. 

Its popular names of "lung fever, " "lung plague, " "congestion of thelungs, " are as graphic and distinctive as anything that medical sciencehas 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 apreference for the lung as a point of attack. In the language of _OldMan Means_ in "The Hoosier Schoolmaster, " the lung is "their fav'ritholt. " 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 thedeaths that occur in a community, young or old. No other great organ orsystem 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 airor 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 shapeof food which are loaded into our stomachs. Even from the point of viewof infections, food is at least as likely to be contaminated withdisease-germs as air is. Yet there is no disease or combination ofdiseases of the whole food canal which has half the mortality ofconsumption alone, in civilized communities, while in the Orient thepneumonic form of the plague is a greater scourge than cholera. 

It has even been suggested that there may possibly be a historic orancestral reason for this weakness to attack, and one dating clear backto the days of the mud-fish. It is pointed out that the lung is the lastof our great organs to develop, inasmuch as over half of our family treeis under water. When our mud-loving ancestor, the lung-fish (who wasprobably "one of three brothers" who came over in the Mayflower--therecords have not been kept) began to crawl out on the tide-flats, he hadevery organ that he needed for land-life in excellent working conditionand 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 oldswim-bladder. This, of course, was several years ago. But the lung hasnot quite caught up yet. The two or three million year lead of the otherorgans was too much to be overcome all at once. So carelessly andhastily was this impromptu lung rigged up that it was allowed to openfrom the front of the gullet or [oe]sophagus, instead of the back, whilethe upper part of the mouth was cut off for its intake tube, as we havealready seen in considering adenoids, thus making every mouthfulswallowed cut right across the air-passages, which had to be providedwith a special valve-trap (the epiglottis) to prevent food from fallinginto the lungs. 

So, whenever you choke at table, you have a right to call down abenediction upon the soul of your long departed ancestor, the lung-fish. However applicable or remote we may regard "the bearin's of thisobservation, " the practical and most undesirable fact confronts usto-day that this crossing and mutual interference of the air and thefood-passages is a fertile cause of pneumonia, inasmuch as the germs ofthis disease have their habitat in the mouth, and are from thatlurking-place probably inhaled into the lung, as is also the case withthe germs of several milder bronchitic and catarrhal affections. 

It may be also pointed out that, history apart, our lung-cells at thepresent day are at another disadvantage as compared with all the othercells of the body, except those of the skin; and that is, that they arein constant contact with air, instead of being submerged in water. Ninety-five per cent of our body-cells are still aquatic in theirhabits, and marine at that, and can live only saturated with, and bathedin, warm saline solution. Dry them, or even half-dry them, and they die. Even the pavement-cells coating our skin surfaces are practically deadbefore they reach the air, and are shed off daily in showers. 

We speak of ourselves as "land animals, " but it is only our lungs thatare really so. All the rest of the body is still made up of seacreatures. It is little wonder that our lungs should pay the heaviestpenalty of our change from the warm and equable sea water to the gustyand changeable air. 

Even if we have set down the lung as a point of the least resistance inthe body, we have by no means thereby explained its diseases. Our pointof view has distinctly shifted in this respect within recent years. Twenty years ago pathologists were practically content with tracing acase of illness or death to an inflammation or disease of someparticular organ, like the heart, the kidney, the lung, or the stomach. Now, however, we are coming to see that not only may the causation ofthis heart disease, kidney disease, lung disease, have lain somewhereentirely outside of the heart, kidney, or lung, but that, as a rule, theentire body is affected by the disease, which simply expresses itselfmore violently, focuses, as it were, in this particular organ. In otherwords, diseases of definite organs are most commonly the localexpressions of general diseases or infections; and this localaggravation of the disease would never have occurred if the generalresisting power and vigor of the entire body had not been depressedbelow par. So that even in guarding against or curing a disease of aparticular organ it is necessary to consider and to treat the wholebody. 

Nowhere is this new attitude better illustrated than in pneumonia. Frankand unquestioned infection as it is, wreaking two-thirds of its visibledamage in the lung itself, the liability to its occurrence and theoutlook for its cure depend almost wholly upon the general vigor andrallying power of the entire body. It is perfectly idle to endeavor toavoid it by measures directed toward the protection of the lung or ofthe air-passages, and equally futile to attempt to arrest its course bytreatment directed to the lung, or even the chest. The best place towear a chest-protector is on the soles of the feet, and poulticing thechest for pneumonia is about as effective as shampooing the scalp forbrain-fag. 

This clears the ground of a good many ancient misconceptions; forinstance, that the chief cause of pneumonia is direct exposure to coldor a wetting, or the inhalation of raw, cold air. Few beliefs were morefirmly fixed in the popular mind--and, for the matter of that, in themedical--up to fifteen or twenty years ago. It has found its way intoliterature; and the hero of the shipwreck in an icy gale or of weeks ofwandering in the Frozen North, who must be offered up for artisticreasons as a sacrifice to the plot, invariably dies a victim ofpneumonia, from his "frightful exposure, " just as the victim ofdisappointed love dies of "a broken heart, " or the man who sees theambitions of years come crashing about his ears, or the woman who haslost all that makes life worth living, invariably develops "brainfever. "

There is a physical basis for all of these standard catastrophes, but itis much slenderer than is usually supposed. For instance, almost everyone can tell you how friends of theirs have "brought on congestion ofthe lungs, " or pneumonia, by going without an overcoat on a winter day, or breaking through the ice when skating, or even by getting their feetwet and not changing their stockings; and this single dramatic instancehas firmly convinced them that the chief cause of "lung fever" is achill or a wetting. Yet when we come to tabulate long series of causes, rising into thousands, we find that the percentage in which even thepatients themselves attribute the disease to exposure, or a chill, sinksto a surprisingly small amount. For instance, in the largest seriescollected with this point in mind, that of Musser and Norris, out offorty-two hundred cases only seventeen per cent gave a history ofexposure and "catching cold"; and the smaller series range from ten tofifteen per cent. So that, even in the face of the returns, not morethan one-fifth of all cases of pneumonia can reasonably be attributed tochill. And when we further remember that under this heading of exposureand "catching cold" are included many mere coincidences and the chillysensations attending the beginning of those milder infections which weterm "common colds, " it is probable that even this small percentagecould be reduced one-half. Indeed, most cautious investigators of thequestion have expressed themselves to this effect. This harmonizes witha number of obstinate facts which have long proved stumbling-blocks inthe way of the theory of exposure as a cause of pneumonia. One of theclassic ones was that, during Napoleon's frightful retreat from Moscowin the dead of winter, while his wretched soldiers died by thousands offrost-bite and starvation, exceedingly little pneumonia developed amongthem. Another was that, as we have already seen with colds, instead ofbeing commoner and more frequent in the extreme Northern climate and onthe borders of the Arctic Zone, pneumonia is almost unknown there. Ofcourse, given the presence of the germ, prolonged exposure to cold maydepress 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 whichthis feature of exposure to the weather plays the most insignificantpart. Last and most conclusive of all, since definite statistics havebegun to be kept upon a large scale, pneumonia has been found to beemphatically a disease of cities, instead of country districts. Evenunder the favorable conditions existing in the United States, forinstance, the death-rate per hundred thousand living, according to thelast census, was in the cities two hundred and thirty-three, and for thecountry districts one hundred and thirty-five, --in other words, nearlyseventy per cent greater in city populations. 

How, then, did the impression become so widely spread and so firmlyrooted that pneumonia is chiefly due to exposure? Two things, I think, will explain most of this. One is, that the disease is most common inthe winter-time, the other, that like all febrile diseases it mostfrequently begins with sensations of chilliness, varying all the wayfrom a light shiver to a violent chill, or _rigor_. The savage, bone-freezing, teeth-rattling chill which ushers in an attack ofpneumonia 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 andundisputed fact, and it has been for centuries set down in medical worksas one of the diseases chiefly due to changes in temperature, humidity, and directions of the wind. Years of research have been expended inorder to trace the relations between the different factors in theweather and the occurrence of pneumonia, and volumes, yes, wholelibraries, published, pointing out how each one of these factors, thetemperature, humidity, direction of wind, barometric pressure, andelectric tension, is in succession the principal cause of the spread ofthis plague. Many interesting coincidences were shown. But one thingalways puzzled us, and that was, that the heaviest mortality usuallyoccurred, not just at the beginning of winter, when the shock of thecold 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 forpneumonia begins to rise in December, increases in January, goes higherstill in February, reaching its climax in that month or in March. Aprilis 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 drawingconclusions when you are not in possession of all the facts. One thingwas entirely overlooked in all this speculation until about twenty yearsago, --that pneumonia was due not simply to the depressing effects ofcold, but to a specific germ, the pneumococcus of Fraenkel. This threwan entirely new light upon our elaborate weather-causation theories. Andwhile these still hold the field by weight of authority and that mentalinertia which we term conservatism, yet the more thoughtful physiciansand pathologists are now coming to regard these factors as chieflyimportant according to the extent to which we are crowded together inoften badly lighted and ill-ventilated houses and rooms, with thewindows and doors shut to save fuel, thus affording a magnificenthothouse hatching-ground for such germs as may be present, and idealfacilities for their communication from one victim to another. At thesame time, by this crowding and the cutting off of life and exercise inthe open air which accompanies it, the resisting power of our bodies islowered. And when these two processes have had an opportunity ofprogressing side by side for from two to three months; when, in otherwords, the soil has been carefully prepared, the seed sown, and themoist heat applied as in a forcing-house, then we suddenly reap theharvest. In other words, the heavy crop of pneumonia in January, February, and March is the logical result of the seed-sowing and forcingof the preceding two or three months. 

The warmth of summer is even more depressing in its immediate effectsthan the cold of winter, but the heat carries with it one blessing, inthat it drives us, willy-nilly, into the open air, day and night. And onlooking at statistics we find precisely what might have been expected onthis theory, that the death-rate for pneumonia is lowest in July andAugust. 

It might be said in passing that, in spite of our vivid dread ofsunstroke, of cholera, and of pestilence in hot weather, the hot monthsof the year in temperate climates are invariably the months of fewestdiseases and fewest deaths. Our extraordinary dread of the summer heathas but slender rational physical basis. It may be but a subconsciousafter-vibration in our brain cells from the simoons, the choleras, andthe 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 ourdeadliest enemy. 

If this view be well founded, then the advance of modern civilizationwould tend to furnish a more and more favorable soil for the spread ofthis disease. This, unfortunately, is about the conclusion to which weare being most unwillingly driven. Almost every other known infectiousdisease is diminishing, both in frequency and in fatality, undercivilization. Pneumonia alone defies our onslaughts. In fact, ifstatistics are to be taken at their surface-value, we are facing theappalling situation of an apparently marked increase both in itsprevalence and in its mortality. For a number of years past, ever since, in fact, accurate statistics began to be kept, pneumonia has been listedas the second heaviest cause of death, its only superior beingtuberculosis. 

About ten years ago it began to be noticed that the second competitor inthe race of death was overtaking its leader, and this ghastly rivalrycontinued until about three years ago pneumonia forged ahead. In somegreat American cities it now occupies the bad eminence of the most fatalsingle disease on the death-lists. 

The situation is, however, far from being as serious and alarming as itmight appear, simply from this bald statement of statistics. First ofall, because the forging ahead of pneumonia has been due in greaterdegree to the falling behind of tuberculosis than to any actual advanceon its part. The death-rate of tuberculosis within the last thirty yearshas diminished between thirty and forty per cent; and pneumonia at itsworst has never yet equaled the old fatality of tuberculosis. Furthermore, all who have carefully studied the subject are convincedthat much of this apparent increase is due to more accurate and carefuldiagnosis. Up to ten years or so ago it was generally believed thatpneumonia was rare in young children. Now, however, that we make thediagnosis with a microscope, we discover that a large percentage of thecases of capillary bronchitis, broncho-pneumonia, and acute congestionof 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 tobronchitis, asthma, heart failure, yes, even to old age, have now beenshown on bacteriological examination to be due to this ubiquitous imp ofmalevolence; so that, on the whole, all that we are probably justifiedin saying is that pneumonia is not decreasing under civilization. Thisis not to be wondered at, inasmuch as the inevitable crowding andcongestion which accompanies civilization, especially in its derivativesense of "citification, " tends to foster it in every way, both bymultiplying the opportunities for infection and lowering the resistingpower of the crowded masses. 

Moreover, it was only in the last ten years, yes, within the last fiveyears, that we fairly grasped the real method and nature of the spreadof the disease, and recognized the means that must be adopted againstit. And as all of these factors are matters which are not onlyabsolutely within our own control, but are included in that programme ofgeneral betterment of human comfort and vigor to which the truestintelligence and philanthropy of the nation are now being directed, theoutlook for the future, instead of being gloomy, is distinctlyencouraging. 

Our chief difficulty in discovering the cause of pneumonia lay in theswarm of applicants for the honor. Almost every self-respectingbacteriologist seemed to think it his duty to discover at least one, andthe abundance and variety of germs constantly or accidentally present inthe human saliva made it so difficult positively to isolate the realcriminal that, although it was identified and described as long ago as1884 by Fraenkel, the validity of its claim was not generally recognizedand established until nearly ten years later. 

It is a tiny, inoffensive-looking little organism, of an oval orlance-head shape, which, after masquerading under as many aliases as aconfidence man, has finally come to be called the pneumococcus, forshort, or "lung germ. " Though by those who are more precise it is stillknown as the _Diplococcus pneumoniæ_ or _Diplococcus lanceolatus_, fromits faculty of usually appearing in pairs, and from its lance-likeshape. Its conduct abounds in "ways that are dark and tricks that arevain, " whose elucidation throws a flood of light upon a number ofinteresting problems in the spread of disease. 

First of all, it literally fulfills the prognostic of Scripture, that "aman's foes shall be they of his own household, " for its chosen abidingplace and normal habitat is no less intimate a place than the humanmouth. Outside of this warm and sheltering fold it perishes quickly, ascold, sunlight, and dryness are alike fatal to it. 

We could hardly believe the evidence of our senses when studies of thesaliva of perfectly healthy individuals showed this deadly littlebacillus to be present in considerable numbers in from fifteen toforty-five per cent of the cases examined. Why, then, does not every onedevelop pneumonia? The answer to this strikes the keynote of our modernknowledge of infectious disease, namely, that while an invading germ isnecessary, a certain breaking down of the body defenses and a loweringof the vital resistance are equally necessary. These invaders lie inwait at the very gates of the citadel, below the muzzles of our guns, asit were, waiting for some slackening of discipline or of watchfulness torush in and put the fortress to sack. Nowhere is this more strikinglytrue than in pneumonia. It is emphatically a disease where, in thelanguage of the brilliant pathologist-philosopher Moxon, "While it ismost important to know what kind of a disease the patient has got, it iseven more important to know what kind of a patient the disease has got. "

The death-rate in pneumonia is an almost mathematically accuratededuction from the age, vigor, and nutrition of the patient attacked. Noother disease has such a brutal and inveterate habit of killing theweaklings. The half-stifled baby in the tenement, the underfed, overworked laboring man, the old man with rigid arteries and stiffeningmuscles or waning life vigor, the chronic sufferer from malnutrition, alcoholism, Bright's disease, heart disease--_these_ are its chosenvictims. 

Another interesting feature about the pneumococcus is its vitalityoutside of the body. If the saliva in which it is contained be keptmoist, 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, itwill survive four hours. If exposed to sunlight, or even diffusedaylight, it dies within an hour. In other words, under the conditionsof dampness and darkness which often prevail in crowded tenements it mayremain alive and malignant for weeks; in decently lighted and ventilatedrooms, less than two hours. This explains why, in private practice andunder civilized conditions, epidemics of this admittedly infectiousdisease 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 laterinvestigations of the sputum of slum-dwellers, carried out by cityboards of health, that the percentage of individuals harboring thepneumococcus steadily increases all through the winter months, from tenper cent in December to forty-five, fifty, and even sixty per cent inFebruary and March. The old proverb, "When want comes in at the door, Love flies out at the window, " might be revised to read, "When sunlightcomes in at the window the pneumococcus flies 'up the flue. '"

Authorities are still divided as to the meaning and even the precisefrequency of the occurrence of the pneumococcus in the healthy humanmouth. Some hold that its presence is due to recent infection which haseither been unable to gain entrance to the system or is preparing itsattack; others, that it is a survival from some previous mild attack ofthe disease, and the body tissues having acquired immunity against it, it remains in them as a harmless parasite, as is now well known to bethe case with the germs of several of our infectious diseases--forinstance, typhoid--for months and even years afterward. Others hold thehighly suggestive view that it is a normal inhabitant of the healthymouth, which can become injurious to the body, or _pathogenic_, onlyunder certain depressed or disturbed conditions of the latter. Indefense of this last it may be pointed out that dental bacteriologistshave now already isolated and described some thirty different forms oforganisms which inhabit the mouth and teeth; and the pneumococcus maywell be one of these. Further, that a number of our most dangerousdisease 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 normallyinhabit our throats, our intestines, or our immediate surroundings. Theultimate foundation question of the science of bacteriology is, How didthe disease germs become disease germs? But the question is stillunanswered. 

However, fortunately, here, as in other human affairs, imperfect as ourknowledge is, it is sufficient to serve as a guide for practicalconduct. Widely present as the pneumococcus is, we know well that it ispowerless for harm except in unhealthful surroundings. There is anotherinteresting feature of its life history which is of practicalimportance, and that is, like many other bacilli it is increased invirulence and infectiousness by passing through the body of a patient. Flushed with victory over a weakened subject, it acquires courage toattack a stronger. This is the reason why, in those comparativelyinfrequent instances in which pneumonia runs through a family, it is thestrongest and most vigorous members of the family who are the last to beattacked. It also explains one of the paradoxes of this disease, that, while emphatically a disease of overcrowding and foul air, and attackingchiefly weakened individuals, it is a veritable scourge of camps, whether mining or military. When once three or four cases of pneumoniahave occurred in a mining camp, even though this consist almostexclusively of vigorous men, most of them in the prime of life, itacquires a virulence like that of a pestilence, so that, whileordinarily not more than fifteen to twenty per cent of those attackeddie, death-rates of forty, fifty, and even seventy per cent are by nomeans uncommon in mining camps. The fury and swiftness of this "miners'pneumonia" is equally incredible. Strong, vigorous men are taken with achill while working in their sluicing ditches, are delirious beforenight, and die within forty-eight hours. So widely known are thesefacts, and so dreaded is the disease throughout the Far West and inmountain regions generally, that there is a widespread belief thatpneumonia at high altitudes is particularly deadly. 

I had occasion to interest myself in this question some years ago, andby writing to colleagues practicing at high elevations and collectingreports from the literature, especially of the surgeons of army posts inmountain regions, was somewhat surprised to find that the mortality ofall cases occurring above five thousand feet elevation was almostidentical with that of a similar class of the population at sea-level. It is only when a sufficient number of cases occur in succession toraise the virulence of the pneumococcus in this curious manner that anepidemic with high fatality develops. 

That this increase in virulence in the organism does occur was clearlydemonstrated by a bacteriologist friend of mine, who succeeded insecuring some of the sputum from a fatal case in the famous Tonopahepidemic of some years ago, an epidemic so fatal that it was locallyknown as the "Black Death. " Upon injecting cultures from this sputuminto guinea-pigs, the latter died in one-quarter of the time that itusually took them to succumb to a similar dose of an ordinary culture ofthe pneumococcus. 

It is therefore evident that just as "no chain is stronger than itsweakest link, " so in the broad sense no community is stronger than itsweakest group of individuals, and pneumonia, like other epidemics, maybe well described as the vengeance which the "submerged tenth" may wreakfrom time to time upon their more fortunate brethren. 

Now that we know that under decent and civilized conditions of light andventilation the pneumococcus will live but an hour to an hour and ahalf, this reduces the risk of direct infection under these conditionsto a minimum. It is obvious that the principal factors in the control ofthe disease are those which tend to build up the vigor and resistingpower of all possible victims. The more broadly we study the disease themore clearly do the data point in this direction. 

First of all, is the vivid and striking contrast between hospitalstatistics and those gathered from private practice. While manyindividuals of a fair wage-earner's income and good bodily vigor aretreated in our hospitals, yet the vast majority of hospital patients aretechnically known as the "hospital classes, " apt to be both underfed, overworked, and overcrowded. On the other hand, while a great many bothof the very poor and even of the destitute are treated in privatepractice, yet the majority of such cases who feel "able to afford adoctor, " as they say, are among the comparatively vigorous, well-fed, and well-housed section of the community. And the difference between thedeath-rate of the two classes in pneumonia is most significant. Inprivate practice, while epidemics differ in virulence, the rate rangesall the way from five per cent to fifteen per cent, the average beingnot much in excess of ten per cent, occasionally falling as low as threeper cent. In the hospital reports on the contrary the death-rate beginsat twenty per cent and climbs to thirty, forty, and forty-five per cent. It is only fair to say, of course, that hospital statistics probablyinclude a larger percentage of more serious cases, the milder ones beingtaken care of at home, or not presenting themselves for treatment atall. But even when this allowance has been made, the contrast isconvincing. 

A similar influence is exercised by age. Although pneumonia is common atall ages, its heaviest death-rate falls at the two extremes, under sixyears of age and over sixty, with a strong preponderance in the latter. Under five years of age, the mortality may reach twenty to thirty percent; 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 soon, increasing gradually with every decade until by sixty years of agethe mortality has reached fifty per cent, and from sixty to seventy-fivemay be expressed in terms of the age of the patient. One consolingfeature, however, about it is that its mortality is lowest in the agesat which it is most frequent, namely, from ten to thirty-five years ofage. And its frequency diminishes even more rapidly than its fatalityincreases in later years. So that while it is much more serious in amiddle-aged man, he is less liable to develop it than a younger one. Where the mortality from pneumonia is highest, is in the most denselypopulated wards, especially among negroes and foreigners of the hospitalclass, in individuals who are victims of chronic alcoholism, and alsoamong those who are for long periods insufficiently nourished. Lastly, it is only within comparatively recent years that we have come clearlyto recognize the large rôle which pneumonia plays in giving thefinishing stroke to chronic diseases and degenerative processes. It is, for instance, one of the commonest actual causes of death in Bright'sdisease, in diabetes, in lingering forms of tuberculosis, and in heartdisease; and last of all, in that progressive process of normaldegeneration and decay which we term "Old Age. " It is one of the mostfrequent and fatal of what Flexner described a decade ago as "terminalinfections. " 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 theresisting power below a certain level, some acute infection steps in andmercifully ends the scene. This is peculiarly true of pneumonia in oldage. 

To the medical profession to "die of old age" is practically equivalentto dying of pneumonia. The disease is so mild in its symptoms and sorapid in its course that it often utterly escapes recognition as such. 

The old man complains of a little pain in his chest, a failure ofappetite, a sense of weakness and dizziness. He takes to his bed, withinforty-eight hours he becomes unconscious, and within twenty-four more heis peacefully breathing his last. After death, two-thirds of the lungwill be found consolidated. So mild and rapid and painless is theprocess 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 towake the patient out of a sound sleep, followed by a stabbing pain inthe side, cough, high fever, rapid respiration, the sputum rusty ororange-colored from leakage of blood from the congested lung, withinforty-eight hours the attacked area of the lung has become congested; inforty-eight more, almost solidified by the thick, sticky exudate pouredout 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 toseven or eight days. Then, as suddenly as the initial attack, comes aplunge down of the temperature to normal. Pain and restlessnessdisappear, the respiration drops from thirty-five or forty to fifteen ortwenty per minute, and the disease has practically ended by "_crisis_. "Naturally, after such a furious onslaught, the patient is apt to begreatly weakened. He may have lost twenty or thirty pounds in the weekof the fever, and from one to three weeks more in bed may be necessaryfor him to regain his strength. But the chief risk and danger areusually over within a week or ten days at the outside. 

Violent and serious as are the changes in the lung, it is very seldomthat death comes by interference with the breathing space. In fact, while regarded as a lung disease, we are now coming to recognize thatthe actual cause of death in fatal cases is the overwhelming of theheart by the toxins or poisons poured into the circulation from theaffected lung. The mode of treatment is, therefore, to support thestrength of the patient in every way, and measures directed to theaffected lung are assuming less and less importance in our arsenal ofremedies. Our attitude is now very similar to that in typhoid, tosupport the strength of the patient by judicious and liberal feeding, toreduce the fever and tone up his blood-vessels by cool sponging, packing, and even bathing; to relieve his pain by the mildest possibledoses of sedatives, knowing that the disease is self-limited, and thatin patients in comfortable surroundings and fair nutrition from eightyto ninety per cent will throw off the attack within a week. Socompletely have we abandoned all idea of medicating or protecting thelung as such, that in place of overheated rooms, loaded with vapor bymeans of a steam kettle, for its supposed soothing effect upon theinflamed lung, we now throw the windows wide open. And some of our moreenthusiastic clinicians of wide experience are actually introducing theopen-air cure, which has worked such wonders in tuberculosis, in thetreatment of pneumonia. In more than one of our New York hospitals now, particularly those devoted to the care of children, following thebrilliant example of Dr. William Northrup, wards are established forpneumonia cases out on the roof of the hospital, even when the snow isbanked up on either side, and the covering is a canvas tent. Nurses, physicians, and ward attendants are clothed in fur coats and gloves, thepatients are kept muffled up to the ears, with only the face exposed;but instead of perishing from exposure, little, gasping, strugglingtots, whose cases were regarded as practically hopeless in the wardsbelow, often fall into the sleep that is the turning point towardrecovery within a few hours after being placed in this winterroof-garden. 

In short, our motto may be said to be, "Take care of the patient, andthe 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 obtaininggreater and greater control every day, and which certainly should, within the next decade, yield to our attack, as tuberculosis and typhoidare already beginning to do. 

CHAPTER IX

THE NATURAL HISTORY OF TYPHOID FEVER

Why should not a disease have a natural history, as well as anindividual? At first sight, this might appear like a reversion to theold, crude theory of disease as a demonic obsession, or invasion by anevil spirit, of which traces still remain in such expressions as, "Shewas _seized_ with a convulsion, " "He was strong enough to _throw off_the illness, " "He was _attacked_ by a fever, " etc. But apart entirelyfrom such conceptions, which were perfectly natural in the infancy ofthe race, while clearly recognizing that disease is simply a pervertedstate of nutrition or well-being in the body of the patient, adisturbance of balance, so to say, yet it is equally true that it has abirth, an ancestry, a life-course, and a natural termination, or death. 

This recognition of the natural causation and development of disease hasbeen one of the greatest triumphs, not merely of pathology, but ofintelligence and rationalism. It has done more to diminish that dread ofthe unknown which hangs like a black pall of terror over the mind of thesavage and the semi-civilized mind than any other one advance. Itcontributes enormously to our courage, our hopefulness, and our power ofprotection in more ways than one: first of all, by revealing to us theexternal cause of disease, usually some careless, dirty, or bad habiton the part of an individual or of the community, and thus enabling usto limit its spread and even exterminate it; secondly, by assuring usthat nearly all diseases, excepting a few of the most obstinate andserious, have not only a definite beginning, but a definite end, are, infact, if left to themselves, self-limited, either by the exhaustion andloss of virulence of their cause, or by the resisting power of the body. 

All infectious diseases, and many others, tend to run a definite courseof so many days, or so many weeks, within certain limits, and at leastninety per cent of them tend to terminate in recovery. It is a mostserious and fatal disease which has a death-rate of more than twenty percent. Typhoid, pneumonia, diphtheria, and yellow fever all fall belowthis, smallpox barely reaches it, and only the bubonic plague, cholera, and lockjaw rise habitually above it. The recognition of this fact hasenormously increased the efficiency of the medical profession in dealingwith disease, by putting us on the track of imitating the methods whichthe body itself uses for destroying, or checking the spread of, invadinggerms and leading us to trust nature and try to work with her instead ofagainst her. Our antitoxins and anti-serums, which are our brightesthope in therapeutics at present, are simply antidotes which are formedin the blood of some healthy, vigorous animal against the bacillus whosevirulence we wish to neutralize, such as that of diphtheria orsepticemia. 

Diphtheria antitoxin, for instance, the first and best known triumph ofthe new medicine, is the antidotal substance formed in the blood of ahorse in response to a succession of increasing doses of the bacilli ofdiphtheria. Similar antidotal substances are formed in the blood in allother non-fatal cases of infectious diseases, such as typhoid, pneumonia, blood-poisoning, etc. ; and the point at which they haveaccumulated in sufficient amounts to neutralize the poison of theinvading germs, forms the crisis, or "turn" of the disease. So that whenwe speak of a disease "running its course, " we mean continuing for suchlength of time as the body needs to produce anti-bodies in sufficientamounts to check it. 

The principal obstacle to the securing of antitoxins like that ofdiphtheria for all our infectious diseases is, that their germs formtheir poison so slowly that it is difficult to collect it in sufficientamounts to produce a strong concentrated antitoxin in the animal intowhich it is injected. But the overcoming of this difficulty is probablyonly a question of time. 

Obviously, if infectious disease be, as we say, "self-limited, " that isto say, if the body will defeat the invaders with its own weapons, on anaverage in nine cases out of ten, our wisest course, as physicians, isto 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 waterand fresh air, with the gratifying result that we have already reducedthe death-rate in most fevers, even such as we have no antitoxinagainst, or may not even have discovered the causal germ of, to one-halfand even three-fourths of their former fatality. The recognition of thefact that disease has a natural history, a birth, a term of naturallife and a death, has already turned a hopeless fight in the dark into avictorious campaign in broad daylight. Huxley's pessimistic saying thattyphoid was like a fight in the dark between the disease and thepatient, and the doctor like a man with a club striking into the mélée, sometimes hitting the disease and sometimes the patient, is no longertrue since the birth of bacteriology. 

Nowhere can the natural history of disease be more clearly seen or moreadvantageously studied than in the case of typhoid fever. 

The cause of typhoid is simplicity itself, merely drinking the excretaof some one else, "eating dirt, " in the popular phrase; simple, but of adeadly effectiveness, and disgracefully common. The demon may beexorcised by an incantation of one sentence: _Keep human excreta out ofthe drinking water. _ This sounds simple, but it is n't. Eternalvigilance is the price of health as well as of liberty. 

We can, however, make our pedigree of typhoid a little more precise. Itis not merely dirt of human origin which is injurious, but dirt of aparticular type, namely, discharges from a previous case of the disease. Just as in the fight against malaria we have not the enormous problem ofthe extermination of all varieties of mosquito, but only of oneparticular genus, and only the infected specimens of that, so intyphoid, the contamination of water or food which we have to guardagainst is that from previous cases. From one point of view, this leavesthe problem as wide as ever, for, obviously, the only way to insureagainst poisoning of water by typhoid discharges is to shut outabsolutely all sewage contamination. On the other hand, it is of immenseadvantage in this regard, --it enables us to fight the enemy at both endsof the line, to turn his flank as well as crush his centre. 

While we are protecting our water-supplies against sewage, we can, inthe meantime, render that sewage comparatively harmless by thoroughlydisinfecting and sterilizing all discharges from every known case of thedisease. A similar method is used in the fight against yellow fever andmalaria. Not only are the breeding places of the two mosquito criminalsbroken up, but each known case of the disease is carefully screened, _soas to prevent the insects from becoming infected_, and thus able totransmit 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 previouscase_. It is neither healthy nor exhilarating to drink a clear solutionof sewage, no matter how dilute; but, as a matter of fact, it isastonishing how long communities may drink sewage-laden water withcomparative impunity, so long as the sewage contains no typhoiddischarges. One case of typhoid fever imported into a watershed will seta 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 ourmost important knowledge is nowhere better illustrated than in the caseof typhoid. Although there had been vague descriptions of a fatal fever, slow and lingering in its character and accompanied by prolonged stuporand delirium, which was associated with camps and dirty cities andfamines, from as far back as the age of Cæsar, the first descriptionclear enough to be recognizable was that of Willis, of an epidemicduring the English civil war in 1643, both Royalist and Roundhead armiesbeing seriously crippled by it. Since that time a smouldering, slowlyspreading fever has been pretty constantly associated with armies incamps, besieged cities, filthy jails, and famines, to which accordinglyhave been given the names, familiar in historical literature, of "faminefever, " "jail fever, " and "military fever. "

So slowly, however, did accurate knowledge come, that it was actuallynot until 1837 that it was clearly and definitely recognized that thisfamine fever was, like Mrs. Malaprop's Cerberus, "two gentlemen atonce, " one form of it being typhus or "spotted fever, " which has nowbecome 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 twinsurvivor, though as to the relations between the two diseases, if any, we are quite in the dark, as the former practically disappeared beforethe days of bacteriology. The fact of its disappearance is bothsignificant and interesting, in that it was unquestionably due to theranker and viler forms of both municipal and individual filthiness andunsanitariness, which even our moderate progress in civilization hasnow abolished. There can be no question that, with a step higher in thescale of cleanliness, and further quickening of the biologic conscience, typhoid will also disappear. 

Typhus, the bubonic plague, the sweating sickness, were alike plaguesand products of times when table-scraps were thrown on the dining-roomfloor and covered daily with fresh rushes for a week at a stretch, andfertilizer accumulated in a living-room as now in a modern stable. Clothing was put on for the season, shirts were unknown, and strongperfumes took the place of a bath. Michelet's famous characterization ofthe Middle Ages in one phrase as _Un mille ans sans bain_ (a thousandyears without a bath) was painfully accurate. 

Doubtless certain habits of our own to-day will be regarded with equaldisgust by our descendants. Typhus, by the way, may possibly beremembered by the dramatic "Black Assize" of Oxford, in 1577, in whichnot merely the wretched prisoners in the jail, but the jurors, thelawyers, the judges, and every official of the court were attacked, andmany of them died. 

It was only in 1856 that the method of transmission of the disease wasclearly recognized, and in 1880 that the bacillus was discovered andidentified by the bacteriologist Eberth, whose name it bears, so that itis only within the last thirty years that real weapons have been putinto our hands with which to begin a fight of extermination against thedisease. 

What is the habitat of our organism, and is it increasing its spread?Its habitat is the entire civilized world, and it goes wherevercivilization goes. In this sense its spread is increasing, but, in everyother, 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 recognizeduntil such a short time ago that no statistics of any real value forcomparison are available; and, secondly, because even to-day, on accountof its insidious character and the astonishing variety of its forms, anddegrees of mildness and virulence, a considerable percentage of casesare yet unrecognized and unreported. 

It might be mentioned in passing that this statement applies to thealleged increase of nearly all diseases which are popularly believed tobe modern inventions, like appendicitis, insanity, and cancer. We haveno statistics more than thirty years old which are of real value forpurposes of comparison. 

However, when it comes to the number of deaths from the disease, thereis a striking and gratifying diminution for twenty years past, which isincreasing in ratio instead of diminishing. That we are really gettingcontrol of typhoid is shown by the, at first sight, singular anddecidedly unexpected fact that it is no longer a disease of cities, butof the country. The death-rate per thousand living in the cities of theUnited States is lower than in the rural districts. For instance, themortality in the State of Maryland, outside of Baltimore, is two andone-half times as great as that in the city itself. Our period ofgreatest outbreak in the large cities is now the month of September, when city dwellers have just returned from their vacations in the pureand healthful country, bringing the bacilli in their systems. 

The moral is obvious. Great cities are developing some sort of asanitary conscience. Farmers and country districts have as yet little ornone. Bad as our city water often is, and defective as our systems ofsewage, they cannot for a moment compare in deadliness with that mostunheavenly pair of twins, the shallow well and the vault privy. A moreingenious combination for the dissemination of typhoid than thisprecious couple could hardly have been devised. The innocent householdersallies forth, and at an appropriate distance from his cot he digs twoholes, one about thirty feet deep, the other about four. Into theshallower one he throws his excreta, while upon the surface of theground he flings abroad his household waste from the back stoop. Thegentle rain from heaven washes these various products down into the soiland percolates gradually into the deeper hole. When the interestingsolution has accumulated to a sufficient depth, it is drawn up by theold oaken bucket or modern pump, and drunk. Is it any wonder that inthis progressive and highly civilized country three hundred and fiftythousand cases of typhoid occur every year, with a death penalty of tenper cent? Counting half of these as workers, and the period of illnessas two months, which would be very moderate estimates, gives a loss ofproductive 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 itssinister victories in war are even more renowned than its daily triumphsin peace. Strange as it may seem, the deadliest enemies of the soldierare not bullets but bacilli, and sewage is mightier than the sword. Forinstance, in the Franco-Prussian War, typhoid alone caused sixty percent of all the deaths. In the Boer War it caused nearly six thousanddeaths as compared with seven thousand five hundred from wounds inbattle, while other diseases caused five thousand more. In the majorityof modern campaigns, from two-thirds to five-sixths of all deaths aredue to disease and not to battle. It may be that we sanitarians willachieve the ends of the peace congresses by an unexpected route, andmake war a healthful and comparatively harmless form of nationalgymnastics. Its battle-mortality rate, for the number engaged, is not sovery far above football now!

Given the bacillus, how does it get into the human system? Here theevidence is so abundant and overwhelming that we may content ourselveswith bald statements of fact. The three great routes of this pestilenceare water, milk, and flies. Of the three, the first is far the mostcommon and important. While only a rough statement is possible, probablyeighty-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 risesand sets. The only embarrassment in proving it lies in selecting fromthe swarm of instances. There is the classic case of the Swiss villageson opposite sides of the same mountain chain, the second of which drewits water-supply from a spring that came through the mountain from abrooklet running by the first village. Typhoid fever broke out in thefirst village, and twenty days later it appeared in the second village, twenty miles away on the other side of the mountain. Colored particlesthrown into the brook on one side promptly appeared in the spring uponthe other. Then there was the gruesome modern instance of Plymouth, Pennsylvania, in 1885. A single case of imported typhoid occurring onthe watershed of a reservoir was followed, thirty days later, by anepidemic of eleven hundred cases in a population of eight thousand. 

An equally vivid instance came under my own observation. A school and apenitentiary drew their water-supply from the same power-flume, carryinga superb volume of purest water from a mountain stream. Early in theautumn a single case of typhoid appeared in a small town near the headof the flume. The discharges were thrown into the swiftly running water. Two weeks later an epidemic of typhoid broke out in the school, andthree weeks later in the penitentiary. An unexpected freak, however, wasthe appearance of fifteen or twenty cases in another state institutionfarther down on the same stream, which did not draw its water-supplyfrom 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 fromthe flume had been used for sprinkling and washing purposes in theinstitution, being allowed to run through the water-pipes only at night, while the well-water was used in the daytime. This was enough tocontaminate the pipes, and a small epidemic began, which promptlystopped as soon as the cause was suspected and the flume-water no longerused. 

This last instance is peculiarly interesting, as illustrating howtyphoid infection gets into milk, the second--though at a longinterval--most frequent means of its spread. It does not come from thecow, for, fortunately, none of the domestic animals, with the possibleexception of the cat, is subject to typhoid. Nor is it possible thatcattle, drinking foul and even infected water, can transmit the bacillusin their milk. That superstition was exploded long ago. Every epidemicof typhoid spread by milk--and there are scores of them now onrecord--can be traced to the handling of the milk by persons sufferingfrom mild forms of typhoid, or engaged in waiting upon members of thefamily who are ill of the disease, or the dilution of milk with infectedwater, or even, almost incredible as it may seem, to such slightcontamination as washing the cans with infected water. 

Health officers now watch like hawks for the appearance of any case oftyphoid among or in the families of dairymen. The New York City Board ofHealth, for instance, requires the weekly filing of a certificate fromthe family physician of all dairymen that no such cases exist. And themore intelligent dairymen keep a vigilant eye upon any appearance ofillness accompanied by fever among their employees, some that I haveknown even keeping a fever thermometer in the barn for the purpose oftesting every suspicious case. How effective such precautions can bemade may be illustrated by the fact that, in the past five years, therehas not been a single epidemic of typhoid traceable to milk in GreaterNew York, even with its inadequate corps of ten inspectors, and the sixstates they have to cover. The moment a single case of typhoid appears, the dairy or milkman supplying that customer is given a most rigidspecial inspection, and, if any source of infection can be discovered, the milk is shut out of New York City until the department is satisfiedthat all danger has been removed. One or two lessons of this sort areenough for a whole county of dairymen. The danger of transmission oftyphoid through milk has been enormously exaggerated, and, as in thecase of all other milk-borne diseases, is entirely due to filthyhandling, and may be prevented by intelligent sanitary policing. Evenwith our present exceedingly imperfect systems, probably not more thanbetween five and ten per cent of typhoid is transmitted in this way;and, if the water-supply were kept clean, this would practicallydisappear. 

Typhoid may not only be transmitted from the earth beneath and the waterunder the earth, but also from the heavens above, through the medium offlies and dust. The first method is bulking larger every day, especiallyin country districts and in camps. The _modus operandi_ is simplicityitself. The fly lives and moves and has its being in dirt. It breeds indirt and it feeds on food, and, as it never wipes its feet, theinteresting 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 aclearly recorded track of the footprints of the flies written in clumpsof bacilli sown by their filthy feet. More definitely, flies have beencaught in the houses of typhoid patients, put under the microscope, andtheir feet, stomachs, and specks found swarming with typhoid bacilli. Asingle flyspeck may contain three thousand. 

Fortunately, we have a simple and effective remedy. We cannot disinfectthe fly nor make him wipe his feet, but we _can_ exterminate himutterly! This sounds difficult, but it isn't. Like the mosquito, the flycan only breed in one particular kind of place, and that place is a heapof 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 morethan a week at a stretch. Abolish, screen, or poison these dirtaccumulations, and flies will disappear, and with them not merely risksfrom typhoid, but half a dozen other diseases, as well as all sorts offilth and much discomfort and inconvenience. It was largely throughflies that the disgraceful epidemic of typhoid, which ravaged our campson our own soil during the Spanish-American War and killed many timesmore than fell by Spanish bullets, was spread. 

It is also believed that typhoid bacilli may be carried in the infecteddust of streets and camps. Here again we are dealing with a dangerouspublic enemy to both health and comfort, which can and ought to beabated by cleanliness, oilings, and sprinklings. Typhoid bacilli arealso occasionally carried by shellfish, especially oysters, on accountof the interesting modern custom of planting them in bays and harborsnear the mouths of sewers to fatten them. The cheerful motto of theoysterman is, "The muddier the water the fatter the oyster. " And nowheredo 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. Thisis a relatively rare means of spread, so much so that it is generallystated that typhoid is not contagious; but it is a real source of dangerand one against which precautions should by all means be taken. The onlymethod is, of course, by the soiling of the hands of the nurse or otherattendant, and then eating or touching food, or putting the fingers intothe mouth before thoroughly cleansing. If the hands be washed with astrong antiseptic solution after waiting upon the patient, and thecheerful habit sometimes indulged in of putting fruit or otherdelicacies into the sick-room for a day or so, in the hope that they maytempt the appetite of the patient, and then taking them out and lettingthe children eat them as a treat, be abolished, and the nurse be notallowed to officiate in the kitchen, risk from this source will be doneaway with. 

When the bacillus has been introduced into the stomach through food ordrink, it rapidly proceeds to diffuse itself throughout the tissues ofthe body. Because the most striking symptoms of the disease arediarrh[oe]a, abdominal distention, and pain, and the most strikinglesions after death ulcers in the small intestine, it was supposed thatthe process was confined to the abdominal organs. This is now known tobe an error, as cultures and examinations made from the blood andvarious parts of the body have shown the presence of the typhoidbacillus in almost every organ and tissue. This process of scattering, or invasion of the body, takes from three to ten days to accomplish; andthe first sign of trouble is usually a feeling of depression, withheadache, and perhaps slight nausea, before any characteristic bowelsymptoms begin to show themselves. 

The general invasion of the system throws an interesting sidelight uponthe subject of premonitions. There are several well authenticated caseson record where individuals just before coming down with typhoid havebeen strangely impressed with a sense of impending death, and have evengone so far as to make their wills and set their affairs in order. Because these strong impressions appeared before any clearly markedintestinal symptoms of the disease, they have been put down in popularliterature as instances of the "second sight, " or "sixth sense, " whichpopular superstition believes many of us to possess under certaincircumstances. Now, however, we know that the tissues of that individualwere already swarming with bacilli, and his fear of impending death wassimply the effect of his toxin-laden blood upon his brain centres. Inother words, it was prophecy after the fact, like nearly all propheciesthat happen to come true; and the "premonition" was an early symptom ofthe disease itself. 

As it is, of course, difficult to fix the precise drink of water ormouthful of food in which the infection was conveyed, we were for a longtime in doubt as to the length of time which it took to spread throughthe system, --the "period of incubation, " as it is termed, --although weknew 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 Parisianhospitals, in a fit of despondency, decided to commit suicide. Like atrue Parisienne, she would be nothing if not up to date, and chose, asthe most _recherché_ and original method of departing this life, toswallow a pure culture of typhoid germs, which she abstracted from thelaboratory. Three days later she began to complain of headache, andwithin a week had developed a beautiful crop of symptoms, and a typicalcase of typhoid, from which, under modern treatment, she promptlyrecovered, --a wiser and, we trust, a happier woman. 

By just what avenue the infecting bacilli go from the stomach into thegeneral system we do not know. Metschnikoff suggests that they can onlypenetrate the intestinal wall through wounds or abrasions of the mucousmembrane, made by intestinal worms or other parasites. Certain it isthat the average stomach has a considerable degree of resisting poweragainst them, for in no known civil epidemic has the number of those whocaught the disease exceeded ten per cent of the total number drinkingthe infected water or milk. In one or two camps in time of war thepercentage has risen as high as eighteen or twenty per cent of thoseexposed, but this is exceptional. However, now that we know thatintestinal symptoms do not constitute the entire disease, and may evenbe entirely absent, we strongly suspect that many cases of slightdepression, with feverishness, loss of appetite, and disturbances of thedigestion, which occur during an epidemic, may really have been verymild cases of the disease. 

One of the singular features of the disease is that, unlike many otherinfections, we are entirely unable to say what conditions or influencesseem either to protect against it or to predispose toward it. In thedays when we believed it to be an exclusively intestinal disease it wasnaturally supposed that chronic digestive disturbances, and especiallyacute attacks of bowel trouble or dysentery, would predispose to it, butthis has been entirely disproved. Soldiers in barracks with chronicdigestive disturbances, and even with dysentery, have shown no higherpercentage of typhoid during an epidemic than others. Nor does it seemmuch more likely to occur in those who are constitutionally weak, or rundown, or overworked, as some of the most violent and unmanageable casesoccur in vigorous men and women, who were previously in perfect health. So that, although we have unquestionably a high degree of resistanceagainst it, since not more than one in ten exposed contracts it, andonly one in ten of those who contract it dies, we have not the leastidea in what direction, so to speak, to build up our resisting powers inorder to increase them. 

The best remedy is to destroy the disease altogether, and this could bedone in five years by intelligent concerted effort. It was at one timesupposed that typhoid fever was a disease exclusively confined to adultlife; but it is now known to occur frequently in children, though oftenin such a mild and irregular form as to escape recognition. Somethinglike seventy per cent of all cases occur between the fifteenth and thefortieth year, and it is, for some reason, though rarer, peculiarlyserious and more often fatal after the fiftieth year. 

When once the outer wall has been pierced, the sack of the city rapidlyproceeds. The bacilli multiply everywhere, but seem for some reason tofocalize chiefly in the alimentary canal, and especially the middle partof it, the small intestines. After headache, backache, and loss ofappetite comes usually a mild diarrh[oe]a. This diarrh[oe]a is due to anattack of the bacillus or its toxins upon certain clumps of lymphoidtissue in the wall of the small intestine, known as the "patches ofPeyer. " This produces inflammation, followed by ulceration, which insevere cases may eat through the wall of a blood-vessel, causing profusehemorrhages, or even perforate the bowel wall and set up a fatalperitonitis. The temperature begins to swing from two to five degreesabove the normal level, following the usual daily vibration, and rangingfrom 100 degrees to 101 degrees in the morning up to 102 degrees to 105degrees in the afternoon. The face becomes flushed. 

There is usually comparatively little pain, and the patient lies in asort of mild stupor, paying little attention to his surroundings. He ismuch enfeebled and seldom cares to lift his head from the pillow. Aslight rash appears upon the surface of the body, but this is so faintthat it would escape attention unless carefully looked for. Littlegroups of vesicles, containing clear fluid, appear upon the chest andabdomen. If one of these faint rose-colored spots be pricked with aneedle and a drop of blood be drawn, typhoid bacilli will often be foundin it, and they will also be present in the clear fluid of the tinysweat blisters. 

This condition will last for from ten days to four weeks, the patientgradually becoming weaker and more apathetic, and the temperaturemaintaining an afternoon level of 102 to 104 degrees. Then, in the vastmajority of cases, a little decline of the temperature will be noticed. The patient begins to take a slight interest in his surroundings. Hewill perhaps ask for something to drink, or something to eat, instead ofapathetically swallowing what is offered to him. Next day thetemperature is a little lower still, and within a week, perhaps, willhave returned to the normal level. The patient has lost from twenty toforty pounds, is weak as a kitten, and it may be ten days after thefever has disappeared before he asks to sit up in bed. 

Then follows the period of return to health. The patient becomes awalking appetite, and, after weeks of liquid diet, will beg like aspoiled child for cookies or hard apples or pie, or something that hecan set his teeth into. But his tissues are still swarming with thebacilli, and any indiscretion, either of diet, exposure, or exertion, atthis time, may result in forming a secondary colony, or abscess, somewhere in the lungs, the liver, or the muscles. He must be kept quietand warm, and abundantly, but judiciously, fed, for at least threeweeks after the disappearance of the fever, if he wishes to avoid thethousand and one ambuscades set by the retreating enemy. 

Now, what has happened when recovery begins? One would suppose thateither the bacilli had poisoned themselves, exhausted the supplies ofnourishment in the body of the patient, so that the fever had "burntitself out, " as we used to say, or that the tissues had rallied from theattack and destroyed or thrown out the invaders. But, on the contrary, we find that our convalescent patient, even after he is up and walkingabout, is still full of the bacilli. 

To put it very crudely, what has really happened is that the body hassucceeded in forming such antidotes against the poison of the bacillithat, although they may be present in enormous numbers, they can nolonger produce any injurious effect. In other words, it has acquiredimmunity against this particular germ and its toxin. In fact, one of ournewest 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 oreighth day of the illness. And, while it is an immensely difficult andcomplicated subject, we are justified in saying that this immunity isnot merely a substance formed in the body, the stock of which willshortly become exhausted, but a faculty acquired by the body-cells, which they will retain, like other results of education, for years, andeven for life. When once the body has learned the wrestling trick ofthrowing and vanquishing a particular germ or bacillus, it no longerhas much to dread from that germ. This is why the same individual isseldom attacked the second time by scarlet fever, measles, typhoid, andsmallpox. 

While, however, the individual may be entirely immune to the germs of agiven disease, he may carry them in his body in enormous numbers, andinfect others while escaping himself. 

This is peculiarly true of typhoid, and we are beginning to extend oursanitary care over recovered patients, not merely to the end of acuteillness, but for the period of at least a month after they haveapparently recovered. Several most disquieting cases are on record ofso-called "typhoid carriers, " or individuals who, having recovered fromthe disease itself, carried and spread the infection wherever they wentfor months and even years afterward. This, however, is probably a rarestate of affairs, though a recent German health bulletin reports thediscovery of some twenty cases during the past year. The lair of thebacilli is believed to be the gall-bladder. 

As to treatment, it may be broadly stated that all authorities andschools 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, andfollow--so to speak--her instinctive methods: first of all, by puttingthe patient to bed the moment that a reasonable suspicion of the diseaseis formed; this conserves his strength, and greatly diminishes thedanger of serious complications; cases of "walking typhoid" have amongthe highest death-rates; second, by meeting the great instinctivesymptom of fever patients since the world began, thirst, encouraging thepatient to drink large quantities of water, taking care, of course, thatthe water is pure and sterile. The days when we kept fever patientswrapped up to their necks in woolen blankets in hot, stuffy rooms, andrigorously limited the amount of water that they drank--in other words, fought against nature in the treatment of disease--have passed. Atyphoid-fever patient now is not only given all he wants to drink, butencouraged to take more, and some authorities recommend an intake of atleast three or four quarts, and, better, six and eight quarts a day. This internal bath helps not only to allay the temperature, but to makegood the enormous loss by perspiration from the fevered skin, and toflush the toxins out of the body. 

Third, by liberal and regular feeding chiefly with some liquid orsemi-liquid food, of which milk is the commonest form. The old attitudeof mind represented by the proverb, "Feed a cold and starve a fever, "has completely disappeared. One of the fathers of modern medicine askedon his death-bed, thirty years ago, that his epitaph should be, "He fedfevers. "

Fourth. We respond to the other great thirst of fever patients, forcoolness, by sponge baths and tub baths, whenever the temperature risesabove a certain degree. 

Simple as these methods sound, they are extremely troublesome to putinto execution, and require the greatest skill and judgment in theircarrying out. But intelligent persistence in the careful elaboration ofthese methods of nature has resulted in already cutting the death-ratein two, --from fifteen or twenty per cent to less than ten per cent, --andwhere the full rigor of the tub bath is carried out it has been broughtdown to as low as five per cent. 

Meanwhile the bacteriologists are steadily at work on a vaccine orantitoxin. Wright, of the English Army Medical Staff, has alreadysecured a serum, which has given remarkable results in protectingregiments sent out to South Africa and other infected regions. Chantemesse has imported some six hundred successive cases treated withan antitoxin, whose mortality was only about a third of the ordinaryhospital rate, and the future is full of promise. 

CHAPTER X

DIPHTHERIA

That was a dark and stern saying, "Without the shedding of blood thereis no remission, " and, like all the words of the oracles, of limitedapplication. But it proves true in some unexpected places outside of therealm of theology. Was there something prophetic in the legend that itwas only by the sprinkling of the blood of the Paschal Lamb above thedoorway that the plague of the firstborn could be stayed? To-day theguinea-pig is our burnt offering against a plague as deadly as any sentinto Egypt. 

Scarcely more than a decade ago, as the mother sat by the cradle of herfirstborn, musing over his future, one moment fearfully reckoning thegauntlet of risks that his tiny life had to run, and the next buildingrosy air-castles of his happiness and success, there was one shadow thatever fell black and sinister across his tiny horoscope. Certain risksthere were which were almost inevitable, --initiation ceremonies intolife, mild expiations to be paid to the gods of the modern underworld, the diseases of infancy and of childhood. Most of these could be passedover with little more than a temporary wrinkle to break her smile. Theywere so trivial, so comparatively harmless: measles, a mere reddening ofthe eyelids and peppering of the throat, with a headache and purplishrash, dangerous only if neglected; chicken-pox, a child's-play atdisease; scarlatina, a little more serious, but still with the chancesof twenty to one in favor of recovery; diphtheria--ah! that drove thesmile 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 fightbetween the Angel of Life and the Angel of Death was waged on almostequal terms, with none daring to say which would be the victor, and noneable to lift a hand with any certainty to aid. 

Nor was the doctor in much happier plight. Even when the life at stakewas not one of his own loved ones, --though from the deadlycontagiousness of the disease it sadly often was (I have known moredoctors made childless by diphtheria than by any other disease excepttuberculosis), --he faced his cases by the hundred instead of by twos andthrees. The feeling of helplessness, the sense of foreboding, with whichwe faced every case was something appalling. Few of us who have been inpractice twenty years or more, or even fifteen, will ever forget theshock of dismay which ran through us whenever a case to which we hadbeen summoned revealed itself to be diphtheria. Of course, there was afighting chance, and we made the most of it; for in the milder epidemicsonly ten to twenty per cent of the patients died, and even in theseverest a third of them recovered. But what "turned our liver towater"--as the graphic Oriental phrase has it--was the knowledge which, like Banquo's ghost, would not down, that while many cases would recoverof themselves, and in many border-line ones our skill would turn thebalance in favor of recovery, yet if the disease happened to take acertain sadly familiar, virulent form we could do little more to stayits fatal course than we could to stop an avalanche, and we never knewwhen 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 singularcharacter and history. It is not a modern invention or development, asis sometimes believed, for descriptions are on record of so-called"Egyptian ulcer of the throat" in the earliest centuries of our era; andit would appear to have been recognized by both Hippocrates and Galen. Epidemics of it also occurred in the Middle Ages; and, coming to morerecent times, one of the many enemies which the Pilgrim Fathers had tofight was a series of epidemics of this "black sore throat, " ofparticularly malignant character, in the seventeenth century. Nevertheless, it does not seem to have become sufficiently common to bedistinctly recognized until it was named as a definite disease, andgiven the title which it now bears, by the celebrated French physician, Bretonneau, about eighty years ago. Since then it has become either morewidely recognized or steadily more prevalent, and it is the generalopinion of pathologists that the disease, up to some thirty or fortyyears ago, was steadily increasing, both in frequency and in severity. 

So that we have not to deal with a disease which, like the otherso-called diseases of childhood, has gradually become milder and milderby a sort of racial vaccination, with survival of the less susceptible, but one which is still full of virulence and of possibilities of futuredanger. 

Unlike the other diseases of childhood, also, one attack confers nopositive immunity for the future, although it greatly diminishes theprobabilities; and, further, while adults do not readily or frequentlycatch the disease, yet when they do the results are apt to beexceedingly serious. Indeed, we have practically come to the conclusionthat one of the main reasons why adults do not develop diphtheria sofrequently as children, is that they are not brought into such close andintimate contact with other children, nor are they in the habit ofpromptly and indiscriminately hugging and kissing every one who happensto attract their transient affection, and they have outgrown thatcheerful spirit of comradeship which leads to the sharing of candy inalternate sucks, and the passing on of slate-pencils, chewing-gum, andother _objets d'art_ from hand to hand, and from mouth to mouth. Statistics show that of nurses employed in diphtheria wards, before thecause or the exact method of contagion was clearly understood, nearlythirty per cent developed the disease; and even with every modernprecaution there are few diseases which doctors more frequently catchfrom their patients than diphtheria. It is a significant fact that therisk of developing diphtheria is greatest precisely at the ages whenthere is not the slightest scruple about putting everything that may bepicked up into the mouth, --namely, from the second to the fifthyear, --and diminishes steadily as habits of cleanliness and caution inthis regard are developed, even though no immunity may have been gainedby a mild or slight attack of the disease. The tendency to discourageand forbid the indiscriminate kissing of children, and the crusadeagainst the uses of the mouth as a pencil-holder, pincushion, andgeneral receptacle for odds and ends, would be thoroughly justified bythe risks from diphtheria alone, to say nothing of tuberculosis andother infections. 

In addition to being almost the only common disease of childhood whichis not mild and becoming milder, diphtheria is unique in anotherrespect, and that is its point of attack. Just as tuberculosis seizesits victims by the lungs, and typhoid fever by the bowels, diphtheria--like the weasel--grips at the throat. Its bacilli, enteringthrough the mouth and gaining a foothold first upon the tonsils, thepalate, or back of the throat (pharynx), multiply and spread until theyswarm down into the larynx and windpipe, where their millions, swarmingin the mesh of fibrin poured out by the outraged blood-vessels, growinto the deadly false membrane which fills the air-tube and slowlystrangles its victim to death. 

The horrors of a death like that can never fade from the memory of onewho has once seen it, and will outweigh the lives of a thousandguinea-pigs. No wonder there was such a widespread and peculiar horrorof the disease, as of some ghostly thug or strangler. 

But not all of the dread of diphtheria went under its own name. Most ofus can still remember when the commonest occupant of the nursery shelfwas the bottle of ipecac or soothing-syrup as a specific against croup. The thing that most often kept the mother or nurse of young childrenawake 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 therewere two kinds of croup, the so-called "spasmodic" and the "membranous, "the former comparatively common and correspondingly harmless, the latterone of the deadliest of known diseases. The fear that made the mother'sheart leap into her mouth as she heard the ringing croup-cough was lestit might be membranous, or, if spasmodic, might turn into the deadlyform later. To-day most young mothers hardly know the name of wine ofipecac or alum, and the coughs of young children awaken little moreterror than a similar sound in an adult. Croup has almost ceased to beone of the bogies of the nursery. And why? Because membranous croup hasbeen discovered to be diphtheria, and children will not developdiphtheria unless they have been exposed to the contagion, while, ifthey should be, we have a remedy against it. 

He was a bold man who first ventured to announce this, and for years thebattle raged hotly. It was early admitted that certain cases ofso-called membranous croup in children occurred after or while othermembers of the family or household had diphtheria; and for a time theopposing camps used such words as "sporadic" or scattered croup, whichwas 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 croupexactly as against any other form of diphtheria. 

Cases of fatal croup still occasionally occur which cannot be directlytraced to other cases of diphtheria, but the vast majority of them areclearly traceable to infection, usually from some case in another child, which was so mild that it was not recognized as diphtheria until thebaby became "croupy" and search was made through the family throats forthe bacilli. 

For years we were in doubt as to the cause of diphtheria. Half a dozendifferent theories were advanced, bad sewerage, foul air, overcrowding;but it was not until shortly after the Columbus-like discovery, byRobert Koch, of the new continent of bacteriology, that the germ whichcaused it was arrested, tried, and found guilty, and our real knowledgeof and control over the disease began. This was in 1883, when thebacteriologist Klebs discovered the organism, followed a few monthslater (in 1884) by Löffler, who made valuable additions to our knowledgeof it; so that it has ever since been known as the Klebs-Löfflerbacillus. This put us upon solid ground, and our progress was both sureand rapid: in ten years our knowledge of the causation, the method ofspread, the mode of assault upon the body-fortress, and last, but notleast, the cure, stood out clear cut as a die, a model and a prophecy ofwhat may be hoped for in most other contagious diseases. 

Great as is the credit to which bacteriologists are entitled for thissplendid piece of scientific progress, there was another co-laborer, asilent partner, with them in all this triumph, an unsung hero and martyrof science who deserves his meed of praise--the tiny guinea-pig. He welldeserves his niche in the temple of fame; and as other races and ageshave worshiped the elephant, the snake, and the sacred cow, so this ageshould erect its temples to the guinea-pig. From one of the mosttrifling and unimportant, --kept merely as a pet and curiosity by thesmall boys of all ages, --he has become, after the horse, the cow, thepig, and the sheep, easily our most useful and important domesticanimal. It may be urged that he deserves no credit, since hissacrifice--though of inestimable value--was entirely involuntary on hisown part; but this should only make us the more deeply bound toacknowledge our obligation to him. 

By a stern necessity of fate, which no one regrets more keenly than thelaboratory workers themselves, the guinea-pig has had to be used as astepping-stone for every inch of this progress. Upon it were conductedevery one of the experiments whose results widened our knowledge, untilwe found that this bacillus and no other would cause diphtheria; thatinstead of getting, like many other disease-germs, into the blood, itchiefly limited itself to growing and multiplying upon a comparativelysmall patch of the body-surface, most commonly of the throat; that mostof its serious and fatal results upon the body were produced, not by theentrance of the germs themselves into the blood, but by the absorptionof the toxins or poisons produced by them on the moist surface of thethroat, just as the yeast plant will produce alcohol in grape juice orsweet cider. 

Here was a most important clew. It was not necessary to fight the germsthemselves in every part of the body, but merely to introduce someferment or chemical substance which would have the power of neutralizingtheir poison. Instantly attention was turned in this direction, and itwas quickly found that if a guinea-pig were injected with a very smalldose of the diphtheria toxin and allowed to recover, he would then beable to throw off a still larger dose, until finally, after a number ofweeks, he could be given a dose which would have promptly killed him inthe beginning of the experiments, but which he now readily resisted andrecovered from. Evidently some substance was produced in his blood whichwas a natural antidote for the toxin, and a little further searchquickly resulted in discovering and filtering out of his body the nowfamous antitoxin. A dose of this injected into another guinea-pigsuffering from diphtheria would promptly save its life. 

Could this antitoxin be obtained in sufficient amounts to protect thebody of a human being? The guinea-pig was so tiny and the process ofantitoxin-forming so slow, that we naturally turned to larger animals asa possible source, and here it was quickly found that not only would thegoat and the horse develop this antidote substance very quickly and inlarge amounts, but that a certain amount of it, or a substance acting asan antitoxin, was present in their blood to begin with. Of the two, thehorse was found to give both the stronger antitoxin and the largeramounts of it, so that he is now exclusively used for its production. 

After his resisting power had been raised to the highest possible pitchby successive injections of increasing doses of the toxin, and his serum(the watery part of the blood which contains the healing body) had beenused hundreds and hundreds of times to save the lives ofdiphtheria-stricken guinea-pigs, and had been shown over and over againto be not merely magically curative but absolutely harmless, it wastried with fear and trembling upon a gasping, struggling, suffocatingchild, as a last possible resort to save a life otherwise hopelesslydoomed. 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? Inagonies of suspense, vibrating between hope and dread, doctors andparents 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 bluenessof its lips to diminish, and its breathing become easier. In a few hoursmore the color had returned to the ashen face and it was breathingquietly. Then it began to cough and to bring up pieces of the loosenedmembrane that had been strangling it. Another dose was eagerly injected, and within twenty-four hours the child was sleeping peacefully--out ofdanger. And the most priceless and marvelous life-saving weapon of thecentury had been placed in the hand of the physician. 

Of course there were many disappointments and failures in the earliercases. Our first antitoxins were too weak and too variable. We wereafraid to use them in sufficient doses. Often their injection would notbe consented to until the case had become hopeless. But courage andindustry have conquered these difficulties one after another, until nowthe fact that the prompt and intelligent use of antitoxin will effect acure of from ninety to ninety-five per cent of all cases of diphtheriais as thoroughly established as any other fact in medicine. The mass offigures from all parts of the world in support of its value has becomeso overwhelming that it is neither possible nor necessary to specifythem in detail. The series of Bayeaux, covering two hundred and thirtythousand cases of diphtheria, chiefly from hospitals and hence of theseverest type, showing that the death-rate had been reduced from over_fifty-five_ per cent to below _sixteen_ per cent already, and that thisdecrease was still continuing, will serve as a fair sample. 

Three-quarters of even this sixteen per cent mortality is due to delayin the administration of the antitoxin, as is vividly shown in thousandsof cases now on record, classified according to the day of the diseaseon which the antitoxin was given, of which MacCombie's "Report of theLondon Asylums Board" is a fair type. Of one hundred and eighty-sevencases treated the first day of the disease, none died; of eleven hundredand eighty-six injected on the second day of the disease, four and ahalf per cent died; of twelve hundred and thirty-three not treated untilthe third day of the disease, eleven per cent died; of nine hundred andsixty-three cases escaping treatment until the fourth day, seventeen percent died; while of twelve hundred and sixty not seen until the fifthday, twenty per cent died. In other words, the chances for cure by theantitoxin are in precise proportion to the earliness with which it isadministered, and are over four times as great during the first two daysof the disease as they are after the fourth day. One "stick" in timesaves five. 

This brings us sharply to the fact that the most important factor in thecure of diphtheria, just as in the case of tuberculosis, is earlyrecognition. How can this be secured? Here again the bacteriologistcomes to our relief, and we needed his aid badly. The symptoms of a mildcase of diphtheria for the first two, or even three, days are very muchlike those of an ordinary sore throat. As a rule, even the well-knownmembrane does not appear in sufficient amounts to be recognizable by thenaked eye until the middle of the second, or sometimes even of thethird, day. By any ordinary means, then, of diagnosis, we would often bein doubt as to whether a case were diphtheria or not, until it was bothwell 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 takea sterilized swab of cotton on the end of a wire, rub it gently over thesurface of the throat and tonsils, restore it to its glass tube, smearing it over the surface of some solidified blood-serum placed atthe bottom of the tube, close the tube and send it to the nearestlaboratory. The culture is put into an incubator at body heat, the germssown upon the surface of the blood-serum grow and multiply, and intwelve hours a positive diagnosis can be made by examining this growthwith a microscope. Often, just smearing the mucus swabbed out of thethroat over the surface of a glass slide, staining this smear, andputting 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, foruse in any doubtful case, within half an hour. Twelve hours later a freereport can be had from the public laboratory. If every case ofsuspicious sore throat in a child were promptly swabbed out, and a smearfrom the swab examined at a laboratory, it would not be long beforediphtheria would be practically exterminated, as smallpox has been byvaccination, and this is what we are working toward and looking forwardto. 

Our knowledge of the precise cause of diphtheria, the Klebs-Löfflerbacillus, has furnished us not only with the cure, but also with themeans of preventing its spread. While under certain circumstances, particularly the presence of moisture and the absence of light, thisgerm may live and remain virulent for weeks outside of the body, carefulstudy of its behavior under all sorts of conditions has revealed theconsoling fact that its vitality outside of the human or some otherliving animal body is low; so that it is relatively seldom carried fromone case to another by articles of clothing, books, or toys, andcomparatively seldom even through a third party, except where the latterhas come into very close contact with the disease, like a doctor, anurse, or a mother, or--without disrespect to the preceding--a pet cator dog. 

More than this, the bacillus must chiefly be transmitted in the moistcondition and does not float in the air at all, clinging only to suchobjects as may have become smeared with the mucus from the child'sthroat, as by being coughed or sneezed upon. As with most of ourgerm-enemies, sunlight is its deadliest foe, and it will not live morethan two or three days exposed to sunshine. So the principal dangeragainst which we must be on our guard is that of direct personalcontact, as in kissing, in the use of spoons or cups in common, in theinterchange of candy or pencils, or through having the hands or clothingsprayed by a cough or a sneeze. 

The bacillus comparatively seldom even gets on the floor or walls of aroom where reasonable precautions against coughing and spitting havebeen taken; but it is, of course, advisable thoroughly to disinfect andsterilize the room of a patient and all its contents with corrosivesublimate and formalin, as a number of cases are on record in which thedisease has been carried through books and articles of clothing whichhad been kept in damp, dark places for several months. The chief methodof spread is through unrecognized mild cases of the disease, especiallyof the nasal form. For this reason boards of health now always insistupon smears being made from the throats and noses of every other childin the family or house where a case of diphtheria is recognized. Nosmall percentages of these are found to be suffering from a mild form ofthe disease, so slight as to cause them little inconvenience and nointerference with their attending school. Unfortunately, a case caughtfrom one of these mild forms may develop into the severest laryngealtype. If a child is running freely at the nose, keep it at home or keepyour own child away from it. A profuse nasal discharge is generallyinfectious, in the case of influenza or other "colds, " if not ofdiphtheria. 

This also emphasizes the necessity for a thorough and expert medicalinspection of school-children, to prevent these mild cases fromspreading disease and death to their fellows. By an intelligentcombination of the two methods, home examination of every infectedfamily and strict school inspection, there is little difficulty instamping out promptly a beginning infection before it has had time toreach the proportions of an epidemic. 

One other step makes assurance doubly sure, and that is the promptinjection of all other children and young adults living in the family, where there is a case of diphtheria, with small doses of the antitoxinfor preventive purposes. Its value in this respect has been onlysecondary to its use as a cure. There are now thousands of cases onrecord of children who had been exposed to diphtheria or were inhospitals where they were in danger of becoming exposed to it, with thedelightful result that only a very small per cent of those so protecteddeveloped the disease, and of these not a single one died! Thisprotective vaccination, however, cannot be used on a large scale, as inthe case of smallpox, for the reason that the period of protection is acomparatively short one, probably not exceeding two or three weeks. 

Suppose that, in spite of all our precautions, the disease has gained afoothold in the throat, what will be its course? This will depend, firstof all, upon whether the invading germs have lodged in their commonestpoint of attack, the tonsils, palate, and upper throat, or havepenetrated down the air-passages into the larynx or voice-organ. In theformer, which is far the commoner case, their presence will cause anirritation of the surface cells which brings out the leucocyte cavalryof the body to the defense, together with squads of the serum or wateryfluid of the blood containing fibrin. These, together with thesurface-cells, are rapidly coagulated and killed by the deadly toxin;and their remains form a coating upon the surface, which at first isscarcely perceptible, a thin, grayish film, but which in the course oftwenty-four to forty-eight hours rapidly thickens to the well-known anddreaded false membrane. Before, however, it has thickened in more thanoccasional spots or patches, the toxin has begun to penetrate into theblood, and the little patient will complain of headache, feverishness, and backache, often--indeed, usually--before any very marked soreness inthe throat is complained of. Roughly speaking, attacks of sore throat, which begin first of all with well-marked soreness and pain in thethroat, followed later by headache, backache, and fever, are not verylikely to be diphtheria. The bacilli multiply and increase in theirdeadly mat on the surface of the throat, larger and larger amounts ofthe poison are poured into the blood, the temperature goes up, theheadache increases, the child often begins to vomit, and becomesseriously ill. The glands of the neck, in their efforts to arrest andneutralize the poison, become swollen and sore to the touch, the breathbecomes foul from the breaking down of the membrane in the throat, thepulse becomes rapid and weak from the effect of the poison upon theheart, and the dreaded picture of the disease rapidly develops. 

This process in from sixty to eighty per cent of cases will continue forfrom three to seven days, when a check will come and the condition willgradually improve. This is a sign that the defensive tissues of the bodyhave succeeded in rallying their forces against the attack, and havepoured out sufficient amounts of their natural antitoxin to neutralizethe poisons poured in by the invaders. The membrane begins to break downand peel off the throat, the temperature goes down, the headachedisappears, the swelling in the glands of the neck may either subside orgo on to suppuration and rupture, but within another week the child isfairly 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 lessheadache, temperature, and general sense of illness; but he begins tocough, and the cough has a ringing, brassy sound. Within forty-eight, oreven twenty-four, hours he begins to have difficulty in respiration. This rapidly increases as the delicate tissues of the larynx swell underthe attack of the poison, and the very membrane which is created in anattempt at defense becomes the body's own undoing by increasing theblocking of the air-passages. The difficulty of breathing becomesgreater and greater, until the little victim tosses continually fromside to side in one constant, agonizing struggle for breath. After atime, however, the accumulation of carbon dioxide in the blood producesits merciful narcotic effect, and the struggles cease. The breathingbecomes shallower and shallower, the lips become first blue, then ashypale, and the little torch of life goes out with a flicker. This waswhat we had to expect, in spite of our utmost effort, in from seventy toninety per cent of these laryngeal cases, before the days of the blessedantitoxin. Now we actually reverse these percentages, prevent the vastmajority of cases from developing serious laryngeal symptoms at all, andsave from seventy to eighty per cent of those who do. 

Our only resource in this form of the disease used to be by mechanicalor surgical means, opening the windpipe below the level of theobstruction and inserting a curved silver tube--the so-calledtracheotomy operation; or later, and less heroic, by pushing forciblydown into the larynx, and through and past the obstruction at the vocalcords, a small metal tube through which the child could manage tobreathe. This was known as intubation. But these were both distressingand painful methods, and, what was far worse, pitifully broken reeds todepend upon. In spite of the utmost skill of our surgeons, from fifty toeighty per cent of cases that were tracheotomized, and from forty tosixty per cent of those that were intubated, died. In many cases theywere enabled to breathe, their attacks of suffocation were relieved--butstill they died. 

This leads us to the most important single fact about the course of thedisease, and that is that the chief source of danger is not so much fromdirect suffocation as from general collapse, and particularly failure ofthe 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 membranehas become loosened and the temperature has begun to subside, in bothordinary throat and in laryngeal forms of the disease, the patient is byno means out of danger. While the antitoxins poured out by his body havecompletely defeated the invading toxins in the open field of the blood, yet almost every tissue of the body is still saturated with these latterand has often been seriously damaged by them before their course waschecked. For instance, nearly two-thirds of our diphtheria cases, whichare properly examined, will show albumin in the urine, showing that thekidney-cells have been attacked and poisoned by the toxin. This may goon to a fatal attack of uremia; but fortunately, not commonly, far lessso than in scarlet fever. The kidneys usually recover completely, butthis may take weeks and months. Again, many cases of diphtheria willshow a weak and rapid pulse, which will persist for weeks after thepatient has apparently recovered; and if the little ones are allowed tosit up too soon, or to indulge in any sudden movements or muscularstrains, this weak and rapid pulse will suddenly change into an attackof heart failure and, possibly, fatal collapse. This, again, illustratesthe saturation of the poison, as these effects are now known to be duein part to a direct poisoning of the muscle of the heart itself, andlater to serious damage done to the nerves controlling the heart, chiefly the pneumo-gastric. Moral: Keep the little patient in bed for atleast two weeks or, better, three. He will have to spend a month or morein quarantine, anyway. 

Last of all, and by no means least interesting, are the effects whichare produced upon the nervous system. One day, while the child isrecovering, and is possibly beginning to sit up in bed, a glass of milkis handed to him. The little one drinks it eagerly and attempts toswallow, but suddenly it chokes, half strangles, and back comes themilk, pouring out through the nostrils. Paralysis of the soft palate hasoccurred from poisoning of the nerves controlling it, caused by directpenetration of the toxin. Sometimes the muscles of the eye becomeparalyzed 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 oreven longer. In a certain number, however, the nerves of respiration, orthose controlling the heart-beat, become affected, and the patient diessuddenly from heart failure. 

This strange after-effect upon the nervous system, which was firstclearly noticed in diphtheria and syphilis, has now been found to occurin lesser degree in a large number of our infectious diseases, so thatmany of our most serious paralyses and other diseases of the nervoussystem are now traceable to such causes. 

These effects of the diphtheria toxin are also of interest for asomewhat unexpected reason, since it has been claimed that they areeffects of the antitoxin, by those who are opposed to its use. Every oneof them was well recognized as a possible result of diphtheria longbefore the antitoxin was discovered, and every one of them can bereadily produced by injections of diphtheria bacilli or their toxin intoanimals. 

It is quite possibly true that there are more cases of nerve-poisoning(neuritis) and of paralysis following diphtheria than there were beforethe use of antitoxin, but that is for the simple and sufficient reasonthat there are more children left alive to display them! And between achild with a temporary squint and a dead child few mothers wouldhesitate 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 andimportant group of diseases in the whole realm of pathology than thosewhich we calmly dub "the diseases of childhood, " and thereby dismiss tothe limbo of unavoidable accidents and discomforts, like flies, mosquitoes, and stubbed toes, which are best treated with a shrug of theshoulders and such stoic philosophy as we can muster. They areinteresting, because the moment we begin to study them intelligently westumble upon some of the profoundest and most far-reaching problems ofresistance to disease; important, because, trifling as we regard them, and indeed largely just because we so regard them, they kill, orhandicap for life, more children in civilized communities than the mostdeadly pestilence. Measles, for instance, according to the last UnitedStates census, causes yearly nearly thirteen thousand deaths, whilesmallpox causes so few that it is not listed among the important causesof death. Scarlet fever causes sixty-three hundred and thirty-threedeaths, as compared with barely five thousand from appendicitis and thesame number from rheumatism. Whooping-cough causes ninety-nine hundredand fifty-eight deaths, more than double the mortality from diabetes andnearly equal to that of malarial fever. 

In medicine, as in war, the gravest and deadliest mistake that you canmake is to despise your enemy. These trivial disorders, these triflingailments, which every one takes as a matter of course, and expects to gothrough with, like teething, tight shoes, and learning to smoke, sweepaway every year in these United States the lives of from forty to fiftythousand children, reaching the bad eminence of fifth upon our mortalitylists, only consumption, pneumonia, heart disease, and diarrh[oe]aldiseases ranking above them. Of course, it is obvious that thesediseases outrank many other more serious ones among the "captains of themen of death, " largely upon the familiar principle of the old riddle, whereby the white sheep eat more grass than the black, "because thereare more of them. "

While only a relatively small percentage of us ever have the bad luck tobe attacked by typhoid fever, rheumatism, or appendicitis, to saynothing of cholera and smallpox, the vast majority of us have gonethrough two or more of these diseases of childhood; so that, though thedeath-rate of each and all of them is low, yet the number of cases is soenormous that the absolute total mounts high. But the pity and, at thesame time, the practical importance of this heavy death-roll is that _atleast two-thirds of it is absolutely preventable_, and by the exerciseof only a very moderate amount of intelligence and vigilance. It is, ofcourse, obvious that in a group of diseases which numbers its victimsliterally by the million every year there will inevitably occur acertain minute percentage of fatal results due to what might be termedunavoidable causes, like a badly nourished condition of the childattacked, unusual circumstances preventing proper shelter or nursing, oran exceptional virulence of the disease, such as will occur in two orthree cases of every thousand in even the most trifling infectiousmalady. But even after making liberal allowance for what might be termedthe unavoidable fatalities, at least two-thirds, and more probablynine-tenths, of the deaths from children's diseases might be preventedupon two grounds:--

First, that they are contagious and absolutely dependent upon a livinggerm, whose spread can be prevented; and secondly, and practically evenmore important, that more than half the deaths from them are due, not tothe disease itself, but to complications occurring during the period ofrecovery, caused, for the most part, by gross carelessness on the partof the mother or nurse. A large majority, for instance, of the nearlythirteen 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 andweakened bronchial mucous membrane, or an infection by one of the scoreof disease-germs, such as those of influenza, pneumonia, bronchitis, andeven tuberculosis, which are continually lying in wait for just such anemergency as this--just such a weakening of the vital resistance. 

It is a sadly familiar statement in the history of fatal cases oftuberculosis that the trouble "began with an attack of measles, " orwhooping-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 thatthere was no dislodging. As breakers of the wall of the hollow square ofthe body-cells, drawn up to resist the cavalry charges of tuberculosis, pneumonia, and rheumatism, few can be compared in deadliness with thediseases of childhood and "common colds. "

Further, while all of them except scarlet fever have a mortality so lowthat it might almost be described as what the French delicately term_une quantité négligeable_, yet a surprisingly large number of thesurvivors do not escape scot-free, but bear scars which they may carryto their graves, or which may even carry them to that bourne later. Again, the actual percentage of the survivors who are marked in thisfashion is small, but such milliards of children are attacked every yearthat, on the old familiar principle, "if you throw plenty of mud some ofit will stick, " quite a serious number are more or less handicapped bythese remainders. For instance, quite a noticeable percentage of casesof chronic eye troubles, particularly of the lids and conjunctiva, suchas "granulated" lids, styes, ulcers of the cornea, date from an attackof measles or even whooping-cough. Many cases of nasal catarrh orchronic throat trouble or bronchitis in children date from the samesource. A large group of chronic discharges from the ear andperforations of the ear-drum are a direct after-result of scarlet fever;and the frequency with which this disease causes serious disturbances ofthe kidneys is almost a household word. Less definitely traceable, buteven more serious in their entirety, are the large group of chronicdepression of vigor, loss of appetite, various forms of indigestion andof bowel trouble, which are left behind after the visitation of one ofthese minor pests, particularly among the children of the poorerclasses, who are unable to obtain the highly nutritious, appetizing, anddelicately cooked foods which are so essential to the full recovery ofthe little invalids. 

One of the English commissions which was investigating the allegedphysical deterioration of city and town populations stumbled upon asingularly interesting and significant fact in this connection, whileplotting the curves of the rate of growth of the children in a givendistrict in Scotland during a series of years. They were struck with thefact that children born in certain years in the same families, neighborhoods, and presumably the same circumstances, grew more rapidlyand had a lower death-rate than those born in other years; and that, onthe other hand, children born in other years fell almost as far belowthe normal in their rate of growth. The only factor which they found tocoincide with these differences was that in the years in which thosechildren who made the slowest growth were born there had been unusuallyheavy epidemics of children's diseases and a high mortality; while, onthe other hand, those years whose "crop" of children made the bestgrowth had been unusually free from such epidemics and had acorrespondingly low mortality, showing clearly that even the survivorsof children's diseases were not only not benefited, but distinctlyhandicapped 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 aphilosophic and a practical point of view is most interesting andprofoundly significant; and that is the question with which we opened:Why is a disease a disease of childhood? The old, primitive view was asguileless and as simple as the age in which the diseases occurred. Theywere regarded not merely by the laity but by grave and reverendphysicians of the Dark Ages as a sort of necessary vital crisis peculiarand appropriate to each particular age of life, --a sort of sweating outand erupting of "peccant humors" of the blood, which must be got ridof or else the individual would not thrive. Incredible as it mayseem, so far was this idea extended, that the great Arabianphysician-philosopher, Rhazes, actually included smallpox in this group, as the last of the "crises of growth" which had to appear and have itsway in young manhood or womanhood. Quaint little echoes of this simplefaith still ring in the popular mind, as, for instance, in thewidespread notion about the dangerousness of doing anything to check theeruption in measles and cause it to "strike in. " Any mother in Israelwill tell you, the first time you propose a bath or a wet pack to reducethe temperature in measles, that if you so much as touch water to theskin of that child it will "drive the rash in" and cause it to die inconvulsions. And, of course, one of the commonest of a physician'smemories is the expression of relief from the mother or aunt in any ofthese mild eruptive fevers, where the skin was well reddened andspotted: "Well, anyway, doctor, it is a splendid thing to get the rashso well out!" Until within the last ten or fifteen years it was nouncommon thing to hear the expression: "Well, I suppose we might just aswell let Willie and Susie go on to school and get the measles and havedone with it. It seems to be a real mild sort this time. " Of course thisview was scientifically shattered two or more decades ago by ourrecognition of the infectious nature of these diseases, but practicallyits hold on the public mind constitutes one of the most serious andvital obstacles in the way of the health-officer when he endeavors toattack and break up an epidemic of measles, whooping-cough, orchicken-pox. 

It cannot be too strongly emphasized that, mild and in their immediateresults trifling, as most of these "little diseases" are, they aregenuine members of that class of pathologic poison-snakes, thegerm-infections; that when they bite, they bite to kill; that two tofive times in every hundred they do kill; that, like all otherinfections, they are capable of inflicting serious and permanent damageupon the great vital organs, the heart, the kidneys, the liver, and thebrain; and that they are the very jackals of diseases, tracing down andpointing out the prey to the lions that work in partnership with them. With whatever we may treat measles and whooping-cough, _never_ treatthem with contempt!

The next conception of the "whyness" of children's diseases was that asone star differs from another in glory, so does one germ differ fromanother in virulence; that the germs of these particular diseases justhappened to be from the beginning unusually mild and at the same timehighly contagious, so that they remained permanently scattered aboutthroughout the community, and attacked each successive brood of newbornchildren as quickly as they could conveniently get at them. Being somild and so comparatively seldom fatal, little or no alarm was excitedby them and few efforts made to check their spread, so that theycontinued to flourish, generation after generation. Upon this theory thegerms of measles, chicken-pox, whooping-cough, mumps, would be insomething like the same class as the numerous species of bacteria andother germs that normally inhabit the human mouth, stomach, andintestines; for the most part, comparatively harmless parasites, or whatare technically now known as "_symbiotes_" (from two Greek words, _bios_, "life, " and _syn_, "with"), a sort of little partners ornon-paying boarders, for the most part harmless, but occasionallycapable of making trouble. There are scores of species of such germs inour food-canals, some of which may be even slightly helpful in theprocess of digestion. Only a very small per cent of the bacilli of anysort in the world are harmful; the vast majority are exceedinglyhelpful. 

There is evidently some truth in this view of children's diseases, especially so far as the reason for their steady persistence andundiminished spread is concerned, namely, the comparative carelessnessand indifference with which they are regarded and treated. But somerather striking developments of recent years have raised grave doubts inour minds as to whether they were always the mild and inoffensive "housecats" that they pass for at present. These are the astonishing andalmost incredible developments that occur when for the first time thesemild and harmless "diseaselets" are introduced to a savage orhalf-civilized tribe. Like an Arabian Nights' transformation, oursleepy, purring, but still able to scratch, "pussy cat" flashes out as aravenous man-eating tiger, killing and maiming right and left. Measles--harmless, tickly, snuffly, "measly" little measles--kills fromthirty to sixty per cent of whole villages and tribes of Indians andcripples half the remainder!

My first direct experience with this feature of our "household pets" wason the Pacific Coast. All the old settlers told me of a dread pestilencewhich had preceded the coming of the main wave of invading civilization, sweeping down the Columbia River. Not merely were whole clans andvillages swept out of existence, but the valley was practicallydepopulated; so that, as one of the old patriarchs grimly remarked, "Itmade it a heap easier to settle it up quietly. " So swift and so fatalhad been its onslaught that villages would be found deserted. The canoeswere rotting on the river bank above high-water mark. The curtains ofthe lodges were flapped and blown into shreds. The weapons and garmentsof the dead lay about them, rusting and rotting. The salmon-nets werestill standing in the river, worn to tatters and fringes by thecurrent. Yet, from the best light that I was able to secure upon it, itappeared to have been nothing more than an epidemic of the measles, caught from the child of some pioneer or trapper and spreading likewildfire in the prairie grass. A little later I had an opportunity tosee personally an epidemic of mumps in a group of Indians, and I haveseldom seen fever patients, ill of any disease, who were more violentlyattacked and apparently more desperately ill than were sturdy youngIndian boys attacked by this trifling malady. Their temperatures rose toone hundred and five or one hundred and six degrees, they becamedelirious, their faces were red and swollen, they ached in every limb, and the complications that occasionally follow mumps even in civilizedpatients were frequent and exceedingly severe. In like manner, influenzawill 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 amongIndians and other savage tribes are now known to have been only measles. At first, pathologists were inclined to receive these reports with somedegree of skepticism, and to regard them either as travelers' tales, oras instances of exceptional and accidental virulence in that particulartribe, the high death-rate due to bad nursing or horrible methods ofvoodoo treatment. 

But from all over the world came ringing in the same story, not merelyfrom scores of travelers, but also from army surgeons, medicalmissionaries, and medical explorers, until it has now become adefinitely established fact that the mild, trifling diseases of infancy, "colds" and influenzas of civilized races, leap to the proportions of adeadly pestilence when communicated to a savage tribe. Whether thattribe be the Eskimo of the Northern ice-sheet or the Terra del Fuegianof the Southern, the Hawaiian of the islands of the Pacific or theAymarás of the Amazon, all fall like grain before the scythe under theattack of a malady which is little more than the proverbial "little'oliday" of three days in bed to civilized man. Evidently civilized manhas acquired a degree and kind of immunity that uncivilized man has not. Either the disease has grown milder or civilized man tougher with theages. 

The probability is that both of these explanations are true. Thesediseases may originally have been comparatively severe and serious; butas generation after generation has been submitted to their attack, thosewho were most susceptible died or were so crippled as to be seriouslyhandicapped in the race of life and have left fewer and less vigorousoffspring. So that, by a gradual process of weeding out the moresusceptible, the more resisting survived and became the resistantcivilized races of to-day. 

On the other hand, any disease which kills its victim so quickly that ithas not time to make sure of its transmission to another one before hisdeath, will not have so many chances of survival as will a milder andmore chronic disorder. Hence, the milder and less fatal strains of germswould stand the better chance of survival. This, of course, is a verycrude outline, but it probably represents something of the process bywhich almost all known diseases, except a few untamable hyenas, like theBlack Death, the cholera, and smallpox, have gradually grown milder withcivilization. If we escape the attack of these attenuated diseases ofinfancy until fifteen or sixteen years of age, we can usually defy themafterward; though occasionally an unusually virulent strain will attackan adult, with troublesome consequences. 

At all events, whatever explanation we may give, the consoling factstands out clearly that civilized man is decidedly more resistant tothese pests of civilization than is any half-civilized race, and thereis good reason to believe that this is a typical instance of hiscomparative vigor and endurance all along the line. 

If this view of the original character and taming of these diseases becorrect, it also accounts for the extraordinary and otherwiseinexplicable cases where they suddenly assume the virulence of cholera, or yellow fever, and kill within forty-eight or ninety-six hours, notmerely in children but also in adults. 

To group these three diseases together simply because they all happen tooccur in children would appear scarcely a rational principle ofclassification. Yet, practically, widely different as they are in theirultimate results and, probably, in their origin, they have so manypoints in common as to their method of spread, prevention, and generaltreatment, that what is said of one will with certain modificationsapply to all. 

I said "probably" of widely different origin, because, by one of thosestrange paradoxes which so often confront us in real life, though theinfectiousness and the method of spread of all these diseases is asfamiliar as the alphabet and as firmly settled, the most careful studyand innumerable researches have failed to identify positively the germin any one of them. There are a number of "suspects" against which agreat deal of circumstantial evidence exists: a streptococcus in scarletfever, a bacillus in whooping-cough, and a protozoan in measles; butnone of these have been definitely convicted. The principal reason forour failure is a very common one in bacteriological research, whoseimportance is not generally known, and that is, that there is not asingle species of the lower animals that is subject to the diseases orcan be inoculated with them. This unfortunate condition is the greatestbarrier which can now exist to our discovery of the causation of anydisease. We were absolutely blocked, for instance, by it in smallpox andsyphilis until we discovered that our nearest blood relatives, the apeand the monkey, are susceptible to them; and then the _CytoryctesVariolæ_ and the _Treponema pallida_ were discovered withincomparatively a few months. Some lucky day, perhaps, we may stumble onthe animal or bird which will take measles, scarlet fever, orwhooping-cough, and then we will soon find out all about them. 

But, fortunately, our knowledge of these little diseases, likeMercutio's wound, is "not so deep as a well, nor so wide as a churchdoor; but 't is enough" for all practical purposes. The general plan oftreatment in all of them might be roughly summed up as, rest in bed in awell-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 antisepticwashes for nose and throat, and mild internal antiseptics, withlaxatives, for the bowels and kidneys. There is no known drug which isspecific in any one of them, though their course may be made milder andthe patient more comfortable by the intelligent use of a variety ofremedies, which assist nature in her fight against the toxin. Notknowing the precise cause, we have as yet no reliable antitoxin for any. 

Now very briefly as to the earmarks of each particular member of thischildren's group. It may be said in advance that the "openings" of allof 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 themucous membranes of the nose, the throat, and the eyes, with consequentsnuffling and blinking and complaints of sore throat. These arefollowed, or in severe, swift cases may be preceded, by flushed cheeks, complaints of headache or heaviness in the head, fever, sometimes risingvery quickly to from one hundred and four to one hundred and fivedegrees, backache, pains in the limbs, and, in very severe cases, vomiting. In fact, the symptoms are almost identical with those of anattack of that commonest of all acute infections, a bad cold, andprobably for the same reason, namely, that the germs, whatever they maybe, attack and enter the system by way of the nose and throat. 

One of the most difficult practical points about the beginning of thisgroup of diseases is to distinguish them from one another, or from acommon cold. The important thing to remember is that, theoreticallyimportant as it may be to make this distinction, practically it isn'tnecessary at all, as they should all be treated exactly alike in thebeginning. The only vital thing is to recognize that you are dealingwith an infection of some sort, isolate promptly the little patient, puthim to bed, and make your diagnosis later as the disease develops. Fortunately neither scarlet fever nor measles usually becomes acutelyinfectious until the rash appears, and as neither is particularlydangerous to adults, especially to such as have had them already, aone-room quarantine is sufficient for the first few days of any of thesediseases. We will lose nothing and gain enormously by adopting thisroutine plan in all cases of snuffling noses, sore throats, headache, and fever in children, for these are the early symptoms of all theirfebrile diseases, from colds to diphtheria; all alike are infectious andall, 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 tothe enemy, whoever he may be, the battle begins to take on itscharacteristic form according to the nature of the invader. We will takefirst the campaign of scarlet fever, since this is the swiftest andfirst to disclose itself. After the preliminary snuffles and headachehave lasted for a few hours, the temperature usually begins to rise; andwhen it does, by leaps and bounds often reaching one hundred and four orone hundred and five degrees within twelve hours, the skin becomes dryand hot, the throat sore, the tongue parched, and the little patientdrowsy and heavy-eyed. Within from twenty-four to forty-eight hours abright red or pinkish rash appears, first on the neck and chest, andthen rapidly spreading all over the surface of the body within anothertwenty-four hours. 

Meanwhile the throat becomes sore and swollen, ranging, according to theseverity of the case, from a slight reddening and swelling to a furiousulcerative inflammation, with the formation of a thick membrane-likeexudate, which sometimes is so severe as to raise a suspicion ofpossible diphtheria. The tongue becomes red and naked, with the papillæshowing light against a red ground, so as to give rise to what has beenknown as "the strawberry tongue. " The temperature is usually high, andthe little patient when he drowses off to sleep is quite apt to becomemore or less delirious. In the vast majority of cases, after two to fourdays 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 reboundtoward recovery sets in. About this time the daily examination of theurine will begin to show traces of albumin, but this, under strict restin bed and careful diet, will usually diminish and ultimately disappear. In the event of a relapse, however, or setback from any cause, thekidneys may become violently attacked, and a considerable per cent ofthe fatal cases die from suppression of the urine. After this crisis hasoccurred, however, in ninety-nine per cent of all cases it iscomparatively plain sailing; the throat is still sore and troublesome, the skin itches and tickles, and the eyes smart, but the little patientsteadily improves day by day. Anywhere from three to five days afterthe break in the fever the skin begins to get rough and scaly, andgradually peels off, until in some cases the entire coating of the bodyis shed, having been killed, as it were, by the violence of theeruption. These _flakes and scales of the skin are exceedinglycontagious_, and no case should be regarded as fit to be released fromisolation until every particle has been shed and got rid of. Thisconstitutes one of the most tiresome and annoying periods of thedisease, as complete shedding is seldom finished before two weeks, andsometimes may last from three to five. 

However, this long period of contagiousness has been found to be reallya blessing in disguise, inasmuch as we now know that even morestrikingly 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 inretreat. Keeping the child at rest for the greater part of the time, inbed or on a lounge, in a well-ventilated room, or later on a porch orterrace, for five weeks from the beginning of the disease, is well worthall the trouble and inconvenience that it causes, for the sake of thealmost absolute protection it gives against dangerous and even fatalcomplications, particularly of the kidneys, heart, or lungs. 

This is a fair description of what might be termed an average case ofthe disease. We also have the sadly familiar type described as thefulminant or, literally, "lightning-stroke" variety. The child goes downas if struck by an invisible hand; vomiting is one of the firstsymptoms; delirium follows within ten or twelve hours; the eruptionbecomes not merely scarlet but purplish from hemorrhage under the skin, giving the name of "black" scarlet fever to this type. The throatbecomes furiously swollen, the urine is absolutely suppressed, the childgoes into convulsions, and dies within forty-eight hours from thebeginning of the attack. Fortunately, this type is rare, but theimportant thing to remember is that it may develop in a child who caughtthe disease from one of the mildest of all possible cases! Hence everycase should be treated with the strictest isolation, as if it wereitself 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 wholeepidemics may be of this character, with a mortality of from twenty tothirty per cent. Generally speaking, however, the death-rate is aboutone in twelve, ranging from as low as one in twenty-five to as high asone in five. 

As in the case of diphtheria, the greatest danger and most powerfulmeans of spread of the disease is through the mild, unrecognized cases, which are supposed to have nothing but a cold and are allowed tocontinue in school or play with other children. We have no antitoxin andno bacteriologic means of positive diagnosis. But one method will stopthe spread and within ten or fifteen years exterminate every one ofthese infections--_isolate at once every child_ that shows symptoms of acold, sore throat, or feverishness, both for its own sake and for thatof the community!

In measles we have to deal with a much more harmless and more nearlydomesticated "beast of prey, " but one of a prevalence to correspond. Though probably (exact data being as yet lacking) not more thanone-third of all individuals are attacked by scarlet fever, it would besafe to say that not more than one-third, and possibly not more thanone-fifth, of us escape measles. Hence, though its mortality is scarcelyone-fourth that of scarlet fever, it more than holds its own in theHerod class, as grimly shown by its total death-roll of over twelvethousand, compared with only a little over six thousand to the credit ofscarlet 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 andrunning at the nose and eyes become more prominent, the child begins toturn its face away from the light because it makes its eyes smart, andcomplains not so much of soreness as of a peppery, burning, itchingsensation in its nose and throat. The tongue is coated, the stomachmildly upset; the little patient is more uncomfortable and fretful thanseriously ill. This condition drags on, without apparently gettinganywhere, for from two to four days, during which time it is often verydifficult even for the most experienced physician to say positively whatthe sufferer has. But about the fourth day a rash begins to appear, typically first upon the cheeks or forehead in the shape of littlewidely separated dull-red blotches. These grow larger and deeper incolor, rising in the middle and spreading at their edges, so thatshortly the whole skin becomes puffed and swollen and of a mottled, pinkish-purple color. If the child's lower lip be pulled down, littlered spots will be seen scattered over the lining membrane of the mouth, showing that the eruption is not confined to the skin. Indeed, theseKoplik's spots (as they are called, after their discoverer) in the mouthwill often appear a day or more before the eruption upon the skin andgive 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 alsoupon the mucous membranes of the eyes, nose, and throat, the windpipeand the bronchial tubes, and which is the cause of the burning, running, and, later, occasional serious inflammatory symptoms in all theseregions. 

When you look at the hot, angry-looking, swollen skin of the littlevictim of measles, the weeping eyes and running nose, and remember thatthis same sort of process is either going on or is likely to occur allover his entire lining, so to speak, from lungs to bowels, you caneasily grasp how important it is to keep him absolutely at rest andprotected from every possible risk in the way of chill, over-exertion, or injudicious feeding, until the whole process has completely subsidedand been forgotten. Neglect of these precautions is the reason why somany cases of measles, on the least and most trifling exposure andoverstrain during the two or three weeks following the disease, willblaze up into a fatal bronchitis or pneumonia. 

The rash takes about two or three days to get out, then it begins tofade and the skin to peel off in tiny, branny scales, so small and thinas to be almost invisible--unlike the huge flakes of scarlet fever. Atthe 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 andfruit, and confinement to the room for at least ten days after thedisappearance of the fever. The very mildest and most insignificant ofattacks may be followed, through carelessness or exposure, by a fatalbronchitis. Indeed, in view of the distressing frequency with which ourhistories of tuberculosis in children contain the words, "Came on aftermeasles, " it is highly advisable to watch carefully every child asregards abundant feeding, avoidance of overwork or overstrain, and ofall unnecessary exposure to infection, wind, or wet, for two monthsafter an attack of measles instead of the customary two weeks. As thedisease is acutely infectious, the little victim should be isolated forat least three weeks after the disappearance of the fever; but thisagain, as in the case of scarlet fever, is emphatically a blessing indisguise from his point of view, as well as a protection to the rest ofthe community. 

Should the "little fever" prove to be whooping-cough, it will be laterstill in positively declaring its definite intentions. The cold orcatarrhal stage will be much milder, the fever lower, the cough a triflemore marked, but will drag on for from a week to ten days beforeanything definite happens. Usually the child is supposed to be sufferingwith a slight cold, hence the prevailing impression that colds run intowhooping-cough, if neglected. Then one day the child is suddenly seizedwith a coughing fit, consisting of from ten to fifteen short coughs inrapid succession of increasing intensity, until all the air seemsliterally pumped out of the lungs of the poor little patient; then, witha tremendous whoop, the youngster gets his breath again and thediagnosis is made. This distressing performance may occur only four orfive times a day, or it may be repeated every half-hour or so. Soviolent is the paroxysm that the eyes of the child protrude, it becomesliterally black in the face, and runs to its mother or nurse, orclutches a chair, to keep from falling. 

As the same great nerves which supply the lungs supply the stomach, theirritation frequently "radiates, " or spills over, from one division ofit to the other, and the coughing fit is frequently followed byvomiting. Unexpectedly enough this may often become the most seriouspractical symptom of the disease, inasmuch as the stomach is emptied sofrequently that the poor little victim is unable to retain anynourishment long enough to absorb it, and may waste away frightfully, and even literally starve to death, or have its resisting power sogreatly lowered that an attack of bronchial trouble or bowel disturbancewill prove rapidly fatal. 

So serious are the disturbances of the circulation all over the body bythese spasmodic suffocation-fits, that rupture of small blood-vesselsmay occur in the eyes, the brain, in the lungs, and on the surface ofthe skin. The heart becomes distended, and if originally weakened may beseriously dilated or overstrained; the lungs become congested andinflamed, and any of the numerous accidental germs which may be presentwill set up a broncho-pneumonia, which is the commonest cause of deathin this disease, as in measles. 

Strangely enough, while, as we do not positively know the germ, andhence cannot state definitely either the cause or the principal seat ofthe trouble, it is not generally believed that the condition of thelungs or the throat has much to do with the cough. 

At all events, it is perfectly idle to treat the disease with coughmixtures or expectorants. The view toward which the majority ofintelligent observers are inclined is that whooping-cough is aninfection, the germ or toxin of which attacks the nervous system, andparticularly the great "lung-stomach" (pneumo-gastric) nerve. At allevents, the only remedies which appear to have any effect upon thedisease are, in the early stages, mild local antiseptics in the nose andthroat, and later those which diminish the irritability of the nerveswithout upsetting the appetite or depressing the general vigor. Thedisease is, for all its mildness, one of the most obstinate known. 

A small percentage of cases run a violent course, in spite of the mostintelligent and anxious care, both medical and household; but the vastmajority of such complications as occur are either caused bycarelessness or become serious only if neglected. Treating all childrenwith whooping-cough as emphatically sick children, entitled to everycare and excuse from exertion, every exemption and privilege that can begiven them until the last whoop has been whooped, would prevent at leasttwo-thirds of the almost ten thousand deaths from whooping-cough thatyearly disgrace the United States. 

To sum up in fine: intelligent, effective isolation of all cases, themild no less than the severe, would stamp out these Herods of thetwentieth century within ten years. In the meantime, six weeks'sick-leave, with all the privileges and care appertaining thereto, willrob 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, likethe "one-hoss shay. " This is largely because we are not all of the sameage, clear through. Some parts of us are older than other parts. We havealways felt a difficulty, not to say a delicacy, in determining the ageof 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 arenot an individual, but a colony; not a monarchy, but a confederacy oforgan-states, each with its millions of cell-citizens. It is not merelyeditors and crowned heads who have a biologic right to say "We. "Therefore, obviously, any statement that we make as to our age can beonly in the nature of an average struck between the ages of our heart, lungs, liver, stomach; and as these vary in ancientness by thousands ofyears, the average must be both vague and misleading. The only reasonwhy there is a mystery about a woman's age is that she is so intenselyhuman and natural. The only statement as to our age that the facts wouldstrictly 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-celleddroplet 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, bysome curious coincidence, explain it as we may, some of our oldestorgans are youngest, in the sense of most vigorous, elastic, andresisting, while some of our youngest are oldest, in the sense ofdecrepit, feeble, and unstable. It is perhaps only natural that an organlike the stomach, for instance, which has a record of honorable serviceand active duty millions of years long, should be better poised, morereliable, and more resourceful than one which, like the lung or theappendix, has, as it were, a "character" of only about one-tenth of thatlength. However this may be, the curious fact confronts us thatscattered about through the body are structures and fragments, theremains of organs which at one time in our ancestral career were, underthe then existing circumstances, of utility and value, but have nowbecome mere survivals, remnants, --in the language of the day, "backnumbers. " Some of these have still a certain degree of utility, thoughdiminished and still diminishing in size and functional importance, likeour third molars or "wisdom" teeth, our fifth or "little" toes, ourgall-bladder, our coccyx or tail-bone, the hair-glands scattered allover the now practically hairless surface of our bodies, and our oncemovable ears, which can no longer be "pricked, " or laid back. These, though of far less utility and importance than they obviously were atone time, still earn their salt, and, though all capable of causing usconsiderable annoyance on slight provocation, seldom give rise toserious 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 ofserious trouble. 

The best known members of this small group are the openings through theabdominal wall, which, originally placed at the strongest and safestposition in the quadrupedal attitude, are now, in the erect attitude, atthe weakest and most dangerous, and furnish opportunity for thoseserious and sometimes fatal escapes of portions of the intestines whichwe call hernia; the tonsils; and our friend the _appendix vermiformis_. 

For once its name expresses it exactly. It _is_ an "appendix, " anafterthought; and it is "_vermiformis_, " a worm-like creature, --and, like the worm, will sometimes turn when trodden on. Its worm-likeness issignificant in another sense also, in that it is this verydiminutiveness in size--the coils into which it is thrown, the spongythickness of its walls, and the readiness with which its calibre or itscirculation is blocked--that is the fundamental cause of its tendency todisease. 

The cause of appendicitis is the appendix. 

"Despise not the day of small things" is good pathology as well asScripture. Here we have a little, worm-shaped tag, or side branch, ofthe food-tube, barely three or four inches long, of about the diameterof a small quill and of a calibre that will barely admit an ordinaryknitting needle. And yet we speak of it with bated breath. When weremember that this little, twisted, blind tube opens directly out of oneof the largest pouches of the intestines (the _cæcum_), and that it iseasy for anything that may be present in the large pouch--food, irritating fragments of waste matter, or bacteria--to find its way intothis fatal little trap, but very difficult to find the way out again, wecan 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 abody in which for the most part there is mutual helpfulness, utility, and perfect smoothness of working through all the great machine? Toattempt to answer this would carry us very far back into ancienthistory. But to make such backward search is absolutely the only meansof reaching an answer. 

"But, " some one will object, "how perfectly irrational, not to sayabsurd, to propose to go back hundreds of thousands of years intoancient history, to account for a disease which has beendiscovered--according to some, invented--within the past twenty-fiveyears!"

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 rankand culture. Our new biologic aristocracy, the "Appendix-Free, " lookdown with gentle disdain upon their appendiciferous fellows who stillbear in their bodies this troublesome mark of their lowly origin. Inshort, the general impression prevails that appendicitis is a newdisease, a disease which has become common, or perhaps occurred at all, only within the last quarter of a century, and which therefore--with theusual flying leap of popular logic--is a serious menace to our future, if it keeps on increasing in frequency and ferocity at anything likethe same rate which it has apparently shown for the past fifteen years. 

As this feeling of apprehension is in many minds quite genuine, it maybe well to say briefly, before proceeding further, first, that, if therebe any disease which absolutely and almost exclusively depends upondefinite peculiarities of structure, it is appendicitis, and that thesestructural peculiarities of this tiny, cramped tag of the food-canalhave existed from the earliest infancy of the race. So it is almostunthinkable that man should not have been subject to fatal disturbancesof this organ from the very earliest times. On the post-mortem table, the appendix of the lowest savage is the same useless, shriveled, andinflammable worm as that of the most highly civilized Aryan, thoughperhaps an inch or so longer. Secondly, there is absolutely no adequateproof that appendicitis is increasing in frequency among civilizedraces. It is only about twenty-five years ago that it was firstdefinitely described, and barely fifteen that the profession began atall generally to recognize it. 

But all of us whose memory extends backward a quarter of a century canclearly 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 ofthe bowels, " of which patients died both painfully and promptly, andwhich we now know were really appendicitis. 

In short, from a careful study of all the data, including the claims sofrequently made of freedom from appendicitis on the part of Orientalraces, colored races, less civilized tribes, vegetarians, and others, weare tending toward the conclusion that the percentage of appendicitis ina given community is simply the percentage of its recognition, --in otherwords, of the intelligence and alertness, first of its physicians, andthen of its laity. As an illustration, my friend Dr. Bloodgood kindlyhad the statistics of the surgical patients treated in the great JohnsHopkins Hospital at Baltimore investigated for me, and found almostprecisely the same percentage of cases of appendicitis among coloredpatients 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 wellfounded, and we now know that a large percentage of cases recover, atleast from the first attack; so that it is quite possible for from halfto two-thirds of the cases of appendicitis actually occurring in a givencommunity to escape recognition, unless promptly reported, carefullyexamined, and accurately diagnosed. Thirdly, in spite of the remarkablenotoriety which the disease has attained, the general dread of itsoccurrence, --which has been recently well expressed in a statement thateverybody either has had it, or expects to have it, or knows somebodywho has had it, --the actual percentage of occurrence of graveappendicitis is small. In the United States census of 1900, which wasthe first census in which it was recognized as a separate cause ofdeath, it was responsible for only 5000 deaths in the entire UnitedStates for the ten years preceding, or about one death in two hundred. This rate is corroborated by the data, now reaching into thousands, fromthe post-mortem rooms of our great hospitals, which report an average ofbetween a half and one per cent. A disease which, in spite of thewidespread terror of it, kills only one in two hundred of those whoactually die--or about one in every ten thousand of our population--iscertainly nothing to become seriously excited over from a racial pointof view. 

While appendicitis is one of the "realest" and most substantial ofdiseases, and, in its serious form, highly dangerous to life, there canbe little doubt that there has come, first of all, a state of mindalmost approaching panic in regard to it; and, second, a preference forit as a diagnosis, as so much more _distingué_ than such plebeian namesas "colic, " "indigestion, " "enteritis, " or the plain old Saxon"belly-ache, " which has reached almost the proportions of a fad. It iscertain that nowadays physicians have almost as frequently to refuse tooperate on those who are clamoring for the distinction, as to urge aneeded operation upon those unwilling to submit to it. 

The satirical proposal that a "closed season" should be established bylaw for appendicitis as for game birds, during which none might betaken, 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 firstquestion for disposal is, How did the appendix become an appendix? Tothis biology can render a fairly satisfactory answer. It is the remainsof one of Mother Nature's experiments with her 'prentice hand upon themammalian food-tube. As is now generally known, the food-canal inanimals was originally a comparatively straight tube, running the lengthof 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_, orstorage and churning-place for the food. Below this, it lengthens intocoils (the so-called _small intestine_), which, as the body becomes morecomplex, increase in number and length until they reach four to tentimes the length of the body. Later, the lower third of the tubedistends and sacculates out into a so-called _large intestine_, in whichthe last remnants of nutritive material and of moisture are extractedfrom the food-residues before they are discharged from the body. Just atthe junction of this large intestine with the small intestine, naturetook it into her head to develop a second pouch, a sort of copy of thestomach. This pouch, from the fact that it ends in a blind sac, is knownas the _cæcum_ (or "blind" pouch), and is apparently simply a means ofdelaying the passage of the foodstuffs until all the nutriment andmoisture have been absorbed out of them for the service of the body. Naturally, it has developed to the largest degree and size in thoseanimals which have lived upon the bulkiest and grassiest of foods, theso-called _Herbivora_, or grass-eaters. In the _Carnivora_, orflesh-eaters, it is usually small, and in one family, the bears, entirely absent. This pouch is no mere figure of speech, as may begathered from the fact that in certain of the rodent _Herbivora_, likethe common guinea-pig, it may have a capacity equal to all of the restof the alimentary canal, and in the horse it will hold something likefour 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 asort of inverse proportion to the stomach; those which have large, sacculate, pouched stomachs, like the cow, sheep, and the ruminantsgenerally, having smaller _cæca_. In other _Herbivora_ with smallstomachs, like the rabbit and the horse, it develops greater size. 

Our primitive ancestors were mixed feeders, and, though probably morelargely herbivorous than we are to-day, had a medium-sized _cæcum_, andmaintained it up to the point at which the anthropoid apes began tobranch off from our family-tree. But at about this point, for somereason, possibly connected with the increasing variety and improvedquality and concentration of the food, due to greater intelligence andability to obtain it, this large _cæcum_ became unnecessary, and beganto shrivel. 

Here, however, is where nature makes her first afterthought mistake. Instead of allowing this pouch to contract and shrivel uniformlythroughout 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-shapedpouch, about six to eight inches long and two inches in diameter, hasbecome distorted down into a narrow, contracted end portion, about aquarter of an inch in diameter, and a distended first portion, for allthe world like a corncob pipe with a crooked stem and an unusually largebowl. And behold--the modern _appendix vermiformis_, with all its fatalpossibilities!

If we want something distinctly human to be proud of, we may take theappendix, for man is the only animal that has this in its perfection. Asomewhat similarly shriveled last four inches of the _cæcum_ is found inthe anthropoid apes and in the wombat, a burrowing marsupial ofAustralia. In some of the monkeys, and in certain rodents like theguinea-pig, a curious imitation appendix is found, which consists simplyof a contracted last four or five inches of the _cæcum_, which, however, on distention with air, is found to relax and expand until of the samesize as the rest of the gut. 

The most strikingly and distinctly human thing about us is not ourbrain, but our appendix. And, while recognizing its power for mischief, it is only fair to remember that it is an incident and a mark ofprogress, of difficulties overcome, of dangers survived. In allprobability, it was our change to a more carnivorous diet, andconsequently predatory habits, which enabled our ancestors to step outfrom the ruck of the "_Bandar-Log_, " the Monkey Peoples. An increase incarnivorousness must have been a powerful help to our survival, both bywidening our range of diet, so that we could live and thrive on anythingand everything we could get our hands on, and by inspiring greaterrespect in the bosoms of our enemies. Let us therefore respect theappendix as a mark and sign of historic progress and triumph, evenwhile recognizing to the full its unfortunate capabilities for mischief. 

But what has this ancient history to do with us in the twentiethcentury? Much in every way. First, because it furnishes the physicalbasis of our troubles; and second, and most important, because, likeother history, it is not merely repeating itself, but continuing. Thisprocess of shriveling on the part of the appendix is not ancient historyat all, but exceedingly modern; indeed, it is still going on in ourbodies, unless we are over sixty-five years of age. 

In the first place, we have actually passed through two-thirds of thisprocess in our own individual experience. 

At the first appearance of the _cæcum_, or blind pouch, in our prenatallife, it is of the same calibre as the rest of the intestine, and ofuniform size from base to tip. About three weeks later the tip begins toshrivel, and from this on the process steadily continues, until at birthit has contracted to about one-fifteenth of the bulk of the _cæcum_. Butthe process doesn't stop here, though its progress is slower. By aboutthe fifth year of life the stem of the cæco-appendix pipe has diminishedto about one-thirtieth of the size of the bowl, which is the proportionthat it maintains practically throughout the rest of adult life. For along time we concluded that the process was here finished, and that theappendix underwent no further spontaneous changes during life; but, after appendicitis became clearly recognized, a more careful study wasmade of the condition of the appendix in bodies coming to thepost-mortem table, dead of other diseases, at all ages of life. Thisquickly revealed an extraordinary and most significant fact, that, whilethe appendix was no longer decreasing in apparent size, its internalcapacity or calibre was still diminishing, and at such a rate that bythe thirty-fifth year it had contracted down so as to become cut offfrom the cavity of the _cæcum_ in about twenty-five to thirty per centof all individuals. By the forty-fifth year, according to the anatomistRibbert (who has made the most extensive study of the subject), nearlyfifty per cent of all appendices are found to be cut off, and by thesixty-fifth year nearly seventy per cent. 

This explains at once why appendicitis is so emphatically a disease ofyoung life, the largest number of cases occurring before thetwenty-fifth year (fifty per cent of all cases occur between ten andthirty years of age), and becoming distinctly rarer after thethirty-fifth, only about twenty per cent occurring after this age. Assoon as the cavity of the appendix is cut off from that of theintestine, it is of course obvious that infectious or other irritatingmaterials can no longer enter its cavity to cause trouble, although, ofcourse, it is still subject to accidents due to kinks, or twists, orinterference 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 forappendicitis. A small, twisted, shriveling spur or side twig of theintestine, opening from a point which has become a kind of settlingbasin in the food-tube, its mouth gaping, as it were, to admit anypoisonous or irritating food, infectious materials, disease-germs, theordinary bacteria which swarm in the alimentary canal, or irritatingforeign bodies, like particles of dirt, sand, hairs, fragments of bone, pins, etc. , which may have been accidentally swallowed. Once theseirritating and infectious materials have entered it, spasm of itsmuscular coat is promptly set up, their escape is blocked, and a violentinflammation easily follows, which may end in rupture, perforation, organgrene. 

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 inthe appendix, but there is now much evidence to indicate that theordinary bacteria which inhabit the alimentary canal, particularly thatfirst cousin of the typhoid bacillus, the colon bacillus, when oncetrapped in this _cul-de-sac_, may quickly acquire dangerous powers andset up an acute inflammation. It is not necessary to suppose that anyparticular germ or infection causes appendicitis. Any one which passesthrough, or attacks, the alimentary canal is quite capable of it, andprobably does cause its share of the attacks. 

Numerous attempts have been made to show that appendicitis isparticularly 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 ofthem, though in none with sufficient frequency or constancy to enable itto be regarded as one of the chief or even one of the important causesof the disease. 

One dread, however, we may relieve our anxious souls of, and that is thefamous grape-seed or cherry-stone terror. To use a Hibernianism, one ofour most positive conclusions in regard to the cause of appendicitis isa negative one: that it is not chiefly, or indeed frequently, due to thepresence of foreign bodies. This was a most natural conclusion in theearly days of the disease, since, given a tiny blind pouch with aconstricted opening gaping upon the cavity of the food-canal, nothingcould be more natural than to suppose that small irritating foodremnants or foreign bodies, slipping into it and becoming lodged, wouldblock it and give rise to serious inflammation. And, moreover, this _apriori_ expectation was apparently confirmed by the discovery, in manyappendices removed by operation, of small oval or rounded masses, closely resembling the seed of some vegetable or fruit. Whereuponanxious mothers promptly proceeded to order their children to "spitout, " with even more religious care than formerly, every grape-seed andcherry-stone. The increased use of fresh and preserved fruits wasactually gravely cited, particularly by our Continental brethren, as oneof the causes of this new American disease. Barely ten years ago I wasspending the summer in the Adirondacks, and was bitterly reproached bythe host of one of the Lake hotels, because the profession had soterrified the public about the dangers of appendicitis from fruit-seedsthat he was utterly unable to serve upon his tables a large stock ofdelicious preserved and canned raspberries, blackberries, and grapeswhich he had put up the previous years. "Why, " he said, "more than halfthe people that come up here will no more eat them than they wouldpoison, for fear that some of the seeds will give 'em appendicitis. "This dread, however, has been deprived of all rational basis, first, byfinding that many inflamed appendices removed, after the operationbecame more common, contained no foreign body whatever; secondly, thatmany perfectly healthy appendices examined on the post-mortem table, death being due to other diseases, contain these apparently foreignbodies; and thirdly, that when these "foreign bodies" were cut into, they were found to be not seeds or pits of any description, but hardenedand, in some cases, partially calcareous masses of the fæces. 

We are in a nearly similar position in regard to the third alleged causeof appendicitis, and that is food. Many are the accusations which havebeen made in this field. On the one hand, meat and animal foodsgenerally have been denounced, on account of their supposed "heating" or"uric-acid-forming" properties; while on the other, vegetables andfruits have been equally hotly incriminated, on account of their seeds, fibres, husks, and irritating substances, and the danger of their beingcontaminated by bacteria and other parasites from the soil. Thesecharges appear to have little adequate foundation, and, so far as we arein a position now to judge, the only way a food can give, or beaccessory to, appendicitis is by its being taken in such excessiveamounts as to set up fermentive or putrefactive changes in thealimentary canal, or by its being in an unsound, decaying, or actuallydiseased condition. Any amounts or quality of food which are capable ofgiving rise to an attack of acute indigestion may secondarily lead to anattack of appendicitis. The only single article of diet whose ingestionis declared by Osler to be rather frequently followed by an attack ofappendicitis is the peanut. 

Therefore, the best thing to do in the way of taking precautions againstthe occurrence of appendicitis is, in the language of the day, to"forget it" as completely as possible, reassuring ourselves that, inspite of its extraordinary notoriety and popularity, it is acomparatively rare disease in its fatal form, responsible for not morethan 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 wereach 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 isthe use of disturbing ourselves over the question of what may become ofit? 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 tipof 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 thequestion of what to do in each particular case its difficulties andperplexities. 

The appendix does not, unfortunately, hang out from the surface of thebody, where it could peacefully decay and drop off without prejudice tothe rest of the body, or be quickly lopped off in the event of itsgiving trouble. On the contrary, it projects its stubby andinsignificant length right into the midst of the most delicate andsusceptible cavity of the body, the general cavity of the abdomen, orperitoneum. The thin, sensitive sheet of peritoneum which lines thiscavity covers every fold and part of the food-tube, from the stomachdown to the rectum. And when once infection or inflammation has occurredat any point in it, there is nothing to prevent its spreading like aprairie fire, all over the entire abdominal cavity from diaphragm topelvis. If this wretched little remnant were a coil of explosive fusewithin the brain-cavity itself, which any jar might set off, it couldhardly be richer in possibilities of danger. 

A redeeming feature of appendicitis is that the appendix lies--so tospeak--in a corner, or wide-mouthed pouch, of the great peritonealcavity; and if the inflammation set up in it can be "walled off" fromthe rest of the peritoneal cavity, and limited strictly to this littlecorner or pouch, all will be well. This is what occurs in those cases ofsevere appendicitis which spontaneously recover. If, however, thisdisturbance bursts its barriers, and lights up an inflammation of theentire 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 andstamp out the process in this manner is the core of the problem thatconfronts us, as attending physicians. 

In the majority of cases, fortunately, the peritoneal fire brigade actspromptly, pours out a wall of exudate, and locks up the appendix in aliving 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 givenits ancestral or traditional rights and allowed to inflict its pettytroubles upon the entire abdominal cavity, and include the body in itsdownfall. 

Lastly come the two most pertinent and appealing questions:--

What is the outlook for me if I should develop appendicitis? And what isto be done?

In regard to the first of these, it is safe to say that our answer ismuch less alarming than it was in the earlier stage of our knowledge. Naturally enough, in the beginning, only the severest and mostunmistakable forms of the disease and those which showed no tendency tolocalization, were recognized, or at least came under the eye of thesurgeon; and as a large percentage of these resulted fatally, theconclusion was reached, both in the medical profession and by the laity, that appendicitis was an exceedingly dangerous disease, with a highfatality in all cases. As, however, physicians became more expert in therecognition of the disease, it was discovered to be vastly more common, while side by side came the consoling knowledge that a considerablepercentage of cases got well of themselves, in the sense of theinflammation being limited to the lower right-hand corner of theabdominal cavity, though, of course, with the possibility of leaving asmouldering fuse which might light up another explosion under any stressin future. 

Further, as the attention of the post-mortem investigators at our largehospitals was directed to the subject, it was found that a veryconsiderable percentage of all bodies, ranging from twenty to--accordingto some estimates--as high as sixty per cent, showed changes in theappendix and its neighborhood which were believed to be due to oldinflammations; so that, while it is possible to speak only with greatcaution and reserve, the balance of opinion among clinicians andpathologists of wide experience and the more conservative surgeonsappears to be that from one-half to two-thirds of all cases ofappendicitis will recover of themselves, in the sense of subsiding moreor less permanently, without causing death. 

On the other hand, it must be remembered that the appendix is an organwhich, so far as any evidence has been adduced, is entirely withoutuseful function; that it is in process of shriveling and disappearance, if left entirely alone, and that the best result which can be expectedfrom a self-cured attack of appendicitis is the destruction of theappendix and its elimination as a further possible cause of mischief. Byavoiding an operation in appendicitis, we may be practically certainthat we save nothing that is worth saving--except the fee. Moreover, even though only from one-fourth to one-third of all cases developserious complications, you never can be quite sure in which divisionyour particular case will fall. 

The situation is in fact a little bit like one related in theexperience of Edison, the inventor. The trustees of a church in aneighboring town had just completed a beautiful new church building witha high spire, projecting far above any other building in the town. Whenit was nearing completion, the question arose, should they put on alightning-rod. The great church itself had strained their financialresources, and one party in the board were of the opinion that theyshould avoid this unnecessary expense, supporting their economicattitude by the argument that, to put on a lightning-rod, would argue alack of trust in Providence. Finally, after much debate, it was decided, as the great electrician was readily accessible, to submit the questionto him. Mr. Edison listened gravely to the arguments presented, pro andcon. 

"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 ona lightning-rod. Providence is apt to be, at times, a trifleabsent-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 beguided entirely by his opinion. An attack of appendicitis is likeshooting the Grand Lachine Rapids. Probably you will come through allright; but there is always the possibility of landing at a moment'snotice on the rocks or in the whirlpools. With a good pilot your riskdoesn't exceed a fraction of one per cent. And fortunately thiscondition has been not merely theoretically but practically reachedalready; for the later series of case-groups of appendicitis treated inthis intelligent way by coöperation between the physician and surgeonfrom the start, with prompt interference in those cases which to thepracticed eye show signs of making trouble, has reduced the actualrecorded mortality of the disease to between two and five per cent. Evenof those cases which come to operation now, the death-rate has beenreduced as low as five per cent, in series of from 400 to 600 successiveoperations. When we contrast this with the first results of operation, when the cases as a rule were seen too late for the best time ofinterference, and from twenty per cent to thirty per cent died; and withthe intermediate stage, when surgeons as a rule were inclined to adviseoperation at the earliest possible moment that the disease could berecognized, and from ten per cent to fifteen per cent died, we can seehow steady the improvement has been, and how encouraging the outlook isfor the future. 

Cases which have weathered one attack of appendicitis are of course byno means free from the risk of another. Indeed, at one time it wasbelieved that a recurrence was almost certain to occur. Laterinvestigations, based upon larger numbers of cases, now running up intothe thousands, give the reassuring result that though this danger is areal one, it is not so great as it was at one time supposed, as theaverage number in whom a second attack occurs appears to be abouttwenty per cent. This, however, is a large enough risk to be worthy ofserious consideration; and in view of the fact that the mortality ofoperations done between attacks is less than one per cent, it isgenerally the feeling of the profession that, where there is anyappreciable soreness, or tenderness, or liability to attacks of pain inthe right iliac region, in an individual who has had one attack ofappendicitis, the really conservative and prudent procedure is to havethe source of the trouble removed once and for all. 

The four principal symptoms of appendicitis are: pain, which is usuallyfelt most keenly somewhere between the umbilicus and the right groin, though this is by no means invariable; tenderness in that same regionupon pressure; rigidity of the muscles of the abdominal wall on theright 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 onfirm pressure down in this right lower or southwest quadrant of theabdomen, --but be careful not to press too hard, it isn't safe, --you mayfeel fairly sure that you haven't got appendicitis. If you are, you maystill 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 OFTHE PIONEER

Malaria has probably killed more human beings than all the wars thathave ever devastated the globe. Some day the epic of medicine will bewritten, and will show what a large and unexpected part it has played inthe progress of civilization. Valuable and essential to that progress aswere the classic great discoveries of fire, ships, wheeled carriages, steam, gunpowder, and electricity, they are almost paralleled by thevictories of sanitary science and medicine in the cure and prevention ofthat greatest disrupter of the social organism--disease. No sooner doesthe primitive human hive reach that degree of density which is the oneindispensable condition of civilization, than it is apt to breed apestilence which will decimate and even scatter it. Smallpox, cholera, and bubonic plague have blazed up at intervals in the centres ofgreatest congestion, to scourge and shatter the civilization that hasbred them. No civilization could long make headway while it incurred thedangers from its own dirtiness; and to-day the most massive and imposingremains of past and gone empires are their aqueducts, their sewers, andtheir public baths. What chance has a community of building up a steadyand efficient working force, or even an army large enough for adequatedefense, 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 ofsome pestilence? The bubonic plague alone is estimated to have slainthirty millions of people within two centuries in Mediæval Europe, andto have turned whole provinces into little better than deserts. 

In malaria, however, we have a disease enemy of somewhat different classand habits. While other great infections attack man usually where he isstrongest and most numerous, malaria, on the contrary, lies in wait forhim where he is weakest and most scattered, upon the frontiers ofcivilization and the borders of the wilderness. It is only of late yearsthat we have begun to realize what a deadly and persistent enemy of thefrontiersman and pioneer it is. We used to hear much of climate as anobstacle to civilization and barrier to settlement. Now, for climate weread "malaria. " Whether on the prairies or even the tundras of theNorth, or by the jungles and swamps of the Equator, the _thing thatkilled_ was eight times out of ten the winged messenger of death withhis 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 thedeadly "jungle fever, " "African fever, " "black fever" of the tropics, from Panama to Singapore. Hardly a generation ago, along the advancingfront of civilization in the Middle West, the whole life of thecommunity was colored with a malarial tinge and the taste of quininewas as familiar as that of sugar. To this day, over something likethree-quarters of the area of these United States, the South, MiddleWest, and Far West, if you feel headachy and bilious and "run down, " yousum it all up by saying that you are feeling "malarious. " Dwellers uponthe rich bottom-lands expected to shake every spring and fall withalmost the same regularity as they put on and shed their winterclothing. Readers of Frank Stockton will remember the gales of merrimentexcited by his quaint touch of the incongruous in making the prospectivebridegroom of the immortal Pomona change the date of their wedding dayfrom Tuesday to Monday, because, on figuring the matter out, he haddiscovered that Tuesday was his "chill-day. "

Though the sufferer from ague seldom received very much sympathy at thetime, but was considered a fair butt for genial ridicule and chaff, yeteven there the trouble had its serious side. Through all thosecommunities there stalked a well-known and dreaded spectre, theso-called "congestive chill, " what is now known in technical language asthe pernicious malarial paroxysm. These were like the three warnings ofdeath in the old parable. You would probably survive the first and mightnever have another; but if you had your second, it was consideredequivalent to a notice to quit the country promptly and without countingthe cost. In my boyhood days in the Middle West, I can recall hearingold pioneers tell of little groups of one or more families moving out onto some particularly rich and virgin bottom-land and losing two orthree or more members out of each family by congestive chills withinthe first year, and in some cases being driven in from the outpost andback to civilization by the fearful death-loss. 

A pall of dread hangs over the whole west coast of Africa. The factoriesand trading-posts are haunted by the ghosts of former agents andexplorers who have died there. Some years ago one German company had thesinister record that of its hundreds of agents sent out to the GoldCoast under a three years' contract, not one had fulfilled the term! Allhad either died, or been invalided and returned home. It was malariamore than any other five influences combined that thwarted the French intheir attempt to dig the Panama Canal and that made the Panama Railroadbear the ghastly stigma of having built its forty miles of track with ahuman body for every tie. 

Malaria ever has been, and is yet, the great barrier against theinvasion of the tropics by the white races; nor has its injuriousinfluence been confined to the deaths that it causes, for these gaps inthe fighting line might be filled by fresh levies drawn from thewholesome North. Its fearfully depressing and degenerating effects uponeven those who recover from its attacks have been still more injurious. It has been held by careful students of tropical disease and conditionsthat no small part of that singular apathy and indifference which stealover the mind and body of the white colonist in the tropics, numbingeven his moral sense, and alternating with furious outbursts of what theFrench have termed "tropical wrath, " characterized by unnatural crueltyand abnormal disregard for the rights of others, is the deadly workof malaria. It is the most powerful cause, not merely of theextinction of the white colonist in the tropics, but of the peculiardegeneracy--physical, mental, and moral--which is apt to steal over eventhe survivors who succeed in retaining a foothold. Two particularlyingenious investigators have even advanced the theory that theimportation of malaria into the islands of Greece and the Italianpeninsula by soldiers returning from African and Southern Asiaticconquests 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, hashad much to do both with the degeneracy of the Southern "cracker, " or"mean white, " and with those wild outbursts of primitive ferocity in allclasses which take the form of White Cap raids and lynching mobs. 

However this may be, the disease and the colonization habit brought in acrude way their own remedy. The Spanish conquerors of Peru were told bythe natives that a certain bark which grew upon the slopes of the Andeswas a sovereign remedy for those terrible ague seizures. Indian remediesdid not stand as high in popular esteem as they do now; but they were indesperate straits and jumped at the chance. To their delight, it proveda positive specific, and a Spanish lady of rank, the Countess Chincona, was so delighted with her own recovery that she carried back a packageof the precious Peruvian bark on her return to Europe, and endeavored tointroduce it. So furious was the opposition of the Church, however, tothis "pagan" remedy that she was completely defeated in her praiseworthyattempt and was obliged to confine her ministrations to those whobelonged to her, the peasantry on her own estate. About half a centurylater, the new remedy excited so much discussion by the numerous curesthat it effected, that it was considered worthy of a special council ofthe Jesuits, who formally pronounced it suitable for the use of thefaithful, thereby attaching to it for many years the name of "Jesuit'sbark. " Virtue, however, is sometimes rewarded in this world, and thedevoted and enlightened countess has, all unknown to herself, attainedimmortality by attaching her name, Chincona, softened into _cinchona_, and hardened into _quinine_, to the greatest therapeutic gift of thegods to mankind. It is not too much to say that the modern colonizationof the tropics and subtropics by Northern races, which is one of thegreatest and most significant triumphs of our civilization, would havebeen almost impossible without it. Its advance depended upon twopowders, one white and the other black, --quinine and gunpowder. 

For nearly three centuries we rested content with the knowledge that inquinine we had a remedy for malaria, which, if administered at theproper time and in adequate doses, would break up and cure ninety percent of all cases. Just how it did it we were utterly in the dark, andmany were the speculations that were indulged in. It was not until1880, that Laveran, a French army surgeon stationed in Algeria, announced the discovery in the blood of malarial patients of an organismwhich at first bore his name, the _Hematozoon-Laveran_, now known as the_Plasmodium malariæ_. This organism, of all curious places, burrowedinto and found a home in the little red corpuscles of the blood. Atperiods of forty-eight hours it ripened a crop of spores, and wouldburst out of the corpuscles, scattering throughout the blood and thetissues of the body, and producing the famous paroxysm. This accountedfor the most curious and well-marked feature of the disease, namely, itsintermittent character, chill and fever one day, and then a day ofcomparative health, followed by another chill day and so on, as long asthe infection continued. One problem, however, was left open, and thatwas why certain forms of the disease had their chills every fourth dayand so were called _quartan_ ague. This was quickly solved by thediscovery of another form of the organism, which ripened its spores inthree days instead of two. So the whole curious rhythm of the diseasewas established by the rate of breeding or ripening of the spores of theorganism. Later still another form was discovered, which had no suchregular period of incubation and gave rise to the so-called irregular, or _autumnal_, malarial fevers. That form of the fever which had aparoxysm every day, the classic _quotidian_ ague, remained a puzzle fora little longer, but was finally discovered to be due chiefly to thepresence of two broods, or infections, of the organism, which ripenedon alternate days and hence kept the entire time of the unfortunatepatient occupied. 

The mystery of the remedial effect of quinine was also solved, as it wasfound that, if administered at the time which centuries of experiencehas shown us to be the most effective, between or shortly before theparoxysms, it either prevented sporulation or killed the spores. So thatat one triumphant stroke the mystery of centuries was cleared up. 

But here will challenge some twentieth-century _Gradgrind_: "This is allvery pretty from the point of view of abstract science, but what is thepractical value of it? The discovery of the plasmodium and itspeculiarities has merely shown us the how and the why of a fact that wehad known well and utilized for centuries, namely, that quinine willcure malaria. " Just listen to what follows. The story of the plasmodiumis one of the most beautiful illustrations of the fact that there is nosuch thing as useless or unpractical knowledge. The only thing thatmakes any knowledge unpractical is our more or less temporary ignoranceof how to apply it. The first question which instantly raised itselfwas, "How did the plasmodium get into human blood?" The verysickle-shape of the plasmodium turned itself into an interrogation mark. The first clew that was given was the new and interesting one that thisorganism 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 incidentalpractical lesson of enormous value, and that was that it paved the wayfor the identification of a whole class of animal parasites causinginfectious diseases, which already includes the organisms of Texas feverin cattle, dourine in horses, the _tsetse_ fly disease, the dreadedsleeping sickness, and finally such world-renowned plagues as syphilisand perhaps smallpox. 

Being an animal, the plasmodium naturally would not grow uponculture-media like the vegetable bacilli and bacteria, and this veryfact had delayed its recognition, but raised at once the probabilitythat it must be conveyed into the human body by some other animal. Obviously, the only animals that bite our human species with sufficientfrequency and regularity to act as transmitters of such a common diseaseare those Ishmaelites of the animal world, the insects. As all theevidence 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 theworst, it must be some insect which flew and bit by night; which bySherlock Holmes's process promptly led the mosquito into the dock as thesuspected criminal. It wasn't long before he was, in the immortallanguage of Mr. Devery, "caught with the goods on"; and in 1895 Dr. Ronald Ross, of the Indian Medical Service, discovered and positivelyidentified the plasmodium undergoing a cycle of its development in thebody of the mosquito. He attempted to communicate the disease to birdsand animals by allowing infected mosquitoes to bite them, but wasunsuccessful. Two Italian investigators, Bignami and Grassi, saw thatthe problem was one for human experiment and that nothing less wouldsolve it. Volunteers were called for and promptly offered themselves. Their blood was carefully examined to make sure that they were notsuffering from any latent form of malaria. They then allowed themselvesto be bitten by infected mosquitoes, and within periods varying from sixto ten days, eight-tenths of them developed the disease. It may be someconsolation to our national pride to know that although the organism wasfirst identified in the mosquito by an Englishman and its transmissionto human beings in its bite by Italians, the first definite andcarefully worked-out statement of the relation of the mosquito tomalaria was made by an American, King of Washington, in 1882; though itis only fair to say that suggestions of the possible connection betweenmosquitoes and malaria had, so to speak, been in the air and been madefrom scores of different sources, from the age of Augustus onward. 

Another mystery was solved--and what a flood of light it did pour uponour speculations as to the how and wherefore of the catching of malaria!In some respects it curiously corroborated and increased our respect forpopular beliefs and impressions. While "bad air" had nothing to do withcausing the disease, except in so far as it was inhabited by songstersof the _Anopheles_ genus, yet it was precisely the air of marshy placeswhich was most likely to be "bad" in this sense. So that, while in onesense those local wiseacres, who would point out to you the pearly mistsof evening as they rose over low-lying meadows and bottom-lands, andinform you that there before your very eyes was the "mylary justa-risin' out of the ground, " were ludicrously mistaken, in another theirpractical conclusion was absolutely sound; for it is in just such air, at such levels above the surface of the water, that the _Anopheles_ mostdelights to disport himself. Furthermore, while all raw or misty air is"bad, " the night air is infinitely more so than that of the day, becausethis is the time at which mosquitoes are chiefly abroad. In fact, therecan be little doubt that this is part of the foundation for that rabidand unreasonable dread of the night air which we fresh-air crusadersfind the bitterest and most tenacious foe we have to fight. We haveliterally discovered the Powers of Darkness in both visible and audibleform, and they have wings and bite, just like the vampire. 

It was also a widespread belief in malarial regions that the hours whenyou are most likely to "git mylary inter yer system" were those justbefore and just after sundown; and now entomologists inform us thatthese are precisely the hours at which the _Anopheles_ mosquito, theonly genus that carries malaria, flies abroad. 

Of course, a number of popular causes, such as bad drainage, thedrinking of water from shallow surface wells, damp subsoils under thehouses, and especially that peculiarly widespread and firmly heldarticle of belief that new settlements, where large areas of prairie sodwere being freshly upturned by the plough, were peculiarly liable tothe attack and spread of malaria, had to go by the board, --with thisimportant reservation, however, that almost every one of these allegedcauses either implied or was pretty safe to be associated with pools orswamps of stagnant water in the neighborhood, which would furnishbreeding-spots for the mosquitoes. 

The discovery explains at once a score of hitherto puzzling facts as tothe distribution of malaria. Why, for instance, in all tropical or othermalarious countries, those who slept in second and third story bedroomswere less likely to contract the disease, supposedly because "bad airdidn't rise to that height, " is clearly seen to be due to the fact thatthe mosquito seldom flies more than ten or twelve feet above the levelof the ground or marsh in which he breeds, except when swept byprevailing winds. It also explained why in our Western and Southwesternstates the inhabitants of the houses situated on the south bank of ariver, though but a short distance back from the stream, would suffervery slightly from malaria, while those living upon the north bank, halfa mile back, or even upon bluffs fifteen or twenty feet above the waterlevel, were simply plagued with it. The prevailing winds during thesummer are from the south and mosquitoes cannot fly a foot against thewind, 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 warmspring and summer months, and its prompt subsidence after a killingfrost, were seen simply to be due to the influence of the weather uponthe flight of mosquitoes. Shakespeare's favorite reference to "the sunof March that breedeth agues" has been placed upon a solid entomologicalbasis by the discovery that, like his pious little brother insect, thebee, the one converted and church-going member of a large criminalfamily, the mosquito hies himself abroad on his affairs at the veryfirst gleam of spring sunshine, and will even reappear upon a warm, sunny day in November or December. Perhaps even some of the popularprejudice against "unseasonable weather" in winter may be traceable tothis fact. 

Granted that mosquitoes do cause and are the only cause of malaria, whatare you going to do about it? At first sight any campaign againstmalaria which involves the extermination of the mosquito would appearabout as hopeless as Mrs. Partington's attempt to sweep back the risingAtlantic tide with her broom. But a little further investigation showedthat it is not only within the limits of possibility, but perfectlyfeasible, to exterminate malaria absolutely from the mosquito end. Inthe first place, it was quickly found that by a most mercifulsqueamishness on the part of the plasmodium, it could live only in thejuices of one particular genus of mosquito, the _Anopheles_; and asnowhere, not even in the most benighted regions of Jersey, has thisgenus been found to form more than about four or five per cent of thetotal mosquito population, this cuts down our problem to one-twentiethof its apparent original dimensions at once. The ordinary mosquito ofcommerce (known as _Culex_) is any number of different kinds of anuisance, but she does not carry malaria. 

Here the trails of the extermination party fork, one of them taking theperfectly obvious but rather troublesome direction of protecting housesand particularly bedrooms with suitable screens and keeping theinhabitants safely behind them from about an hour before sundown on. Bythis simple method alone, parties of explorers, of campers, ofrailroad-builders going through swamps, of the laborers on our PanamaCanal, have been enabled to live for weeks and months in the mostmalarious regions with perfect impunity, so long as these precautionswere strictly observed. The first experiment of this sort was carriedout by Bignami upon a group of laborers in the famous, or ratherinfamous, Roman Campagna, whose deadly malarial fevers have a classicreputation, and has achieved its latest triumphs in the superb successof Colonel Gorgas at Panama. While this procedure should never beneglected, it is obvious that it involves a good deal of irksomeconfinement and interferes with freedom of movement, and it willprobably be carried out completely only under military or officialdiscipline, or in tropical regions where the risks are so great that itsobservance 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 uspractically the whip-hand over malarial and other tropical feverswhenever we choose to exercise it. It had long been known that thebreeding-place of mosquitoes was in water; that their eggs whendeposited in water floated upon the surface like tiny boats, usuallyglued together into a raft; that they then turned into larvæ, of whichthe well-known "wigglers" in the water-butt or the rain-barrel arefamiliar examples; and that they finally hatched into the completeinsect and rose into the air. 

Obviously, there were two points at which the destroyers might strike, the egg and the larvæ. It was first found that, while the eggs requiredno air for their development, the larvæ wiggled up to the surface andinhaled it through curious little tubes developed for this purpose, oddly enough from their tail-ends. If some kind of film could be spreadover the surface of the water, through which the larvæ could not obtainair, they would suffocate. The well-known property of oil in "scummingover" water was recalled, two or three stagnant pools were treated withit, and to the delight of the experimenters, not a single larva was ableto develop under the circumstances. Here was insecticide number one. Thecheapest of oils, crude petroleum, if applied to the pool or marsh inwhich mosquitoes breed, will almost completely exterminate them. Scoresof regions and areas to-day, which were once almost uninhabitable onaccount of the plague of mosquitoes, are now nearly completely free fromthese pests by this simple means. An ounce to each fifteen square feetof water-surface is all that is required, though the oiling needs to berepeated carefully several times during the season. 

But what of the eggs? They require no air, and it was found impossibleto poison them without simply saturating the water with powerfulpoisons; but an unexpected ally was at our hand. It was early noted thatmosquitoes would not breed freely in open rivers or in large ponds orlakes, but why this should be the case was a puzzle. One day anenthusiastic mosquito-student brought home a number of eggs of differentspecies, which he had collected from the neighboring marshes, and putthem into his laboratory aquarium for the sake of watching them developand identifying their species. The next morning, when he went to look atthem, they had totally disappeared. Thinking that perhaps the laboratorycat had taken them, and overlooking a most contented twinkle in thecorner of the eyes of the minnows that inhabited the aquarium, he wentout and collected another series. This time the minnows were ready forhim, and before his astonished eyes promptly pounced on the raft of eggsand swallowed them whole. Here was the answer at once: mosquitoes wouldnot develop freely where fish had free access; and this fact is oursecond most important weapon in the crusade for their extermination. Ifthe pond be large enough, all that is necessary is simply to stock itwith any of the local fish, minnows, killies, perch, dace, bass, --andpresto! the mosquitoes practically disappear. If it be near some largerlake or river containing fish, then a channel connecting the two, toallow of its stocking, is all that is required. 

On the Hackensack marshes to-day trenches are cut to let the water outof the tidal pools; while in low-lying areas, which cannot be thusdrained, the central lowest spot is selected, a barrel is sunk at thisspot, and four or five "killie" fish are placed in it. Trenches are cutconverging into this barrel from the whole of the area to be drained, and behold, no more mosquitoes can breed in that area, and, in thelanguage of the day, "get away with it. "

Finally, most consoling of all, it was discovered that, while theordinary _Culex_ mosquito can breed, going through all the stages fromthe egg to the complete insect, in about fourteen days, so that anypuddle which will remain wet for that length of time, or even suchexceedingly temporary collections of water as the rain caught in atomato-can, in an old rubber boot, in broken crockery, etc. , will serveher for a breeding-place, the _Anopheles_ on the other hand takes nearlythree months for the completion of her development. So that, while aregion might be simply swarming with ordinary mosquitoes, it wouldfrequently be found that the only places which fulfilled all therequirements for breeding-homes for the _Anopheles_, that is, isolationfrom running water or larger streams, absence of fish, and persistencefor at least three months continuously, would not exceed five or six tothe square mile. Drain, fill up, or kerosene these puddles, --for theyare often little more than that, --and you put a stop to the malarialinfection of that particular region. Incredible as it may seem, placesin such a hotbed of fevers as the west coast of Africa, which have beenthoroughly investigated, drained, and cleaned up by mosquito-brigades, have actually been freed from further attacks of fever by draining andfilling not to exceed twenty or thirty of these breeding-pools. 

In short, science is prepared to say to the community: "I have done mypart in the problem of malaria. It is for you to do the rest. " There isliterally no neighborhood in the temperate zone, and exceedingly few inthe tropics, which cannot, by intelligent coöperation and a moderateexpense, be absolutely rid first of malaria, and second of allmosquito-pests. It is only a question of intelligence, coöperation, andmoney. The range of flight of the ordinary mosquito is seldom over twoor three hundred yards, save when blown by the wind, and more commonlynot more than as many feet, and thorough investigation of the groundwithin the radius of a quarter of a mile of your house will practicallydisclose all the danger you have to apprehend from mosquitoes. It is agood thing to begin with your own back yard, including the water-butt, any puddles or open cesspools or cisterns, and any ornamental watergardens or lily-ponds. These latter should be stocked with fish orslightly oiled occasionally. If there be any accumulations of water, like rain-barrels or cisterns, which cannot be abolished, they shouldeither be kept closely covered or well screened with mosquito netting. 

It might be remarked incidentally in passing, that the only reallydangerous sex in mosquitodom, as elsewhere, is the female. The malemosquito, if he were taxed with transmitting malaria, would have achance to reëcho Adam's cowardly evasion in the Garden of Eden, "It wasthe woman that thou gavest me. " Both sexes of mosquitoes under ordinaryconditions are vegetable feeders, living upon the juices of plants. Butwhen the female has thrown upon her the tremendous task of ripening andpreparing her eggs for deposition, she requires a meal of blood--whichmay be a comfort to our vegetarian friends, or it may not. Either sherequires a meal of blood to nerve her up to her criminal deed, or, whenshe has some real work to do, she has to have some real food. 

The mosquito-brigade have still another method of checking the spread ofmalaria, at first sight almost a whimsical one, --no less than screeningthe patient. The mosquito, of course, criminal as she is, does not hatchthe parasites _de novo_ in her own body, but simply sucks them up in ameal of blood from some previous victim. Hence by careful screening ofevery known case of malaria, mosquitoes are prevented from becominginfected and transmitting the disease. Instead of the screens protectingthe victims from the mosquitoes, they protect the mosquitoes against thevictim. 

This explains why hunters, trappers, and Indians may range a region foryears, without once suffering from malaria, while as soon as settlersbegin 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 theintroduction 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 othercolored races, it is true, are far less susceptible; but this we nowknow applies only to adults, as the studies of Koch in Africa showedthat a large percentage of negro children had the plasmodium in theirblood. No small percentage of them die of malaria, but those who recoveracquire a certain degree of immunity. Possibly they may be able toacquire this immunity more easily and with less fatality than the whiterace, but this is the extent of their superiority in this regard. Thenegro races probably represent the survivors of primitive men, who weretoo unenterprising to get away from the tropics, and have had to adjustthemselves 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 thebody escapes damage, though this may not be discovered till long afterthe "fever-and-ague" has been recovered from. 

As the parasite breeds in the red cells of the blood, naturally itsfirst effect is to destroy huge numbers of these, producing the typicalmalarial _anæmia_, or bloodlessness. Instead of 5, 000, 000 to the cubiccentimetre of blood the red cells may be reduced to 2, 000, 000 or even1, 500, 000. The breaking down of these red cells throws their pigment orcoloring-matter afloat in the blood; and soaking through all the tissuesof the body, this turns a greenish-yellow and gives the well-knownsallow 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 toxinsof the parasite, are carried to the liver and spleen to be burned up orpurified 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 readilyfelt with the hand in the left side below the ribs, so that it is notonly relied upon as a sign of malaria in doubtful cases, but has evenreceived the popular name of the "ague-cake" in malarious districts. 

So full is the blood of the parasites, that they may actually choke upthe tiny blood-vessels and capillaries in various organs, so as to blockthe circulation and cause serious and even fatal congestions. Obstructions of this sort may occur in the brain, the liver, the coatsof the stomach, or intestines, and the kidneys; and they are the chiefcause of the deadly "congestive chills, " or pernicious malarialparoxysms, 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 tohave been given a separate name, "Blackwater fever, " from the quantitiesof 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 injuriouseffect upon the system may be produced by successive attacks, keepingthe entire body saturated with the poison; while there is serious riskof the parasite sooner or later finding some weak spot in thebody, --kidney, liver, nervous system, --where its incessant batteringworks permanent damage. 

How long the infection may lurk in the body is uncertain; certainly formonths, and possibly for years. Many cases are on record which hadtypical chills and fever, with abundance of plasmodia in the blood, years after leaving the tropics or other malarious districts; but thereis often the possibility of a recent re-infection. 

Altogether, malaria is a remarkably bad citizen in any community, andits 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'sbox, if the name happens to be rheumatism. It is a term of wondrouselasticity. It will cover every imaginable twinge in any and everyregion of the body--and explain none of them. It is a name that meansjust nothing, and yet it is in every man's vocabulary, from proudestprince to dullest peasant. Its derivative meaning is little short of anabsurdity 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 bothto the sufferer and to the physician. Moreover, incidentally, toparaphrase Portia's famous plea, --

 It blesseth him that _has_ and him that _treats_; 'T is mightier than the mightiest. It doth _fit_ the thronéd monarch _closer_ than his crown. 

To the patient it is a satisfying diagnosis and satisfactory explanationin one; to the doctor, a great saving of brain-fag. When we call adisease rheumatism, we know what to give for it--even if we don't knowwhat 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 andindiscriminate application of the term to a host of widely different, painful conditions, many of which have little else in common save thatthey hurt and can be covered by this charitable name-blanket, a fewdefinite facts are crystallizing here and there out of the chaos. Thefirst is, that out of this swarm of different conditions there can beisolated one large and important central group which has the charactersof a well-defined and constant disease-entity. This is the disease knownpopularly as rheumatic fever, and technically as acute rheumatism oracute articular rheumatism. In fact, the commonest division is toseparate the "rheumatisms" into two great groups: acute, covering the"fever" form, and chronic, containing all the others. From a purelyscientific point of view, this classification has rather an undesirabledegree of resemblance to General Grant's famous division of all musicinto two tunes: one of which was Old Hundred, and the other wasn't. Butfor practical purposes it has certain merits and may pass. 

Every one has seen, or known, or had, the acute articular form ofrheumatism, and when once seen there is no difficulty in recognizing itagain. It is one of the most striking and most abominable ofdisease-pictures, beginning with high fever and headache, thentenderness, quickly increasing to extreme sensitiveness in one or moreof the larger joints, followed by drenching sweats of penetrating acidodor. The joint attacked becomes red, swollen, and glossy, so tenderthat merely pointing a finger at it will send a twinge of agony throughthe entire body, and the patient lies rigid and cramped for fear of theagony caused by the slightest movement. The tongue becomes coated andfoul, the blood-cells are rapidly broken down, and the victim becomesashy pale. He is worn out with pain and fever, yet afraid to fall asleepfor fear of unconsciously moving the inflamed joint and waking intortures; and altogether is about as acutely uncomfortable andcompletely miserable as any human being can well be made in so short atime. 

Fortunately, as with its twin brother, the grip, the bark of rheumatismis far worse than its bite; and a striking feature of the disease is itslow fatality, especially when contrasted with the fury of its onslaughtand the profoundness of the prostration which it produces. Though itwill torture its victim almost to the limits of his endurance for daysand even weeks at a stretch, it seldom kills directly. Its chief dangerlies in the legacies which it bequeaths. Though, like nearly all fevers, it is self-limited, tends to run its course and subside when the bodyhas manufactured an antitoxin in sufficient amounts, it is unique inanother respect, and that is in the extraordinary variability of thelength of its "course. " This may range anywhere from ten days to as manyweeks, the "average expectation of life" being about six weeks. Theagonizing intensity of the pain and acute edge of the discomfort usuallysubside in from five to fifteen days, especially under competent care. When the temperature falls, the drenching sweats cease, the jointsbecome less exquisitely painful, and the patient gradually begins topull himself together and to feel as if life were once more worthliving. He is not yet out of the woods, however, for while the pain issubsiding in the joints which have been first attacked, another jointmay suddenly flare up within ten or twelve hours, and the wholedistressing process be repeated, though usually on a somewhat milder andshorter scale. This uncertainty as to how many joints in the body may beattacked, is, in fact, one of the chief elements in making the durationof the disease so irregular and incalculable. 

Even when the frank and open progress of the disease through the jointsof the body has come to an end, the enemy is still lying in wait andreserving his most deadly assault. Distressing and crippling as are theeffects of rheumatism upon the joints and tendons, its most deadly andpermanent damage is wrought upon the heart. Fortunately, this vitalorgan is not attacked in more than about half the cases of acuterheumatism, and in probably not more than one-third of these are thechanges produced either serious or permanent, especially if the case becarefully watched and managed. But it is not too much to say that, ofall cases of serious or "organic" heart disease, rheumatism is probablyresponsible for from fifty to seventy per cent. The same germ or toxinwhich produces the striking inflammatory changes in the joints may becarried in the blood to the heart, and there attack either the liningand valves of the heart (endocardium), which is commonest, or thecovering of the heart (pericardium), or the heart-muscle. So intense isthe inflammation, that parts of the valves may be literally eaten awayby ulceration, and when these ulcers heal with formation of scar-tissueas everywhere else in the body, the flaps of the valves may be eithertied together or pulled out of shape, so that they can no longerproperly close the openings of the heart-pump. This condition, or somemodification of it, is what we usually mean when we speak of "heartdisease, " or "organic heart disease. " The effect upon the heart-pump issimilar to that which would be produced by cutting or twisting the valvein the "bucket" of a pump or in a bulb syringe. 

In severe cases of rheumatism the heart may be attacked within the firstfew days of the disease, but usually it is not involved until after thetrouble in the joints has begun to subside; and no patient should beconsidered safe from this danger until at least six weeks have elapsedfrom the beginning of the fever. The few cases (not to exceed one or twoper cent) of rheumatic fever which go rapidly on to a fatal termination, usually die from this inflammation of the heart, technically known asendocarditis. The best way of preventing this serious complication andof keeping it within moderate limits, if it occurs, is absolute rest inbed, until the danger period is completely passed. 

Now comes another redeeming feature of this troublesome disease, andthat is the comparatively small permanent effects which it produces uponthe joints in the way of crippling, or even stiffening. To gaze upon arheumatic knee-joint, for instance, in the height of theattack, --swollen to the size of a hornet's nest, hot, red, throbbingwith agony, and looking as if it were on the point of bursting, --onewould almost despair of saving the joint, and the best one would feelentitled to expect would be a roughening of its surfaces and a permanentstiffening 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 picturechanges as if by magic. The pain fades away to one-fifth of its formerintensity within twenty-four, or even within twelve hours; three-fourthsof the swelling follows suit in forty-eight hours; and within three orfour days' time the patient is moving the joint with comparative easeand 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 "limbersup" completely, and usually becomes practically as good as ever. Inshort, the violence and swiftness of the onset are only matched by therapidity and completeness of the retreat. It would probably be safe tosay that not more than one joint in fifty, attacked by rheumatism, isleft in any way permanently the worse. 

But, alas! to counterbalance this mercifulness in the matter ofpermanent damage, unlike most other infections, one attack of rheumaticfever, so far from protecting against another, renders both theindividual and the joint more liable to other attacks. The historicmotto of the British in the War of 1812 might be paraphrased into, "Once rheumatic, always rheumatic. " The disease appears to be lost toall sense of decency and reason; and to such unprincipled lengths may itgo, that I have actually known one luckless individual who had theunenviable record of seventeen separate and successive attacks ofrheumatic fever. As he expressed it, he had "had rheumatism every springbut two for nineteen years past. " Yet only one ankle-joint wasappreciably the worse for this terrific experience. 

Obviously, the picture of acute rheumatism carries upon its face astrong suggestion of its real nature and causation. The hightemperature, the headache, the sweats, the fierce attack and rapiddecline, the self-limited course, the tendency to spread from one jointto another, from the joints to the heart, from the heart to the lungsand the kidneys, all stamp it unmistakably as an infection, a fever. Onthe other hand, there are two rather important elements lacking in theinfection-picture: one, that, although it does at times occur inepidemics, it is very seldom transmitted to others; the other, that oneattack does not produce immunity or protect against another. Themajority of experts are now practically agreed that _acute_ rheumatism, or _rheumatic fever_, is probably due to the invasion of the system bysome microörganism or germ. When, however, we come to fixing upon theparticular bacillus, or micrococcus, there is a wide divergence ofopinion, some six or seven different eminent investigators having eachhis favorite candidate for the doubtful honor. In fact, it is ourinability as yet positively to identify and agree upon the causal germthat makes our knowledge of the entire subject still so regrettablyvague, and renders either a definite classification or successfultreatment so difficult. 

The attitude of the most careful and experienced physicians andbroad-minded bacteriologists may be roughly summed up in the statementthat acute rheumatism is probably due to some germ or germs, but thatthe question is still open which particular germ is at fault, and evenwhether the group of symptoms which we call rheumatism may not possiblybe produced by a number of different organisms, acting upon a particulartype of constitution or susceptibility. There is no difficulty infinding germs of all sorts, principally micrococci, in the blood, in thetissues about the joints, and on the heart-valves of patients withrheumatism, and these germs, when injected into animals, will notinfrequently 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 distinctspecies; and second, and even more important, that almost any of theorganisms of the common infectious diseases are capable at times ofproducing inflammation of the joints and tendons. For instance, thethird commonest point of attack of the tubercle bacillus, after thelungs and the glands, is the bones and joints, as illustrated in thesadly familiar "white-swelling of the knee" and hip-joint disease. Allthe so-called septic organisms, which produce suppuration andblood-poisoning in wounds and surgery, may, and very frequently do, attack the joints; while nearly all the common infections, such astyphoid, scarlet fever, pneumonia, and even measles, influenza, andtonsillitis, may be followed by severe joint symptoms. 

In fact, we are coming to recognize that diseases of the joints, likediseases of the nervous system, are among the frequent results of anyand all of the acute infectious diseases or fevers; and we now tracefrom fifty to seventy-five per cent of both joint troubles anddegenerations of the nervous system to this cause. Two-thirds, forinstance, 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 theseinnumerable forms of joint inflammations and the splitting off of thosewhich are clearly due to certain specific diseases, from the great, central group of true rheumatism. Most of these joint inflammationswhich are due to recognized germs, such as the pus-organisms of surgicalfevers, tuberculosis, and typhoid, differ from true rheumatism in thatthey go on to suppuration (formation of "matter") and permanentlycripple the joint to a greater or less degree. So that there is probablya germ or group of germs which produces the swift attack and rapidsubsidence and other characteristic features of true rheumatism, eventhough we have not yet succeeded in sorting them out of the swarm. Soconfident do we feel of this, that although, as will be shown, there areprobably other factors involved, such as exposure, housing, occupation, food, and heredity, yet the best thought of the profession ispractically agreed that none of these would alone produce the disease, but that they are only accessory causes plus the micrococcus. Inpractically all our modern textbooks of medicine, rheumatism isincluded under the head of infections. 

This theory of causation, confessedly provisional and imperfect as itis, helps us to harmonize the other known facts about the disease; ithas already greatly improved our treatment and given us a foothold forattacking the problem of prevention. For instance, it has long beenknown that rheumatism was very apt to follow tonsillitis or other formsof sore throat; indeed, many of the earlier authorities put downtonsillitis as one of the great group of "rheumatic" disturbances, andpersons of rheumatic family tendency were supposed to have tonsillitisin childhood and rheumatism in later life. Not more than ten or fifteenper cent of all cases gave a history of tonsillitis; but since we havebroadened our conception of infection and begun to inquire, not merelyfor symptoms of tonsillitis, but also for those of influenza, "commoncolds, " measles, whooping-cough, and the like, we reach the mostsignificant result of finding that forty to sixty per cent of our casesof rheumatism have been preceded, anywhere from one to three weeksbefore, by an attack of some sort of "cold, " sore throat, catarrhalfever, cough, bronchitis, or other group of disturbances due to a mildinfection. Further, it has long been notorious that when a rheumaticindividual "catches cold" it is exceedingly apt to "settle in thejoints, " and, if these cases happen to come under the eye of aphysician, they are recognized as secondary attacks of true rheumatism. In other words, the "cold" may simply be a second dose of the same germwhich caused the primary attack of rheumatism. 

This brings us to the widespread article of popular belief thatrheumatism is most commonly due to cold, exposure, chill, or damp. Muchof this is found on investigation to be due to the well-known historicconfusion between "cold, " in the sense of exposure to cold air, and"cold, " in the sense of a catarrh or influenza, with running at thenose, coughing, sore throat, and fever, a group of symptoms now clearlyrecognized to be due to an infection. In short, the vast majority ofcommon colds are unmistakably infections, and spread from one victim toanother, and this is the type of "cold" which causes the majority ofrheumatic 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 often, the rigor which precedes the fever, and has nothing whatever to dowith the external temperature. The large majority of our cases ofrheumatism can give no clear or convincing history of exposure to wet, cold, or damp. But popular impression is seldom entirely mistaken, andthere can be no question that, given the presence of the infectiousgerm, a prolonged exposure to cold, and particularly to wet, will oftenprove to be the last straw which will break down the patient's power ofresistance, and determine an attack of rheumatism. 

This climatic influence, however, is probably not responsible for morethan fifteen or twenty per cent of all cases, and, popular impression tothe contrary notwithstanding, the liability of outdoor workers who aresubject to severe exposure, such as lumbermen, fishermen, and sailors, is only slightly greater than that of indoor workers. The highestsusceptibility, in fact, not merely to the disease, but also to thedevelopment of serious heart involvements, is found among domesticservants, particularly servant girls, agricultural laborers and theirfamilies (in districts where wages are low and cottages bad), andslum-dwellers; in fact, those classes which are underfed, overworked, badly housed, and crowded together. Diet has exceeding little to do withthe disease, and, so far from meat or high living of any sortpredisposing to it, it is most common and most serious in preciselythose classes which get least meat or luxuries of any sort, and are fromstern 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 infectiontheory. Its seasonal occurrence is very similar to that ofpneumonia, --rarest in summer, commonest in winter, the highestpercentage of cases occurring in the late fall and in the early spring;in other words, just at those times when people are first beginning toshut themselves up for the winter, light fires, and close windows, andat the end of their long period of winter imprisonment, when both theirresisting power has been reduced to the lowest ebb in the year andinfections of all sorts have had their most favorable conditions ofgrowth for months. 

The epidemics of rheumatism, which occasionally occur, probably followepidemics of influenza, tonsillitis, or other mild infections, andinstances of two or more cases of rheumatism in one family or householdare most rationally explained as due to the spread of the precedentinfection from one member of the family to the other. Instances of thedirect transmission of the disease from one patient to another areexceedingly rare. 

Our view of the infectious causation of rheumatism, vague as it is, hasgiven us already our first intelligent prospect of prevention. Whatevermay be the character of a germ or germs, the vast majority of them agreein making the nose and throat their first point of attack and of entryinto the system. Hence, vigorous antiseptic and other rational treatmentof all acute disturbances of the nose and throat, however slight, willprove a valuable preventive and diminisher of the percentage ofrheumatism. This simply emphasizes again the truth and importance of thedictum of modern medicine, "Never neglect a cold, " since we are alreadyable to trace, not merely rheumatism, but from two-thirds tothree-fourths of our cases of heart disease, of kidney trouble, and ofinflammations of the nervous system, to those mild infections which weterm "colds, " or to other definite infectious diseases. 

Not only is this good _a priori_ reasoning, but it has been demonstratedin practice. One of our largest United States army posts had acquired anunenviable reputation from the amount of rheumatism occurring in thetroops stationed there. A new surgeon coming to take charge of the postset about investigating the cause of this state of affairs, and came tothe conclusion that the disease began as, or closely followed, tonsillitis and other forms of sore throat. He accordingly saw to itthat every case of tonsillitis, of cold in the head, or sore throat wasvigorously treated with local germicides and with intestinalantiseptics and laxatives, until it was completely cured; with theresult that in less than a year he succeeded in lowering the percentageof cases of rheumatism per company nearly sixty per cent. 

At some of our large health-resorts, where great numbers of cases ofrheumatism are treated, it has been discovered that if a case of commoncold, or tonsillitis, happens to come into the establishment, and runsthrough the inmates, nearly half of the rheumatic patients attacked willhave a relapse or new seizure of their rheumatism. Accordingly, arigorous and hawk-like watch is kept for every possible case of cold, tonsillitis, or sore throat entering the house; the patient is promptlyisolated and treated on rigidly antiseptic principles, with the resultthat epidemics of relapses of rheumatism in the inmates have greatlydiminished in frequency. 

If every case of cold or sore throat were promptly and thoroughlytreated with antiseptic sprays and washes such as any competentphysician can direct his patients to keep in the house, in readiness forsuch an emergency, combined with laxatives and intestinal antiseptictreatment, and, above all, with rest in bed as long as any rise oftemperature is present, there would be a marked diminution in both thefrequency and the severity of rheumatism. If to this were added anabundant and nutritious dietary, good ventilation and pure air, anavoidance of overwork and overstrain, we should soon begin to get thebetter of this distressing disease. In fact, while positive data arelacking, on account of the small fatality of rheumatism and itsconsequent infrequent appearance among the causes of death in our vitalstatistics, yet it is the almost unanimous opinion of physicians ofexperience that the disease is distinctly diminishing, as a result ofthe marked improvement in food, housing, wages, and living conditionsgenerally, which modern civilization has already brought about. 

So much for acute rheumatism. Vague and unsatisfactory as is ourknowledge of it, it is, unfortunately, clearness and precision itselfwhen contrasted with the welter of confusion and fog which covers ourideas about the _chronic_ variety. The catholicity of the term issomething incredible. Every chronic pain and twinge, from corns tolocomotor ataxia, and from stone-in-the-kidney to tic-douloureux, hasbeen put down as "rheumatism. " It is little better than a diagnosticgarbage-dump or dust-heap, where can be shot down all kinds of vague andwandering pains in joints, bones, muscles, and nerves, which have novisible or readily ascertainable cause. Probably at least half of allthe discomforts which are put down as "rheumatism" of the ankle, theelbow, the shoulder, are not rheumatism at all, in any true orreasonable sense of the term, but merely painful symptoms due to otherperfectly definite disease conditions of every imaginable sort. Theremaining half may be divided into two great groups of nearly equalsize. One of these, like acute rheumatism, is closely related to, andprobably caused by, the attack of acute infections of milder character, falling upon less favorable soil. The other is of a vaguer type and isdue, probably, to the accumulation of poisonous waste-products in thetissues, setting up irritative and even inflammatory changes in nerve, muscle, and joint. Either of these may be made worse by exposure to coldor changes in the weather. In fact, this is the type of rheumatism whichhas such a wide reputation as a barometer and weather prophet, secondonly to that of the United States Signal Service. When you "feel it inyour 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 tochanges in temperature, wind-direction, moisture, and electric tension, than sound and normal ones. The change in the weather does not cause therheumatism. It is the rheumatism that enables us to predict the changein the weather, though we have no clear idea what that change will be. 

Probably the only statement of wide application that can be made inregard to the nature of chronic rheumatism is that a very considerablepercentage of it is due to the accumulation of poisons (toxins) in thenerves 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 ofthe muscles supplied. The same broad principles of causation andprevention, therefore, apply here as in acute rheumatism. 

The most important single fact for rheumatics of all sorts, whetheracute or chronic, to remember is that they must _avoid exposure tocolds_, in the sense of infections of all sorts, as they would apestilence; 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), andtreat every cold or mild infection which they may be unfortunate enoughto catch, according to the strictest rigor of the antiseptic law. 

The influence of diet in chronic rheumatism is almost as slight as inthe acute form. Persons past middle age who can afford to indulge theirappetites 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 embarrasstheir liver and kidneys as to create accumulations of waste products inthe blood sufficient to cause rheumatic twinges. The vast majority, however, of the sufferers from chronic rheumatism, like those from theacute form, are underfed rather than overfed, and a liberal and abundantdietary, including plenty of red meats, eggs, fresh butter, greenvegetables, and fresh fruits, will improve their nutrition and diminishtheir tendency to the attacks. 

There appears to be absolutely no rational foundation for the popularbelief that red meats cause rheumatism, either from the point of view ofpractical experience, or from that of chemical composition. We now knowthat white meats of all sorts are quite as rich in those elements knownas the purin bodies, or uric-acid group, as red meats, and many of themmuch richer. It may be said in passing, that this last-mentioned bugbearof our diet-reformers is now believed to have nothing whatever to dowith rheumatism, and probably very little with gout, and that theravings of Haig and the Uric-Acid School generally are now thoroughlydiscredited. Certainly, whenever you see any remedy or any method oftreatment vaunted as a cure for rheumatism, by neutralizing or washingout uric acid, you may safely set it down as a fraud. 

One rather curious and unexpected fact should, however, be mentioned inregard to the relation of diet to rheumatism, and that is that manyrheumatic patients have a peculiar susceptibility to some one article offood. This may be a perfectly harmless and wholesome thing for the vastmajority of the species, but to this individual it acts as a poison andwill promptly produce pains in the joints, redness, and even swelling, sometimes accompanied by a rash and severe disturbances of the digestivetract. The commonest offenders form a curious group in their apparentharmlessness, headed as they are by strawberries, followed byraspberries, 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 curioussusceptibility we do not know, but it not infrequently occurs with thisgroup of foods in rheumatics and also in asthmatics. 

Both rheumatics and asthmatics are also subject to attacks of urticariaor "hives" (nettle-rash), from these and other special articles of diet. 

As to principles of treatment in a disease of so varied and indefinite acharacter, due to such a multitude of causes, obviously nothing can besaid except in the broadest and sketchiest of outline. The prevailingtendency is, for the acute form, rest in bed, the first and mostimportant, also the second, the third, and the last element in thetreatment. This will do more to diminish the severity of the attack andprevent the occurrence of heart and other complications than any othersingle procedure. 

After this has been secured, the usual plan is to assist nature in theelimination of the toxins by alkalies, alkaline mineral waters, andother laxatives; to relieve the pain, promote the comfort, and improvethe rest of the patient by a variety of harmless nerve-deadeners orpain-relievers, chief among which are the salicylates, aspirin, and themilder coal-tar products. By a judicious use of these in competent handsthe pain and distress of the disease can be very greatly relieved, butit has not been found that its duration is much shortened thereby, oreven that the danger of heart and other complication is greatlylessened. The agony of the inflamed joints may be much diminished byswathing in cotton-wool and flannel bandages, or in cloths wrung out ofhot alkalies covered with oiled silk, or by light bandages keptsaturated with some evaporating lotion containing alcohol. As soon asthe fever has subsided, then hot baths and gentle massage of theaffected joints give great relief and hasten the cure. But, when all issaid and done, the most important curative element, as has already beenintimated, is six weeks in bed. 

In the chronic form the same remedies to relieve the pain are sometimesuseful, but very much less effective, and often of little or no value. Dry heat, moist heat, gentle massage, and prolonged baking in specialmetal ovens, will often give much relief. Liniments of all sorts, fromspavin cures to skunk oil, are chiefly of value in proportion to theamount of friction and massage administered when they are rubbed in. 

In short, there is no disease under heaven in which so much depends upona careful study of each individual case and adaptation of treatment toit personally, according to its cause and the patient in whom it occurs. Rheumatism, unfortunately, does tend to "run in families. " Apparentlysome peculiar susceptibility of the nervous system to influences whichwould be comparatively harmless to normal nerves and cells is capable ofbeing inherited. But this inheritance is almost invariably "recessive, "in Mendelian terms, and a majority of the children of even the mostrheumatic parent may entirely escape the disease, especially if theylive rationally and vigorously, feed themselves abundantly, and avoidoverwork 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 insteadof healing quickly. We don't exactly enjoy being shot, or stabbed, orscratched, though, as a matter of fact, in what Mulvaney calls the "fogav fightin'" we hardly notice such trifles unless immediately disabling. But our greatest fear after the bleeding has stopped is lestblood-poisoning may set in. And we do well to dread it, for in the oldendays, --that is, barely fifty years ago, --in wounds of any size orseriousness, two-thirds of the risk remained to be run after thebleeding had been stopped and the bandages put on. Nowadays the dangeris only a fraction of one per cent, but till half a century ago everywound 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 brilliantrepartee of our boyhood days in answer to the inquisitive query, "What'sthe matter?" "Nuthin': it hasn't come to matter yet. It's only a freshcut!"

Even surgeons thought it a necessary part of the process of healing, andthe approving term "laudable pus" was applied to a soft, creamydischarge, without either offensive odor or tinge of blood, upon thesurfaces of the healing wound; and the hospital records of that daynoted with satisfaction that, after an operation, "suppuration wasestablished. " So strongly was this idea intrenched, that a freedischarge or outpouring of some sort was necessary to the proper healingof the wound, that in the Middle Ages it was regarded as exceedinglydangerous to permit wounds to close too quickly. Wounds that hadpartially united were actually torn apart, and liquids like oil and wineand strong acids, which tended to keep them from closing and to set upsuppuration, were actually poured into them; and in some instances theirsides were actually burned with hot irons. There was a solid basis ofreason underlying even these extraordinary methods, viz. , the "rule ofthumb" observation, handed down from one generation to another, thatwounds that discharged freely and "sweetly, " while they were slow inhealing and left disfiguring scars, usually did not give rise to seriousor fatal attacks of blood-poison or wound-fever. And of two evils theychose the less. Plenty of pus and a big ugly scar in preference to anattack of dangerous blood-poisoning. Even if it didn't kill you, itmight easily cripple you for life by involving a joint. The trouble waswith their logic, or rather with their premises. They were firmlyconvinced that the danger came from within, that there was a sort ofmorbid humor which must be allowed to escape, or it would be dammed upin 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 theirgenerations of imitators might have been wrong. He tried the experiment, shut germs out of his wounds, and behold, antiseptic surgery, with allits magnificent line of triumphs, was born!

Now a single drop of pus in an operation wound is as deep a disgrace asa bedbug on the pillow of a model housekeeper, and calls for as vigorousan overhauling of equipment, from cellar to skylight; while a seconddrop means a commission of inquiry and a drumhead court-martial. This isthe secret of the advances of modern surgery, --not that our surgeons areany more skillful with the knife, but that they can enter cavities likethose of the skull, the spinal cord, the abdomen, and the chest, removewhat is necessary, and get out again with almost perfect safety; whereasthese cavities were absolutely forbidden ground to their forefathers, onaccount of the twenty, forty, yes, seventy per cent death risk fromsuppuration and blood-poison. 

The triumphs of antisepsis and asepsis, or keeping the "bugs" out of thecuts, have been illustrated scores of times already by abler pens, andare a household word, but certain of its practical appliances in thewounds and scratches and trifling injuries of every-day life are not yetso thoroughly familiar as they should be. When once we know who ourwound-enemies are, whence they came, and how they are carried, the fateof the battle is practically in our own hands. 

Like most disease-germs our wound-infection foes are literally "they ofour own household. " They don't pounce down upon us from the trees, orlie in wait for us in the thickets, or creep in the grass, or grow inthe soil, or swarm in our food. They live and can live only within theshelter of our own bodies, where it is warm and moist and comfortable. This is one great (in the expressive vernacular) "cinch" that we have onthe vast majority of disease-germs, whether medical or surgical, thatthey do not flourish and breed outside of the body, or of houses closedand warm; and this grip can be improved, with skill and determination, into a veritable strangle-hold on most of them. In the language ofbiology, most of them have become "adapted to their environment" soclosely that they can scarcely flourish and breed anywhere outside ofthe warm, moist, fertile soil of a living body, and many of them cannoteven live long at temperatures more than ten degrees above or fifteendegrees below that of the body. At all events, so poorly are thesepus-germs able to preserve their vigor and power of attack, not merelyoutside of the human body, but outside of some wound or sore spot, thatit is practically certain that eight-tenths of all cases ofwound-infection or blood-poisoning come directly from some previousfestering wound, sore, ulcer, scab, boil, or pimple, in or on some otherhuman being or animal. Practically whenever we get pus in a wound in ahospital, we insist upon finding the precise previous case of pus fromwhich that originated, and seldom is our search unsuccessful. If we keptnot only our wounds surgically clean, but our gums, noses, throats, skins, and fingernails, and burned and sterilized everything that camein contact with a sore, pustule, or scab, we should wipe out nine-tenthsof our cases of wound-infection and suppuration; in fact, practicallyall of them, except such small percentage as may come from contact withinfections in animals. This is the reason why, up to half a century ago, by a strange paradox hospitals were among the most dangerous places toperform operations in, on account of the abundance of wounds or soresalways present for the pus-germs to breed in, and the fact that out offifty or more wound-cases, there was practically certain to be one ortwo infected ones to poison the whole lot. 

Surgeons, ignorant of antisepsis, and careless nurses, spread theinfection along, until in some instances it reached a virulence whichburst into the dreaded "hospital gangrene. " This dread disease was thescourge of all hospitals, especially military ones, all over thecivilized world, as recently as our War of Secession. In some wards ofour military hospitals, from thirty to fifty per cent of all the woundedreceived were attacked, and over five thousand cases were formallyreported during the war, of which nearly fifty per cent died. Thisplague was born solely of those two great mothers of evils, ignoranceand 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 "helpthe poor to die, " in Browning's phrase, had a certain amount offoundation; and cases operated upon in a farmhouse kitchen, where no onein the family happened to have had a boil or a catarrh or a festeringcut within a month or so, and where the knife happened to be clean ornew, would recover with less suppuration than hospital cases. Nowadays, from incessant and eternal vigilance, a hospital is surgically thecleanest and safest place in the world for an operation, so that mostsurgeons decline to operate outside of one, except in emergencies; andsome will not even operate except in one with which they are personallyconnected, so that they know every step in the process of protection. 

It was this terrible risk of the surgeon carrying infection from onecase to another, that made the coroner of London declare, barely sixtyyears ago, that he would hold an inquest upon the next case of deathafter ovariotomy that was reported to him, on account of the fearfulpus-mortality that followed this serious operation, which now has apossible death-rate from all causes connected with the operation of onlya fraction of one per cent. 

The brusque reply is still remembered of Lawson Tait, the great Englishovariotomist, to a distinguished German colleague, who had inquired thesecret of his then marvelously low death-rate: after a glance at thebands of mourning on the ends of the other's fingers, he said, "I keepmy fingernails clean, sir!" There was sadly too much truth in the sayingof another eminent surgeon, that in the pre-Listerian days many a poorwoman'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 geniusis the capacity for taking pains, than antiseptic surgery! Not aloophole must be left unstopped, not a possibility unconsidered, not athing in, or about, or connected with, the operating-room leftunsterilized, except the patient and the surgeon; and these are broughtas 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 ceilingare all waterproof and capable of being washed down with a hose. Theremust be no casings or cornices of any sort to catch dust; and in thebest appointed hospitals no one is permitted to enter, under anypretext, whose hands and garments have not been sterilized. 

In the second place, everything that is brought into the room for usein, or during, the operation, is first thoroughly sterilized. Theknives, instruments, and other operative objects are sterilized byboiling, or by the use of superheated steam; and the towels, dressings, bandages, sheets, etc. , by boiling, baking, or superheated steam. Thenbegins the preparation of the surgeon and the nurse. Dressing-rooms areprovided, in which the outer garments are removed, and the hands givenan ordinary wash. Then the scrubbing-room is entered, where, at a seriesof basins provided with running hot and cold water, whose faucets areturned by pressure with the foot so as to avoid any necessity fortouching them with the hand, the hands are thoroughly scrubbed with hotwater, boiled soap, and a boiled nail-brush. Then they are plunged into, and thoroughly soaked in, some strong antiseptic solution, then washedagain; then plunged into another antiseptic solution, containing somefat solvent like ether or alcohol, to wash off any dirt that may havebeen protected by the natural oil of the skin. Then they are thoroughlyscrubbed with soap and hot water again, to remove all traces of theantiseptics, most of which are irritating to wounded tissues; thenwashed in absolute alcohol, then in boiled or distilled water. Then thenurse, whose hands are already sterilized, takes out of the originalpackage in which it came from the sterilizing oven, a linen surgicalgown or suit which covers the operator from neck to toes. A sterilizedlinen or cotton cap is placed upon his head and pulled down so that thescales or germs of any sort may not fall into the wound. Some surgeonsof stout and comfortable habit, who are apt to perspire in the hightemperature of an operating-room, will tie a band of gauze around theirforeheads, to prevent any unexpected drops of perspiration from fallinginto the wound; while some purists muffle up the mouth and lower part ofthe face lightly in a similar comforter. 

You would think that by this time the hands were clean enough to goanywhere with safety, but no risks are going to be taken. A pair ofrubber or cotton gloves, the former taken right out of a strongantiseptic solution, the latter out of the sterilizing oven, are pulledcarefully on by the nurse. Holding his sacred hands spread out rigidlybefore him, like the front paws of a kangaroo, the surgeon carefullyedges his way into the operating-room, waiting for any doors that he mayhave to pass through to be opened by the nurse, or awkwardly pushingthem with his elbow. In that attitude of benediction, the hands aremaintained until the operation is ready to begin. 

Then comes the patient! If his condition will in any wise permit, he hasbeen given a boiling hot bath and scrub the night before, and put to bedin a sterilized nightgown between sterilized sheets. The region which isto be operated upon has, at the same time, been scrubbed and rubbed andflushed with hot water, germicides, alcohol, soap, --in fact, has gonethrough the same sacred ceremonial of cleansing through which thesurgeons' hands have passed; and a large, closely fitting antisepticdressing, covering the whole field, has been applied and tightly bound. He is brought into a waiting-room and put under ether by an anæsthetist, 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. Abig sheet is thrown over the lower part of his body, another over theupper part, a third, with an oval opening in the centre of it, thrownover the region to be operated upon. The instrument nurse takes a boiledknife out of a sterilized dish of distilled water, hands it to thesurgeon, who takes it in his gloved hand, and the operation begins. 

Now, if you can think of any possible chink through which a wanderingstreptococcus can, by any possibility, sneak into that wound, pleasesuggest it, and it shall be closed immediately!

The intruders against whom all these preparations are made are two innumber: _Streptococcus pyogenes_ and _Staphylococcus pyogenes_--cousins, as you see, by their names. Their last (not family) name really meanssomething, 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, wassuggested, by their rounded shape under the microscope, to somepoetically minded microscopist. Undesirable citizens, both of them! Butthe older, or _Strepto_, cousin is by far the more dangerous characterand desperate individual, giving rise to and being concerned in nearlyall the civilized and dangerous wound-fevers--septicæmia, erysipelas, etc. _Staphylococcus_ is a milder and less harmful individual, seldomgoing farther than to produce the milder forms of festering, discharging, refusing to heal, pustules, etc. He is not to be given ayard of leeway, however, for if he can get a sufficient number of dirtywounds to run through, he can work himself up to a high degree ofvirulence and poisoning power. Indeed, this faculty of his may possiblyfurnish a clew as to how these pus-makers developed their power ofliving 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 ourbodies, particularly the mouths of the sweat-ducts, and the openings ofthe hair follicles. Under peculiarly favorable circumstances, such as avery big wound, an aggravated chafe, or the application of thatchampion "bug-breeder, " a poultice, he may summon up courage enoughto attack some half-dead skin-cells and make a few drops of pus onhis own account. He is the criminal concerned in the so-calledstitch-abscesses, or tiny points of pus which form around the stitchesof a big wound and in some of the smaller pimples which turn to"matter. " It is conceivable that this feeble and harmless white coccusmay at some time have been accelerated under favorable circumstances towhere he was endowed with "yellow" powers, and even, upon another turnof the screw, with strepto-virulence. But this is a mere academicquestion. Practically the only thing needful is to keep all the rascalsout of every wound. 

Now comes the question, how is this to be done? Fortunately it is notnecessary to hunt out and destroy the pus-germs in their breeding-placesoutside of the human body. As we have seen, they do not long retaintheir vitality out of doors, or as a rule even in the dust of rooms anddirt of houses, unless the latter have been recently contaminated withthe dressings of, or discharges from, wounds. There are two main thingsto be watched: first, the wound itself, and second, any unwashed orunsterilized part of your own or some other living body. Dirt of allsorts is a mighty good thing to keep absolutely out of the wound, butpractically a whole handful of ordinary soil or dust rubbed into a woundmight not, unless it happened to contain fertilizer of some sort, behalf so dangerous as a single touch with a finger which had beendressing a wound, picking a scab out of the nose, rubbing an ulceratedgum, or scratching an itching scalp. If it be a cut on the finger, orscratch on the hand, for instance, don't suck it, or lick it, unless youcan give an absolutely clean bill of health to your gums and teeth. Ifnot thoroughly brushed three or four times a day, they are sure to beswarming with germs of twenty or thirty different species, which notinfrequently include one or both of the pus-germs. Indeed, the realreason why the bite of certain animals, and above all of a man, particularly of a "blue-gum nigger, " is regarded as so dangerous is onaccount of the swarms of germs that breed in any remnants of food leftbetween the teeth or in the pockets of ulcerating gums. Many a humanbite is almost as dangerous as a rattlesnake's. The devoted hero whosucks the poison of the dagger out of the wound may be conferring adoubtful 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 isserious. The loss of a few teaspoonfuls, tablespoonfuls, or, for thematter of that, cupfuls, of blood won't do you any harm, and its freeflow will wash out the cut from the bottom, and carry out most of thegerms that may happen to be present on the knife or nail. If water anddressings are not accessible, let the blood cake and dry over the woundwithout disturbing it, even though it does look rather gory. 

A slight cut with a clean knife, or other instrument, into which no dirthas been rubbed, will often require no other dressing than its ownblood-scab. If, however, as oftener happens, you cannot be sure of thecleanness of the knife, tool, or nail, hold the wound under runningwater from a pump or tap (this is not germ-free, but practically nevercontains pus-germs), until the wound has been thoroughly washed out, wiping any gravel or dirt out of the cut with soft rags which have beenrecently washed, or baked in the oven; then dry with a small piece oflinen, or white goods, put on a dressing of absorbent cotton such as canbe purchased for a few cents an ounce at any drug store. Absorbent orsurgical cotton makes a good dressing, because it both sucks up anyfluids which might leak out of the wound, and forms a mesh-filterthrough which no germs can penetrate. 

It is not advisable to use sticking-plaster for any but the most trivialwounds, and seldom even for these, for several reasons. First, becauseits application usually involves licking it to make it stick; second, because it must cover a sufficient amount of skin on either side of thewound to give it firm grip, and this area of skin contains aconsiderable number of both sweat-ducts and hair-follicles, which willkeep on discharging under the plaster, producing a moist and unhealthycondition of the lips of the wound. Moreover, these sweat-ducts andhair-follicles will, as we have seen, frequently contain whitestaphylococci, which are at times capable of setting up a low grade ofinflammation in the wound. A wound always heals better if its surfacesand coverings can be kept dry. This is why cotton makes such an idealdressing, since it permits the free evaporation of moisture, a moderateaccess of air, and yet keeps out all germs. 

If the cut or scratch is of any depth or seriousness whatever, or theknife, tool, or other instrument be dirty, or if any considerable amountof street-dust or garden-soil has got into the wound, then it is, byall means, advisable to go to a physician, have the wound thoroughlycleaned on antiseptic principles, and put up in antiseptic dressing. Asingle treatment of this sort, in a comparatively trifling wound whichhas become in any way contaminated, may save weeks of suffering anddisability, and often danger of life, and will in eight cases out of tenshorten the time of healing from forty to sixty per cent. The rapiditywith which a wound in a reasonably healthy individual, cleaned anddressed 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 somuch from pus-germs, though these may be present, as from another"bug"--the tetanus or lockjaw bacillus. This deadly organism lives inthe alimentary canal of the horse, and hence is to be found in any dirtor soil which contains horse manure. It is, fortunately, not verycommon, or widely spread, but enough so to make it the part of prudenceto have thoroughly asepticized and dressed any wound into whichconsiderable amounts of garden-soil, or street-dust, have been rubbed. The reason why wounds of the feet and hands have had such a badreputation, both for festering and giving rise to lockjaw, is that it isprecisely in these situations that they are most likely to getgarden-soil, or stable manure, into them. The classic rusty nail doesnot deserve the bad reputation as a wound-maker which it enjoys, its badodor being chiefly due to the fact already referred to, that injuriesinflicted by it are most apt to be in the palm of the hand, or in thesole of the foot, and hence peculiarly liable to contamination by thetetanus 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 ingeneral, seem to be peculiarly liable to be followed by tetanus. Thefulminate used in the cap of a toy pistol, and the paper and explosivesof several of the brands of firecrackers, have been thoroughly examinedbacteriologically, but without finding any tetanus germs in them. Somany cases of lockjaw used to follow the Fourth of July celebrations afew years ago, that Boards of Health became alarmed, and not onlyforbade outright the sale of deadly toy pistols, but provided suppliesof the tetanus antitoxin at various depots throughout the cities, sothat all patriotic wounds of this description could have it dropped intothem when they were dressed. Since then, the lockjaw penalty which wepay for our highly intelligent method of celebrating the Fourth, hasdiminished considerably. It is probable that the mortality was chieflydue to infection of the ugly, slow-healing, dirty little wounds withcity-dust, a large percentage of which, of course, is dried horsemanure. What with the tetanus bacillus and the swarms of flies whichbreed chiefly in stable manure, and carry summer diseases, typhoid, diphtheria, and tuberculosis in every direction, it will not be longbefore the keeping of horses within city limits will be as strictlyforbidden 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 bythe health authorities, on account of their having given rise to severalsuccessive cases of the disease. Workers in such fields or gardens, whoscratch or cut themselves, are warned to report themselves promptly fortreatment with the tetanus antitoxin. 

Apart from the tetanus germ, however, the problem of the treatment ofwounds--while there should be perfect cleanliness, the spotlessness ofthe model housekeeper multiplied fivefold--is yet not so much a matterof keeping dirt in general out of the wound, as of keeping out that_particular form of dirt which consists of or contains, discharges fromsome previous wound, sore, ulcer, or boil!_

While both these pus-organisms can breed and flourish freely only inwounds or sores, this is but their starting-point where they gatherstrength to invade the entire organism. We used to make a distinctionbetween those cases in which their toxins or poison-products got intothe blood, with the production of fever, headache, backache, delirium, sweats, etc. , which we term _septicæmia_, and other cases in which thecocci themselves were carried into the blood and swept all over the bodyby forming fresh foci, or breeding-places, which resulted in abscessesall over the body, which we call _pyæmia_. But now we know that there isno hard and fast line to be drawn, and that the germs get into the bloodmuch more easily than we supposed; and the degree and dangerousness ofthe fever which they set up depend, first, upon their virulence, orpoisonousness, and, second, upon the resisting power of the patient atthe time. Anything which lowers the general health and strength andweakens the resisting power of the body will make it much easier forpus-germs to get an entrance into it, and overwhelm it; so that, afterprolonged famines for instance, or among the population of besiegedcities, or in armies or exploring expeditions which have been deprivedof food and exposed to great hardship, the merest scratch will festerand inflame, and give rise to a serious and even fatal attack ofblood-poisoning, erysipelas, hospital gangrene, etc. Famines and siegesin fact are not infrequently followed by positive epidemics ofblood-poisoning, often in exceedingly severe and fatal forms. 

It was long ago noted by the chroniclers that the death-rate fromwound-fever among the soldiers of a defeated army was apt to be muchgreater than among those of the victorious one, and this was quoted asone of the stock evidences of the influence of mind over body. But wenow know that armies are not beaten without some physical cause, thatthe defeated soldiers are apt to be in poorer physical condition tobegin with; that they have often been cut off from their base ofsupplies, have made desperate forced marches without food or shelter inthe course of their retreat; and, until within comparatively recentyears, were never half so well treated or well fed as their captors. 

As the invading germs pass into the body, they travel most commonlythrough the lymph-channels and skin; are arrested and threatened withdestruction by the so-called lymphatic glands, or lymph-nodes. This iswhy, 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 becomepainful. If the lymph-nodes can conquer the germs and eat them up, theswelling goes down and the pain disappears. But if the germs, on theother 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 getinto the body, and by far the most dangerous, is the heart, as inrheumatism and other fevers. Some will also attack the kidneys, givingrise to albumin in the urine, while others attack the membranes of thejoints (_synovia_) and cause suppuration of one or more joints in thebody, which is very apt to be followed by very serious stiffening orcrippling. So that, common, and, in many instances, comparatively mildas they are, the pus-germs in the aggregate are responsible for a verylarge amount of damage to the human body. 

This is the way the _streptococcus_ and _staphylococcus_ behave in anopen wound, or sore; but they have two other methods of operating whichare somewhat special and peculiar. One of these is where the germ digsand burrows, as it were, underground, in a limited space, resulting inthat charming product known as a boil, or a carbuncle. The other, whereit spreads rapidly over the surface just under the skin, after thefashion of the prairie fire, producing _erysipelas_. In the first ofthese he behaves like the famous burrowing owl of our Western plains, who forms, with the prairie-dog, the so-called "happy family. " He nevermakes his own burrow, he simply uses one which is already provided forhim by nature, and that is the little close-fitting pouch surroundingthe root of a hair. Whether the criminal is a harmless native whitecoccus which has suddenly developed anti-social tendencies, or aMongolian immigrant who has been accidentally introduced, is still anopen question. The probabilities are that it is more frequently thelatter, as, while boils are absolutely no respecters, either of personsor places, and may rear their horrid heads in every possible region ofthe human form divine, yet they display a very decided tendency toappear 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 isthat they are liable to a considerable amount of chafing and scratchingas by collars and stocks on the neck, and cuffs on the wrists, or offriction from belts, or pressure or chafing from chairs or saddles. Whenthe tissues have been bruised or chafed after such fashion, especiallyif the surface of the skin has been at the same time broken, and anypus-organism is either present in the hair-follicle, like the whitecoccus, or rubbed into it by a finger or finger-nail which has just beensucked in the mouth, used to pick the nose, or possibly engaged indressing some wound, or cutting meat, or handling fertilizer, then allthe 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 peculiarindividuality of its own. Although it has vaguely personified in darkestages other diseases, like the Plague, the Pestilence, and _Maya_ (theSmallpox), these have rapidly faded away in even the earliest light ofcivilization, and have never approached in concreteness and definitenessthe malevolent personality of Cancer. Its sudden appearance, the utterabsence of any discoverable cause, the twinges of agonizing pain thatshoot out from it in all directions, its stone-like hardness in thesoft, elastic flesh of the body, the ruthless way in which it eats intoand destroys every organ and tissue that come in its way, make thisimpression, not merely of personality, but of positive malevolence, almost unescapable. 

Its very name is instinct and bristling with this idea: _Krebs_, inGerman, _Cancer_, in Latin, French, and English, _Carcinoma_, in Greek, all alike mean "Crab, " a ghastly, flesh-eating parasite, gnawing its wayinto the body. The simile is sufficiently obvious. The hard mass is thebody of the beast; the pain of the growth is due to his bite; the hardridges of scar tissue which radiate in all directions into thesurrounding skin are his claws. 

The singular thing is that, while brushing aside, of course, all thesegrotesque similes, the most advanced researches of science aredeveloping more and more clearly the conception of the independentindividuality--as they term it, the _autonomy_--of cancer. 

More and more decidedly are they drifting toward the unwelcomeconclusion that in cancer we have to deal with a process of revolt of apart of the body against the remainder, "a rebellion of the cells, " asan eminent surgeon-philosopher terms it. Unwelcome, because a man'sworst foes are "they of his own household. " Successful and eveninvigorating warfare can be waged against enemies without, but a contestwith traitors within dulls the spear and paralyzes the arm. Against thefrankly foreign epidemic enemies of the race a sturdy and, of lateyears, a highly successful battle has been fought. We have banished theplague, drawn the teeth of smallpox, riddled the armor of diphtheria, and robbed consumption of half its terrors. In spite of the ravings andgallery-play of the Lombroso school anent "degeneracy, " our bills ofmortality show a marked diminution in the fatality of almost everyimportant disease of external origin which afflicts humanity. 

The world-riddle of pathology the past twenty years has been: Is cancerdue to the invasion of a parasite, a veritable microscopic crab, or isit due to alterations in the communal relations, or, to speakmetaphorically, the allegiance of the cells? Disappointing as it may be, the balance of proof and the opinion of the ablest and broadest-mindedexperts are against the parasitic theory, so far, and becoming moredecidedly so. In other words, cancer appears to be an evil which thebody breeds within itself. 

There is absolutely no adequate ground for the tone of lamentation andthe Cassandra-like prophecy which pervade all popular, and aconsiderable part of medical, discussion of the race aspects of thecancer problem. The reasoning of most of these Jeremiahs is something onthis wise: That, inasmuch as the deaths from cancer have apparentlynearly trebled in proportion to the population within the last thirtyyears, it only needs a piece of paper and a pencil to be able to figureout with absolute certainty that in a certain number of decades, at thisgeometric ratio, there will be more deaths from cancer than there arehuman beings living. 

There could be no more striking illustration, both of the dangerousnessof "a little knowledge" and of the absurdity of applying rigid logic topremises which contain a large percentage of error. Too blind aconfidence in the inerrancy of logic is almost as dangerous assuperstition. Space will not permit us to enter into details, butsuffice it to say:--

First, that expert statisticians are in grave doubt whether thisincrease is real or only apparent, due to more accurate diagnosis andmore complete recording of all cases occurring. Certainly a largeproportion of it is due to the gross imperfection of our records thirtyyears ago. 

Second, that the apparent increase is little greater than that of deathsdue to other diseases of later life, such as nervous, kidney, and heartdiseases. Our heaviest saving of life so far is in the first five-yearperiod, and more children are surviving to reach the cancer and Bright'sdisease age. 

Third, that a disease, eighty per cent of whose death-rate occurs afterforty-five years of age, is scarcely likely to threaten the continuedexistence of the race. 

The nature of the process is a revolt of a group of cells. The cause ofit is legion, for it embraces any influence which may detach the cellfrom its normal surroundings, --"isolate it, " as one pathologistexpresses it. The cure is early and complete amputation of not only therebellious cells, but of the entire organ or region in which they occur. 

A cancer is a biologic anomaly. Everywhere else in the cell-state wefind each organ, each part, strictly subordinated, both in form andfunction, to the interests of the whole. 

Here this relation is utterly disregarded. In the body-republic, wherewe have come to regard harmony and loyalty as the invariable rule, wefind ourselves suddenly confronted by anarchy and revolt. 

The process begins in one great class of cells, the epithelium of thesecreting glands. This is a group of cell-citizens of the highest rank, descended originally from the great primitive skin-sheet, which haveformed themselves into chemical laboratories, ferment-factories for theproduction of the various secretions required by the body, from thesimplest watery mucus, as in the mouth, or the mere lubricant, as in thefat-glands of the hair-follicles, to the most complex gastric orpancreatic juice. They form one of the most active and important groupsin the body, and their revolt is dangerous in proportion. 

The movement of the process is usually somewhat upon this order: Afterforty, fifty, or even sixty years of loyal service, the cells lining oneof the tubules of a gland--for instance, of the lip, or tongue, orstomach--begin to grow and increase in number. Soon they block up thegland-tube, then begin to push out in the form of finger-or root-likecolumns of cells into the surrounding tissues. 

These columns appear to have the curious power of either turning theirnatural digestive ferments against the surrounding tissues, or secretingnew ferments for the purpose, closely resembling pepsin, and thusliterally eating their way into them. So rapidly do these cells continueto breed and grow and spread resistlessly in every direction, that soonthe entire gland, and next the neighboring tissues, become packed andswollen, so that a hard lump is formed, the pressure upon thenerve-trunks gives rise to shooting pains, and the first act of thedrama is complete. 

But these new columns and masses, like most other results of such rapidcell-breeding in the body, are literally a mushroom growth. Scarcely arethey formed before they begin to break down, with various results. Ifthey lie near a surface, either external or internal, they crumble underthe slightest pressure or irritation, and an ulcer is formed, which mayeither spread slowly over the surface, from the size of a shilling tothat of a dinner-plate, or deepen so rapidly as to destroy the entireorgan, or perforate a blood-vessel and cause death by hemorrhage. Thecancer is breaking down in its centre, while it continues to grow andspread at its edge. Truly a "magnificent scheme of decay. "

Then comes the last and strangest act of this weird tragedy. In thecourse of the resistless onward march of these rebel cell-columns someof 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. Surelynow the regular leucocyte cavalry have them at their mercy, and can cutthem down at leisure. We little realize the fiendish resourcefulness ofthe cancer-cell. One such adrift in the body is like a ferret in arabbit warren; no other cell can face it for an instant. It simplyfloats unmolested along the lymph-channels until its progress isarrested in some way, when it promptly settles down wherever it mayhappen to have landed, begins to multiply and push out columns in everydirection, into and at the expense of the surrounding tissues, andbehold, a new cancer, or "secondary nodule, " is born (_metastasis_). 

In fact, it is a genuine "animal spore, " or seed-cell, capable of takingroot and reproducing its kind in any favorable soil; and, unfortunately, almost every inch of a cancer patient's body seems to be such. It ismerely a question of where the spore-cells happen to drift and lodge. The lymph-nodes or "settling basins" of the drainage area of the primarycancer are the first to become infected, probably in an attempt to checkthe invaders; but the spores soon force their way past them toward thecentral citadels of the body, and, one after another, the great, vitalorgans--the liver, the lungs, the spleen, the brain--are riddled by thedeadly columns and choked by decaying masses of new cells, until thefunctions of one of them are so seriously interfered with that deathresults. 

Obviously, this is a totally different process, not merely in degree, but in kind, from anything that takes place as a result of the invasionof the body by an infectious germ or parasite of any sort. There is acertain delusive similarity between the cancer process and an infection. But the more closely and carefully this similarity is examined the moresuperficial and unreal does it become. The invading germ may multiplychiefly at one point or focus, like cancer, and from this spreadthroughout the body and form new foci, and may even produce swarms ofmasses of cells resembling tumors, as, for instance, in tuberculosis andsyphilis. But here the analogy ends. 

The great fundamental difference between cancer and any infection liesin the fact that, in an infection, the inflammations and poisonings andlocal swellings are due solely and invariably to the presence andmultiplication of the invading germs, which may be recovered in millionsfrom every organ and region affected, while swellings or new massesproduced are merely the outpouring of the body-cells in an attempt toattack and overwhelm these invaders. In cancer, on the contrary, thedestroying organism is a group of perverted body-cells. The invasion ofother parts of the body is carried out by transference of their bastardand abortive offspring. Most significant of all, the new growths andswellings that are formed in other parts of the body are composed, notof the outpourings of the local tissues, but of _the descendants ofthese pirate cells_. This is one of the most singular and incrediblethings about the cancer process: that a cancer starting, say, in thepancreas, and spreading to the brain, will there pile up a mass--not ofbrain-cells, or even of connective tissue-cells--but of gland-cells, resembling crudely the organ in which it was born. So far will thisresemblance go that a secondary cancer of the pancreas found in the lungwill yield on analysis large amounts of trypsin, the digestive fermentof the pancreas. Similarly a cancer of the rectum, invading the liver, will there pile up in the midst of the liver-tissue abortive attempts atbuilding up glands of intestinal mucous membrane. 

This fundamental and vital difference between the two processes isfurther illustrated by this fact: While an ordinary infection may betransferred from one individual to another, not merely of the samespecies, but of half a dozen different species, with perfect certainty, and for any number of successive generations, no case of cancer has everyet been known to be transferred from one human being to another. Inother words, the cancer-cell appears utterly unable to live in any otherbody except the one in which it originated. 

So confident have surgeons and pathologists become of this that a scoreof instances are on record where physicians and pathologists, among themthe famous surgeon-pathologist, Senn, of Chicago, only a few years ago, have voluntarily ingrafted portions of cancerous tissue from patientsinto their own arms, with absolutely no resulting growth. In fact, thecancer-cell behaves like every other cell of the normal body, in that, though portions of it can be grafted into appropriate places in thebodies of other human beings and live for a period of days, or evenmonths, they ultimately are completely absorbed and disappear. The onlyapparent exception is the epithelium of the skin, which can be used ingrafting or skinning over a wide raw surface in another individual. However, even here the probability appears to be that the taking root ofthe foreign cells is only temporary, and makes a preliminary covering orprotection for the surface until the patient's own skin-cells canmultiply fast and far enough to take its place. 

A similarly reassuring result has been obtained in animals. Not a singleauthenticated case is on record of the transference of a human cancer toone of the lower animals; and of all the thousands and thousands ofexperiments that have been made in attempting to transfer cancers fromone animal to another, only one variety of tumor with the microscopicappearance of cancer--the so-called Jensen's tumor of mice--has yet beenfound which can be transferred from one animal to another. 

So we may absolutely disabuse our minds of the fear which some of ourenthusiastic believers in the parasitic theory of cancer have done muchto foster, that there is any danger of cancer "spreading, " like aninfectious disease. Disastrous and gruesome as are the conditionsproduced by this disease, they are absolutely free from danger to thoseliving with or caring for the unfortunate victim. In the hundreds ofthousands of cases of cancers which have been treated, in privatepractice, in general hospitals, and in hospitals devoted exclusively totheir care, not a single case is on record of the transference of thedisease to a husband, wife, or child, nurse or medical attendant. Sothat the cancer problem, like the Kingdom of Heaven, is within us. 

This conclusion is further supported by the disappointing result of themagnificent crusade of research for the discovery of the cancer"parasite, " whether vegetable or animal, which has been pursued with asplendid enthusiasm, industry, and ability by the best blood and brainsof the pathological world for twenty years past. I say disappointing, because a positive result--the discovery and identification of aparasite which causes cancer--would be one of the greatest boons thatcould be granted to humanity; not so much on account of the actual lossof life produced by the disease as for the agonies of apprehensionengendered by the fact of the absolute remorselessness and blindnesswith which it may strike, and our comparative powerlessness to cure. Sofar the results have been distressingly uniform and hopelessly negative. 

Scores, yes, hundreds, of different organisms have been discovered inand about cancerous growths, and announced by the proud discoverer asthe cause of cancer. Not one of these, however, has stood the test ofbeing able to produce a similiar growth by inoculation into anotherbody; and all which have been deemed worthy of a test-research by otherinvestigators besides the paternal one have been found to be mereaccidental contaminations, and present in a score of other diseases, oreven in normal conditions. Many of them have been shown to be abnormalproducts of the cells of the body in the course of the cancer process, and some even such ludicrous misfits as impurities in the chemicalreagents used, scrapings from the corks of bottles, dust from the air, or even air-bubbles. These "discoveries" have ranged the whole realm ofunicellular life, --bacilli, bacteria, spirilla, yeasts, moulds, protozoa, --yet the overwhelming judgment of broad-minded and reputableexperts the world over is the Scotch verdict of "not proven"; and we aremore and more coming to turn our attention to the other aspect of theproblem, the factors which cause or condition this isolation andassumption of autonomy on the part of the cells. 

This is not by any means to say that there is no causative organism, andthat this will not some day be discovered. Human knowledge is a blindand short-sighted thing at best, and it may be that some invading cell, which, from its very similarity to the body-cells, has escaped oursearch, will one day be discovered. Nor will the investigators diminishone whit of their vigor and enthusiasm on account of their failure thusfar. 

The most strikingly suggestive proof of the native-born character ofcancer comes from two of its biologic characters. The first is that itshabit of beginning with a mass formation, rapidly deploying into columnsand driving its way into the tissues in a ghastly flying wedge, issimply a perfect imitation and repetition of the method by which glandsare 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 alittle swarm, or mass, elongate into a column, push their way down intothe deeper tissue, and then hollow out in their interior to form atubular gland. The only thing that cancer lacks is the last step offorming a tube, and thereby becoming a servant of the body instead of aparasite 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, andyou will find massing columns and nests of cells pushing out into thesurrounding tissue in all directions, in a way that is absolutelyundistinguishable in its earlier stages from the formation of cancer. Itis a fact of gruesome significance that the two organs--the mammarygland and the uterus--in which this process habitually takes place inadult life are the two most fatally liable to the attack of cancer. 

Another biologic character is even more striking and significant. Acouple of years ago it was discovered by Murray and Bashford, of theEnglish Imperial Cancer Research Commission, that the cells of cancer, in their swift and irregular reproduction, showed an unexpectedpeculiarity. In the simplest form of reproduction, one cell cuttingitself in two to make two new ones, known as mitosis, the change beginsin the nucleus, or kernel. This kernel splits itself up into a series ofthreads or loops, known as the chromosomes, half of which go into eachof the daughter cells. When, however, sex is born and a male germ-cellunites with a female germ-cell to form a new organism, each cellproceeds, as the first step in the process, to get rid of half of thesechromosomes, so that the new organism has precisely the normal number ofchromosomes, half of which are derived from the father and the otherhalf from the mother germ-cell. This, by the way, is the mechanicalbasis of heredity. 

It has been long known that the mitotic processes of cancer and theforming and dividing of the chromosomes were riotous and irregular, likethe rest of its growth. But it was reserved for these investigators todiscover the extraordinary fact that the majority of dividing andmultiplying cancer-cells had, instead of the normal number ofchromosomes, exactly half the quota. In other words, they had resumedthe powers of the germ, or sexual, cells from which the entire body wasoriginally built up, and were, like them, capable of an indefiniteamount of multiplication and reproduction. How extraordinary andlimitless this power is may be seen from the fact that a little group ofcancer-cells grafted into a mouse to produce a Jensen tumor, from whicha graft is again taken and transplanted into another mouse, and so on, is capable, in a comparatively few generations, of producing cancerousmasses a thousand times the weight of the original mouse in which thetumor started!

In short, cancer-cells are obviously a small, isolated group of thebody-cells, which in a ghastly fashion have found the fountain ofperpetual youth, and can ride through and over the law-abiding citizensof the body-state with the primitive vigor of the dawn of life. 

This brings us to the most practical and important questions of theproblem: What are the influences which condition this isolation andoutlawry of the cells? What can we do to prevent or suppress therebellion? To the first of these science can only return a tentative andapproximate answer. The subject is beset with difficulties, chief amongwhich is the fact that we are unable to produce the disease withcertainty in animals, with the single exception of the Jensen's tumorsin mice referred to, nor is it transferred from one human being toanother, so that we can make even an approximate guess at the precisetime at, or conditions under, which the process began. 

Many theories have been advanced, but most investigators who havestudied the problem in a broad-minded spirit are coming gradually toagree to this extent:--

First of all, that one of the most powerful influences conditioning thisisolation and revolt of the cells is age, both of the individual and ofthe organ concerned. Not only does far the heaviest cancer mortalityfall between the ages of forty-five and sixty, but the organs mostfrequently and severely attacked are those which between these years arebeginning to lose their function and waste away. First and moststriking, the mammary gland and the uterus in women, and the shrivelinglips and tongue of elderly men. To put it metaphorically, the mammarygland and the uterus, after the change of life, the lip, after the decayof the teeth, have done their work, outlived their usefulness, and arebeing placed upon a starvation pension by a grateful country. Nineteenout of twenty accept the situation without protest and sink slowly to amere vegetative state of existence, but, in the twentieth, some littleknot of cells rebel, revert to an ancestral power of breeding rapidly toescape extinction, begin to make ravages, and cancer is born. 

The age-preferences are well marked. Cancer is emphatically a disease ofsenility, of age; but, as Roger Williams has pointed out in hisadmirable monograph, not of "completed" senility. 

To express it in percentages, barely twenty per cent of the cases occurbefore forty years of age, sixty per cent between forty and sixty, andtwenty per cent between sixty and eighty. Thus the early period ofdecline, the transition stage between full functional vigor and declaredatrophy (wasting) of the glands, is clearly the period of greatestdanger; precisely the period in which the gland-cells, though losingtheir function, --and income, --have still the strength to inaugurate arebellion, and a sufficient supply of the sinews of war, either in theirown possession or within easy striking distance in the tissues aboutthem, to make it successful. Not less than sixty-five to seventy-fiveper cent of all cancers in women occur in atrophying organs, the uterusand mammary glands. 

A rather alluring suggestion was made by Cohnheim, years ago, thatcancers might be due to the sudden resumption of growth on the part ofislands or _rests_ of embryonic tissue, left scattered about in variousparts 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 deadlyprocess? So far as it is conditioned by age, it is, of course, obviousthat little can be done, for not even the most radical vivisector wouldpropose preventing in any way as large a proportion as possible of thehuman race from reaching fifty or sixty, or even seventy years, to avoidthe barely six per cent liability to cancer after forty-five. 

As regards the influence of chronic inflammations and irritation, muchcan be done, and here is our most hopeful field for prevention. Wartsand birthmarks that are in any way subject to pressure or friction fromclothing or movements should be promptly removed, as both show adistinctly greater tendency than normal tissue to develop into cancer. Cracks, fissures, chafes, and ulcers of all sorts, especially about thelips, tongue, mammary gland, uterus, and rectum, should be early andaseptically dealt with. Jagged remnants of teeth should be removed, allsuppurative processes of the gums antiseptically treated, and the wholemouth-parts kept in a thoroughly aseptic condition. 

Thorough and conscientious attention to this sort of surgical toiletwork is valuable, not only for its preventive effect, --which isconsiderable, --but also because it will insure the bringing undercompetent observation at the earliest possible moment the beginnings oftrue cancer. 

For the disease itself, after it has once started, there is, liketreason 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 theysuppress a symptom only and leave the cause untouched. Only in one formof surface-cancer, the so-called flat-celled or rodent ulcer, which haslittle 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 downcells which have actually become cancerous; but so long as there remainsin the body a single nest, or even cell, of the organ in which therevolt started, so long the life of the patient is in danger. 

Absolutely the only remedy which is of the slightest value is completeremoval with the knife. The one superiority of the knife, shudder as wemay at the name of it, over every other means of removal lies solely inthis fact, that with it can be removed not merely the actual cancer, butthe 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, butthe entire diseased breast, for instance, and all the lymph-glands intowhich it drains, clear up into the armpit, with the muscles beneath itdown to the ribs. Where this is done early enough, the disease does notrecur. Such radical and complete amputation of an organ or region asthis is possible in from two-thirds to three-fourths of all cases ifseen reasonably early. 

With watchfulness and courage, our attitude toward the cancer problem isone of hopeful confidence. 

CHAPTER XVII

HEADACHE: THE MOST USEFUL PAIN IN THE WORLD

Greatness always has its penalties. Other ills besides death love ashining mark. Pain is one of them, and headache its best exemplar. Ifthere be one thing about our bodies of which we are peculiarly andinordinately proud it is that expanded brain-bulb which we call thehead. Yet it aches oftener than all the rest of us put together. Headache is the commonest of all pains, which fact gives the slightconsolation that everybody can sympathize with you when you have it. Onetouch of headache makes the whole world kin, and the man or woman whohas never had it would be looked upon as a creature abnormal and "athing apart. " It has even become incorporated into our social fabric asone of the sacred institutions of the game of polite society. How couldwe possibly protect ourselves against our instructors in youth and ourwould-be friends in later life if there were no such words as "a severeheadache"?

What is a headache, and why does it ache the head? This is a wide andhotly disputed problem. But one fact, which is obvious at the firstintelligent glance, becomes clearer and more important with deeperstudy, and that is that it _is not the fault of the head_. When the headaches, it is, nine times out of ten, simply doing a combination ofscapegoat and fire-alarm duty for the rest of the body. Just as thebrain is the servant of the body, rather than its master, so the devotedhead meekly offers itself as a sort of vicarious atonement for the sinsof the entire body. It is the eloquent spokesman of such "mute, inglorious Miltons" as the stomach, the liver, the muscles, and theheart. The humblest and least distinguished of all the organs of thebody can order the lordly head to ache for it, and the head has noalternative but to obey. 

To discuss the cause of headaches is like discussing the cause of thehuman species. It is one of the commonest facts of every-dayobservation, and can be demonstrated almost at will, that any one of ahundred different causes, --a stuffy room, a broken night's sleep, atroublesome letter, a few extra hours of work, eating something thatdisagrees, a cold, a glare of light in the eyes, --any and all of thesemay bring on a headache. The problem of avoiding headaches is theproblem of the whole conduct of life. 

Two or three broad generalizations, however, can be made from theconfused and enormous mass of data at our disposal, which are of bothphilosophic interest and practical value. One of these is that, whileheadache is felt in the head, and particularly in those regions that lieover the brain, the brain has comparatively little to do with the pain. Headache is neither a mark of intellectuality, nor, with rareexceptions, a sign of cerebral disturbance. Indeed, it is far more amatter of the digestion, the muscles, and the ductless glands, than itis of the brain, or even of the nervous system. It is, therefore, idleto endeavor either to treat or try to prevent it by measures directedto 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 thesepractically and eventually operate by producing a toxic, or poisoned, condition of the blood, which, circulating through certain delicate andsensitive nerve-strands in the head and face, give rise to the sensationof pain. 

Thirdly, the tissues which give out this pain-cry under the torture ofthe toxins in the blood are, in a large majority of cases, neither thebrain, nor the nerves of the eye, nor other special senses, but thenerves of common sensation which supply the face, the scalp, and thestructures of the head generally, most of them derived from one greatpair of nerve-trunks, the so-called _Trigeminus_, or fifth pair ofcranial nerves. Strange as it may seem, the brain substance iscomparatively insensitive to pain, and the acutest pain of an operationupon it, such as for the removal of a tumor, is over when the skin andscalp have been cut through. These poisons, of course, go all over thebody, wherever the circulation goes, but they produce their promptestand loudest pain outcry, so to speak, in the region where the nerves aremost exquisitely sensitive. When your head aches, nine times out of tenyour whole body is suffering, but other regions of it are not able toexpress themselves so promptly and so clearly. 

These newer and clearer views of the nature of headache dispose at onceof some of the most time-honored controversies in regard to its nature. In my student-days one of the most hotly debated problems in medicinewas as to whether headaches were due to lack of blood (anæmia) or excessof blood (hyperæmia) in the brain. Few things could have been morenatural for both the sufferer in, and the observer of, a case ofthrobbing, bursting headache, where every pulse-beat is registered as athrill of agony, than to draw the conclusion that the pain was due to ahuge engorgement and swelling of the brain with blood, resulting inagonizing pressure against its rigid, bony skull-walls. 

One of the most naïve and vivid illustrations of this conception ofheadache is the remedy adopted for generations past, in this all toofamiliar and distressing condition, by the Irish peasantry. It consistsof a band or strip of tough cloth, or better, of twisted or plaitedstraw, which is tied around the head and then tightened vigorously bymeans of a stick inserted tourniquet fashion. This is believed toprevent the head, which is aching "fit to split, " from actually burstingopen, and is considered a cure of wondrous merit through many acountryside. Ludicrous as is the reason which is gravely assigned forits use, it does, in some cases, greatly relieve the pain, a fact whichwe were entirely at a loss to account for until our later knowledgeshowed us that the pain, instead of being inside the skull, was outsideof it in the sensitive nerves supplying the scalp. By steady pressure ofthis sort upon the trunks of these nerves, pressing them against thebone, they can be gradually numbed into a condition of anæsthesia, whennaturally the pain would diminish. 

In politer circles a similar misapprehension has also given rise to afavorite form of treatment. That is the application of cold in the formof the classic wet cloth sprinkled with _eau de Cologne_. The meremention of headache calls up in the minds of most of us memories of adarkened room, a pale face on the pillow with a ghastly bandage over theeyes, and a pervading smell of _eau de Cologne_. It was a perfectlynatural conclusion that, because the head throbbed and felt hot andbursting, there must be some inflammation, or at least congestion, present, and that the application of cold would relieve this. Theresults seemed to justify this belief, for in many cases the sense ofcoolness to the aching head gives great relief; but this is apt to beonly temporary, and in really severe cases makes the situation worse byadding another depressing influence--cold--to the toxin-burdens that areweighing upon the tortured nerves. The chief virtue in these cold clothsand handkerchiefs soaked in cologne was that you were compelled to liedown and keep perfectly still in order to keep them on, while at thesame time they mechanically blindfolded you. Few better devices forautomatically insuring that absolute rest, which is the best and onlyrational cure for a headache, have ever been invented. 

We were not long in discovering that headaches, both of the mildest andthe severest types, might be accompanied either by a rush of blood tothe head, with flushing of the skin, reddening of the eyes, and abursting sense of oppression in the head, or, on the other hand, by anabsolute draining of the whole floating surplus of the blood into theso-called "abdominal pool, " the huge network of vessels supplying thedigestive organs, which, when distended, will contain nearly two-thirdsof the entire blood of the body, leaving the face blanched, the eyeswhite and staring, and the brain so nearly emptied of blood as to causeloss of consciousness or swooning. Other headaches, again, will beaccompanied by a fresh, natural color and a perfectly normal and healthydistribution of the blood-supply. In short, the amount of blood in thehead, whether plus or minus, has practically nothing to do with thepain, but depends solely upon the effect of the poisons producing itupon the heart and great blood-vessels. 

A good illustration of the full-blooded type of headache is that whichso very frequently, indeed almost invariably, occurs in the early stageof a fever or other acute infection, such as typhoid, pneumonia, orblood-poisoning, Here the face is red, the eyes are bloodshot andabnormally bright, the pulse is rapid and full, the headache so severeas to become the first disabling symptom in the disease, --all becausethis is the effect of the poison (toxin) of the disease upon the heart, the temperature, and the surface blood-vessels. Fortunately for thesufferer, this head-pain, like most others in the course of severeinfections, is only preliminary, for as soon as the tissues of the bodyhave become thoroughly saturated with the toxins, the nerves becomedulled and semi-narcotized, so that they no longer respond with thepain-cry. As the patient settles down into the depression and dullnessof the regular course of the fever, the headache usually subsides intolittle more than a sense of heaviness, or oppression and vaguediscomfort. 

Moral: It is a sign of health to be able to feel a headache, anindication that your body is still fighting vigorously against theenemy, whether traitor within or foe without. 

On the other hand, many of our most agonizing, and particularly our mostpersistent and obstinate headaches, occur in individuals who aremarkedly anæmic, with a low, weak pulse, poor circulation, blanchedlips, and dull, lackluster eyes. The one and only thing in commonbetween these two classes of "head-achers" is that their blood andtissues are loaded with poisons. Whether produced by invading germs orby starvation and malnutrition of the body-tissues makes no differenceto the headache nerves. Their business, like good watchdogs, is to barkevery time they smell danger of any sort, whether it be bears orbook-agents. One of the most valuable services rendered us by ourpriceless heads is aching. 

This view of the nature of headache explains at once why it is soextraordinarily frequent and so extraordinarily varied in causation. Itis not too much to say that _any_ influence that injuriously affects thebody may cause a headache. It would, of course, be idle even to attemptto enumerate the different causes and kinds of this pain, as it wouldinvolve a review of the entire environment of the human species, internal and external. It makes not the slightest difference how thepoison gets into the blood, or where it starts. A piece of tainted meator a salad made from spoiled tomatoes will produce a headache just aspromptly and effectively as an over-exposure to the July sun or anattack of influenza. It is even practically impossible to pick out fromsuch a wealth of origins two or three, or even a score of, conditionswhich are the most frequent, most important, or the most interestingcauses. The most exasperating thing about dealing with a headache isthat we never know, until its history has been most carefully examined, whether we have to do with a mere temporary expression of discomfort andunbalance, due to overfatigue, errors in diet, a stuffy room, lack ofexercise, or what-not, which can be promptly relieved by removing thecause; or whether we have to deal with the first symptoms of a dangerousfever, the beginning of a nervous breakdown, or an early warning of somegrave trouble in kidneys, liver, or heart. 

The one thing, however, that stands out clearly is that _headache alwaysmeans something_; that it should be promptly and thoroughly investigatedwith a view to finding and removing the cause, --never as something whichis to be cured as quickly as possible, as the police cure socialdiscontent, by clubbing it over the head, with some narcotic or othersymptom-smotherer. Nor should it be regarded as a malady so triflingthat it is best treated with contempt, and still less as a mere "thornin the flesh, " whose ignoring is to be counted a virtue, or whosepatient endurance without sign a mark of saintship. Martyrdom ismagnificent when it is necessary, but many forms of it are sheerstupidity. 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 todiscover and remove before serious harm has been done. The less easy youfind it to put your finger upon it, the more likely it is to be seriousor chronic, and the more necessary it is to remove it. 

Once, however, we have clearly recognized that no headache should betreated too lightly or indifferently, it may be frankly admitted thatpractically the vast majority of headaches in which we are keenlyinterested--that is, the kind that we individually or the members of ourfamily habitually indulge in--do form a moderately uniform class amongthe hundreds of varieties, and are in the main due to some six or sevengreat groups of causes. We have learned by repeated and unpleasantexperience 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, thatthey are made worse by such and such things, that they are helped byother things, and that they generally get better after a good night'ssleep. 

One of the commonest causes of this group of recurrent and self-limitedheadaches is fatigue, whether bodily, mental, or emotional. This waslong an apparent stumbling-block in the way of a poison theory ofheadache, but now it is one of its best illustrations. Physiologistsyears ago discovered that what produced not merely the sensation butalso the fact of fatigue, or tiredness, was the accumulation in themuscles or nerves of the waste-products of their own activities. Simplywashing these out with a salt solution would start the utterly fatiguedmuscle contracting again, without any fresh nourishment or even periodfor rest. It has become an axiom with physiologists that fatigue issimply a form of self-poisoning, or, as they sonorously phrase it, autointoxication. One of the reasons why we are so easily fatigued whenwe are already ill, or, as we say, "out of sorts, " is that our tissuesare already so saturated with waste-products or other poisons that theslightest addition of the fatigue poisons is enough to overwhelm them. This also explains why our pet variety of headache, which we may haveclearly recognized to be due to overwork or overstrain of some sort, whether with eye, brain, or muscles, is so much more easily brought onby such comparatively small amounts of over-exertion whenever we arealready below par and out of sorts. People who are "born tired, " who areneurasthenic and easily fatigued and "ached, " are probably in a chronicstate of self-poisoning due to some defect in their body-chemistry. Further, the somewhat greater frequency and acuteness of headache inbrain workers--although the difference between them and muscle workersin this regard has been exaggerated--is probably due in part to thegreater sensitiveness of their nerves; but more so to the curious fact, discovered in careful experiments upon the nervous system, that thefatigue products of the nerve-cells are the deadliest and most powerfulpoisons produced in the body. Hence some brain workers can work only afew 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 subdivisionof the great fatigue group, is eye-strain. This is due to an abnormal orimperfect shape of the eye, which is usually present from birth. Hence, the only possible way of correcting it is by the addition to theimperfect eye of carefully fitted lenses or spectacles which willneutralize this mechanical defect. To put it very roughly, if the eye istoo flat to bring the light-rays to a focus upon the retina, which isfar the commonest condition (the well-known "long sight, " or hyperopia), we put a plus or bulging glass before the eye and thus correct itsshape. 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, itoften happens that the headache due to eye-strain is caused not by thegrosser defects, such as interfere with vision so seriously asabsolutely to demand the wearing of glasses to see decently, but fromslighter and more irregular degrees and kinds of misshapenness in theeye, most of which fall under the well-known heading of astigmatism. These interfere only slightly with vision, but keep the eye perpetuallyon the strain, on a twist, as it were, rasping the entire nervous systeminto a state of chronic irritation. Our motto now, in all cases ofchronic headache, is, first examine the patient's habits of life, nexthis eyes. 

Many forms of headache are really stomach-ache in disguise, due todigestive disturbances, the absorption of poisons from the food-tube, whether from tainted, spoiled, or decayed foods, as in the now familiarptomaine poisoning, or from imperfect processes of digestion. Theimmediate effect, however, of diet in the causation of headache is notso great as we once believed. We have no adequate basis for believingthat any particular kinds or amounts of food are especially likely toproduce either headache or what we might call the headache habit, exceptin so far as they upset the digestion. In a certain number ofsusceptible individuals, however, it will be found that some particularkind of food, often perfectly wholesome and harmless in itself, willbring on an attack of headache whenever it is indulged in. Veryfrequently the disturbances of digestion which are put down as the_cause_ of a headache are only _symptoms_ of some general constitutionallack of balance, as eye-strain or neurasthenia, which is the cause ofboth these discomforts. Far fewer headaches can be cured by dieting thanwe at one time believed, and underfeeding is a more frequent cause thanovereating. 

By an odd _bouleversement_ the one type of headache which we have almostunanimously in the past attributed to digestive disturbances, thefamous, or, rather, infamous, "sick headache, " is now known to havelittle 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 causesthe sickness, not the sickness the headache. Stop the pain of a sickheadache in the early stage, and the sickness will never develop at all. The vomiting of sick headache is an interesting illustration of vomitingdue to disturbances of the brain and nervous system, technically knownas central vomiting. Another illustration is the vomiting ofseasickness, due solely to dizziness from the gross contradictionbetween the testimony of our eyes and of the balancing canals in theinner ear. The stomach or its contents has no more to do withseasickness than the water in a pump has with the plunger. Injuries tothe head will bring on severe and uncontrollable vomiting, and theseverer type of fevers is very frequently ushered in by this curioussign. As to what it means, we are as yet utterly in the dark, for innone of these conditions does the process do the slightest good, butsimply adds to the discomfort of the situation. It would appear to be acurious echo of ancestral times, when the animal was pretty much allstomach, and hence emptying that organ would probably relieve two-thirdsof his discomforts. Whatever the explanation, the fact remains thatwhenever our nervous system gets about so panic-stricken, it promptlybegins throwing its cargo overboard, in the blind hope that this maysomehow relieve the situation. The bile that we bring up at the end ofthese interesting acrobatic performances and which makes us feel so muchbetter, --because we have now got the cause of the trouble out of oursystem, --is simply due to the prolonged vomiting, which has reversed thenormal current and caused the perfectly healthy bile from ourunoffending liver to pass upward into the stomach, instead of downwardinto the bowels. 

In another great group of headaches natural poisons or waste-productsare not burned up or got rid of through the body-sewers and pores asrapidly as they should be; for instance, the familiar headache fromsitting too long in a stuffy room. Your well-known and well-earneddiscomfort is, of course, due in part to the irritating and oftenpoisonous gases, dust, and bacteria, which are present in the air of anunventilated room; but it is also due to the steady piling up of thewaste products of your own tissues. These poisons are normally oxidizedin the muscles, burned up and exhaled through the lungs, and sweated outthrough the skin, --all three of which relief agencies are, of course, practically paralyzed, or working at lowest possible level, while youare 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 inBright's disease, is a headache of a peculiar type due to accumulationin 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 dueto the encroachments of work or of amusements, then the mechanism of itsproduction is obvious. The fatigue poisons produced during the day andnormally completely neutralized and burned up during sleep are notentirely 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 itmay sound, the fatigue poisons, which in moderate amounts will producedrowsiness and promote sleep, in excessive amounts will causewakefulness and inability to sleep. Insomnia and headache are usuallysymptoms of this overfatigued, or poisoned, condition, and should bothbe 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 bedue to adenoids or deformities of the septum, or chronic catarrhalconditions. These probably act by their interference with breathing andconsequent imperfect ventilation of the blood, as well as by obstructionand 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 itscause. But the view which seems to come nearest to explaining its manyeccentricities is that it is usually due to a congenital defect, not somuch of the nervous system as of the entire body, by which the poisonsnormally produced in its processes fail to be neutralized and got ridof, and gradually accumulate until they saturate the system to such adegree as to produce a furious explosion of pain. This defect may quitepossibly be in one of the ductless glands or in some of the internalsecretions, rather than in the nervous system. 

Obviously, after what has been said of the world-wide causation ofheadache, to attempt to discuss its treatment would be as absurd as toundertake 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 aheadache due to an inflammation or tumor of the brain would, of course, be wide as the poles from that which would relieve an ordinary fatigueor indigestion pain. Besides, it is utterly irrational and often harmfulto attempt _to treat any headache as such_. That is the open road to themorphine habit and drug addictions of all sorts. Remedies--and there areplenty of them--which simply relieve the pain without doing anything toremove its cause, merely make the latter state of that individual worsethan the first. Headache is always and everywhere nature's vivid warningthat something is going wrong, like the shrieking of a wagon-axle or theclatter of a broken cog in machinery. 

There is, however, fortunately one remedy which alone will cureninety-nine per cent of all headaches, and that is rest. The first thingan intelligent machinist does when squeaking or rattling begins is tostop the machinery. This has the double advantage of preventing thedamage from going any further and of enabling him to get at the cause. Headache, like pain anywhere, is nature's imperative order _to Halt_, atleast long enough to find out what you are doing to yourself that youshouldn'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, betterstill, by going to bed for the remainder of the day and sleeping throughuntil the next morning. If more headaches were treated in this way therewould not only be fewer headaches, but two-thirds of the risks ofnervous breakdown, collapse, insomnia, and chronic degenerative changesin the liver, kidneys, and blood-vessels would be avoided. 

This, of course, is a counsel of perfection, and incapable of generalapplication for the sternest of reasons; but it does indicate therational attitude toward headache and its treatment, and one which iscoming to be more and more adopted. No motorist would dream of pushingahead with a shrieking axle or a scorching hot box, unless his journeywere one of most momentous importance or a matter of life and death. Pain is nature's automatic speed regulator. It is often necessary todisregard it, to get the work of the world done and to discharge oursacred obligations to others; but this disregarding should not beexalted to too high a pinnacle of virtue, and least of all worshiped asinherently and everywhere a mark of piety and one of the insignia ofsaintship. 

A business firm or a factory, for instance, which would send home forthe day each of its employees who reported a genuine case of badheadache, 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 physicallyunfit to attempt it. And the higher the type of work that has to bedone, the more the elements of insight, grasp, and sound judgment enterinto it, the graver and costlier are the mistakes that are likely to bemade under such circumstances. 

Of course, it will probably be objected at this point: "What is the useof wasting a day, or even half a day, when by taking two or threecapsules of So-and-So's Headache Cure I can get rid of the pain and goright on with my work?" It is perfectly true that there are a number ofremedies which will relieve the average headache; but there are twoimportant things to be borne in mind. The first is that all of these aresimply weaker or stronger nerve-deadeners; most of them actualnarcotics. All that they do is to stop the pain and thus cheat you intothe impression that you are better. You are just as tired and as unfitfor work as you were before. Your nervous system is just as saturatedwith poisons, and the chances are ten to one that the quality of thework 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 somewhatsimilar conditions, the remedy which you have taken, while producing afalse sense of comfort and even exhilaration by deadening your pain anddiscomfort, in that very process itself takes off the finer edge of yourjudgment, the best keenness of your insight, and the highest balance ofyour control. In short, your nervous system has to struggle with all thepoisons that were present before, with another one added to them!

After you have taken nature's wise advice, and obeyed her orders, andput yourself at rest, then there are a number of mild sedatives, withwhich every physician is familiar, one of which, according to thespecial circumstances of your case, it may be perfectly legitimate totake in moderate doses, with the approval of a physician, as a means ofrelieving the pain and helping to get that sleep which will complete thecure. 

One other measure of relief, which, like rest, is also indicated byinstinct, is worth mentioning, and that is gentle friction of the head. One of the most instinctive tendencies of most of us when suffering froma severe headache is to put the hands to the head, either for thepurpose of frantically clutching at it, rubbing as if our lives dependedupon it, or pressing hard over the aching region. The mere picture of aman 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 dosomething to or with the offending member. We would sometimes like tothrow it away if we could, or at others to bang it against the wall. Butpart of it is due to the discovery, ages ago, that pressure and frictionwould give a certain amount of relief. 

For some curious reason the nerves most frequently involved are thosewhich are most readily accessible for this kind of treatment, namely, the long nerve-threads which run from the inner third of the eyebrow upthe forehead and over the crown of the head (the so-called supraorbitalor 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 cervicalplexus); and a smaller pair run up just in front of the ear into thetemple, and from there on upward to join the other two pairs at the topof the head. 

Broadly speaking, the position of the pain depends upon which pair ofthese nerves is lifting up its voice most vigorously in protest. If itbe the front pair (supraorbitals) then we get the well-known frontal orforehead headache; if the back pair (known as the occipitals) then wehave the deadly, constricting, band-around-the-head pain which clutchesus across the back of the neck and base of the brain. If the lateralpair 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 torespond more readily to calls coming in from certain regions of thebody, as, for instance, the forehead nerves to eye-strain, theback-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 pelvicdisturbances and anæmic conditions, the lateral branches in the templesto diseases of the teeth and throat, yet there is little fixeduniformity in these relations. Eye-strain, for instance, may causeeither frontal or occipital headache; and, as every one knows fromexperience, the pain may be felt in all parts of the head at once. 

Gentle and intelligent massage over the course of these nerves of thescalp, according to the location of the pain, will often do much torelieve 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 disabilityas it causes. 

CHAPTER XVIII

NERVES AND NERVOUSNESS

Nerves are real things. In spite of their connection with imaginarydiseases and mental disturbances, there is nothing imaginary orunsubstantial about them. There is no more genuine and obstinate maladyon earth than a nervous disease. Because nerves lie in that twilightborderland between mind and matter, body and soul, the real and theideal, the impression has got abroad that they are little better thanfigures of speech. Though their disturbances give rise to visions of allsorts there is nothing visionary about them; they are just as genuineand substantial a part of our bodily structure as our bones, muscles, and blood-vessels. In fact, it was this very substantiality that at thebeginning prevented their proper recognition, and handicapped them withtheir present absurd and inappropriate name. 

"Nerve" is from the Greek _neuron_, meaning tendon, or sinew, and wasoriginally applied indiscriminately to all the different shining cordswhich run down the limbs and among the muscles. In fact the firstrecognition of nerves was an utter failure to recognize. The tendoncords, which are the ropes with which the muscles work the jointpulleys, were actually included under one head with the less numerousbut almost equally large and tough cords of grayer color, flatteroutline, and less glistening hue, which were afterwards found to benerve-trunks. Cutting either paralyzed the limb below the cut, --and whatmore proof could you ask of their having the same function?

Such is the persistence of ancient memories, that any physician couldtell you of scores of cases in which he has heard the naïve remark, inreference most frequently to a deep gash across the wrist, that the"nerves" were cut, and the hand was paralyzed, when what had happenedwas simply that the tendons had been cut across. When, after centuriesof blundering in every possible direction until the right one wasfinally stumbled upon (which is the mechanism of progress), it wasrealized that some of these "nerves, " the grayer and flatter ones, carried messages instead of pulling ropes, they were still far frombeing properly understood. 

It is an amusing illustration of the blissful ignorance and charmingnaïveté which marked their study and discussion at this time, thatnerves were for centuries regarded as hollow tubes, carrying a supply of"animal spirits" from the central reservoir of the brain to thedifferent limbs. So seriously was this believed, that, in amputations, the cut nerve-trunks were carefully sought out and tied, for fear thevital spirits would leak out and the patient thus literally bleed todeath. One can imagine how this must have added to the comfort of theluckless patient. 

The term "nerves" still persists, in the old sense, in both botany andentomology, which speak of the "nerves" of a butterfly's wing, or the"nervation" of a leaf, meaning simply the branching, fibrous frameworkof 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 firstconvincing demonstration of this fact. It was in one of the firstsurgical clinics that I attended as a medical student. A woman patientwas brought in, with a history of suffering the tortures of the damnedfor 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 torelieve a furious neuralgia, for the surgeon to cut down upon thenerve-trunk, free it from its surrounding attachments, and, slipping histenaculum or finger under it, stretch the nerve with a considerabledegree of force. Whether it acts by merely setting up some trophicchange in the nerve-tissue, or by tearing loose inflammatory adhesionswhich are binding down the nerve-trunk, the procedure gives excellentresults, nearly always temporary relief, and sometimes a permanent cure. 

The patient was placed upon the table and anæsthetized, and the surgeonmade a free, sweeping incision down the back of the thigh, exposing thesciatic nerve. He thrust his finger into the wound, loosened up theadhesions about the nerve, hooked two fingers underneath it, and, to mywide-eyed astonishment, heaved upward upon it, until he brought intoview through the gaping wound a flattened, bluish-gray cord about twicethe size of a clothesline, with which he proceeded to lift the hips ofthe patient clear of the table. In my ignorant horror, I expected everymoment 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 realthings. Though it has nothing to do with this discussion, for thebenefit of those of my readers who cannot bear to have a story leftunfinished, I will add that the operation was as successful as it wasdramatic, and the patient left the hospital completely relieved of hersciatica. 

When at last it was clearly recognized that the nerves were concerned inthe sending of messages from the centre to the brain, known as_sensory_, or centripetal, and carrying back messages from the brain tothe muscles and surface, known as _motor_, or centrifugal, --in otherwords that they were the organs of the mind, --still another source ofconfusion sprang up, and that was the determination on the part of someto regard them from a purely mental and, so to speak, spiritual point ofview, and on the part of others to regard them from a physical andanatomical point of view. This confusion is of course in full riot atthe present time. 

The term "nerves, " and its adjective, "nervous, " are used in two totallydistinct senses: one, that which is vague and unsubstantial, purelymental or subjective, and, in the realm of disease at least, imaginary;the other, purely anatomical, referring to certain strands of tissuedevoted to the purpose of transmitting impulses, and the conditionaffecting these strands. I am not so rash as to raise the questionhere, --still less to attempt to settle it, --which of these two views isthe right and rational one. Whether the brain secretes thought as theliver does bile, or whether the mind created the brain and nervoussystem, or, as it has been epigrammatically put in a recent work onpsychology, "whether the mind has a body, or the body has a mind, " Imerely call attention to the fact that this confusion of meaningsexists, and that its injection into the field of medicine and pathology, at least, has done an enormous amount of harm in the way of confusingproblems and preventing a proper recognition of the actual facts. 

The more carefully and exhaustively and dispassionately we study thedisorders of the nervous system which come in the field of medicine, themore irresistibly we are drawn to the conclusion that from neurastheniaand hysteria to insanity and paralysis they are every one of them theresult of some definite morbid change in some cell or strand of thenervous system. The man or woman who is nervous has poisonednerve-cells, either from hereditary defect, or direct saturation of thetissues with toxic substances. The patient who has an imaginary diseaseis suffering from some kind of a hallucination produced by poison-soakednerve-cells, such as in highest degree give rise to the delirium offevers, and the horrid spectres of delirium tremens. 

Even the man who is suffering from a "mind diseased, " and confined inone of our merciful asylums for the insane, is in that condition andposition on account of physical disease, not merely of his brain, but ofhis entire body. The lunatic is insane, in the for once correctderivative sense of unhealthy, to the very tips of his fingers. Notmerely his mind and his brain, but his liver, his stomach, his skin, hishair and fingernails, the very sweat-glands of his surface which controlhis bodily odor, are diseased and have been so usually for years beforehis mind breaks down. 

Tell a competent expert to pick out of a crowd of a thousand men andwomen the ten who are likely to become insane, and his selection will befound almost invariably to include the two or three who will actuallybecome so. 

In fact, from even the crudest and scantiest knowledge of the actualgrowth of our own bodies from the ovum to the adult, it will bedifficult to conceive how this relation could be otherwise, Thenerve-cells and their long processes, which form the nerve-trunks, aresimply one of a score of different specialized cells which exist side byside in the body. Primarily all our body-cells had the power ofresponding to stimuli, of digesting and elaborating food, of moving bycontraction, of reproducing their kind. The nerve-cells are simply agroup which have specialized exclusively upon the power of receiving andtransmitting impulses. They still take food, but it has to be preparedfor them by the other cells; and here, as we shall see later, is one ofthe dangers to which they are exposed. They still reproduce their kind, but in very much smaller and more limited degree. They still, incredibleas it may seem, probably have slight powers of movement or contraction, and can draw in their processes. But they have surrendered many of theirrights and neglected some of their primitive accomplishments, in orderto devote themselves more exclusively and perfectly to the carrying outof one or two things. 

In spite of all this, however, they still remain blood-brothers andcomrades 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, whichcontinued up to a late hour last night, and is still going on, thenerve-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 thesame body-lymph. 

It is of course perfectly clear that any influence, whether beneficialor injurious, affecting the body, will also be likely to affect thenervous system, as a part of it; and this is precisely the fact, as wefind it. If the body be well fed, well warmed, sufficiently exercised, without being overworked, and allowed a liberal allowance of thatrecharging of the human battery which we call sleep, then the nervoussystem will work smoothly and easily, at peace with itself and with allmankind. Its sense-organs will receive external impressions promptly andaccurately. Its conducting fibres will transmit them to the centre withneither delay nor friction. The brain clearing-house will receive anddispose of them with ease and good judgment. And then, just because hisnervous 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 achievedthis. They have literally effaced themselves in the well-being of thebody. 

If on the other hand, the food-supply is inadequate, if the sleepallowance has been cut short, whether by the demands of work or by thoseof fashion, if the body has been starved of oxygen and deprived ofsunlight, if the whole system has been kept on the rack, whether in thesweatshop, or in the furnace of affliction, what is the effect on thenervous system? Just what might have been expected. The sense-organsshy, like a frightened horse, at every shadow or fluttering leaf. Theconducting wires break, and cross, and tangle in every imaginablefashion. The central exchange, half wild with hunger, or crazed withfatigue-toxins, shrieks out as each distorted message comes in, or sulksbecause it can't understand them. And then, with charming logicality, wedeclare that such an one is "all nerves. "

The brain, by which we mean the biggest one near the mouth, --we havelittle brains, or _ganglia_ all over our bodies, --so far from being anabsolute monarch, is not even a constitutional one, or a president of arepublic, but a mere house of congress of the modern type, which can dolittle but register and obey the demands of its constituents. The brainoriginates nothing. Impulses are brought to it from the sense-organs bythe nerves. They set up in it certain vibrations, or chemicaldisturbances. It responds to these much as blue litmus paper turns redwhen a weak acid is dropped on it, or as lemonade fizzes when you putsoda in it. If more than one of these vibrations are set upsimultaneously, it "chooses" between them, by responding to thestrongest. If the response differs from the stimulus, it is because ofits huge deference to precedent as established by the records ofprevious stimuli with which its tissues are stored. 

This brings us to the interesting and important question, What are thecauses of these disturbances of the nerve-tissues? Probably the mostimportant single result that has been reached in our study of nervousdiseases in the last fifteen years, is that the cause of them in easilyeighty per cent of all cases _lies entirely outside of the nervoussystem_. 

The stomach burns, the nerve-tissues send in the fire alarm and orderout the engines. The liver goes on a strike, and the body-garbage, whichit has failed to burn to clean ashes and clear smoke, poisons thenerve-cells, and they remonstrate accordingly, on behalf of the othertissues. The heart, or blood-vessels, fails to supply a certain musclewith its due rations of blood and the nerves of the region cry out inthe agony of cramp. 

We have discovered, by half a century of careful study in the hospitaland in the sick-room, not only that the nerve-tissues are usuallypoisoned by defect of other tissues of the body, but that they are amongthe very last of the body-stuffs to succumb to an intoxication. Thecomplications of a given disease involving the nervous system are almostinvariably the last of all to appear. This is one of the things that hasgiven nervous diseases such a bad name for unmanageableness andincurableness, and that for years made us regard their study as sonearly hopeless, so far as any helpful results were concerned. 

When a disease has, so to speak, soaked into the inmost core of thenerve-fibre, it has got a hold which it will take months and even yearsto dislodge. And before your remedies can reach it, it will often havedone irreparable damage. An illustration of the care taken to spare thenervous system is furnished by its behavior in starvation. If a man oran animal has almost died of starvation, the tissues of the body will befound to have been wasted in very varying degrees, the fat, of course, most of all; in fact this will have almost entirely disappeared, all butthree per cent. Then come the liver and great glands, which will haveshrunk about sixty per cent; then the muscles, thirty per cent; then theheart and blood-vessels. Last of all, the nervous system, which willscarcely have wasted to any appreciable degree. In fact, it is anobvious instance of jettison on the part of the body, throwing overboardthose tissues which it could most easily spare, and hanging on like grimdeath to those which were absolutely essential to its continuedexistence, viz. , the heart and the nervous system. To use acannibalistic and more correct illustration, it is killing and eatingthe less useful and valuable members of its family, in order that theirflesh may keep alive the two or three most indispensable. 

Another illustration is the actual behavior of the nerve-stuff indisease. This is most clearly shown in those clear-cut disturbanceswhich are definitely known to be due to a specific infection; in otherwords, invasion of the body by a disease-organism, or germ. 

First of all, it may be stated that physicians are now substantiallyagreed that two-thirds of the general diseases of the nervous system aredue to the extension of one of these acute infections to thenerve-tissue; and this extension almost invariably comes late in thedisease. The only exceptions to this rule in the whole list ofinfectious diseases are two, epidemic cerebro-spinal meningitis (spottedfever), and tetanus (lockjaw). Both of these have an extraordinary anddeadly preference for the nervous system from the very start, and thisis what gives them their frightful mortality and discouraging outlook. Even of this small number of exceptions, we are not altogether certainas to epidemic meningitis, inasmuch as we do not know how long the germmay have existed in the other tissues of the body before it succeeded inworking its way to and attacking the brain and spinal cord. 

The case of tetanus, however, is perfectly clear in this regard, andexceedingly interesting, inasmuch as it explains why a disease speciallyinvolving the nervous system from the start is so excessively hard tocheck or cure. The germ of the disease, long ago identified as onehaving its habitat in farm or garden soils, --particularly those whichhave been heavily fertilized with horse manure, --gets into the systemthrough a cut or scratch upon the surface, into which the soil isrubbed. These infected cuts, for obvious reasons, are most frequentlyupon the hands or feet. 

Small doses of the organism have been injected into animals; then, whenthey have recovered, larger ones, and so on, after the manner of thebacillus of diphtheria, until a powerful antitoxin can be obtained fromtheir blood, very minute quantities of which will promptly kill thebacilli in a test-tube. For seven or eight years past we have beeninjecting this into every patient with tetanus that came under ourobservation, but so far with very limited benefit, even though theinjections were made directly into the spinal cord, or brain substance. The problem puzzled us for years, until finally Cattani stumbled uponthe explanation. While we had been supposing that the poison wascarried, as almost every other known poison is, through theblood-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 thegeneral circulation and fluids of the body, as the copper of theAtlantic cable is from the eroding action of the sea-water. If, in hisexperimental animals, he carefully sought for the cut end of thenerve-trunk in the wound that had been infected, and injected theantitoxin directly into that, the disease was stopped. Or it might evenbe "headed off" by the crude method of cutting directly across thenerve-trunk at a point above that yet reached by the infection. 

The commonest and most fatal of all forms of general diseases of thenervous system are those which are due to the later extensions ofgeneral infections. 

First and foremost stands syphilis, due to the invasion of the blood bya clearly defined _spirillum_, the _Treponema pallida_ of Schaudinn. This first attacks the mucous membranes of the throat and mouth, thenthe skin, then the great internal organs like the liver and stomach, then the bones, and, last of all, the nervous system. The length of timewhich the poison takes to reach the nervous system is something which atfirst sight is almost incredible, viz. , from one and a half to fifteenyears. It is true that in rare instances brain symptoms will manifestthemselves within six or eight months; but these are usually due topressure by inflammatory growths on the bones of the skull and itslining membrane (_dura mater_). It is not too much to say that thisdisease plays the greatest single rôle in nervous pathology. Three ofthe 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 topenetrate to the nerve-tissues, it does irreparable damage long beforeit can be dislodged or neutralized. 

A similar aftermath may occur in almost all of the acute infectiousdiseases. Every year adds a new one to the list capable of causingcerebral complications. Tuberculosis, diphtheria, scarlet fever, typhoid, smallpox, influenza, have now well-recognized cerebral andnervous complications, some temporary, some permanent. A form oftuberculosis attacking the coverings (_meninges_) of the brain--henceknown as meningitis--is far the commonest fatal brain-disease ofinfancy and childhood. 

Perhaps the most striking illustration of just how acute affectionsattack the nervous system, is that furnished by diphtheria. A childdevelops an attack of this disease, passes the crisis safely, and beginsto recover. A few days later, it is allowed to sit up in bed. Suddenly, after some slight exertion, or often without any apparent cause, theface blanches, the eyes stare widely, the child gasps two or threetimes, and is dead: sudden heart failure, due to the poisoning either ofthe heart muscle itself, or of the nerves supplying the heart, by thetoxin of the disease. Moral: Keep diphtheria patients strictly at restin bed for at least a week after the crisis is past. Another case willpass this period safely, though perhaps with a rapid and weak heart, fordays or weeks; then one morning the child will choke when swallowingmilk. The next time it is attempted, the milk, instead of going down thethroat, comes back through the nostrils. Paralysis of the soft palatehas developed, apparently from a local saturation of the nerves with thepoison. 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 ofrespiration supplying the diaphragm may be involved, and the child diesof suffocation. In the majority of cases, however, fortunately, afterthis paralysis has lasted from three to six weeks, it graduallysubsides, and may clear up completely, though not at all infrequentlyone or more muscles may remain permanently damaged by the attack, giving, for instance, a palatal tone to the voice, or interfering withthe production of singing tones. Occasionally a permanent squint mayfollow. 

It might be said in passing, that, with one of the charming logicalitiesof popular reasoning, these nerve complications have been said to be_caused by_ antitoxin, simply because the use of the antitoxin savesmore children alive to develop them. 

The next group of nervous diseases may be roughly described as due tothe failure of some part of the digestive system, like the stomach andintestines, properly to elaborate its food; or of one of the greatglands, like the liver, thyroid, or suprarenal, properly to supply itssecretion, which is needed to neutralize the poisons normally producedin the body. This class is very large and very important. It has longbeen known how surely a disordered liver "predicts damnation";melancholia, or "black bilious condition, " hypochondria, or "under therib-cartilages" (where the liver lies), are every-day figures of speech. A thorough house-cleaning of the alimentary canal, together with properstimulation of the skin and kidneys, and an intelligent regulation ofdiet, are our most important measures in the treatment of diseases ofthe nervous system, even in those extreme forms known as insanity. 

Closely allied to these are those disturbances of the nervous systemlumped together under the soul-satisfying designation of "neurasthenia, "which are chiefly due to the accumulation in the system of the fatiguepoisons, or substances due to prolonged overstrain, under-rest, orunderfeeding of the system. Neurasthenia is the "fatigue neurosis, " as aleading expert terms it. It may be due to any morbid condition underheaven. It is "that blessed word Mesopotamia" of the slipshoddiagnostician. Nearly one-fourth of the cases which come into oursanatoria for tuberculosis have been diagnosed and treated for monthsand even years as "neurasthenia. " It satisfies the patient--and it meansnothing; though some experts contend for a distinct disease entity ofthis name but admit its rarity. 

The intelligent neurologist, nowadays, has practically no known specificfor any form of nervous disease, no remedy which acts directly andcuratively upon the nervous system itself. He relies chiefly--and thisapplies to the asylum physician also--upon intestinal antisepsis, uponrest, upon baths, upon regulation diet, and habits of life. 

A number of the more sudden and fatal disturbances of the nervoussystem, as for instance, the familiar "stroke of paralysis, " orapoplexy, of later middle life, are due to a defect, not in the nervoussystem at all, but in the blood-vessels supplying the brain; rupture ofa vessel, and consequent escape of blood, destroys so much of thesurrounding brain-tissue as to produce paralysis, and, in extreme cases, death. Just why the blood-vessels of the brain in general, and of onepart of the basal ganglia in particular (the _Lenticulostriate_ arteryin the internal capsule of the _corpus striatum_, the old jawganglion), are so liable to rupture we do not know; but it certainly ischiefly from a defect of the blood-vessels, and not of the brain. All ofwhich 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 partof the nervous system against underfed blood, under-ventilated muscles, lack of sunlight, lack of exercise, lack of sleep, excess of work, orbad habits. In other words, it is the danger signal, the red lightshowing 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 termedinhibition, we may ignore and for a time suppress the symptom, but thisin the long run is just as rational as cutting the wire that rings afire alarm, or blowing out the red light without closing the switch. 

Nervousness is a _symptom_ which should always have _something done forit_, especially in children. In fact, it has passed into an axiom bothwith intelligent teachers and with physicians who have much to do withthe little ones, that crossness, fretfulness, laziness, lack ofinitiative, and readiness to weep, in children, are almost invariablythe signs of physical disease. And this doctrine will apply to aconsiderable percentage of children of larger growth. 

Unfortunately, one of the first and most decided tendencies on the partof the badly fed or poisoned nervous system, is to exaggerate thedifficulties of the situation, and to minimize its good features. Theindividual "has lost his nerve, " is afraid to undertake things, shrinksfrom responsibility, exaggerates the difficulties that may be in theway; hence the floods of tears, or outbursts of temper, with whichnervous children will greet the suggestion of any task or duty, howevertrifling. If the nervous individual has reached that stage of maturitywhen she realizes that she is not merely "naughty, " but sick, then thissame process applies itself to her disease. She is sure that she isgoing to die, that another attack like that will end in paralysis; as apatient 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 herdisease, that the impression irresistibly arises that the disease itselfis a fabrication. This view of her condition by her family or herphysician is the tragedy of the neurasthenic. 

Broadly speaking, _no_ disease, even of the nervous system, is everpurely 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 findtrouble enough in some part of our complex bodily machinery, if we goaround hunting for it; but this is precisely what the healthy man, orwoman, _never_ does. They have other things to occupy them, and are farmore liable to run into danger by pushing ahead at full steam, andneglecting small creakings and jarrings until something important in thegear jams, or goes snap, and brings them to a halt, than they are to bewasting 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 verycrudely, whenever the blood and fluids of a body become impoverishedbelow a certain degree, or become loaded with fatigue poisons, or otherwaste products above a certain point, then the nervous system proceedsto make itself felt. Either the perceptive end-organs become color-blindand read yellow for blue, or are astigmatic and report oval for round;or the conducting nerve-strands tangle up the messages, or deliver themto the wrong centre; or the central clearing-house, puzzled by thecrooked messages, loses its head, and begins to throw the inkstandsabout, or goes down in a sulk. In other words, the nervous system goeson a strike. But it is perfectly idle to endeavor to treat it withcheering words, or kindly meant falsehoods, to the effect that "nothingis really the matter. " Like any other strike, it can be rationally dealtwith only by improving the conditions under which the operatives have towork, and meeting their demands for higher wages, or shorter hours. 

We were accustomed at one time to divide diseases into two greatclasses, organic and functional. By the former, we meant those in whichthere was some positive defect of structure, which could be recognizedby the eye or the microscope; by the latter, those diseases in whichthis could not be discovered, in which, so to speak, the machine was allright, but simply wouldn't work. It goes without saying that the latterclass was simply a confession of our ignorance, and one which issteadily and rapidly diminishing as science progresses. 

If the machine won't work, there is a reason for it somewhere, and ourbusiness is to find it out, and not loftily to assure our patients thatthere is nothing much the matter, and all they need is rest, or a littlecheerful occupation. Furthermore, the most inane thing that asympathizing friend or kindly physician can do to a neurasthenic, is toadvise him to take his mind off himself or his symptoms. The utterinability to do that very thing is one of the chief symptoms of thedisease, which will not disappear until the underlying cause has beencarefully studied out and removed. 

"Nerves, " "neurasthenia, " "psychasthenia, " and "hysteria, " are all thenames of _symptoms_ of _definite bodily disease_. The modern physicianregards it as his duty to study out and discover the nature of thisdisease, and, if possible, remove it, rather than to give high-sounding, soul-satisfying names to the symptoms, and advise the patient to "cheerup"; which advice costs nothing--and is worth just what it costs. 

"But, " some one will say at once, "if nervous diseases are simply thereflection of general bodily states, as sanitary conditions improveunder civilization, should they not become less frequent? And yet, anynewspaper will tell you that nervous diseases are rapidly on theincrease. " This is a widespread belief, not only on the part of thepublic, 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 positivestatement, either one way or another. Our ignorance of the preciseprevalence of disease in savagery, in barbarism, and even undercivilization up to fifty years ago, is absolute and profound. It is onlysince 1840 that vital statistics of any value, except as to gross deathsand births, began to be kept. So far as we are able to judge from ourstudy of savage tribes by the explorer, the army surgeon, and themedical missionary, the savage nervous system is far less well balancedand adjustable than that of civilized man. Hysteria, instead ofoccurring only in individual instances, attacks whole villages andtribes. In fact, the average savage lives in a state alternating betweennaïve and childish self-satisfaction and panic-stricken terror, withtheir resultant cowardice and cruelty on the one hand, and unbridledlust and delusions of grandeur on the other. The much-vaunted strain ofcivilization 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 wifeand children carried into slavery. Read the old hymns and see howdevoutly thankful our pious ancestors _were every day_ at findingthemselves alive in the morning, --"Safely through another night, "--andfancy the nerve-strain of never knowing, when you lay down to sleep, whether some one of the djinns, or voodoos, or vampires would swoop downupon you before morning. Think of facing death by famine every winter, by drought or cyclone every summer, and by open war or secretscalp-raid every month in the year; and then say that the rackingnerve-strain of the commuter's time-table, the deadly clash of thewheat-pit, or the rasping grind of office-hours, would be ruinous to theuncivilized nervous system. Certainly, in those belated savages, thedwellers in our slums, hysteria, diseases of the imagination, enjoymentof ill health, and the whole brood of functional nervous disturbancesare just as common as they are on Fifth Avenue. 

It is not even certain that insanity is increasing. Insanity is quitecommon among savages; just how common is difficult to say, on account oftheir peculiar methods of treating it. The stupid and the dangerousforms are very apt to be simply knocked on the head, while the moreharmless and fantastic varieties are turned into priests and prophetsand become the founders of the earlier religions. A somewhat similarstate of affairs of course prevailed among civilized races up to withinthe last three-quarters of a century. The idiot and the harmless lunaticwere permitted to run at large, and the latter, as court and villagefools, furnished no small part of popular entertainment, since organizedinto vaudeville. Only the dangerous or violent maniacs were actuallyshut up; consequently, the number of insane in a community a century agorefers solely to this class. Hence, in every country where statisticshave been kept, as larger and larger percentages of these unfortunateshave been gathered into hospitals, where they can be kindly cared forand intelligently treated, the number of the registered insane hassteadily increased up to a certain point. This was reached some fifteenyears ago in Great Britain, in Germany, in Sweden, and in othercountries which have taken the lead in asylum reform, and has remainedpractically stationary since, at the comparatively low rate of from twoto three per thousand living. This limit shows signs of having beenreached in the United States already; and this gradual increase ofrecognition and registration is the only basis for the alleged increaseof insanity under modern conditions. 

It is also a significant fact that the lower and less favorably situatedstratum of our population furnishes not only the largest number ofinmates, but the largest percentage of insanity in proportion to theirnumbers, while the most highly educated and highly civilized classesfurnish the lowest. Immigrants furnish nearly three times as manyinmates per thousand to our American asylums as the native born. 

It is, however, true that in each succeeding census a steadilyincreasing number and percentage of the deaths is attributed to diseasesof the nervous system. This, however, does not yet exceed fifteen ortwenty per cent of the whole, which would be, so to speak, the naturalprobable percentage of deaths due to failure of one of the five greatsystems of the body: the digestive, the respiratory, the circulatory, the glandular, the nervous. Two elements may certainly be counted uponas contributing in very large degree to this apparent increase. One isthe enormous saving of life which has been accomplished by sanitationand medical progress during the first five years of life, infantmortality having been reduced in many instances fifty to sixty percent, thus of course leaving a larger number of individuals to die laterin life by the diseases especially of the blood-vessels, kidneys, andnervous system, which are most apt to occur after middle life. The otheris the great increase in medical knowledge, resulting in the moreaccurate discovery of the causes of death, and a more correct reportingand classifying of the same. 

In short, a careful review of all the facts available to date leads usdecidedly to the conclusion that the nervous system is the toughest andmost resisting tissue of the body, and that its highest function, themind, has the greatest stability of any of our bodily powers. Only oneman in six dies of disease of the nervous system, as contrasted withnearly one in three from diseases of the lungs; and only one individualin four hundred becomes insane, as contrasted with from three to tentimes that number whose digestive systems, whose locomotor apparatus, whose heart and blood-vessels become hopelessly deranged withoutactually 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 thathis body is under the control of his mind. Even if he didn't quitebelieve it in his heart of hearts, he has always wanted to. The reasonis obvious. The one thing that he felt absolutely sure he could controlwas 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 hebecomes confident of one link in the chain he becomes doubtful of theother. Nowadays he has quite as many qualms of uncertainty as to whetherhe can control his mind as about the power of his mind over his body. Bya strange paradox we are discovering that our most genuine and lastingcontrol over our minds is to be obtained by modifying the conditions ofour bodies, while the field in which we modify bodily conditions bymental influence is steadily shrinking. 

For centuries we punished the sick in mind, the insane, loading themwith chains, shutting them up in prison-cells, starving, yes, evenflogging them. We exorcised their demons, we prayed over them, we arguedwith them, --without the record of a single cure. Now we treat theirsick and ailing bodies just as we would any other class of chronicpatients, with rest, comfortable surroundings, good food, baths, andfresh air, correction of bad habits, gentleness, and kindness, leavingtheir minds and souls practically without treatment, excepting in so faras ordinary, decent humanity and consideration may be regarded as mentalremedies, --and we cure from thirty to fifty per cent, and make all butfive per cent comfortable, contented, comparatively happy. 

We are still treating the inebriate, the habitual drunkard, as a minorcriminal, by mental and moral means--with what hopeful results let thedisgraceful records of our police courts testify. We are now treatingtruancy by the removal of adenoids and the fitting of glasses; juvenilecrime by the establishment of playgrounds; poverty and pauperism bygood food, living wages, and decent surroundings; and all for the firsttime with success. 

In short, not only have all our substantial and permanent victories overbodily ills been won by physical means, but a large majority of oursuccesses in mental and moral diseases as well. Yet the obsessionpersists, and we long to extend the realm of mental treatment in bodilydisease. 

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 isthat the whole history of the progress of medicine has been a record ofdiminishing resort to this power as a means of cure. The measure of oursuccess and of our control over disease has been, and is yet, in exactproportion to the extent to which we can relegate this resource to thebackground and avoid resorting to it. Instead of mental influence beingthe newest method of treatment it is the oldest. Two-thirds of themethods 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 ofhistory, and, it may be frankly stated, in civilized countries, aswidely discredited as tested. The proportion to which it survives in themedicine of any race is the measure of that race's barbarism andbackwardness. To-day two of the most significant criteria of the measureof enlightenment and of control over disease of either the medicalprofession of a nation or of an individual physician are the extent towhich they resort to and rely upon mental influence and opium. Psychotherapy and narcotics are, and ever have been, the sheet-anchorsof the charlatan and the miracle-worker. 

The attitude of the medical profession toward mental influence in thetreatment of disease is neither friendly nor hostile. It simply regardsit as it would any other remedial agency, a given drug, for instance, abath, 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 otherremedies. Its distrust of it, so far as this exists, is simply thefeeling that it has toward half a hundred ancient drugs and remedialagencies which it has dropped from its list of working remedies asobsolete, many of which still survive in household and folk medicine. Mypurpose is neither to champion it nor to discredit it, and least of allto antagonize or throw doubt upon any of the systems of philosophy or ofreligion with which it has been frequently associated, but merely toattempt to present a brief outline of its advantages, its character, andits limitations, exactly as one might of, say, calomel, quinine, orbelladonna. 

As in the study of a drug, the chief points to be considered are: Whatare its actual powers? What effects can be produced with it, both inhealth and sickness? What are the diseases in which such effects may beuseful, and how frequent are they? In what way does it produce itseffects, directly or indirectly?

The first and most striking claim that is made for mental influence indisease is based upon the allegation that it has the power of producingdisease and even death; the presumption, of course, being that, if ableto produce these conditions, it would certainly have some influence inremoving or preventing them. Upon this point the average man issurprisingly positive and confident in his convictions. Popularliterature and legend are full of historic instances where individualshave not merely been made seriously ill but have even been killed bypowerful impressions upon their imaginations. Most men are ready torelate to you instances that have been directly reported to them ofpersons who were literally frightened to death. But the moment that wecome to investigate these widely quoted and universally acceptedinstances, 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 theother, a collection of rare and extraordinary instances of sudden deathwhich have happened to be preceded by a powerful mental impression, manyof which bear clearly upon their face the imprint of death by rupture ofa blood-vessel, heart failure, or paralysis, in the course of somewell-marked and clearly defined chronic disease, like valvularheart-mischief, diabetes, or Bright's disease. 

Upon investigation most of these cases which have been seen by aphysician previous to death have been recognized as subject to a diseaselikely to terminate in sudden death; and practically all in which apost-mortem examination has been made have shown a definite physicalcause of death. The fright, anger, or other mental impression, wasmerely the last straw, which, throwing a sudden strain upon alreadyweakened vessels, heart, or brain, precipitated the final catastrophe. In some cases, even the sense of fright and the premonition ofapproaching death were merely the first symptoms of impendingdissolution. 

The stories of death from purely imaginative impressions, such as thevictims being told that they were seriously ill, that they would die onor about such and such a date, fall into two great classes. The first ofthese--involving death at a definite date, after it had been prophesiedeither by the victim or some physician or priest--may be dismissed in afew words, as they lead at once into the realm of prophecy, witchcraft, and voodoo. Most of them are little better than after-echoes of theethnic stories of the "evil eye, " and of bewitched individuals fadingaway and dying after their wax image has been stuck full of pins orotherwise mutilated. There have occurred instances of individuals dyingupon the date at which some one in whose powers of prophecy they hadconfidence declared they would, or even upon a date on which they hadsettled in their own minds, and announced accordingly; but these are sorare as readily to come within the percentage probabilities of purecoincidence. Most such prophecies fail utterly; but the failures are notrecorded, only the chance successes. 

The second group of these alleged instances of death by mentalimpression is in most singular case. Practically every one with whom youconverse, every popular volume of curiosities which you pick up, isready to relate one or more instances of such an event. But the more youlisten to these relations, the more familiar do they become, untilfinally they practically simmer down to two stock legends, which we haveall heard related in some form. 

First, and most famous, is the story of a vigorous, healthy man accostedby a series of doctors at successive corners of the street down which heis 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 groupof morbidly curious and spiteful doctors who desire to see whether ahuman being can be killed by the power of his imagination. A condemnedcriminal is accordingly turned over to them. He is first allowed to seea dog bled to death, one of the physicians holding a watch and timingthe 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 todeath instead of guillotined, his eyes are bandaged and a small, insignificant vein in his arm is opened. A basin is held beneath hisarm, into which is allowed to drip and gurgle water from a tube so as toimitate the sounds made by the departing life-blood. Again thedeath-watch is set and the stages of his decline are called off: "Now heweakens! Now his heart is failing!" until finally, with the solemnpronouncement, "Now he dies!" he falls over, gasps a few times and isdead, though the total amount of blood lost by him does not exceed a fewteaspoonfuls. 

A variant of the story is that the trick was played for pure mischief inthe initiation ceremonies of some lodge or college fraternity, with thehorrifying result that death promptly resulted. 

The stories seem to be little more than pure creatures of the same forcewhose power they are supposed to illustrate, amusing and dramaticfairy-tales, handed down from generation to generation from Heaven knowswhat antiquity. Death under such circumstances as these _may_ haveoccurred, but the proofs are totally lacking. One of our leadingneurologists, who had extensively experimented in hypnotism andsuggestion, declared a short time ago: "I don't believe that death wasever caused solely by the imagination. "

Now as to the scope of this remedy, the extent of the field in which itcan reasonably be expected to prove useful. This discussion is, ofcourse, from a purely physical point of view. But it is, I think, nowgenerally admitted, even by most believers in mental healing, that it isonly, at best, in rarest instances that mental influence can be reliedupon to cure organic disease, namely, disease attended by actualdestruction of tissue or loss of organs, limbs, or other portions of thebody. This limits its field of probable usefulness to the so-called"functional diseases, " in which--to put it crudely--the body-machine isin apparently perfect or nearly perfect condition, but will not work;and particularly that group of functional diseases which is believed tobe due largely to the influence of the imagination. 

Nowhere can the curious exaggeration and over-estimation of the realstate of affairs in this field be better illustrated than in the popularimpression 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 oflife. The pages of the novel are full, the scenes of the drama arecrowded with imaginary invalids. Not merely are they one of the mostvaluable stock properties for the humorist, but whole stories andcomedies have been devoted to their exploitation, like Molière's classic"Le Malade Imaginaire, " and "Le Médecin Malgré Lui. " Generation aftergeneration has shaken its sides until they ached over these pompous oldhypochondriacs and fussy old dowagers, whose one amusement in life is toenjoy ill health and discuss their symptoms. They are as indispensablemembers of the _dramatis personæ_ of the stock company of fiction as thewealthy uncle, the crusty old bachelor, and the unprotected orphan. Evenwhere they are only referred to incidentally in the course of the story, you are given to understand that they and their kind furnish theprincipal source of income for the doctor; that if he hasn't the tact tohumor or the skilled duplicity to plunder and humbug these self-madesufferers, he might as well retire from practice. In short, the entireatmosphere of the drama gives the strong impression that ifpeople--particularly the wealthy classes--would shake themselves and goabout their business, two-thirds of the illness in the world woulddisappear at once. 

Much of this may, of course, be accounted for by the delicious andirresistible attractiveness, for literary purposes, of this type ofinvalid. Genuine, serious illness, inseparable from suffering and endingin 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 ofapoplexy, and does not furnish much valuable material for the novelistor the play-writer. Battle, murder, and sudden death, while horribleand repulsive, can be contemplated with vivid, gruesome interest, andhence are perfectly available as interest producers. But much as wedelight to talk about our symptoms, we are never particularly interestedin listening to those of others, still less in seeing them portrayedupon the stage. On account of their slow course, utter absence ofpicturesqueness, and depressing character, the vast majority of diseasesare quite unsuitable for artistic material. In fact, the literary workeris almost limited to a mere handful, at one extreme, which will producesudden and dramatic effects, like heart failure, apoplexy, or theghastly introduction of a "slow decline" for a particularly patheticeffect; and at the other extreme, those imaginary diseases, migrainesand vapors, which furnish amusement by their sheer absurdity. 

Be that as it may, such dramatic and literary tendencies have producedtheir effect, and the popular impression of the doctor is that of a manwho spends his time between rushing at breakneck speed to save the livesof those who suddenly find themselves _in articulo mortis_ and willperish unless he gets there within fifteen minutes, and dancingattendance upon a swarm of old hypochondriacs, neurotics, and nervousdyspeptics, of both sexes. As a matter of fact, these two supposedprincipal occupations of the doctor are the smallest and rarest elementsin his experience. 

A few years ago a writer of world-wide fame deliberately stated, in thecourse of a carefully considered and critical discussion of variousforms of mental healing, that it was no wonder that these methodsexcited huge interest and wide attention in the community, because, ifvalid, they would have such an enormous field of usefulness, seeing thatat least seven-tenths of all the suffering which presented itself forrelief to the doctor was imaginary. 

This, perhaps, is an extreme case, but is not far from representing thegeneral impression. If a poll were to be taken of five hundredintelligent men and women selected at random, as to how much of thesufferings of all invalids, or sick people who are not actuallyobviously "sick unto death" or ill of a fever, was real and how muchimaginary, the estimate would come pretty close to an equal division. But when one comes to try to get at the actual facts, an astonishinglydifferent state of affairs is revealed. I frankly confess that my ownawakening was a matter of comparatively recent date. 

A friend of mine was offered a position as consulting physician to alarge and fashionable sanatorium. He hesitated because he was afraidthat much of his time would be wasted in listening to the imaginarypains, and soothing the baseless terrors, of wealthy and fashionableinvalids, who had nothing the matter with them except--in the languageof the resort--"nervous prosperity. " His experience was a surprise. Atthe end of two years he told me that he had had under his care betweensix and seven hundred invalids, a large percentage of whom were drawnfrom the wealthier classes; and out of this number there were _onlyfive_ whose sufferings were chiefly attributable to their imagination. Many of them, of course, had comparatively trivial ailments, and othersexaggerated the degree or mistook the cause of their sufferings; but thevast majority of them were, as he naïvely expressed it, "really sickenough 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 astonishmentraked up, from over twenty years' medical experience, barely a baker'sdozen. Inquiries among my colleagues resulted in a surprisingly similarstate of affairs. While most of them were under the general impressionthat at least ten to twenty per cent of the illnesses presentingthemselves were without substantial physical basis and largely imaginaryin character, when they came actually to cudgel their memories forwell-marked cases and to consult their records, they discovered thattheir memories had been playing the same sort of tricks with them thatthe 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 nervousdiseases, stated in a public address that purely or even chieflyimaginary diseases were among the rarer conditions that the physicianwas called upon to treat. Shortly after, two of the leading neurologistsof Philadelphia, one of them a man of international reputation, practically repeated this statement; and they put themselves on recordto the effect that the vast majority of those who imagined themselves tobe ill were ill, though often not to the degree or in precisely themanner that they imagined themselves to be. 

Obviously, then, this possible realm of suffering in which the mind canoperate is very much more limited than was at one time believed. Infact, imaginary diseases might be swept out of existence, and humanitywould scarcely know the difference, so little would the total sum of itssuffering be reduced. 

Another field in which there has been much general misunderstanding andlooseness of both thought and statement, which has again led toexaggerated ideas of the direct influence of the mind over the body, isthe well-known effect of emotional states, such as fright or anger, uponthe ordinary processes of the body. Instances of this relation are, ofcourse, household words, --the man whose "hair turned white in a singlenight" from grief or terror; the nursing mother who flew into a furiousfit of passion and whose child was promptly seized with convulsions anddied the next time it was put to the breast; the father who isprostrated by the death or disgrace of a favorite son, and dies within afew weeks of a broken heart. The first thing that is revealed by even abrief study of this subject is that these instances are exceedinglyrare, and owe their familiarity in our minds to their striking anddramatic character and the excellent "material" which they make for thedramatist and the gossip. It is even difficult to secure clear and validproof of the actual occurrence of that sudden blanching of the hair, which has in the minds of most of us been accepted from our earliestrecollection. 

More fundamental, however, and vital, is the extent to which we haveoverlooked the precise method in which these violent emotionalimpressions alter bodily activities, like the secretions. Granting, forthe sake of argument, that states of mind, especially of great tension, have some direct and mysterious influence as such, and through meanswhich defy physical recognition and study, it must be remembered thatthey have a perfectly definite physiological sphere of influence uponvital activities. Indeed, we are already in a position to explain atleast two-thirds of these so-called "mental influences" upon purelyphysical and physiological grounds. 

First of all, we must remember that these emotions which we are pleasedto term "states of mind" are also states of body. If any man were tostand 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, " withouttremor in his voice, or paling of his countenance, or widening eyes, ortwitching muscles, or preparations either to escape or to fight, youwould simply laugh at him. You would readily conclude, either that hewas making fun of you and felt no such emotion, or that he wasrepressing it by an act of miraculous self-control. The man who isfrightened and doesn't do anything or look as if he were going to doanything, the man who is angry and makes no movement or even twitchingsuggesting 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-ninecases out of a hundred is conditioned upon our memory of previoussimilar objects and their dangerousness, or our recollection of what wehave been told about their deadliness. Then instantly, irrepressibly, comes the lightning-flash of horror to our heart, to our muscles, toour 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 theafter-echoes of muscular contractions. By the time an emotion has fairlygot us in its grip so that we are really conscious of it, theblood-supply of half the organs in our body has been powerfully altered, and often completely reversed. 

To what extent muscular contractions condition emotions, as ProfessorJames has suggested, may be easily tested by a quaint and simple littleexperiment upon a group of the smallest voluntary muscles in the body, those that move the eyeball. Choose some time when you are sittingquietly in your room, free from all disturbing thoughts and influences. Then stand up and, assuming an easy position, cast the eyes upward andhold them in that position for thirty seconds. Instantly andinvoluntarily you will be conscious of a tendency toward reverential, devotional, contemplative ideas and thoughts. Then turn the eyessideways, glancing directly to the right or to the left, throughhalf-closed lids. Within thirty seconds images of suspicion, ofuneasiness, or of dislike, will rise unbidden in the mind. Turn the eyesto one side and slightly downward, and suggestions of jealousy orcoquetry will be apt to spring unbidden. Direct your gaze downwardtoward the floor, and you are likely to go off into a fit of reverie orof abstraction. 

In fact, as Darwin long ago remarked, quoting in part from Bain: "Mostof our emotions [he should have said all] are so closely connected withtheir expression that they hardly exist if the body remains passive. AsLouis XVI, facing a mob, exclaimed, 'Afraid? Feel my pulse!' so a manmay intensely hate another, but until his bodily frame is affected hecan hardly be said to be enraged. "

And, a little later, from Maudsley:--

"The specific muscular action is not merely an exponent of passion, buttruly an essential part of it. If we try, while the features are fixedin the expression of one passion, to call up in the mind a differentone, we shall find it impossible to do so. "

It will also be recollected what an important part in the production ofhypnosis and the trance state, fixed and strained positions of thesesame ocular muscles have always been made to play. Many hypnotists canbring their subjects under their influence solely by having them gazefixedly 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 emotionalstates is the art of the actor. Not only would it be impossible for anactor to make an audience believe in the genuineness of his supposedemotion if he stood glassy-eyed and wooden-limbed declaiming his linesin a monotone, without gestures or play of expression of any sort, butit would also be impossible for him to feel even the counterfeitsensation which he is supposed to represent. So definite and so wellrecognized is this connection, that many actors take some little time, as they express it, to "warm up" to their part, and can be visibly seenworking themselves up to the pitch of emotion desired for expression bytwitching muscles, contractions of the countenance, and catchings of thebreath. This last performance, by the way, is not by any means confinedto the stage, but may be seen in operation in clashes and disagreementsin real life. An individual who knows his case to be weak, or himself tobe lacking in determination, can be seen working himself up to thenecessary pitch of passion or of obstinacy. There is even a lovely oldfairy-tale of our schoolboy days, which is still to be found in ancientworks on natural history, to the effect that the King of Beasts himselfwas 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 hisenemy!

What, then, will be the physical effect of a shock or fright or furiousoutburst of anger upon the vital secretions? Obviously, that anyprocesses which require a full or unusually large share of blood-supplyfor their carrying out will be instantly stopped by the diversion ofthis from their secreting cells, in the wall of the stomach, in theliver, or in the capillaries of the brain, to the great muscular massesof the body, or by some strange, atavistic reflex into the so-called"abdominal pool, " the portal circulation. The familiar results are justwhat might have been expected. The brain is so suddenly emptied of bloodthat connected thought becomes impossible, and in extreme cases we standas one paralyzed, until the terror that we would flee from crashes downupon us, or we lose consciousness and swoon away. If the process ofdigestion happens to be going on, it is instantly stopped, leaving thefood to ferment and putrefy and poison the body-tissues which it wouldotherwise have nourished. The cells of the liver may be so completelydeprived of blood as to stop forming bile out of broken-down bloodpigment, and the latter will gorge every vessel of the body and escapeinto the tissues, producing jaundice. 

Every one knows how the hearing of bad news or the cropping up ofdisagreeable subjects in conversation at dinner-time will tend topromote indigestion instead of digestion. The mechanism is preciselysimilar. The disagreeable news, if it concern a financial or executivedifficulty, will cause a rush of blood to the brain for the purpose ofdeciding what is to be done. But this diminishes the proper supply ofblood to the stomach and to the digestive glands, just as really as theparalysis of violent fright or an explosion of furious anger. If theunpleasant subject is yet a little more irritating and personal, it willlead to a corresponding set of muscular actions, as evidenced inheightened color, loud tones, more or less violent gesticulation, withmarked interruption of both mastication and the secretion of saliva andall other digestive juices. In short, fully two-thirds of the influencesof emotional mental states upon the body are produced by their callingaway from the normal vital processes the blood which is needed for theirmuscular and circulatory accompaniments. No matter how bad the news orhow serious the danger, if they fail to worry us or to frighten us, --inother words, to set up this complicated train of muscular andblood-supply changes, --then they have little or no effect upon ourdigestions or the metabolism of our liver and kidneys. 

The classic "preying upon the damask cheek" of grief, and the carkingeffect of the Black Care that rides behind the horseman, have aperfectly similar physical mechanism. While the primary disturbance ofthe banking balances of the body is less, this is continued over weeksand months, and in addition introduces another factor hardly lesspotent, by interfering with all the healthful, normal, regular habits ofthe body, --appetite, meal-times, sleep, recreation. These wastings andpinings and fadings away are produced by mental influence, in the sensethat they cannot be cured by medicines or relieved at once by the bestof hygienic advice; but it is idle to deny that they have also a broadand substantial physical basis, in the extent to which states ofemotional agony, despair, or worry interfere with appetite, sleep, andproper exercise and recreation in the open air. Just as soon as theycease to interfere with this normal regularity of bodily functions, thesufferer begins to recover his health. 

We even meet with the curious paradox of individuals who, thoughsuffering the keenest grief or anxiety over the loss or serious illnessof those nearest or dearest to them, are positively mortified andashamed because their countenances show so little of the pallid hues andthe haggard lines supposed to be inseparably associated with grief. Solong as the body-surplus is abundant enough to stand the heavyoverdrafts made on it by grief and mental distress, without robbing thestomach 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 oftrouble, but a symptom of the stomach's inability to digest food; inthis instance, because it finds that it can no longer draw upon thenatural resources of the body in sufficient abundance to carry out itsoperations. The state is exactly like a tightness of the money market, when, on account of unnatural retention or hoarding in some parts of thefinancial field, the accumulation of sufficient amounts of floatingcapital at the banks for moving the crop or paying import duties cannotbe carried out as usual. The vital system is, in fact, in a state ofpanic, so that the stomach cannot get the temporary credit or capitalwhich it requires. 

A similar condition of temporary panic, call it mental or bodily, as youwill, occurs in disease and is not confined to the so-called imaginarydiseases, or even to the diseases of the nervous system, but is apt tobe present in a large number of acute affections, especially thoseattended by pain. Sudden invasion of the system by the germs ofinfectious diseases, with their explosions of toxin-shells all throughthe redoubts of the body, often induces a disturbance of the bodilybalance akin to panic. This is usually accompanied and aggravated by anemotional dread and terror of corresponding intensity. The relief of thelatter, by the confident assurance of an expert and trusted physicianthat the chances are ten to one that the disease will run its course ina few days and the patient completely recover, --especially if coupledwith the administration of some drug which relieves pain or diminishescongestion in the affected organs, --will often do much toward restoringbalance and putting the patient in a condition where the naturalrecuperative powers of the system can begin their work. The historicpopularity of opium, and of late of the coal-tar products (phenacetineand acetanilide), in the beginning of an acute illness, is largely basedon the power which they possess of dulling pain, relieving disturbancesof the blood-balance, and soothing bodily and mental excitement. Fever-panic or pain-panic, like a banking panic, though it has a genuineand substantial basis, can be dealt with and relieved much more readilyafter checking excessive degrees of distrust and excitement. An opiatewill relieve this physical pain-panic, just as a strong mentalimpression will relieve the fright-paralysis and emotional panic whichoften accompany it, and thus give a clearer field and a breathing spacefor the more slowly acting recuperative powers of nature to assert theirinfluence and get control of the situation. 

_But neither of them will cure. _ The utmost that they can do is to givea breathing spell, a lull in the storm, which the rallying powers of thebody, if present, can take advantage of. If the latter, however, be notadequate to the situation, the disease will progress to serious or evenfatal termination, just as certainly as if no such influence had beenexerted, and often at an accelerated rate. In fact, our dependence uponopiates and mental influence have been both a characteristic and acause of the Dark Ages of medicine. The more we depended upon these, themore content we were to remain in ignorance of the real causes ofdisease, whether bodily or mental. 

The second physical effect produced by mental influence is probably themost important of all, and that is _the extent to which it induces thepatient to follow good advice_. We as physicians would be the last tounderestimate the importance of the confidence of our patients. But weknow perfectly well that our retention of that confidence will dependalmost entirely upon the extent to which we can justify it; that itsprincipal value to us lies in the extent to which it will insure promptobedience to our orders, and intelligent and loyal coöperation with usin our fight against disease. The man who would depend upon theconfidence of his patients as a means of healing, would soon findhimself without practice. We know by the bitterest of experience that nomatter how absolute and boundless the confidence of our patients may bein our ability to heal them, no matter how much they may expressthemselves as cheered and encouraged by our presence, ninety-nine percent of the chance of their recovery depends upon the gravity of thedisease, the vigor of their powers of resistance, and our skill andintelligence 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 leansupon it too heavily, be he patient or physician. We can all recall, asamong our saddest and most heart-breaking experiences, the cases offatal disease, which were well-nigh hopeless from the start, and yet inwhich the sufferers expressed, and maintained to the last moments ofconscious speech, a bright and pathetically absolute confidence in ourpowers of healing, based upon our success in some previous case, or upontheir 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 irrepressiblehopefulness and confidence that they will get well, on the part of aconsiderable percentage of its victims. This has even been formallydesignated in the classical medical treatises as the "_Spes Phthisica_, "or "Consumptive Hope. " But these hopeful consumptives die just as surelyas the depressed ones; in fact, if anything, in a little largerproportion. It well illustrates the other side of the shield of hope andconfidence, the danger of unwavering expectancy, in that it is chieflythose who are early alarmed and turn vigorously to fight the diseaseunder intelligent medical direction, who make the recoveries. Too serenea courage, too profound a confidence in occult forces, is only a form offatalism and a very dangerous one. 

Broadly speaking, mental states in the sick-room are a pretty fairindex--I don't mind saying, product--of bodily states. Hopefulness andconfidence are usually favorable signs, for the reason that they aremost likely to be displayed by individuals who, although they may beseriously ill, are of good physique, have high resisting power, andwill 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 reliablesigns; and as a rule we are but little affected by either the hopes orthe 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 asufficiently vivid and lively fear of impending death, we feel prettysure that they are not seriously ill; but when they assure us dreamilythat they "feel first-rate, " forget to ask us how they are gettingalong, or become drowsily indifferent to the outlook for the future, then we redouble our vigilance, for we fear that we recognize thegradual approach of the Great Restbringer, the merciful drowsiness whichin nine cases out of ten precedes and heralds the coming of the LongSleep. 

Lastly, the cases in which the sufferings of the patient are due chieflyto a morbid action of his or her imagination, are a small percentage ofthe total of the ills which come before us for relief. But, even of thissmall percentage, _only a very few are in perfect or even reasonablygood physical health_. A large majority of even these neurasthenics, psychasthenics, imaginary invalids, and bodily or mental neurotics, havesome physical disturbance, organic or functional, which is the chiefcause of their troubles. And the important point is that our success inrelieving these sufferers will depend upon our skill in ferreting outthis physical basis, and the extent to which we can succeed incorrecting or relieving it. We no longer ridicule or laugh at theseunfortunates. On the contrary we pity them from the bottom of ourhearts, because we know that their sufferings, however polarly remotethey may be from endangering their lives in any way, and howeverimaginary in a purely material sense, are _to them_ real. Theirhappiness is destroyed and their efficiency is crippled just asgenuinely and effectively as if they had a broken limb or a diseasedheart. 

We are now more and more firmly convinced that these patients, howeverludicrously absurd their forebodings, are _really sick_, either bodilyor mentally, and probably both. A perfectly healthy individual seldomimagines himself or herself to be ill. And as the list of so-calledfunctional diseases--that is to say, those diseases in which nodefinite, objective mark of degeneration or decay in any tissue or organcan be discovered--are steadily and swiftly diminishing under thescrutiny of the microscope and the methods of the laboratory, so thesepurely 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 partof the patient, but is patiently traced back, stage by stage, until ifpossible the primary "strangulated emotion" which caused it isdiscovered; and where this can be found the whole morbid tendency canoften be relieved and reversed almost as if by magic. 

To sum up: My contention is, that the direct influence of emotionalstates upon bodily organs and functions has been greatly exaggerated;that it is exceedingly doubtful whether, for instance, any individual ina reasonable condition of health was ever killed by an imaginary or evenan emotional shock; that there is surprisingly little valid evidencethat the hair of any human being turned white in a single night, or wascompletely 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 ofthe latter, diverting the energy of the body into other channels anddisturbing the general balance of its forces and blood-supply; that theactual percentage of cases in which the imagination plays the chief, oreven a dominant part, is small, probably not to exceed five or ten percent; that a very considerable share of the influence of mentalimpressions in the cure of disease is due to the relief of mental panic, permitting the rallying of the recuperative powers of the body, and tothe extent to which they produce the reform of bad physical habits orsurroundings or conditions. 

The most important element in the cure of disease by mentalimpression is _time_ plus the _vis medicatrix naturæ_. The mentalimpression--suggestion, scolding, securing of confidence--diverts theattention of the patient until his own recuperative power and theintelligent correction of bad physical habits remedy his defect. Puremental impression, however vivid, which is not followed up byimprovement of the environment, or correction of bad physical habits, will be almost absolutely sterile. Faith without works is as dead inmedicine as in religion. Mental influence is little more than anintroduction committee to real treatment. Even the means used forproducing mental impressions are physical, --impressions made upon someone of the five senses of the individual. In short, as Barker aptly putsit, "Every psychotherapy is also a physical therapy. "

Furthermore, even mental worry, distress, or depression, in nine casesout of ten has a physical cause. To remedy conditions of mental stressby correcting the underpay, overwork, bad ventilation, or underfeedingon account of illness or death of the wage-earner of the family, is, ofcourse, nothing but the most admirable common sense; but to call it the_mental_ treatment of disease is a mere juggling with words. "Take careof the body and the mind will take care of itself, " is a maxim whichwill 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. 

 Cæcum, 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; coöperating 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. 

 Pyæmia, 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. 

 Septicæmia, 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 naturæ, 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. 

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