Preventable Diseases
by Woods Hutchinson · English · Gutenberg #21965 · 721,716 chars · public domain (US)
The Project Gutenberg eBook of Preventable Diseases
This eBook is for the use of anyone anywhere in the United States and
most other parts of the world at no cost and with almost no restrictions
whatsoever. You may copy it, give it away or re-use it under the terms
of the Project Gutenberg License included with this eBook or online
at www.gutenberg.org. If you are not located in the United States,
you will have to check the laws of the country where you are located
before using this eBook.
Title: Preventable Diseases
Author: Woods Hutchinson
Release date: June 29, 2007 [eBook #21965]
Language: English
Other information and formats: www.gutenberg.org/ebooks/21965
Credits: Produced by Audrey Longhurst, Janet Blenkinship and the
Online Distributed Proofreading Team at http://www.pgdp.net
(This file was produced from images from the Home Economics
Archive: Research, Tradition and History, Albert R. Mann
Library, Cornell University)
*** START OF THE PROJECT GUTENBERG EBOOK PREVENTABLE DISEASES ***
Produced by Audrey Longhurst, Janet Blenkinship and the
Online Distributed Proofreading Team at http://www.pgdp.net
(This file was produced from images from the Home Economics
Archive: Research, Tradition and History, Albert R. Mann
Library, Cornell University)
PREVENTABLE DISEASES
BY
WOODS HUTCHINSON, A.M., M.D.
_Author of "Studies in Human and Comparative Pathology," "Instinct and
Health," etc., etc. Clinical Professor of Medicine, New York Polyclinic,
late Lecturer in Comparative Pathology, London Medical Graduates College
and University of Buffalo_
BOSTON AND NEW YORK HOUGHTON MIFFLIN COMPANY The Riverside Press
Cambridge
COPYRIGHT, 1907, 1908 AND 1909, BY THE CURTIS PUBLISHING COMPANY
COPYRIGHT, 1909, BY WOODS HUTCHINSON
ALL RIGHTS RESERVED
_Published November 1909_
FIFTH IMPRESSION
* * * * *
By Woods Hutchinson
THE CONQUEST OF CONSUMPTION. Illustrated.
12mo, $1.00 _net_. Postage extra.
PREVENTABLE DISEASES. 12mo, $1.50 _net_.
Postage 13 cents.
HOUGHTON MIFFLIN COMPANY
BOSTON AND NEW YORK
* * * * *
CONTENTS
I. The Body-Republic and its Defense 1
II. Our Legacy of Health: the Power of Heredity
in the Prevention of Disease 31
III. The Physiognomy of Disease: what a Doctor
can tell from Appearances 55
IV. Colds and how to catch Them 83
V. Adenoids, or Mouth-Breathing: their Cause
and their Consequences 103
VI. Tuberculosis, a Scotched Snake. I 123
VII. Tuberculosis, a Scotched Snake. II 140
VIII. The Unchecked Great Scourge: Pneumonia 174
IX. The Natural History of Typhoid Fever 198
X. Diphtheria: the Modern Moloch 222
XI. The Herods of Our Day: Scarlet Fever,
Measles, and Whooping-Cough 243
XII. Appendicitis, or Nature's Remnant Sale 267
XIII. Malaria: the Pestilence that walketh in Darkness;
the greatest Foe of the Pioneer 289
XIV. Rheumatism: what it Is, and particularly
what it Isn't 311
XV. Germ-Foes that follow the Knife, or Death
under the Finger-Nail 331
XVI. Cancer, or Treason in the Body-State 350
XVII. Headache: the most useful Pain in the World 367
XVIII. Nerves and Nervousness 387
XIX. Mental Influence in Disease, or how the Mind
affects the Body 411
Index 439
PREVENTABLE DISEASES
CHAPTER I
THE BODY-REPUBLIC AND ITS DEFENSE
The human body as a mechanism is far from perfect. It can be beaten or
surpassed at almost every point by some product of the machine-shop or
some animal. It does almost nothing perfectly or with absolute
precision. As Huxley most unexpectedly remarked a score of years ago,
"If a manufacturer of optical instruments were to hand us for laboratory
use an instrument so full of defects and imperfections as the human eye,
we should promptly decline to accept it and return it to him. But," as
he went on to say, "while the eye is inaccurate as a microscope,
imperfect as a telescope, crude as a photographic camera, it is all of
these in one." In other words, like the body, while it does nothing
accurately and perfectly, it does a dozen different things well enough
for practical purposes. It has the crowning merit, which overbalances
all these minor defects, of being able to adapt itself to almost every
conceivable change of circumstances.
This is the keynote of the surviving power of the human species. It is
not enough that the body should be prepared to do good work under
ordinary conditions, but it must be capable, if needs be, of meeting
extraordinary ones. It is not enough for the body to be able to take
care of itself, and preserve a fair degree of efficiency in health,
under what might be termed favorable or average circumstances, but it
must also be prepared to protect itself and regain its balance in
disease.
The human automobile in its million-year endurance-run has had to learn
to become self-repairing; and well has it learned its lesson. Not only,
in the language of the old saw, is there "a remedy for every evil under
the sun," but in at least eight cases out of ten that remedy will be
found within the body itself. Generations ago this self-balancing,
self-repairing power was recognized by the more thoughtful fathers in
medicine and even dignified by a name in their pompous Latinity--the
_vis medicatrix naturæ_, the healing power of nature.
In the new conception of disease, our drugs, our tonics, our
prescriptions and treatments, are simply means of rousing this force
into activity, assisting its operations, or removing obstacles in its
way. This remedial power does not imply any gift of prophecy on nature's
part, nor is it proof of design, or beneficent intention. It is rather
one of those blind reactions to certain stimuli, tending to restore the
balance of the organism, much as that interesting, new scientific toy,
the gyroscope car, will respond to pressure exerted or weight placed
upon one side by rising on that side, instead of tipping over. Let the
onslaught of disease be sufficiently violent and unexpected, and nature
will fail to respond in any way.
Moreover, we and our intelligences are a product of nature and a part
of her remedial powers. So there is nothing in the slightest degree
irrational or inconsistent in our attempting to assist in the process.
However, a great, broad, consoling and fundamental fact remains: that in
a vast majority of diseases which attack humanity, under ninety per cent
of the unfavorable influences which affect us, nature will effect a cure
if not too much interfered with. As the old proverb has it, "A man at
forty is either a fool or a physician"; and nature is a good deal over
forty and has never been accused of lacking intelligence.
In the first place, nature must have acquired a fair knowledge of
practical medicine, or at least a good working basis for it, from the
fact that the body, in the natural processes of growth and activity, is
perpetually manufacturing poisons for its own tissues.
In this age of sanitary reform, we are painfully aware that the most
frequent causes of human disease are the accumulations about us of the
waste products of our own kitchens, barns, and factories. The "bad air"
which we hear so frequently and justly denounced as a cause of disease,
is air which we have ourselves polluted. This same process has been
going on within the body for millions of years. No sooner did three or
four cells begin to cling together, to form an organism, a body, than
the waste products of the cells in the interior of the group began to
form a source of danger for the others. If some means of getting rid of
these could not be devised, the group would destroy itself, and the
experiment of coöperation, of colony-formation, of organization in fact,
would be a failure.
Hence, at a very early period we find the development of the rudiments
of systems of body-sewerage, providing for the escape of waste poisons
through the food-tube, through the kidneys, through the gills and lungs,
through the sweat glands of the skin. So that when the body is
confronted by actual disease, it has all ready to its hand a remarkably
effective and resourceful system of sanitary appliances--sewer-flushing,
garbage-burning, filtration. In fact, this is precisely what it does
when attacked by poisons from without: it neutralizes and eliminates
them by the same methods which it has been practicing for millions of
years against poisons from within.
Take, for instance, such a painfully familiar and unheroic episode as an
attack of colic. It makes little difference whether the attack is due to
the swallowing of some mineral poison, like lead or arsenic, or the
irritating juice of some poisonous plant or herb, or to the every-day
accident of including in the menu some article of diet which was
beginning to spoil or decay, and which contained the bacteria of
putrefaction or their poisonous products. The reaction of defense is
practically the same, varying only with the violence and the character
of the poison. If the dose of poisonous substances be unusually large or
virulent, nature may short-circuit the whole attack by causing the
outraged stomach to reject its contents. The power of "playing Jonah" is
a wonderful safety-valve.
If the poison be not sufficiently irritating thus to short-circuit its
own career, it may get on into the intestines before the body thoroughly
wakes up to its presence. This part of the food-tube being naturally
geared to discharge its contents downward, the simplest and easiest
thing is to turn in a hurry call and cut down the normal schedule from
hours to minutes, with the familiar result of an acute diarrh[oe]a.
Both vomiting and purging are defensive actions on nature's part,
remedies instead of diseases. Yet we are continually regarding and
treating them as if they were diseases in themselves. Nothing could be
more irrational than to stop a diarrh[oe]a before it has accomplished
its purpose. Intelligent physicians now assist it instead of trying to
check it in its early stages; and paradoxical as it may sound, laxatives
are often the best means of stopping it. It is only the excess of this
form of nature's house-cleaning which needs to be checked. Many of the
popular Colic Cures, Pain-Relievers, and "Summer Cordials" contain opium
which, while it relieves the pain and stops the discharge, simply locks
up in the system the very poisons which it was trying to get rid of.
Laxatives, intestinal antiseptics, and bowel irrigations have almost
taken the place of opiates in the treatment of these conditions in
modern medicine. We try to help nature instead of thwarting her.
Supposing that the poison be of more insidious form, a germ or a
ptomaine, for instance, which slips past these outer "firing-out"
defenses of the food-tube and arouses no suspicion of its presence until
it has been partially digested and absorbed into the blood. Again,
resourceful nature is ready with another line of defense. It was for a
long time a puzzle why every drop of the blood containing food and its
products absorbed from the alimentary food-canal had to be carried,
often by a most roundabout course, to and through the liver, before it
could reach any part of the general system. Here was the largest and
most striking organ in the body, and it was as puzzling as it was large.
We knew in some crude way that it "made blood," that it prepared the
food-products for use by the body-cells, and that it secreted the bile;
but this latter secretion had little real digestive value, and the other
changes seemed hardly important enough to demand that every drop of the
blood coming from the food-tube should pass through this custom-house.
Now, however, we know that in addition to its other actions, the liver
is a great poison-sponge or toxin-filter, for straining out of the blood
poisonous or injurious materials absorbed from the food, and converting
them into harmless substances. It is astonishing what a quantity of
these poisons, whether from the food or from germs swallowed with it,
the liver is capable of dealing with--destroying them, converting them,
and acting as an absolute barrier to their passage into the general
system. But sometimes it is overwhelmed by appalling odds; some of the
invaders slip through its lines into the general circulation, producing
headache, backache, fever, and a "dark-brown taste in the mouth"; and,
behold, we are bilious, and proceed to blame the poor liver. We used to
pour in remedies to "stir it up," to "work on it"--which was about as
rational as whipping a horse when he is down, instead of cutting his
harness or taking his load off. Nowadays we stop the supply of further
food-poisons by stopping eating, assist nature in sweeping out or
neutralizing the enemies that are still in the alimentary canal, flush
the body with pure water, put it at rest--and trust the liver.
Biliousness is a sign of an overworked liver. If it wasn't working at
all, we shouldn't be bilious: we should be dead, or in a state of
collapse.
Moral: Don't rush for some remedy with which to club into insensibility
every symptom of disease as soon as it puts in an appearance. Give
nature a little chance to show what she intends to do before attempting
to stop her by dosing yourself with some pain-reliever or colic cure.
Don't trust her too blindly, for the best of things may become bad in
extremes, and the body may become so panic-stricken as to keep on
throwing overboard, not merely the poisons, but its necessary daily
food, if the process be allowed to continue too long.
This is where the doctor comes in. This is the point at which it takes
brains to succeed in the treatment of disease--to decide just how far
nature knows what she is doing, even in her most violent expulsive
methods, and is to be helped; and just when she has lost her head, or
got into a bad habit, and must be thwarted. This much we feel sure of,
and it is one of the keynotes of the attitude of modern medicine, that a
large majority of the symptoms of disease are really nature's attempts
to cure it.
This is admirably shown in our modern treatment of fevers. These we now
know to be due to the infection of the body by more or less definitely
recognized disease-germs or organisms. Fever is a complicated process,
and we are still in the dark upon many points in regard to it, but we
are coming more and more firmly to the conclusion that most of its
symptoms are a part of, or at least incidents in, the fight of the body
against the invading army. The flushed and reddened skin is due to the
pumping of large quantities of blood through its mesh, in order that the
poisons may be got rid of through the perspiration. The rapid pulse
shows the vigor with which the heart is driving the blood around the
body, to have its poisons neutralized in the liver, burned up in the
lungs, poured out by the kidneys and the skin. The quickened breathing
is the putting on of more blast in the lung poison-crematory. It is
possible that even the rise of temperature has an injurious effect upon
the invading germs or assists the body in their destruction.
In the past we have blindly fought all of these symptoms. We shut our
patients up in stove-heated rooms with windows absolutely closed, for
fear that they would "catch cold." We took off the sheets and piled
blankets upon the bed, setting a special watch to see that the wretched
sufferer did not kick them off. We discouraged the drinking of water and
insisted on all drinks that were taken being hot or lukewarm. Nowadays
all this is changed. We throw all the windows wide-open, and even put
our patients out of doors to sleep in the open air, whether it be
typhoid, tuberculosis, or pneumonia; knowing that not only they will not
"catch cold," but that, as their hurried breathing indicates, they need
all the oxygen they can possibly get, to burn up the poison poured out
in the lungs and from the skin. We encourage the patient to drink all
the cool, pure water he will take, sometimes gallons in a day, knowing
that his thirst is an indication for flushing and flooding all the great
systems of the body sewers. Instead of smothering him in blankets, we
put him into cold packs, or put him to soak in cool water.
In short, we trust nature instead of defying her, coöperate with her in
place of fighting her,--and we have cut down the death-rate of most
fevers fifty to seventy-five per cent already. Plenty of pure, cool
water internally, externally, and eternally, rest, fresh air, and
careful feeding, are the best febrifuges and antipyretics known to
modern medicine. All others are frauds and simply smother a symptom
without relieving its cause, with the exception of quinine in malaria,
mercury, and the various antitoxins in their appropriate diseases, which
act directly upon the invading organism.
Underneath all this storm and stress of the fever paroxysm, nature is
quietly at work elaborating her antidote. In some marvelous fashion,
which we do not even yet fully understand, the cells of the body are
producing in ever-increasing quantities an _anti-body_, or _antitoxin_,
which will unite with the toxin or poison produced by the hostile germs
and render it entirely harmless. By a curious paradox of the process, it
does not kill the germs themselves. It may not even stop their further
multiplication. Indeed, it utilizes part of their products in the
formation of the antitoxin; but it domesticates them, as it were--turns
them from dangerous enemies into harmless guests.
The treaty between these germs and the body, however, is only of the
"most-favored-nation" class; for let these tamed and harmless friends of
the family escape and enter the body of another human being, and they
will attack it as virulently as ever.
Now, where and how did nature ever succeed in getting the rehearsal and
the practice necessary to build up such an extraordinary and complicated
system of defense as this? Take your microscope and look at a drop of
fluid from the mouth, the gums, the throat, the stomach, the bowels, and
you will find it simply swarming with bacteria, bacilli, and cocci, each
species of which numbers its billions. There are thirty-three species
which inhabit the mouth and gums alone! We are literally alive with
them; but most of them are absolutely harmless, and some of them
probably slightly helpful in the processes of digestion. In fevers and
infections the body merely applies to disease-germs the tricks which it
has learned in domesticating these millions of harmless vegetable
inhabitants.
Still more curious--there is a distinct parallel between the method in
which food-materials are split up and prepared for assimilation by the
body, and the method adopted in breaking up and neutralizing the toxins
of disease-germs. It is now known that poisons are formed in the process
of digesting and absorbing the simplest and most wholesome foods; and
the liver uses the skill which it has gained in dealing with these
"natural poisons" in disposing of the toxins of germs.
When a fever has run its course, as we now know nearly all infections
do, within periods ranging from three or four days to as many weeks, it
simply means that it has taken the liver and the other police-cells this
length of time to handle the rioters and turn them into peaceable and
law-abiding, even though not well-disposed citizens. In this process the
forces of law and order can be materially helped by skillful and
intelligent coöperation. But it takes brains to do it and avoid doing
more harm than good. It requires far more intelligence on the part of
the doctor, the nurse, or the mother, skillfully to help nature than it
did blindly to fight her.
This is what doctors and nurses are trained for nowadays, and they are
of use in the sick-room simply because they have devoted more time and
money to the study of these complicated processes than you have. Don't
imagine that calling in the doctor is going to interfere with the
natural course of the disease, or rob the patient of some chance he
might have had of recovering by himself. On the contrary, it will simply
give nature and the constitution of the patient a better chance in the
struggle, probably shorten it, and certainly make it less painful and
distressing.
If these symptoms of the summer fevers and fluxes are indicative of
nature's attempts to cure, those of the winter's coughs and colds are no
less clearly so. As we walk down the streets, we see staring at us in
large letters from a billboard, "_Stop that Cough! It is Killing you!_"
Yet few things could be more obvious to even the feeblest intelligence,
than that this "killing" cough is simply an attempt on the part of the
body to expel and get rid of irritating materials in the upper
air-passages. As long as your larynx and windpipe are inflamed or
tickled by disease-germs or other poisons, your body will do its best to
get rid of them by coughing, or, if they swarm on the mucous membrane of
the nose, by sneezing. To attempt to stop either coughing or sneezing
without removing the cause is as irrational as putting out a
switch-light without closing the switch. Though this, like other
remedial processes, may go to extremes and interfere with sleep, or
upset the stomach, within reasonable limits one of the best things to do
when you have a cold is to cough. When patients with severe
inflammations of the lungs become too weak or too deeply narcotized to
cough, then attacks of suffocation from the accumulation of mucus in the
air-tubes are likely to occur at any time. Young children who cannot
cough properly, not having got the mechanism properly organized as yet,
have much greater difficulty in keeping their bronchial tubes clear in
bronchitis or pneumonia than have grown-ups. Most colds are infectious,
like the fevers, and like them run their course, after which the cough
will subside along with the rest of the symptoms. But simply stopping
the cough won't hasten the recovery. Most popular "Cough-Cures" benumb
the upper throat and stop the tickling; smother the symptoms without
touching the cause. Many contain opium and thus load the system with two
poisons instead of one.
Lastly, in the realm of the nervous system, take that commonest of all
ills that afflict humanity--headache. Surely, this is not a curative
symptom or a blessing in disguise, or, if so, it is exceedingly well
disguised. And yet it unquestionably has a preventive purpose and
meaning. Pain, wherever found, is nature's abrupt command, "Halt!" her
imperative order to stop. When you have obeyed that command, you have
taken the most important single step towards the cure. _A headache
always means something_--overwork, under-ventilation, eye-strain,
underfeeding, infection. Some error is being committed, some bad
physical habit is being dropped into. There are a dozen different
remedies that will stop the pain, from opium and chloroform down to the
coal-tar remedies (phenacetin, acetanilid, etc.) and the bromides. But
not one of them "cures," in the sense of doing anything toward removing
the cause. In fact, on the contrary they make the situation worse by
enabling the sufferer to keep right on repeating the bad habit, deprived
of nature's warning of the harm that he is doing to himself. As the
penalties of this continued law-breaking pile up, he requires larger and
larger doses of the deadening drug, until finally he collapses, poisoned
either by his own fatigue-products or by the drugs which he has been
taking to deaden him against their effect.
In fine, follow nature's hints whenever she gives them: treat pain by
rest, infections by fresh air and cleanliness, the digestive
disturbances by avoiding their cause and helping the food-tube to flush
itself clean; keep the skin clean, the muscles hard, and the stomach
well filled--and you will avoid nine-tenths of the evils which threaten
the race.
The essence of disease consists, not in either the kind or the degree of
the process concerned, but only in its relations to the general balance
of activities of the organism, to its "resulting in discomfort,
inefficiency, or danger," as one of our best-known definitions has it.
Disease, then, is not absolute, but purely relative; there is no single
tissue-change, no group even of changes or of symptoms, of which we can
say, "This is essentially morbid, this is everywhere and at all times
disease."
Our attainment of any clear view of the essential nature of disease was
for a long time hindered, and is even still to some degree clogged, by
the standpoint from which we necessarily approached and still approach
it, not for the study of the disease itself, but for the relief of its
urgent symptoms. Disease presents itself as an enemy to attack, in the
concrete form of a patient to be cured; and our best efforts were for
centuries almost wasted in blind, and often irrational, attempts to
remove symptoms in the shortest possible time, with the most powerful
remedies at our disposal, often without any adequate knowledge whatever
of the nature of the underlying condition whose symptoms we were
combating, or any suspicion that these might be nature's means of
relief, or that "haply we should be found to fight against God." There
was sadly too much truth in Voltaire's bitter sneer, "Doctors pour drugs
of which they know little, into bodies of which they know less"; and I
fear the sting has not entirely gone out of it even in this day of
grace.
And yet, relative and non-essential as all our definitions now recognize
disease to be, it is far enough (God knows) from being a mere negative
abstraction, a colorless "error by defect." It has a ghastly
individuality and deadly concreteness,--nay, even a vindictive
aggressiveness, which have both fascinated and terrorized the
imagination of the race in all ages. From the days of "the angel of the
pestilence" to the coming of the famine and the fever as unbidden guests
into the tent of Minnehaha; from "the pestilence that walketh in
darkness" to the plague that still "stalks abroad" in even the prosaic
columns of our daily press, there has been an irresistible impression,
not merely of the positiveness, but even of the personality of disease.
And no clear appreciation can possibly be had of our modern and rational
conceptions of disease without at least a statement of the earlier
conceptions growing out of this personifying tendency. Absurd as it may
seem now, it was the legitimate ancestor of modern pathogeny, and still
holds well-nigh undisputed sway over the popular mind, and much more
than could be desired over that of the profession.
The earliest conception of disease of which we have any record is, of
course, the familiar Demon Theory. This is simply a mental magnification
of the painfully personal, and even vindictive, impression produced upon
the mind of the savage by the ravages of disease. And certainly we of
the profession would be the last to blame him for jumping to such a
conclusion. Who that has seen a fellow being quivering and chattering in
the chill-stage of a pernicious malarial seizure, or tossing and raving
in the delirium of fever, or threatening to rupture his muscles and
burst his eyes from their sockets in the convulsions of tetanus or
uræmia, can wonder for a moment that the impression instinctively arose
in the untutored mind of the Ojibwa that the sufferer was actually in
the grasp, and trying to escape from the clutch, of some malicious but
invisible power? And from this conception the treatment logically
followed. The spirits which possessed the patient, although invisible,
were supposed to be of like passions with ourselves, and to be affected
by very similar influences; hence dances, terrific noises, beatings and
shakings of the unfortunate victim, and the administration of bitter and
nauseous messes, with the hope of disgusting the demon with his
quarters, were the chief remedies resorted to. And while to-day such
conceptions and their resultant methods are simply grounds for laughter,
and we should probably resent the very suggestion that there was any
connection whatever between the Demon Theory and our present practice,
yet, unfortunately for our pride, the latter is not only the direct
lineal, historic descendant of the former, but bears still abundant
traces of its lowly origin. It will, of course, be admitted at once that
the ancestors of our profession, historically, the earliest physicians,
were the priest, the Shaman, and the conjurer, who even to this day in
certain tribes bear the suggestive name of "medicine men." Indeed, this
grotesque individual was neither priest nor physician, but the common
ancestor of both, and of the scientist as well. And, even if the history
of this actual ancestry were unknown, there are scores of curious
survivals in the medical practice of this century, even of to-day, which
testify to the powerful influence of this conception. The extraordinary
and disgraceful prevalence of bleeding scarcely fifty years ago, for
instance; the murderous doses of calomel and other violent purges; the
indiscriminate use of powerful emetics like tartar emetic and ipecac;
the universal practice of starving or "reducing" fevers by a diet of
slops, were all obvious survivals of the expulsion-of-the-demon theory
of treatment. Their chief virtue lay in their violence and
repulsiveness. Even to-day the tendency to regard mere bitterness or
distastefulness as a medicinal property in itself has not entirely died
out. This is the chief claim of quassia, gentian, calumbo, and the
"simple bitters" generally, to a place in our official lists of
remedies. Even the great mineral-water fad, which continues to flourish
so vigorously, owed its origin to the superstition that springs which
bubbled or seethed were inhabited by spirits (of which the "troubling of
the waters" in the Pool of Bethesda is a familiar illustration). The
bubble and (in both senses) "infernal" taste gave them their reputation,
the abundant use of pure spring water both internally and externally
works the cure, assisted by the mountain air of the "_Bad_," and we
sapiently ascribe the credit to the salts. Nine-tenths of our cells are
still submarine organisms, and water is our greatest panacea.
Then came the great "humoral" or "vital fluid" theory of disease which
ruled during the Middle Ages. According to this, all disease was due to
the undue predominance in the body of one of the four great vital
fluids,--the bile, the blood, the nervous "fluid," and the lymph,--and
must be treated by administering the remedy which will get rid of or
counteract the excess of the particular vital fluid in the system. The
principal traces of this belief are the superstition of the four
"temperaments," the _bilious_, the _sanguine_, the _nervous_, and the
_lymphatic_, and our pet term "biliousness," so useful in explaining any
obscure condition.
Last of all, in the fullness of time,--and an incredibly late fullness
it was,--under the great pioneer Virchow, who died less than a decade
ago, was developed the great cellular theory, a theory which has done
more to put disease upon a rational basis, to substitute logic for
fancy, and accurate reasoning for wild speculation, than almost any
discovery since the dawn of history. Its keynote simply is, that every
disturbance to which the body is liable can be ultimately traced to some
disturbance or disease of the vital activities of the individual cells
of which it is made up. The body is conceived of as a cell-state or
cell-republic, composed of innumerable plastid citizens, and its
government, both in health and disease, is emphatically a government "of
the cells, by the cells, for the cells." At first these cell-units were
regarded simply as geographic sections, as it were, sub-divisions of the
tissues, bearing much the same relation to the whole body as the bricks
of the wall do to the building, or, from a little broader view, as the
Hessians of a given regiment to the entire army. They were merely the
creatures of the organism as a whole, its servants who lived but to obey
its commands and carry out its purposes, directed in purely arbitrary
and despotic fashion by the lordly brain and nerve-ganglia, which again
are directed by the mind, and that again by a still higher power. In
fact, they were regarded as, so to speak, individuals without
personality, mere slaves and helots under the ganglion-oligarchy which
was controlled by the tyrant mind, and he but the mouthpiece of one of
the Olympians. But time has changed all that, and already the triumphs
of democracy have been as signal in biology as they have been in
politics, and far more rapid. The sturdy little citizen-cells have
steadily but surely fought their way to recognition as the controlling
power of the entire body-politic, have forced the ganglion-oligarchy to
admit that they are but delegates, and even the tyrant mind to concede
that he rules by their sufferance alone. His power is mainly a veto, and
even that may be overruled by the usual two-thirds vote.
In fact, if we dared to presume to criticise this magnificent theory of
disease, we would simply say that it is not "cellular" enough, that it
hardly as yet sufficiently recognizes the individuality, the
independence, the power of initiative, of the single constituent cell.
It is still a little too apt to assume, because a cell has donned a
uniform and fallen into line with thousands of its fellows to form a
tissue in most respects of somewhat lower rank than that originally
possessed by it in its free condition, that it has therefore surrendered
all of its rights and become a mere thing, a lever or a cog in the great
machine. Nothing could be further from the truth, and I firmly believe
that our clearest insight into and firmest grasp upon the problems of
pathology will come from a recognition of the fact that, no matter how
stereotyped, or toil-worn, or even degraded, the individual cells of any
tissue may have become, they still retain most of the rights and
privileges which they originally possessed in their free and untrammeled
am[oe]boid stage, just as in the industrial community of the world about
us. And, although their industry in behalf of and devotion to the
welfare of the entire organism is ever to be relied upon, and almost
pathetic in its intensity, yet it has its limits, and when these have
been transgressed they are as ready to "fight for their own hand,"
regardless of previous conventional allegiance, as ever were any of
their ancestors on seashore or rivulet-marge. And such rebellions are
our most terrible disease-processes, cancer and sarcoma. More than this:
while, perhaps, in the majority of cases the cell does yeoman service
for the benefit of the body, in consideration of the rations and fuel
issued to it by the latter, yet in many cases we have the curious, and
at first sight almost humiliating, position of the cell absorbing and
digesting whatever is brought to it, and only turning over the surplus
or waste to the body. It would almost seem as if our lordly _Ego_ was
living upon the waste-products, or leavings, of the cells lining its
food-tube.
Let us take a brief glance at the various specializations and trade
developments, which have taken place in the different groups of cells,
and see to what extent the profound modifications which many of them
have undergone are consistent with their individuality and independence,
and also whether such specialization can be paralleled by actually
separate and independent organisms existing in animal communities
outside of the body. First of all, because furthest from the type and
degraded to the lowest level, we find the great masses of tissue welded
together by lime-salts, which form the foundation masses, leverage-bars,
and protection plates for the higher tissues of the body. Here the
cells, in consideration of food, warmth, and protection guaranteed to
themselves and their heirs for ever by the body-state, have, as it were,
deliberately surrendered their rights of volition, of movement, and
higher liberties generally, and transformed themselves into masses of
inorganic material by soaking every thread of their tissues in
lime-salts and burying themselves in a marble tomb. Like Esau, they have
sold their birthright for a mess of "potash," or rather lime; and if
such a class or caste could be invented in the external industrial
community, the labor problem and the ever-occurring puzzle of the
unemployed would be much simplified. And yet, petrified and mummified as
they have become, they are still emphatically alive, and upon the
preservation of a fair degree of vigor in them depends entirely the
strength and resisting power of the mass in which they are embedded, and
of which they form scarcely a third. Destroy the vitality of its cells,
and the rock-like bone will waste away before the attack of the
body-fluids like soft sandstone under the elements. Shatter it, or twist
it out of place, and it will promptly repair itself, and to a remarkable
degree resume its original directions and proportions.
So little is this form of change inconsistent with the preservation of
individualism, that we actually find outside of the body an exactly
similar process, occurring in individual and independent animals, in the
familiar drama of coral-building. The coral polyp saturates itself with
the lime-salts of the sea-water, much as the bone-corpuscles with those
of the blood and lymph, and thus protects itself in life and becomes the
flying buttress of a continent in death.
In the familiar connective-tissue, or "binding-stuff," we find a process
similar in kind but differing in the degree, so to speak, of its
degradation.
The quivering responsiveness of the protoplasm of the am[oe]boid
ancestral cell has transformed itself into tough, stringy bands and webs
for the purpose of binding together the more delicate tissues of the
body. It has retained more of its rights and privileges, and
consequently possesses a greater amount of both biological and
pathological initiative. In many respects purely mechanical in its
function, fastening the muscles to the bones, the bones to each other,
giving toughness to the great skin-sheet, and swinging in hammock-like
mesh the precious brain-cell or potent liver-lobule, it still possesses
and exercises for the benefit of the body considerable powers of
discretion and aggressive vital action. Through its activity chiefly is
carried out that miracle of human physiology, the process of repair. By
the transformation of its protoplasm the surplus food-materials of the
times of plenty are stored away within its cell-wall against the time of
stress.
Whatever emergency may arise, nature, whatever other forces she may be
unable to send to the rescue, can always depend upon the
connective-tissues to meet it; and, of course, as everywhere the medal
of honor has its reverse side, their power for evil is as distinguished
as their power for good. From their ranks are recruited a whole army of
those secessions from and rebellions against the body at large--the
tumors, from the treacherous and deadly sarcoma, or "soft cancer," to
the harmless fatty tumor, as well as the tubercle, the gumma of
syphilis, the interstitial fibrosis of Bright's disease. They are the
sturdy farmers and ever ready "minute-men" of the cell-republic, and we
find their prototype and parallel in the external world, both in
material structure and degree of vitality, in the well-known sponge and
its colonies.
Next in order, and, in fact, really forming a branch of the last, we
find the great group of storage-tissues, the granaries or bankers of the
body-politic, distinguished primarily, like the capitalist class
elsewhere, by an inordinate appetite, not to say greed. They sweep into
their interior all the food-materials which are not absolutely necessary
for the performance of the vital function of the other cells. These they
form first into protoplasm, and then by a simple degenerative process it
is transformed, "boiled down" as it were, into a yellow hydrocarbon
which is capable of storage for practically an indefinite period. Not a
very exalted function, and yet one of great importance to the welfare of
the entire body, for, like the Jews of the Middle Ages, the fat-cells,
possessing an extraordinary appetite for and faculty of acquiring
surplus wealth in times of plenty, can easily be robbed of it and
literally sucked dry in times of scarcity by any other body-cell which
happens to need it, especially by the belligerent military class of
muscle-cells. In fever or famine, fat is the first element of our
body-mass to disappear; so that Proudhon would seem to have some
biological basis for his demand for the _per capita_ division of the
fortunes of millionaires. And yet, rid the fat-cell of the weight of his
sordid gains, gaunt him down, as it were, like a hound for the
wolf-trail, and he becomes at once an active and aggressive member of
the binding-stuff group, ready for the repair of a wound or the barring
out of a tubercle-bacillus.
And this form of specialization has also its parallel outside of the
body in one of the classes in a community of Mexican ants, whose most
distinguishing feature is an enormously distended [oe]sophagus, capable
of containing nearly double the weight of the entire remainder of the
body. They are neither soldiers nor laborers, but accompany the latter
in their honey-gathering excursions, and as the spoils are collected
they are literally packed full of the sweets by the workers. When
distended to their utmost capacity they fall apparently into a
semi-comatose condition, are carried into the ant-hill, and hung up by
the hind legs in a specially prepared chamber, in which (we trust)
enjoyable position and state they are left until their contents are
needed for the purposes of the community, when they are waked up,
compelled to disgorge, and resume their ordinary life activities until
the next season's honey-gathering begins. It scarcely need be pointed
out what an unspeakable boon to the easily discouraged and unlucky the
introduction of such a class as this into the human industrial community
would be, especially if this method of storage could be employed for
certain liquids.
Another most important class in the cell-community is the great group
of the blood-corpuscles, which in some respects appear to maintain their
independence and freedom to a greater degree than almost any other class
which can be found in the body. While nearly all other cells have become
packed or felted together so as to form a fixed and solid tissue, these
still remain entirely free and unattached. They float at large in the
blood-current, much as their original ancestor, the am[oe]ba, did in the
water of the stagnant ditch. And, curiously enough, the less numerous of
the two great classes, the white, or leucocytes, are in appearance,
structure, pseudopodic movements, and even method of engulfing food,
almost exact replicas of their most primitive ancestor.
There is absolutely no fixed means of communication between the
blood-corpuscles and the rest of the body, not even by the tiniest
branch of the great nerve-telegraph system, and yet they are the most
loyal and devoted class among all the citizens of the cell-republic.
They are called hither and thither partly by messenger-substances thrown
into the blood, known as _hormones_, partly by the "smell of the battle
afar off," the toxins of inflammation and infection as they pour through
the blood.
The red ones lose their nuclei, their individuality, in order to become
sponges, capable of saturating themselves with oxygen and carrying it to
the gasping tissues. The white are the great mounted police, the
sanitary patrol of the body. The moment that the alarm of injury is
sounded in a part, all the vessels leading to it dilate, and their
channels are crowded by swarms of the red and white hurrying to the
scene. The major part of the activity of the red cells can be accounted
for by the mechanism of the heart and blood-vessels. They are simply
thrown there by the handful and the shovelful, as it were, like so many
pebbles or bits of chalk.
But the behavior of the white cells goes far beyond this. We are almost
tempted to endow them with volition, though they are of course drawn or
driven by chemical and physical attractions, like iron-filings by a
magnet, or an acid by a base. Not only do all those normally circulating
in the blood flowing through the injured part promptly stop and begin to
scatter themselves through the underbrush and attack the foe at close
quarters, but, as has been shown by Cabot's studies in leucocytosis, the
moment that the red flag of fever is hoisted, or the inflammation alarm
is sounded, the leucocytes come rushing out from their feeding-grounds
in the tissue-interspaces, in the lymph-channels, in the great serous
cavities, and pour themselves into the blood-stream, like minute-men
leaving the plough and thronging the highways leading towards the
frontier fortress which has been attacked. Arrived at the spot, if there
be little of the pomp and pageantry of war in their movements, their
practical devotion and heroism are simply unsurpassed anywhere, even in
song and story. They never think of waiting for reinforcements or for
orders from headquarters. They know only one thing, and that is to
fight; and when the body has brought them to the spot, it has done all
that is needed, like the Turkish Government when once it has got its
sturdy peasantry upon the battlefield: they have not even the sense to
retreat. And whether they be present in tens, or in scores, or in
millions, each one hurls himself upon the toxin or bacillus which stands
directly in front of him. If he can destroy the bacillus and survive, so
much the better; but if not, he will simply overwhelm him by the weight
of his body-mass, and be swept on through the blood-stream into the
great body-sewers, with the still living bacillus literally buried in
his dead body. Like Arnold Winkelried, he will make his body a sheath
for a score of the enemy's spears, so that his fellows can rush in
through the gap that he has made. And it makes no difference whatever if
the first ten or hundred or thousand are instantly mowed down by the
bacillus or its deadly toxins, the rear ranks sweep forward without an
instant's hesitation, and pour on in a living torrent, like the Zulu
_impis_ at Rorke's Drift, until the bacilli are battered down by the
sheer impact of the bodies of their assailants, or smothered under the
pile of their corpses. When this has happened, in the language of the
old surgeon-philosophers, "suppuration is established," and the patient
is saved.
Or if, as often happens, an antitoxin is formed, which protects the
whole body, this is largely built out of substances set free from the
bodies of slain leucocytes. And the only thing that dims our vision to
the wonder and beauty of this drama, is that it happens every day, and
we term it prosaically "the process of repair," and expect it as a
matter of course. Every wound-healing is worthy of an epic, if we could
only look at it from the point of view of these citizens of our great
cell-republic. And if we were to ask the question, "Upon what does
their peculiar value to the body-politic depend?" we should find that it
was largely the extent to which they retained their ancestral
characteristics. They are born in the lymph-nodes, which are simply
little islands of tissue of embryonic type, preserved in the body
largely for the purpose of breeding this primitive type of cells. They
are literally the Indian police, the scavengers, the Hibernians, as it
were, of the entire body. They have the roving habits and fighting
instincts of the savage. They cruise about continually through the
waterways and marshes of the body, looking for trouble, and, like their
Hibernian descendants, wherever they see a head they hit it. They are
the incarnation of the fighting spirit of our ancestors, and if it were
not for their retention of this characteristic in so high a degree, many
classes of our fixed cells would not have been able to subside into such
burgher like habits.
Although even here, as we shall see, it is only a question of quickness
of response, for while the first bands of the enemy may be held at bay
by the leucocyte cavalry, and a light attack repelled by their
skirmish-line, yet when it comes to the heavy fighting of a
fever-invasion, it is the slow but substantial burgher-like fixed cells
of the body which form the real infantry masses of the campaign. And I
believe that upon the proportional relation between these primitive and
civilized cells of our body-politic will depend many of the singular
differences, not only in degree but also in kind, in the immunity
possessed by various individuals. While some surgeons and anatomists
will show a temperature from the merest scratch, and yet either never
develop any serious infection or display very high resisting power in
the later stages, others, again, will stand forty slight inoculations
with absolute impunity, and yet, when once the leucocyte-barrier is
broken down, will make apparently little resistance to a fatal systemic
infection. And this, of course, is only one of a score of ways in which
the leucocytes literally _pro patria moriuntur_. Our whole alimentary
canal is continually patrolled by their squadrons, poured into it by the
tonsils above and Peyer's patches below; if it were not for them we
should probably be poisoned by the products of our own digestive
processes.
If, then, the cells of the body-republic retain so much of their
independence and individuality in health, does it not seem highly
probable that they do also in disease? This is known to be the case
already in many morbid processes, and their number is being added to
every day. The normal activities of any cell carried to excess may
constitute disease, by disturbing the balance of the organism. Nay, most
disease-processes on careful examination are found to be at bottom
vital, often normal to the cells concerned in them. The great normal
divisions of labor are paralleled by the great processes of degeneration
into fat, fibrous tissue, and bone or chalk. A vital chemical change
which would be perfectly healthy in one tissue or organ, in another may
be fatal.
Ninety-nine times out of a hundred any group of cells acts loyally in
the interests of the body; once in a hundred some group acts against
them, and for its own, and disease is the result. There is a perpetual
struggle for survival going on between the different tissues and organs
of the body. Like all other free competition, as a rule, it inures
enormously to the benefit of the body-whole. Exceptionally, however, it
fails to do so, and behold disease. This struggle and turmoil is not
only necessary to life--it is life. Out of the varying chances of its
warfare is born that incessant ebb and flow of chemical change, that
inability to reach an equilibrium, which we term "vitality." The course
of life, like that of a flying express train, is not a perfectly
straight line, but an oscillating series of concentric curves. Without
these oscillations movement could not be. Exaggerate one of them unduly,
or fail to rectify it by a rebound oscillation, and you have disease.
Or it is like the children's game of shuttlecock. So long as the flying
shuttle keeps moving in its restless course to and fro, life is. A
single stop is death. The very same blow which, rightly placed, sends it
like an arrow to the safe centre of the opposing racket, if it fall
obliquely, or even with too great or too little force, drives it
perilously wide of its mark. It can recover the safe track only by a
sudden and often violent lunge of the opposing racket. The straight
course is life, the tangent disease, the saving lunge recovery.
One and the same force produces all.
In the millions of tiny blows dealt every minute in our body-battle,
what wonder if some go wide of the mark!
CHAPTER II
OUR LEGACY OF HEALTH: THE POWER OF HEREDITY IN THE PREVENTION OF DISEASE
The evil in things always bulks large in our imaginations. It is no mere
coincidence that the earliest gods of a race are invariably demons. Our
first conception of the great forces of nature is that they are our
enemies. This misconception is not only natural, but even necessary on
the sternest of physical bases. The old darky, Jim, in Huckleberry Finn,
hit upon a profound and far-reaching truth when he replied in answer to
Huck's question whether among all the signs and portents with which his
mind was crammed--like black cats and seeing the moon over your left
shoulder and "harnts"--some were not indications of good luck instead of
all being of evil omen:--
"Mighty few--an' _dey_ ain't no use to a body. What fur you want to know
when good luck's a-comin'? Want to keep it off?"
It isn't the good, either in the forces of nature or in our fellows,
that keeps us watchful, but the evil. Hence our proneness to declare in
all ages that evil is stronger than good and that "all men are liars."
One injury done us by storm, by sunstroke, by lightning-flash, will make
a more lasting impression upon our memories than a thousand benefits
conferred by these same forces. Besides, evil has to be sharply looked
out for and guarded against. Well enough can be safely let alone.
The conviction is steadily growing, among both physicians and
biologists, that this attitude has caused a serious, if not vital,
misconception of the influence of that great conservative and
preservative force of nature--heredity. We hear a great deal of
hereditary disease, hereditary defect, hereditary insanity, but very
little of hereditary powers of recovery, of inherited vigor, and the
fact that ninety-nine and seven-tenths per cent of us are sane.
One instance of hereditary defect, of inherited degeneracy, fills us
with horror and stirs us to move Heaven and earth to prevent another
such. The inheritance of vigor, of healthfulness, and of sanity we
placidly accept as a matter of course and bank upon it in our plans for
the future, without so much as a thank you to the force that underlies
it.
When once we clear away these inherited misconceptions and look the
facts of the situation squarely in the face, we find that heredity is at
least ten times as potent and as frequently concerned in the
transmission and securing of health and vigor as of disease and
weakness; that its influence on the perpetuation of bodily and mental
defects has been enormously exaggerated and that there are exceedingly
few hereditary diseases.
It is not necessary for our present purpose to enter into a discussion
of the innumerable theories of that inevitable tendency of like to beget
like, of child to resemble parent, which we call heredity. One
reference, however, may be permitted to the controversy that has
divided the scientific world: whether _acquired_ characters, changes
occurring during the lifetime of the individual, can be inherited.
Disease is nine times out of ten an acquired character; hence, instead
of the probabilities being that it would be inherited, the balance of
evidence to date points in exactly the opposite direction. The burden of
proof as to the inheritance of disease is absolutely upon those who
believe in its possibility.
Another fundamental fact which renders the inheritance of disease upon a
_priori_ grounds improbable and upon practical grounds obviously
difficult, is that characters or peculiarities, in order to be inherited
certainly for more than a few generations, must be beneficial and
helpful in the struggle. A moment's reflection will show this to be
mathematically necessary, in that any family or race which tended to
inherit defects and injurious characters would rapidly go down in the
struggle for survival and become extinct. An inherited disease of any
seriousness could not run for more than two or three generations in any
family, simply for the reason that by the end of that time there would
be no family left for it to run in. A slight defect or small peculiarity
of undesirable character might run for a somewhat longer period, but
even this would tend toward disappearance and elimination by the stern,
selective influence of environment.
Naturally, this great conservative tendency of nature has, like all
other influences, "the defects of its virtues," as the French say. It
has no gifts of prophecy, and in the process of handing down to
successive generations those mechanisms and powers which have been
found useful in the long, stern struggle of the past, it will also hand
down some which, by reason of changes in the environment, are not only
no longer useful, but even injurious. As the new light of biology has
been turned on the human body and its diseases, it has revealed so many
of these "left-overs," or remnants in the body-machine--some of most
dramatic interest--that they at first sight have done much to justify
the popular belief in the malignant tendencies of heredity.
Yet, broadly considered, the overwhelming majority of them should really
be regarded as honorable scars, memorials of ancient victories,
monuments to difficulties overcome, significant and encouraging
indications of what our body-machine is still capable of accomplishing
in the way of further adjustment to conditions in the future. The really
surprising thing is not their number, but the infrequency with which
they give rise to serious trouble.
The human automobile is not only astonishingly well built, with all the
improvements that hundreds of thousands of generations of experience
have been able to suggest, but it is self-repairing, self-cleaning, and
self-improving. It never lets itself get out of date. If only given an
adequate supply of fuel and water and not driven too hard, it will stand
an astonishing amount of knocking about in all kinds of weather,
repairing itself and recharging its batteries every night, supplying its
own oil, its own paint and polish, and even regulating its own changes
of gear, according to the nature of the work it has to do. Simply as an
endurance racer it is the toughest and longest-winded thing on earth
and can run down and tire out every paw, pad, or hoof that strikes the
ground--wolf, deer, horse, antelope, wild goat. This is only a sample of
its toughness and resisting power all along the line.
These wide powers of self-support and adjustment overbalance a hundred
times any little remnant defects in its machinery or gearing. Easily
ninety-nine per cent of all our troubles through life are due to
inevitable wear and tear, scarcity of food-fuel, of water, of rest, and
external accidents--injuries and infectious diseases. Still, it
occasionally happens that these little defects may furnish the point of
least resistance at which external stresses and strains will cause the
machine to break down. They are often the things which prevent us from
living and "going to pieces all at once, all at once and nothing fust,
just as bubbles do when they bust," like the immortal One-Hoss Shay. It
is just as well that they should, for, of all deaths to die, the
loneliest and the most to be dreaded is that by extreme old age.
These _vestigia_ or remnants--instances of apparently hidebound
conservatism on nature's part--are very much in the public eye at
present, partly on account of their novelty and of their exceptional and
extraordinary character. Easily first among these trouble-breeding
remnants is that famous, or rather notorious, scrap of intestine, the
_appendix vermiformis_, an obvious survival from that peaceful,
ancestral period when we were more largely herbivorous in our diet and
required a longer and more complicated food-tube, with larger side
pouches in the course of it, to dissolve and absorb our food. Its
present utility is just about that of a grain of sand in the eye. Yet,
considering that it is present in every human being born into the world,
the really astonishing thing is not the frequency with which it causes
trouble, but the surprisingly small amount of actual damage that arises
from it. Never yet in even the most appendicitis-ridden community has it
been found responsible for more than one half of one per cent of the
deaths.
Then there is that curious and by no means uncommon tendency for a loop
of the intestine to escape from the abdominal cavity, which we call
hernia. This is one of a fair-sized group of dangers clearly due to the
assumption of the erect position and our incomplete adjustment thereto.
In the quadrupedal position this necessary weak spot--a partial opening
through the abdominal wall--was developed in that region which was
highest from the point of view of gravity and least exposed to strain.
In the bipedal position it becomes lowest and most exposed; hence the
much greater frequency of hernia in the human species as compared with
any of the animals.
Another fragment, of the impertinence of whose presence many of us have
had painful proof, is the third or last molar, so absurdly misnamed the
wisdom tooth. If there be any wisdom involved in its appearance it is of
the sort characterized by William Allen White's delicious definition:
"That type of ponderous folly of the middle-aged which we term 'mature
judgment.'" The last is sometimes worst as well as best, and this
belated remnant is not only the last to appear, but the first to
disappear. In a considerable percentage of cases it is situated so far
back in the jaw that there is no room for it to erupt properly, and it
produces inflammatory disturbances and painful pressure upon the nerves
of the face and the jaw.
Even when it does appear it is often imperfectly developed, has fewer
cusps and fewer roots than the other molars, is imperfectly covered with
enamel and badly calcified. In no small percentage of cases it does not
meet its fellow of the jaw below and hence is almost useless for
purposes of mastication. But it comes in every child born into the
world, simply because at an earlier day, when our jaws were longer--to
give our canine teeth the swing they needed as our chief weapons of
defense--there was plenty of room for it in the jaw and it was of some
service to the organism. If the Indiana State Legislature would only
pass a law prohibiting the eruption of wisdom teeth in future, and
enforce it, it would save a large amount of suffering, inconvenience,
and discomfort, with little appreciable lack of efficiency!
In this list of admitted charges against heredity must also come the
gall-bladder, that curious little pouch budded out from the bile ducts,
which has so little known utility as compared with its possibility as a
starting-point for inflammations, gall-stones, and cancer.
Then there is that disfiguring facial defect, hare-lip, due to a failure
of the three parts of which our upper jaw is built to unite
properly,--this triple construction of the jaw being an echo of
ancestral fishlike and reptilian times when our jaws were built in five
pieces to permit of wide distention in the act of swallowing our prey
alive. All over the surface of the body are to be found innumerable
little sebaceous glands originally intended to lubricate hairs, which
have now atrophied and disappeared. These useless scraps, under various
forms of irritation, both external and internal, become inflamed and
give rise to pimples, acne, or "a bad complexion."
And so the list might be drawn out to most impressive length. But this
length would be no indication of its real importance, inasmuch as the
vast majority of entries upon it would come under the head of
pathological curiosities, or conditions which were chiefly interesting
on account of their rareness and unusual character. With the exception
of the appendix, the gall-bladder, and hernia, these vestigial
conditions may be practically disregarded as factors in the death-rate.
In the main, when the fullest possible study and recognition have been
made of all the traces of experimentation and even of ancient failure
that are to be found in this Twentieth Century body-machine of ours, the
resulting impression is one of enormously increased respect for and
confidence in the machine and its capabilities. While they are of great
interest as indicating what the past history and experiences of the
engine have been, and of highest value as enabling us to interpret and
even anticipate certain weak spots in its construction and joints in its
armor, their most striking influence is in the direction of emphasizing
the enormous elasticity and resourcefulness of the creature.
Not only has it met and survived all these difficulties, but it is
continuing the selfsame processes to-day. So far as we are able to
judge, it is as young and as adaptable as it ever was, and just as ready
to "with a frolic welcome greet the thunder and the sunshine" as it ever
was in the dawn of history.
These ancestral and experimental flaws, even when unrecognized and
unguarded against, have probably not at any time been responsible for
more than one or two per cent of the body's breakdowns; while, on the
other hand, every process with which it fights disease, every trick of
strategy which it uses against invading organisms, every step in the
process of repair after wounds or injury, is a trick which it has
learned in its million-year battle with its surroundings.
Take such a simple thing as the mere apparently blind habit possessed by
the blood of coagulating as soon as it comes in contact with the edges
of a cut or torn blood-vessel, and think what an enormous safeguard this
has been and is against the possibility of death by hemorrhage. So well
is it developed and so rapidly does it act that it is practically
impossible to bleed some animals to death by cutting across any vessel
smaller than one of the great aortic trunks. The rapidity and toughness
of the clotting, combined with the other ancestral tricks of lowering
the blood pressure and weakening down the heart, are so immensely
effective that a slash across the great artery of the thigh in the
groin of a dog will be closed completely before he can bleed to death.
So delicate and so purposeful is this adjustment that the blood will
continue as fluid as milk for ten, twenty, forty, eighty years--as long
as it remains in contact with healthy blood-vessels. But the instant it
is brought in contact with a broken or wounded piece of a vessel-wall,
that instant it will begin to clot. So inevitable is this result that it
gives rise to some of the sudden forms of death by bloodclot in the
brain or lung (apoplexy, "stroke"), the clot having formed upon the
roughened inner surface of the heart or of one of the blood-vessels and
then floated into the brain or lung.
Then take that matchless and ingenious process of the healing of wounds,
whose wondrousness increases with every step that we take into the
deeper details of its study. First, the quick outpouring and clotting of
the blood after enough has escaped to wash most poisonous or offending
substances out of the wound. This living, surgical cement, elastic,
self-moulding, soothing, not only plugs the cut or torn mouths of the
blood-vessels, but fills the gap of the wound level with the surface.
Here, by contact with the air and in combination with the hairs of the
animal it forms a tough, firm, protective coating or scab, completely
shutting out cold, heat, irritants, or infectious germs.
Into the wedge-shaped, elastic clot which now fills the wound from
bottom to top like jelly in a mould, the leucocytes or white blood-cells
promptly migrate and convert it into a mesh of living cells. They are
merely the cavalry and skirmishers of the repair brigade and are
quickly followed by the heavy infantry of the line in the shape of cells
born of the injured tissues on either side of the wound. These join
hands across the gap, the engineer corps and the commissariat department
move up promptly to their support in the form of little
vein-construction switches, which bud out from the wounded
blood-vessels. The clot is transformed into what we term granulation
tissue and begins to organize. A few days later this granulation tissue
begins to contract and pull the lips of the wound together. If the gap
has not been too wide the wound will be completely closed, its lips and
deeper parts drawn together in nearly perfect line, separated only by a
thin scar on the surface with a vertical keel of scar tissue descending
from it. If the lips cannot be drawn together and there be no surgical
skill at hand to assist them with stitches or bandages, then the gap
will be filled up by the fibrous transformation of this granulation
tissue and a thick, heavy scar result. Meanwhile, the skin-cells of the
surface have not been idle, but are budding out on either side of the
healing wound, pushing a little line of colonists forward across the raw
surface. In longer or shorter time, according to the width of the gap,
these two lines meet, and the site of our wound or the scar that it has
left is perfectly coated over with a layer of healthy skin. This drama
has occurred so many score of times in every one of us that custom has
blinded our eyes to its ingenious perfection, but it took a million
years to bring it to its present finish.
It may be a healthy corrective to our overweening conceit to remind
ourselves that, remarkable and valuable as it is, it is a mere infant
in arms compared to the superb powers of replacement and repair
possessed by our more remote ancestors. Most invertebrates and many of
the lowest two classes of backboned animals, the fishes and the
amphibians, cannot merely stop up a rent, but renew an entire limb,
fin,--yes, even eye or head. Cut an earthworm in two and the rear half
will grow a new head and the front half a new tail. It may even be cut
in four or five segments, each of which will proceed to form a head at
one end and a tail at the other. The lobster can regrow a complete gill
and any number of claws or an eye. A salamander will reproduce a foot
and part of a limb. Take out the crystalline lens in the eye of a
salamander and the edge of the iris, or colored part of the eye, will
grow another lens. Take out both the lens and the iris and the choroid
coat of the eye will reproduce both.
We are in the A, B, C class in powers of repair by comparison with the
angleworm, the lobster, or the salamander. Yet we are not without
gruesome echoes of this lost power of regeneration in that our whole
brood of tumors, including the deadly cancer and sarcoma, are due to a
strange resumption, on the part of some little knot of our body-cells,
of the power of reproducing themselves or the organ in which they are
situated, without any regard to the welfare of the rest of the body.
Cancer is, in one sense, a throwing off of the allegiance to the
body-state and a resumption of amphibian powers of independent growth on
the part of certain groups of our body-cells--literally, a "rebellion of
the cells."
These are but a handful of scores of instances that could be adduced,
showing that the majority of the processes upon which we rely in
combating disease and preserving life are the result of the hereditary
experiences of our cells. Intelligent physicians are receding completely
from that curiously warped and jaundiced view which led us to regard
heredity chiefly as a factor in the _production_ of disease. It was,
perhaps, natural enough, since it was inevitably only its injurious, or,
so to speak, malicious, effects which were brought to our attention to
be corrected. But, just as in the growth of our ethnic religions it is
Evil that is worshiped first as strongest and most aggressive, and the
recognition of the greater power of good comes only at a later stage, so
it has been in pathology.
Not only do we regard heredity as a comparatively small and steadily
receding factor in the production of disease, but we fully and frankly
recognize it as the strongest and most important single force in its
prevention. All our processes of repair, all the reactions of the body
against the attack of accident or of disease, are hereditary endowments,
worked out with infinite pains and labor through tens of thousands of
generations. The utmost that we can do with our drugs and remedies is to
appeal to and rouse into action the great healing power of nature, the
classic "_Vis medicatrix Naturæ_," an incarnation of our past
experiences handed down by heredity. Enormously valuable and important
as are the services to human welfare, health, and happiness which can be
rendered by the destruction of the living external causes of disease and
the prevention of contagion, our most permanent and substantial
victories are won by appealing to and increasing this long-descended and
hard-won power of individual resistance.
"But," says some one at once, "I thought there were a large number of
hereditary diseases." Fifty years ago there were a score of such, twenty
years ago the score had sunk to five or six. Now there is scarcely one
left. There is no known disease which is directly inherited as such.
There is scarcely even a disease in which we now regard heredity as
playing a dominant or controlling part. Among the few diseases in which
there is serious dispute as to this are tuberculosis, insanity,
epilepsy, and cancer.
Then there are diseases which for a long time puzzled us as to the
possibility of their inheritance, but which have now resolved themselves
clearly into instances of the fact that a mother who happens to contract
an acute infectious disease of any sort may communicate that disease to
the unborn child. If this occurs at an early stage of development the
child will naturally be promptly killed. In fact, this is the almost
invariable result in smallpox and yellow fever. If, on the other hand,
development be further advanced or the infection be of a milder
character, like scarlet fever or syphilis, the child may be born
suffering with the disease or with the virus in its blood, which will
cause the disease to develop within a few days after birth. This,
however, is clearly not inheritance at all, but direct infection. We no
longer use the term _hereditary_ syphilis but have substituted for it
the word _congenital_, which simply means that a child is born with the
disease.
There is no such thing as this disease extending "unto the third and
fourth generation," like the wrath of Jehovah. One fact must, of course,
be remembered, which has probably proved a source of confusion in the
popular mind, and that is its extraordinary "long-windedness." It takes
not merely two or three weeks or months to develop its complete drama,
but anywhere from three to thirty years, so that it is possible for a
child to be born with the taint in its blood and yet not exhibit to the
non-expert eye any sign of the disease until its eighth, twelfth, or
even fifteenth year.
The case of tuberculosis is almost equally clear-cut. In all the
thousands of post-mortem examinations which have been held upon newborn
children and upon mothers dying in or shortly after childbirth, the
number of instances of the actual transference of the bacilli of
tuberculosis from mother to child could be counted upon the fingers of
two hands. It is one of the rarest of pathologic curiosities and, for
practical purposes, may be entirely disregarded. When tuberculosis
appears in several members of a family, in eight cases out of ten it is
due to direct infection from parents or older children. This is
strikingly brought out in the admirable work done by the Associated
Dispensaries for Tuberculosis of the Charity Organization Society of New
York.
One of the first steps in advance which they took was to establish in
connection with every clinic for tuberculosis an attendant nurse, whose
duty it was to visit the patients at their homes and advise and instruct
them as to improvements in their methods of living, ventilation, food,
and the prevention of infection.
It was not long before these intelligent women began to bring back
reports of other cases in the same family. Now the procedure is
regularly adopted, whenever a case presents itself, of rounding up the
remainder of the family group for examination, with the astounding
result that where a mother or father is tuberculous, from twenty to
sixty per cent of the children will be found to be suffering from some
form of the infection. Instances of three infected children out of five
living in the same room with a tuberculous mother are actually on
record.
No one can practice long in any of our great climatic health resorts for
tuberculosis, like Colorado or the Pacific Slope, without coming across
scores of painful and distressing instances of children of tuberculous
parents dying suddenly in convulsions from tuberculous meningitis, or by
a wasting diarrh[oe]a from tuberculosis of the bowels, or from a violent
attack of distention of the bowels due to tuberculous peritonitis. The
favorite breeding-place of the tubercle bacillus is unfortunately in the
home.
On the other hand, while the vast majority of cases of so-called
hereditary tuberculosis are due to direct infection, and may be
prevented by proper disposal of the sputum and other methods for
avoiding contagion, there is probably a hereditary element in the spread
of tuberculosis to this degree: that, inasmuch as all of us have been
exposed to the attack and invasion of the tubercle bacillus, not merely
scores, but hundreds of times, and have been able to resist or throw
off that attack without apparent injury, the development of an invasion
of the tubercle bacillus sufficiently extensive to endanger life is, in
nine cases out of ten, in itself a proof of lowered resisting power on
the part of the patient. This may be, and often is, only temporary, due
to overwork, underfeeding, overconfinement, or that form of gradual
suffocation which we politely term inadequate ventilation.
In a certain percentage of cases, however, it is due to a chronic lack
of vigor and vitality; a lowering of the whole systemic tone, which may
have existed from birth. In that case it is hardly to be expected that
such an individual, becoming a parent, will be able to transmit to his
or her offspring more vigor than he originally possessed. It is
therefore probable that the children of a considerable percentage of
tuberculous parents would not possess the same degree of resisting power
against tuberculosis, or any other infection, as the average individual.
It is doubtful whether this factor of inherited lowered resistance plays
any very important part in the propagation of tuberculosis, partly
because it is comparatively seldom that consumptive marries consumptive,
and such tendencies to lowered vigor and vitality as may be transmitted
by one parent will be neutralized by the other; partly also because, by
the superb and beneficent logic of nature, the pedigree of any disease
is of the most mushroom and insignificant length, while the pedigree of
health stretches back to the very dawn of time. In the struggle for
dominance which takes place between the germ cells of the father and
those of the mother, the chances are at least ten to one in favor of
the old ancestral traits of vigor, of resisting power, and of survival.
How deeply this idea is implanted in the convictions of the scientific
world, the bitterly and widely debated biologic question whether
acquired characters or peculiarities can under any circumstances be
inherited clearly shows. Victory for the present rests with those who
deny the possibility of such inheritance, and disease is emphatically an
acquired character.
Truth here, as everywhere, probably lies between the extremes, and both
biologists and the students of disease have arrived at practically the
same working compromise, namely, that while no gross defect, such as a
mutilation, nor definite disease factor, such as a germ, nor even a
cancer, can possibly be inherited, yet, inasmuch as the two cells, which
by their development form the new individual, are nourished by the blood
of the maternal body, influences which affect the nutritiousness or
healthfulness of that blood may unfavorably influence the development of
the offspring.
Disease cannot be inherited any more than a mutilating defect, but the
results of both, in so far as they affect the nutrition of the offspring
in the process of formation, may be transmitted, though to a very much
smaller extent than we formerly believed. In the case of tuberculosis,
if the mother, during the months that she is building up the body and
framework of a child, is in a state of reduced or lowered nutrition on
account of consumption or any other disease, or has her tissues
saturated with the toxins of this disease, it is hardly to be expected
that the development of the child will proceed with the same perfection
as it would under perfectly normal maternal surroundings.
However, even this influence is comparatively small; for one of the most
marvelous things in nature is the perfection of the barrier which she
has erected between the child before birth and any injurious conditions
which may occur in the body of the mother. Here preference, so to speak,
is given to the coming life, and whenever there is a contest for an
adequate supply of nutrition, as, for instance, in cases of underfeeding
or of famine, it is the mother who will suffer in her nutrition rather
than the child. The unborn child, biologically considered, feeds upon
the best she has to offer, rejecting all that is inferior, doing nothing
and giving nothing in return.
How perfectly the coming generation is protected under the most
unfavorable circumstances we have been given a striking object-lesson in
one family of the lower animals. In the effective crusade against
tuberculosis in dairy cattle waged by the sanitary authorities in
Denmark, it was early discovered that the greatest practical obstacle to
the extermination of tuberculosis in cattle was the enormous financial
sacrifice involved in killing all animals infected. The disease was at
that time particularly rife among the high-bred Jersey, Holstein, and
other milking breeds. It was determined as a working compromise to test
the truth of the modern belief that tuberculosis was transmitted only by
direct infection, by permitting the more valuable cows to be saved alive
for breeding purposes. They were isolated from the rest of the herd and
given the best of care and feeding. The moment that their calves were
born they were removed from them altogether and brought up on the milk
of perfectly healthy cows. The milk of the infected cows was either
destroyed or sterilized and used for feeding pigs.
The results were brilliantly successful. Scarcely one of the calves thus
isolated developed tuberculosis in spite of their highly infected
ancestry. And not only were they not inferior in vigor and perfection of
type to the remainder of their breed, but some of them have since become
prize-winners. The additional care and more abundant feeding that they
received more than compensated for any problematic defect in their
heredity.
As to the heredity of cancer, all that can be said is that the burden of
proof rests upon those who assert it. It is really curious how
widespread the belief is that cancer "runs in families," and how
exceedingly slender is the basis of evidence for such a belief. There
are so many things that we do not know about cancer that any positive
statement of any kind would be unbecoming. It would be absurd to declare
that a disease, of which the cause is still unknown, either is or is not
inherited. And this is our position in regard to cancer. An overwhelming
majority of the evidence so far indicates that it is not a parasite; if
it were, of course, we could say positively that it is not inherited.
Although we are getting a discouraging degree of familiarity with the
process and clearly recognize that it consists chiefly in the sudden
revolt or rebellion of some group of cells, a tendency which quite
conceivably might be transmitted to future generations, yet it is highly
improbable, on both biological and pathological grounds, that such is
the case. If this rebellious tendency were transmitted we should at
least have the right to expect that it would appear in the cells of the
same organ or region of the body. It is a singular fact that in all the
hundreds of cases in which cancer has appeared in the child of a
cancerous parent it has almost invariably appeared in some different
organ from that affected in the parent.
For instance, cancer of the lip in the father may be followed by cancer
of the liver in the son or daughter, while cancer of the breast in the
mother will be followed by cancer of the lip in a son. Further than
this, the percentage of instances in which cancer appears in more than
one member of a family is decidedly small, considering the frequency of
the disease.
I took occasion to look into the matter carefully from a statistical
point of view some ten or twelve years ago, and out of a collection of
some fifty thousand cases of cancer less than six per cent were found to
give any history of cancer in the family. And this, of course, simply
means that some one of the relatives of the patient had at one time
developed the disease.
In fact, the consensus of intelligent expert opinion upon the subject of
heredity of cancer is, that though it may occur, we have comparatively
little proof of the fact; that the percentage of cases in which there is
cancer in the family is but little larger than might be expected on the
doctrine of probabilities from the average distribution. Though possibly
the offspring of a cancerous individual may display a slightly greater
tendency toward the development of that strange, curious process of
"autonomy" than the offspring of the average individual, this tendency
is so small and occurs so infrequently as to be a factor of small
practical importance in the propagation and spread of the disease.
In insanity and epilepsy we have probably the last refuge and almost
only valid instance of the old belief in the remorseless heredity of
disease. But even here the part played by heredity is probably only a
fraction of that which it is popularly, and even professionally,
believed to play. It is, of course, obvious that diseases which tend
quickly to destroy the life of the patient, especially those which kill
or seriously cripple him before he has reached the age of reproduction,
or prevent his long surviving that epoch, will not, for mechanical
reasons, become hereditary. The Black Death, or the cholera, for
instance, could not "run in a family." Supposing that children were born
with a special susceptibility to this disease, there would obviously
soon be no family left.
The same is true in a lesser degree of milder or more chronic diseases.
The family which was hereditarily predisposed to scarlet fever, measles,
smallpox, or tuberculosis would not last long, and in fact the whole
progress of civilization has been a continuous process of the weeding
out of those who were most susceptible and the survival of those who
were least so.
But when we come to deal with certain conditions, fortunately rare, such
as functional disturbances of the nervous system, which neither
seriously unfit their possessor for the struggle of life nor prevent
him from reproducing his kind, then it becomes possible that a tendency
to such disease may be transmitted through several successive
generations.
Such is the case with insanity, with epilepsy, with _hemophilia_, or
"bleeders," and with certain rare and curious disturbances of the
nervous system, such as the hereditary _ataxias_ and "tics" of various
sorts. However, even here the only conditions on which these diseases
can continue to run in a family for more than one or two generations is
either that they shall be mild in form or that only a comparatively
small percentage of the total family shall be affected by them. If, for
instance, two-thirds, one-half, or even a third of the descendants of a
mentally unsound individual were to become insane, it would only need a
few generations for that family to be crushed to the wall.
While the descendants of insane persons are distinctly more liable to
become insane than the rest of the community, yet, on account of their
fewness, this tendency probably does not account for more than a small
fraction of the total insanity. We should, by all means, prevent the
marriage of the insane and discourage that of their children, and the
development of any well-defined form of insanity should act at once,
_ipso facto_, as a ground and cause of divorce.
But the consoling fact remains that even of such children, providing, of
course, as usually happens, that the other parent--husband or wife--is
sound and sane, not more than ten or fifteen per cent would probably
become insane. In other words, insanity is acquired and the result of
individual stress and strain at least five times as frequently as it is
inherited. We have absolutely no rational or statistical basis for
gloomy predictions that, at present rates, within a couple of centuries
more, we shall all be shut up in asylums with nobody left to support us
and pay the taxes. The apparent increase of insanity of recent decades
is probably only "on paper," due to better registration.
To put it very roughly, probably ninety-eight per cent of us are so
born, thanks to heredity, that the possibility of our becoming insane,
even under the severest stress, is almost infinitesimal. Of the two per
cent born with this taint, this possible tendency to mental unbalance,
only about one-tenth now become completely insane,[1] and this
percentage might be greatly diminished by general sanitary improvements.
Our alienists now claim that, by checking the reproduction of the
obviously unstable, and careful hygienic treatment and training of the
predisposed two per cent, insanity is almost as preventable as
tuberculosis.
[Footnote 1: The proportion of registered insane in civilized countries
to-day ranges from two to three per 1000 of the population.]
In fine, from all the broad field of pathology, the mists of tradition
which have dimmed the fair name and reputation of heredity are slowly
but surely lifting, until we now behold it, not as our worst enemy, but
as our best friend in the prevention of disease and the upbuilding of
the race.
CHAPTER III
THE PHYSIOGNOMY OF DISEASE: WHAT A DOCTOR CAN TELL FROM APPEARANCES
It is our pride that medicine, from an art, and a pretty black one at
that, originally, is becoming a science. And the most powerful factor in
this development, its indispensable basis, in fact, has been the
invention of instruments of precision--the microscope, the fever
thermometer, the stethoscope, the ophthalmoscope, the test-tube, the
culture medium, the triumphs of the bacteriologist and of the chemist.
Any man who makes a final diagnosis in a serious case without resorting
to some or all of these means is regarded--and justly--as careless and
derelict in his duty to his patient.
At the same time, priceless and indispensable as are these laboratory
methods of investigation, they should not be allowed to make us too
scornful and neglectful of the evidence gained by the direct use of our
five senses. We should still avail ourselves of every particle of
information that can be gained by the trained eye, the educated ear, the
expert touch,--the _tactus eruditus_ of the medical classics,--and even
the sense of smell. There is, in fact, a general complaint among the
older members of the profession that the rising generation is being
trained to neglect and even despise the direct evidence of the senses,
and to accept no fact as a fact unless it has been seen through the
microscope or demonstrated by a reaction in the test-tube. As one of our
keenest observers and most philosophic thinkers expressed it a few
months ago:--
"I fear that certain physicians on their rounds are most careful to take
with them their stethoscope, their thermometer, their hemoglobin papers,
their sphygmomanometer, but leave their eyes and their brains at home."
And it is certain that the art of sight diagnosis, which seems like half
magic, possessed in such a wonderful degree by the older physicians of
the passing and past generations, has been almost lost by the new.
A healthful reaction has, however, set in; and while we certainly do not
love the Cæsar of laboratory methods and accuracy the less, we are
beginning to have a juster affection for the Rome of the rich harvest
that may be gained from the careful, painstaking, detective-like
exercise of our eye, ear, and hand.
As a matter of fact, the conflict between the two methods is only
apparent. Not only is each in its proper sphere indispensable, but they
are enormously helpful one to the other. Instead of our being able to
tell less by the careful, direct eye-and-hand examination of our
patients than the doctor of a century ago, we can tell three to five
times as much. Signs that he could interpret only by the slow and
painful method of two-thirds of a lifetime of plodding experience, or by
occasional flashes of half-inspired insight, we are now able to
interpret absolutely upon a physiological--yes, a chemical--basis from
the revelations of the microscope, the test-tube, and the culture
medium. His only way of determining the meaning of a particular tint of
the complexion, or line about the mouth, or eruption on the skin, was by
slowly and laboriously accumulating a long series of similar cases in
which that particular symptom was found always to occur, and deducing
its meaning. Now, we simply take a drop of our patient's blood, a
scraping from his throat, a portion of some one of his secretions, a
little slice of a tumor or growth, submit them to direct examination in
the laboratory, and get a prompt and decisive answer.
The observant physician begins to gather information about a patient
from the moment he enters the sick-room or the patient steps into his
consulting-room; and the value of the information obtained in the first
thirty seconds, before a word has been spoken, is sometimes
astonishingly great. While no intelligent man would dream of depending
upon this first _coup d'[oe]il_, "stroke of the eye" as the French so
graphically call it, for his final diagnosis, or accept its findings
until he had submitted them to the most ruthless cross-examination with
the stethoscope and in the laboratory, yet it will sometimes give him a
clew of almost priceless value. It is positively uncanny to see the
swift, intuitive manner in which an old, experienced, and thoughtful
physician will grasp the probable nature of a case in one keen look at a
patient. Often he can hardly explain to you himself how he does it, what
are the data that determine it; yet not infrequently, three times out
of five, your most elaborate and painstaking study of the case with all
the modern methods will bring you to the same conclusion as that sensed
within forty-five seconds by this keen-eyed old sleuth-hound of the
fever trails. Time and again, in my interne days, have I gone the rounds
of the wards or the out-patient departments with some kindly-faced,
keen-eyed old Sherlock Holmes of the profession, and seen him point to a
new case across the ward with the question: "When did that pneumonia
come in?" or pick out a pain-drawn, ashy mask in the waiting line, with
an abrupt, "Bring me that case of cancer of the stomach. He's in pain.
I'll take him first."
And, in later years, I have had colleagues with whom it was positively
painful to walk down a crowded street, from the gruesome habit that they
had of picking out, and condemning to lingering deaths, the cases of
cancer, of Bright's disease, or of locomotor ataxia, that we happened to
meet. Of course, they would be the first to admit that this was only
what they would term a "long shot," a guess; but it was a guess based
upon significant changes in the patient's countenance or gait, which
their trained eye picked out at once, and it was surprising how often
this snapshot diagnosis turned out to be correct.
The first thing that a medical student has to learn is that appearances
are _not_ deceptive--except to fools. Every line of the human figure,
every proportion of a limb, every detail of size, shape, or relation in
an organ, _means_ something. Not a line upon any bone in the skeleton
which was not made by the hand-grip or thumbprint of some muscle,
tendon, or ligament; no bump or knuckle which is not a lever or
hand-hold for the grip of some muscle; not a line or a curve or an
opening in that Chinese puzzle, the skull, which was not made to protect
the brain, to accommodate an eye, to transmit a blood-vessel, or to
allow the escape of a nerve. Every minutest detail of structure means
something to the man who will take the pains to puzzle it out. And if
this is true of the foundation structure of the body, is it to be
expected that the law ceases to run upon the surface?
Not a line, not a tint, not a hollow of that living picture, the face,
but means something, if we will take the time and labor to interpret it.
Even coming events cast their shadows before upon that most exquisitely
responsive surface--half mirror, half sensitive plate--the human
countenance. The place where the moving finger of disease writes its
clearest and most unmistakable message is the one to which we must
naturally turn, the face; not merely for the infantile tenth part of a
reason which we often hear alleged, that it is the only part of the
body, except the hand, which is habitually exposed, and hence open to
observation, but because here are grouped the indicators and registers
of almost every important organ and system in the body.
What, of course, originally made the face the face, and, for the matter
of that, the head the head, was the intake opening of the food-canal,
the mouth. Around this necessarily grouped themselves the outlook
departments, the special senses, the nose, the eyes, and ears; while
later, by an exceedingly clumsy device of nature, part of the mouth was
split off for the intake of a new ventilating system. So that when we
glance at the face we are looking first at the automatically controlled
intake openings of the two most important systems in the body, the
alimentary and the respiratory, whose muscles contract and relax, ripple
in comfort or knot in agony, in response to every important change that
takes place throughout the entire extent of both.
Second, at the apertures of the two most important members of the
outlook corps, the senses of sight and of smell. These are not only
sharply alert to every external indication of danger, but by a curious
reversal, which we will consider more carefully later, reflect signals
of distress or discomfort from within. Last, but not least, the
translucent tissues, the semi-transparent skin, barely veiling the
pulsating mesh of myriad blood-vessels, is a superb color index,
painting in vivid tints--"yellow, and ashy pale, and hectic red"--the
living, ever changing, moving picture of the vigor of the life-centre,
the blood-pump, and the richness of its crimson stream. Small wonder
that the shrewd advice of a veteran physician to the medical student
should be: "The first step in the examination is to look at your
patient; the second is to look again, and the third to take another look
at him; and keep on looking all through the examination."
It is no uncommon thing for an expert diagnostician deliberately to lead
the patient into conversation upon some utterly irrelevant subjects,
like the weather, the crops, or the incidents of his journey to the
city, simply for the purpose of taking his mind off himself, putting
him at his ease, and meanwhile quietly deciphering the unmistakable
cuneiform inscription, often twice palimpsest, written by the finger of
disease upon his face. It takes time and infinite pains. In no other
realm does genius come nearer to Buffon's famous description, "the
capacity for taking pains," but it is well worth the while. And with all
our boasted and really marvelous progress in precise knowledge of
disease, accomplished through the microscope in the laboratory, it
remains a fact of experience that so careful and so trustworthy is this
face-picture when analyzed, that our best and most depended upon
impressions as to the actual condition of patients, are still obtained
from this source. Many and many a time have I heard the expression from
a grizzled consultant in a desperate case, "Well, the last blood-count
was better," or, "The fever is lower," or, "There is less albumen,--but
I don't like the look of him a bit"; and within twenty-four hours you
might be called in haste to find your patient down with a hemorrhage, or
in a fatal chill, or sinking into the last coma.
It would really be difficult to say just what that careful and loving
student of the _genus humanum_ known as a doctor looks at first in the
face of a patient. Indeed, he could probably hardly tell you himself,
and after he has spent fifteen or twenty years at it, it has become such
a second nature, such a matter of instinct with him, that he will often
put together all the signs at once, note their relations, and come to a
conclusion almost in the "stroke of an eye," as if by instinct, just as
a weather-wise old salt will tell you by a single glance at the sky
when and from what quarter a storm is coming.
I shall never forget the remark of my greatest and most revered teacher,
when he called me into his consultation-room to show me a case of
typical locomotor ataxia, gave me a brief but significant history, put
the patient through his paces, and asked for a diagnosis. I hesitated,
blundered through a number of further unnecessary questions, and finally
stumbled upon it. After the patient had left the room, I, feeling rather
proud of myself, expected his commendation, but I didn't get it. "My
boy," he said, "you are not up to the mark yet. You should be able to
recognize a disease like that just as you know the face of an
acquaintance on the street." A positive and full-blown diagnosis of this
sort can, of course, only be made in two or three cases out of ten. But
the method is both logical and scientific, and will give information of
priceless value in ninety-nine cases out of a hundred.
Probably the first, if not the most important, character that catches
the physician's eye when it first falls upon a patient is his
expression. This, of course, is a complex of a number of different
markings, but chiefly determined by certain lines and alterations of
position of the skin of the face, which give to it, as we frequently
hear it expressed, an air of cheerfulness or depression, comfort or
discomfort, hope or despair. These lines, whether temporary or
permanent, are made by the contractions of certain muscles passing from
one part of the skin to another or from the underlying bones to the
skin. These are known in our anatomical textbooks by the natural but
absurd name of "muscles of expression."
Their play, it is true, does make up about two-thirds of the wonderful
shifting of relations, which makes the human countenance the most
expressive thing in the world; but their original business is something
totally different. Primarily considered, they are solely for the purpose
of opening or closing, contracting or expanding, the different orifices
which, as we have seen, appear upon the surface of the face. This
naturally throws them into three great groups: those about and
controlling the orifice of the alimentary canal, the mouth; those
surrounding the joint openings of the air-tube and organ of smell, and
those surrounding the eyes.
As there are some twenty-four pairs of these in an area only slightly
greater than that of the outspread hand, and as they are capable of
acting with every imaginable grade of vigor and in every possible
combination, it can readily be seen what an infinite and complicated
series of expressions--or, in other words, indications of the state of
affairs within those different orifices--they are capable of. Only the
barest and rudest outlines of their meaning and principles of
interpretation can be attempted. To put it very roughly, the main
underlying principle of interpretation is that we make our first
instinctive judgment of the site of the disease from noting which of the
three great orifices is distorted furthest from its normal condition.
Then by constructing a parallel upon the similarity or the difference of
the lines about the other two openings, we get what a surveyor would
call our "lines of triangulation," and by following these to their
converging point can often arrive at a fairly accurate localization.
The greatest difficulty in the method, though at times our greatest
help, is the extraordinary and intimate sympathy which exists between
all three of these groups. If pain, no matter where located, once
becomes intense enough, its manifestations will travel over the
face-dial, overflowing the organ or system in which it occurs, and eyes,
nostrils, and mouth will alike reveal its presence. Here, of course, is
where our second great process, so well known in all clew-following,
elimination, comes in.
A patient comes in with pain-lines written all over his face. To put it
very roughly--has he cancer of the stomach? Pneumonia? Brain tumor? If
there be no play of the muscles distending and contracting the nostrils
with each expiration, no increased rapidity of breathing, no gasp when a
full breath is drawn, and no deep red fever blush on the cheeks, we
mentally eliminate pneumonia. The absence of these nasal signs throws us
back toward cancer or some other painful affection of the alimentary
canal. If the pain-lines about the mouth are of recent formation, and
have not graved themselves into the furrows of the forehead above and
between the eyebrows; if the color, instead of ashy, be clear and red,
we throw out cancer and think of colic, ulcer, hyperacidity, or some
milder form of alimentary disease.
If, on the other hand, the pain-lines are heaviest about the brows, the
eyes, and the forehead, with only a sympathetic droop or twist of the
corners of the mouth, if the nostrils are not at all distorted or too
movable, if there is no fever flush and little wasting, and on turning
to the eyes we find a difference between the pupils, or a wide
distention or pin-point-like contraction of both or a slight squint, the
picture of brain tumor would rise in the mind. Once started upon any one
of these clews, then a hundred other data would be quickly looked for
and asked after, and ultimately, assisted by a thorough and exhaustive
examination with the instruments of precision and the tests in the
laboratory, a conclusion is arrived at. This, of course, is but the
roughest and crudest outline suggestive of the method of procedure.
Probably not more than once in three times will the first clew that we
start on prove to be the right one; but the moment that we find this
barred, we take up the next most probable, and in this manner hit upon
the true scent.
As to the cause and rationale of these pain-lines, only the barest
outlines can be given. Take the mouth for an example. When all is going
well in the alimentary canal, without pain, without hunger, and both
absorption of food and elimination of waste are proceeding normally, the
tissues about the mouth, like those of the rest of the body, are apt to
be plump and full; the muscles which open the aperture, having fulfilled
their duty and received their regular wages, are quietly at rest; those
that close the opening, having neither anticipation of an early call for
the admission of necessary nutriment, nor an instinctive desire to shut
out anything that may be indigestible or undesirable, are now in their
normal condition of peaceful, moderate contraction; the face has a
comfortable, well-fed, wholesome look. On the other hand, let the
digestive juices fail to do their duty properly, or the swarms of
bacteria pets which we keep in our food-canals get beyond control; or if
for any other reason the tissues be kept from getting their proper
supply of nourishment from the food-canal, the state of affairs is
quickly revealed in the mouth mirror. Those muscles which open the
mouth, instead of resting peacefully in the consciousness of duty well
done, are in a state of perpetual fidget, twitching, pulling, wondering
whether they ought not to open the portal for the entrance of new
supplies of material, since the tissues are crying for food.
As the strongest of these are those which pull the corners of the mouth
outward and downward, the resultant expression is one of depression,
with downward-curving angles to the mouth. The eyes, and even the
nostrils, sympathetically follow suit, and we have that countenance
which, by the cartoonist's well-known trick, can be produced by the
alteration of one pair of lines, those at the angles of the mouth,
turning a smiling countenance into a weeping one. On the other hand, if
all these processes of nutrition and absorption are proceeding as they
should, they are accompanied by mild sensations of comfort which,
although they no longer reach our consciousness, reveal themselves in
the mouth-opening muscles, and they gently contract upward and outward,
in pleasurable anticipation of the next intake, and we get the grin or
the smile.
If, on the other hand, these digestive disturbances be accompanied by
pain, then another shading appears on our magic mirror, and that is a
curious contraction of the mouth, with distortion of the lines
surrounding it, so violent in some cases as positively to whiten the
lips or produce lines of paleness along the course of the muscles. This
is the set or twisted mouth of agony, and is due to a curious
transference and reflex on this order: that inasmuch as the last food
which entered the alimentary canal seems to have caused this disturbance
and pain, no more will be allowed to enter it at present under any
conditions. And as our alimentary instincts are the most fundamental of
all, by a due process of transference, mental agony calls into action
this same set of muscles, to shut out any possible addition to the agony
already present.
The lines of determination, similarly, about the mouth, are those of the
individual who has the courage to say "No" to the tempting morsel when
he doesn't need it; and the lines of weakness and irresolution are those
of the nature which cannot resist either gastronomic or other
temptation. Similarly, the well-known lines of disgust or of discontent
about the corners of the mouth are the unconscious contractions
accompanying nausea, and preparations to expel the offending morsel
whether from stomach or mouth.
If, on the other hand, our first glance shows us that the deepest
pain-lines are those about the nostrils and upper lip, especially if the
wings of the nostrils can be seen to dilate with each breath, and
breathing be faster than normal, our clew points in the direction of
some disease of the great organs above the diaphragm--that is, the
lungs or heart.
Signs in this region might refer to either of these, for the reason
that, although a sufficient intake of air is one of the necessary
conditions of proper oxygenation, a free and abundant circulation of the
blood through the air-cells is equally essential. In fact, that common
phenomenon known as "shortness of breath" is more frequently due to
disturbances of the heart and circulation than it is to the lungs,
especially in patients who are able to be up and about. If, in addition
to the danger signal of the rise and fall of the nostrils with each
breath, we have a pale, translucent skin, with a light, hectic flush
showing just below the knife-like lower edge of the cheekbone, a widely
open, shining eye, and a clustering abundance of hair of a glossiness
bordering on dampness, red lips slightly parted, showing the teeth
between, a painfully strong suspicion of consumption would arise
unbidden.
This pathetic type of face has that fatal gift which the French
clinicians, with their usual happiness of phrase, term _La beauté du
diable_. The eager eyes, dilated nostrils, parted lips, give that weird
air of exaltation which, when it occurs, as it occasionally does in the
dying, is interpreted as the result of glimpses into a spirit world.
When to this is added the mild delirium of fever, when memories of
happier days and of those who have passed before rise unbidden and
babble themselves from the tongue, one can hardly wonder at this
interpretation.
The last group of lines to be noted is that about the eyes and
forehead. These are less reliable than either of the other two, for the
reason that they are so sympathetic as almost invariably to be present
in addition, whenever the lower dial-plates of the face are disturbed.
It is only when they appear alone that they are significant; then they
may be interpreted as one of three things: first, and commonest, eye
strain; second, disease in some part of the nervous system or muscular
system, not connected with the organs of the chest or abdomen; and
third, mental disturbances.
This last relation, of course, makes them in many respects the least
reliable of all the face indices, because--as is household
knowledge--they indicate mental conditions and operations, as well as
bodily. "The wrinkled brow of thought," the "deep lines of perplexity,"
etc., are in the vocabulary of the grammar grades. They are, however, a
valuable check upon the other two groups. They are not apt to be present
in consumption and in other forms of serious disease, attended by fever,
on account of the curious effect produced by the toxins of the disease,
which is often not only stimulating, but even of an exhilarating nature,
or will produce a slight stupor or lethargy, such as is typical of
typhoid.
One of the most singular transformations in the sick-room, especially in
serious disease marked by lethargy or stupor, is that in which the
patient's countenance will appear like a sponged-off slate, so
completely have the lines of worry and of thought been obliterated.
One distinct value of the pain-lines about the eyes and brow is that you
can often test their genuineness. Just engage your hypochondriac or
hysterical patient in lively conversation; or, on the reverse principle,
wound his vanity, so as to produce an outburst of temper, and see how
the lines of undying agony will fade away and be replaced by the curves
of amusement or by the straight-drawn brows of indignation.
As with the painter, next to line comes color. Every one, of course,
knows that a fresh, rosy color is usually associated with health, while
a pale, sallow complexion suggests disease. But our color signals, while
more vivid, are much less reliable and more apt to deceive than our
line-markings.
Surprising as it may sound, careful analyses have shown, first, that the
kind of pigment present in the human skin of every race is absolutely
one and the same. The only difference between the negro and the white
man is that the negro has two or three times as much of it. Secondly,
that every skin except that of the albino has a certain, and usually a
considerable, amount of this pigment present in it.
"The red hue of health" is even more apt to mislead us, because, being
due to the abundance of blood in the meshes of the skin, many fevers, by
increasing the rapidity of the heart-beat and dilating the vessels in
the skin, give a ruddiness of hue equal to or in excess of the normal.
However, a little careful checking up will eliminate most of the
possible mistakes and enable us to obtain information of the greatest
value from color. For instance, if our patient be of Southern blood, or
tanned from the seashore, the good red blood in his arteries is pretty
safe to show through at the normal blush area on the cheeks; or, failing
that, through the translucent epithelium of the lips and gums. If, on
the other hand, this yellow tint be due to the escape of broken-down
blood-pigments into the tissues, or a damming up of the bile, and a
similar escape of its coloring matter, as in jaundice, then we turn to
the whites of the eyes, and if a similar, but more delicate, yellowish
tint confronts us there, we know we have to deal with a severe form of
anæmia or jaundice, according to the tint. In extreme cases of the
latter, the mucous membrane of the lips and of the gums will even show a
distinctly yellowish hue. The frightful color of yellow fever, and the
yellow "death mask," which appears just before the end of several fatal
forms of blood poisoning, is due to the tremendous breaking down of the
red cells of the blood under the attack of the fever toxins, and their
leaking out into the tissues. A similar process of a milder and less
serious extent occurs in those temporary anæmias of young girls, known
for centuries past in the vernacular as "the green sickness." And a
delicate lemon tint of this same origin, accompanied by a waxy pallor,
is significant of the deadly, pernicious anæmia and the later stages of
cancer.
The most significant single thing about the red flush, supposed to be
indicative of health, is its location. If this be the normal "blush
area," about the middle of each cheek,--which is one of nature's sexual
ornaments, placed, like a good advertisement, where it will attract most
attention and add most beauty to the countenance,--and it fades off
gradually at the edges into the clear whiteness or brownness of the
healthy skin, it is probably both healthy and genuine. If the work of
either fever or of art, it will generally reveal itself as a base
imitation. In eight cases out of ten of fever, the flush, instead of
being confined to this definite area, extends all over the face, even up
to the roots of the hair. The eyes, instead of being clear and bright,
are congested and heavy-lidded; and if with these you have an increased
rapidity of respiration, and a general air of discomfort and unrest, you
are fairly safe in making a diagnosis of fever. If the first touch of
the tips of the fingers on the wrist shows a hot skin and a rapid pulse,
the diagnosis is almost as certain as with the thermometer.
Now for two of the instances in which it most commonly puzzles us. The
first of these is consumption; for here the flush, both in position and
in delicacy and gentle fading away at the proper margins, is an almost
perfect imitation of health. It, however, usually appears, not as the
normal flush of health does, upon a plump and rounded cheek, but upon a
hollow and wasted one. It rises somewhat higher upon the cheekbones,
throwing the latter out into ghastly prominence. The lips and the eyes
will give us no clew, for the former are red from fever, and the latter
are bright from the gentle, half-dreamy state produced by the toxins of
the disease, the so-called "_spes phthisica_"--the everlasting and
pathetic hopefulness of the consumptive. But here we call for help upon
another of the features of disease--the hand. If, instead of being cool,
and elastic, this is either dry and hot, or clammy and damp, and feels
as if you were grasping a handful of bones and nerves, and the
finger-tips are clubbed and the nails curved like claws, then you have a
strong _prima facie_ case.
The other color condition which is apt to puzzle us is that of the plump
and comfortable middle-aged gentleman with a fine rosy color, but a
watery eye and loose and puffy mouth, a wheezy respiration and apparent
excess of adipose. Here the high color is often due to a paralytic
distention of the blood-vessels of the face and neck, and an examination
of his heart and blood-vessels shows that his prospects are anything but
as rosy as his countenance.
The varying expressions of the face of disease are by no means confined
to the countenance. In fact, they extend to every portion of--in
Trilby's immortal phrase--"the altogether." Disease can speak most
eloquently through the hand, the carriage, the gait, and, in a way that
the patient may be entirely unconscious of, the voice. These forms of
expression are naturally not so frequent as those of the face, on
account of the extraordinary importance of the great systems whose
clock-dials and indices form what we term the human countenance. But
when they do occur they are fully as graphic and more definitely and
distinctively localizing.
Next in importance to the face comes the hand, and volumes have been
written upon this alone. Containing, as it does, that throbbing little
blood-tube, the radial artery, which has furnished us for centuries with
one of our oldest and most reliable guides to health conditions, the
pulse, it has played a most important part in surface diagnoses. To this
day, in fact, Arabic and Turkish physicians in visiting their patients
on the feminine side of the family are allowed to see nothing of them
except the hand, which is thrust through an opening in a curtain. How
accurate their diagnoses are, based upon this slender clew, I should not
like to aver, but a sharp observer might learn much even from this
limited area.
We have--though, of course, in lesser degree--all the color and line
pictures with which we have been dealing upon the face. Though not an
index of any special system, it has the great advantage of being our one
approach to an indication of the general muscular tone of the body, as
indicated both in its grasp and in the poses it assumes at rest. The
patient with a limp and nerveless hand-clasp, whose hand is inclined to
lie palm upward and open instead of palm downward and half-closed, is
apt to be either seriously ill, or not in a position to make much of a
fight against the attack of disease.
The nails furnish one of our best indices of the color of the blood and
condition of the circulation. Our best surface test of the vigor of the
circulation is to press upon a nail, or the back of the finger just
above it, until the blood is driven out of it, and when our thumb is
removed from the whitened area to note the rapidity with which the red
freshet of blood will rush back to reoccupy it.
In the natural growth of the nail, traveling steadily outward from root
to free edge, its tissues, at first opaque and whitish, and thus
forming the little white crescent, or _lunula_, found at the base of
most nails, gradually become more and more transparent, and hence pinker
in color, from allowing the blood to show through. During a serious
illness, the portion of the nail which is then forming suffers in its
nutrition, and instead of going on normally to almost perfect
transparency, it remains opaque. And the patient will, in consequence,
carry a white bar across two or three of his nails for from three to
nine months after the illness, according to the rate of growth of his
nails. Not infrequently this white bar will enable you to ask a patient
the question, "Did you not have a serious illness of some sort two,
three, or six months ago?" according to the position of the bar. And his
fearsome astonishment, if he answers your question in the affirmative,
is amusing to see. You will be lucky if, in future, he doesn't incline
to regard you as something uncanny and little less than a wizard.
Another of the score of interesting changes in the hand, which, though
not very common, is exceedingly significant when found, is a curious
thickening or clubbing of the ends of the fingers, with extreme
curvature of the nails, which is associated with certain forms of
consumption. So long has it been recognized that it is known as the
"Hippocratic finger," on account of the vivid description given of it by
the Greek Father of Medicine, Hippocrates. It has lost, however, some of
its exclusive significance, as it is found to be associated also with
certain diseases of the heart. It seems to mean obstructed circulation
through the lungs.
Next after the face and the hand would come the carriage and gait. When
a man is seriously sick he is sick all over. Every muscle in his body
has lost its tone, and those concerned with the maintenance of the erect
position, being last developed, suffer first and heaviest. The bowed
back, the droop of the shoulders, the hanging jaw, and the shuffling
gait, tell the story of chronic, wasting disease more graphically than
words. We have a ludicrously inverted idea of cause and effect in our
minds about "a good carriage." We imagine that a ramrod-like stiffening
of the backbone, with the head erect, shoulders thrown back and chest
protruded, is a cause of health, instead of simply being an effect, or
one of the incidental symptoms thereof. And we often proceed to drill
our unfortunate patients into this really cramped and irrational
attitude, under the impression that by making them look better we shall
cause them actually to become so. The head-erect, chest-out,
fingers-down-the-seam-of-your trousers position of the drillmaster is
little better than a pose intended chiefly for ornament, and has to be
abandoned the moment that any attempt at movement or action is begun.
So complete is this unconscious muscular relaxation, that it is
noticeable not only in the standing and sitting position, but also when
lying down. When a patient is exceedingly ill, and in the last state of
enfeeblement, he cannot even lie straight in bed, but collapses into a
curled-up heap in the middle of the bed, the head even dropping from the
pillow and falling on the chest. Between this _débâcle_ and the slight
droop of shoulders and jaw indicative of beginning trouble there are a
thousand shades of expression significant instantly to the experienced
eye.
Though more limited in their application, yet most significant when
found, are the alterations of the gait itself. Even a maker of proverbs
can tell at a glance that "the legs of the lame are not equal." From the
limp, coupled with the direction in which the toe or foot is turned, the
tilt of the hips, the part of the foot that strikes first, the presence
or absence of pain-lines on the face, a snap diagnosis can often be made
as to whether the trouble is paralysis, hip-joint disease, knee or ankle
mischief, or flatfoot, as your patient limps across the room. Even where
both limbs are affected and there is no distinct limp, the form of
shuffle is often significant.
Several of the forms of paralysis have each its significant gait. For
instance, if a patient comes in with a firm, rather precise, calculated
sort of gait, "clumping" each foot upon the floor as if he had struck it
an inch sooner than he had expected, and clamping it there firmly for a
moment before he lifts it again, as though he were walking on ice, with
more knee action than seems necessary, you would have a strong suspicion
that you had to deal with a case of _locomotor ataxia_, in which loss of
sensation in the soles of the feet is one of the earliest symptoms. If
so, your patient, on inquiry, will tell you that he feels as if there
were a blanket or even a board between his soles and the surface on
which he steps. If a quick glance at the pupils shows both smaller or
larger than normal, and on turning his face to the light they fail to
contract, your suspicion is confirmed; while if, on asking him to be
seated and cross his legs, a tap on the great extensor tendon of the
knee-joint just below the patella fails to elicit any quick upward jerk
of the foot, the so-called "knee-kick," then you may be almost sure of
your diagnosis, and proceed to work it out at your leisure.
On the other hand, if an elderly gentleman enters with a curiously blank
and rather melancholy expression of countenance, holding his cane out
stiffly in front of him, and comes toward you at a rapid, toddling gait,
throwing his feet forward in quick, short steps, as if, if he failed to
do so, he would fall on his face, while at the same time a vibrating
tremor carries his head quickly from side to side, you are justified in
suspecting that you have to do with a case of _paralysis agitans_, or
shaking palsy.
Last of all, your physiognomy of disease includes not merely its face,
but its voice; not only the picture that it draws, but the sound that it
makes. For, when all has been allowed and discounted that the most
hardened cynic or pessimistic agnostic can say about speech being given
to man to conceal his thoughts, and the hopeless unreliability of human
testimony, two-thirds of what your patients tell you about their
symptoms will be found to be literally the voice of the disease itself
speaking through them. They may tell you much that is chiefly imaginary,
but even imagination has got to have some physical basis as a
starting-point. They may tell you much that is clearly and ludicrously
irrelevant, or untrue, on account of inaccuracy of observation,
confusion of cause and effect, or a mental color-blindness produced by
the disease itself. But these things can all be brushed aside like the
chaff from the wheat if checked up by the picture of the disease in
plain sight before you.
In the main, the great mass of what patients tell you is of great value
and importance, and, with proper deductions, perfectly reliable. In
fact, I think it would be safe to say that a sharp observer would be
able to make a fairly and approximately accurate diagnosis in seven
cases out of ten, simply by what his eye and his touch tell him while
listening to symptoms recounted by the patient. Time and again have I
seen an examination made of a reasonably intelligent patient, and when
the recital had been finished and the hawk-like gaze had traveled from
head to foot and back again, from ear-tip to finger-nail, from eye to
chest, a symptom which the patient had simply forgotten to mention would
be promptly supplied; and the gasp with which the patient would
acknowledge the truth of the suggestion was worth traveling miles to
see.
Of course, you pay no attention to any statement of the patient which
flatly contradicts the evidence of your own senses. But even where
patients, through some preconceived notion, or from false ideas of shame
or discredit attaching to some particular disease, are trying to mislead
you, the very vigor of their efforts will often reveal their secret,
just as the piteous broken-winged utterings of the mother partridge
reveal instantly to the eye of the bird-lover the presence of the young
which she is trying to lure him away from. Only let a patient talk
enough about his or her symptoms, and the truth will leak out.
The attitude of impatient incredulity toward the stories of our
patients, typified by the story of that great surgeon, but greater bear,
Dr. John Abernethy, has passed, never to return. When a lady of rank
came into his consulting-room, and, having drawn off her wraps and
comfortably settled herself in her chair, launched out into a luxurious
recital of symptoms, including most of her family history and
adventures, he, after listening about ten minutes pulled out his watch
and looked at it. The lady naturally stopped, open-mouthed. "Madam, how
long do you think it will take you to complete the recital of your
symptoms?" "Oh, well,"--the lady floundered, embarrassed,--"I hardly
know." "Well, do you think you could finish in three-quarters of an
hour?" Well, she supposed she could, probably. "Very well, madam. I have
an operation at the hospital in the next street. Pray continue with the
recital of your symptoms, and I will return in three-quarters of an hour
and proceed with the consideration of your case!"
When you can spare the time,--and no time is wasted which is spent in
getting a thorough and exhaustive knowledge of a serious case,--it is as
good as a play to let even your hypochondriac patients, and those who
are suffering chiefly from "nervous prosperity" in its most acute form,
set forth their agonies and their afflictions in their fullest and most
luxurious length, breadth, and thickness, watching meanwhile the come
and go of the lines about the face-dials, the changes of the color, the
sparkling and dulling of the eye, the droop or pain-cramp, or luxurious
loll of each group of muscles, and quietly draw your own conclusions
from it all. Many and many a time, in the full luxury of
self-explanation, they will reveal to you a clew which will prove to be
the master-key to your control of the situation, and their restoration
to comfort, if not health, which you couldn't have got in a week of
forceps-and-scalpel cross-examination.
In only one class of patients is this valuable aid to knowledge absent,
and that is in very young children; and yet, by what may at first sight
seem like a paradox, they are, of all others, the easiest in whom to
make not merely a provisional, but a final, diagnosis. They cannot yet
talk with their tongues and their lips, but they speak a living language
in every line, every curve, every tint of their tiny, translucent
bodies, from their little pink toes to the soft spot on the top of their
downy heads. Not only have they all the muscle-signs about the
face-dial, of pain or of comfort, but, also, these are absolutely
uncomplicated by any cross-currents of what their elders are pleased to
term "thought."
When a baby knits his brows he is not puzzling over his political
chances or worrying about his immortal soul. He has got a pain somewhere
in his little body. When his vocal organs emit sounds, whether the
gurgle or coo of comfort, or the yell of dissatisfaction, they are just
squeezed out of him by the pressure of his own internal sensations, and
he is never talking just to hear himself talk. Further than this, his
color is so exquisitely responsive to every breath of change in his
interior mechanism, that watching his face is almost like observing a
reaction in a test-tube, with its precipitate, or change of color. In
addition, not only will he turn pale or flush, and his little muscles
contract or relax, but so elastic are the tissues of his surface, and so
abundant the mesh of blood-vessels just underneath, that, under the
stroke of serious illness, he will literally shrivel like a green leaf
picked from its stem, or wilt like a faded flower.
A single glance at the tiny face on the cot pillow is usually enough to
tell you whether or not the little morsel is seriously ill. Nothing
could be further from the truth than the prevailing impression that,
because babies can't talk, it is impossible, especially for a young
doctor, to find out what is the matter with them. If they can't talk,
neither can they tell lies, and when they yell "Pin!" they mean pin and
nothing else.
In fact, the popular impression of the puzzled discomfiture of the
doctor before a very small, ailing baby is about as rational as the
attitude of a good Quaker lady in a little Western country town, who had
induced her husband to subscribe liberally toward the expenses of a
certain missionary on the West Coast of Africa. On his return, the
missionary brought her as a mark of his gratitude a young half-grown
parrot, of one of the good talking breeds. The good lady, though
delighted, was considerably puzzled with the gift, and explained to a
friend of mine that she really didn't know what to feed it, and it
wasn't quite old enough to be able to talk and tell her what it wanted!
CHAPTER IV
COLDS AND HOW TO CATCH THEM
Ancient vibrations are hard to stop, and still harder to control.
Whether they date from our driving back by the polar ice-sheet, together
with our titanic Big Game, the woolly rhinoceros, the mammoth, and the
sabre-toothed tiger, from our hunting-grounds in Siberia and Norway, or
from recollections of hunting parties pushing north from our tropical
birth-lands, and getting trapped and stormbound by the advance of the
strange giant, Winter, certain it is that our subconsciousness is full
of ancestral memories which send a shiver through our very marrow at the
mere mention of "cold" or "sleet" or "wintry blasts."
From the earliest dawn of legend cold has always been ranked, with
hunger and pestilence and storm, as one of the demons to be dreaded and
fought. And, at a little later date, the ancient songs and sayings of
every people have been full of quaint warnings against the danger of a
chill, a draft, wet feet, or damp sheets. There is, of course, a
bitterly substantial basis for this feeling, as the dozens of stiffened
forms whose only winding-sheet was the curling snowdrift, or whose
coffin the frozen sleet, bear ghastly witness. It was, however, long ago
discovered that when we were properly fed and clothed, the Cold Demon
could be absolutely defied, even in a tiny hut made out of pressed snow
and warmed by a smoky seal-blubber lamp; that the Storm King could be
baffled just by burrowing into his own snowdrifts and curling up under
the crust, like an Eskimo dog. Hence, nearly all the legends depict the
hero as finally conquering the Storm King, like Shingebis in the Song of
Hiawatha.
The ancient terror, however, still clings, with a hold the more
tenacious as it becomes narrowed, to one large group of these calamities
believed to be produced by cold,--namely, those diseases supposed to be
caused by exposure to the weather. Even here, it still has a
considerable basis in fact; but the general trend of opinion among
thoughtful physicians is that this basis is much narrower than was at
one time supposed, and is becoming still more restricted with the
progress of scientific knowledge. For instance, fifty years ago, popular
opinion, and even the majority of medical belief, was that consumption
and all of its attendant miseries were chiefly due to exposure to cold.
Now we know that, on the contrary, abundance of pure, fresh, cold air is
the best cure for the disease, and foul air and overcrowding its chief
cause. An almost equally complete about-face has been executed in regard
to pneumonia. Prolonged and excessive exposure to cold may be the match
that fires the mine, but we are absolutely certain that two other things
are necessary, namely, the presence of the diplococcus, and a lowered
and somewhat vitiated state of bodily resistance, due to age, overwork,
underfeeding, or over-indulgence in alcohol.
Not only do these two diseases not occur in the land of perpetual cold,
the frozen North, except where they are introduced by civilized
visitors,--and scarce a single death from pneumonia has ever yet
occurred in the crew of an Arctic expedition,--but it has actually been
proposed to fit up a ship for a summer trip through the Arctic regions,
as a floating sanatorium for consumptives, on account of the purity of
the air and the brilliancy of the sunlight.
There is one realm, however, where the swing of this ancient
superstition vibrates with fullest intensity, and that is in those
diseases which, as their name implies, are still believed to be due to
exposure to a lowered temperature--"common colds." Here again it has a
certain amount of rational basis, but this is growing less and less
every day. The present attitude of thoughtful physicians may be
graphically indicated by the flippant inquiry of the riddle-maker, "When
is a cold not a cold?" and the answer, "Two-thirds of the time." This
much we are certain of already: that the majority of so-called "colds"
have little or nothing to do with exposure to a low temperature, that
they are entirely misnamed, and that a better term for them would be
_fouls_. In fact, this proportion can be clearly and definitely proved
and traced as infections spreading from one victim to another. The best
place to catch them is not out-of-doors, or even in drafty hallways, but
in close, stuffy, infected hotel bedrooms, sleeping-cars, churches, and
theatres.
Two arguments in rebuttal will at once be brought forward, both
apparently conclusive. One is that colds are vastly more frequent in
winter, and the other that when you sit in a draft until you feel
chilly, you inevitably have a cold afterward. Both these arguments
alike, however, are based upon a misunderstanding. The frequency of
colds in winter is chiefly due to the fact that, at this time of the
year, we crowd into houses and rooms, shutting the doors and windows in
order to keep warm, and thus provide a ready-made hothouse for the
cultivation and transmission from one to another of the influenza and
other bacilli. As the brilliant young English pulmonary expert, Dr.
Leonard Williams, puts it, "a constant succession of colds implies a
mode of life in which all aërial microbes are afforded abundant
opportunities." At the same time, we take less exercise and sit far less
in the open air, thus lowering our general vigor and resisting power and
making us more susceptible to attack. Those who live out-of-doors winter
and summer, and who ventilate their houses properly, even in cold
weather, suffer comparatively little more from colds in the winter-time
than they do in summer; although, of course, the most vigorous
individual, in the best ventilated surroundings, will occasionally
succumb to some particularly virulent infection.
The second fact of experience, catching cold after sitting in a draft or
a chilly room until you begin to cough or sneeze, is one to which a
majority of us would be willing to testify personally, and yet it is
based upon something little better than an illusion. It is a well-known
peculiarity of many fevers and infections to begin with a chill. The
patient complains of shiverings up and down his spine, his fingernails
and his lips become blue, in extreme cases his teeth chatter, and his
limbs begin to twitch and shake, and he ends up in a typical ague fit.
The best known, because most striking, illustration is malaria, or fever
and ague, "chills and fever," as it is variously termed. But this form
of attack, milder and much slighter in degree, may occur in almost every
known infection, such as pneumonia, typhoid, tuberculosis, scarlet
fever, measles, and influenza. It has nothing whatever to do with either
external or internal temperature; for if you slip a fever-thermometer
under your chilling patient's tongue, it will usually register anywhere
from 102 to 105°.
This method of attack is especially common, not only in influenza, but
also in all the other so-called "common colds." In fact, when we begin
to shiver and sneeze and hunt around for an imaginary draft or lowering
of the temperature which has caused it, we are actually in the first
stage of the development of an infection which was contracted hours, or
even days, before.
When you begin to shiver and sneeze and run at the eyes you are not
"catching" cold; you have already caught it long before, and it is
beginning to break out on you. Mere exposure to cold will never cause
sneezing. It takes a definite irritation of the nasal mucous membrane,
by gas or dust from without, or toxins from within, to produce a sneeze.
As to mere exposure to cold weather and wet and storm being able to
produce it, it is the almost unanimous testimony of Arctic explorers
that, during their sojourn of from two to three years in the frozen
North, they never had so much as a sneeze or a sore throat, even though
frequently sheltered in extemporized huts, and running short of adequate
food-supply before spring. Within a week of their return to civilization
they would begin sneezing and coughing, and catch furious colds.
Lumbermen, trappers, hunters, and prospectors in Alaska give similar
testimony. I have talked with scores of these pioneers, visiting them,
in fact, in their camps under conditions of wet, cold, and exposure that
would have made one afraid of either pneumonia or rheumatism before
morning, and found that, so long as they remained up in the mountains or
out in the snow, and no case of influenza, sore throat, or cold happened
to be brought into the camp, they would be entirely free from coughs and
colds; but that, upon returning to civilization and sleeping in the
stuffy room of a rude frontier hotel, they would frequently catch cold
within three days.
One unusually intelligent foreman of a lumber camp in Oregon told me
that an experience of this kind had occurred to him three different
times that he could distinctly recollect.
It is difficult to catch a cold or pneumonia unless the bacilli are
there to be caught. Boswell has embalmed for us, in the amber of his
matchless biography, the fact that it had been noted, even in those
days, that the inhabitants of one of the Faroe Islands never had colds
in the head except on the rare occasions when a ship would touch
there--usually not oftener than once a year. Then, within a week, half
the population would be blowing and sneezing. The great Samuel commented
upon the fact at length, and advanced the ingenious explanation that, as
the harbor was so difficult of entry, the ships could beat in only when
the wind was in a certain quarter, and that quarter was the nor'east.
_Hinc illæ lacrimæ!_ (Hence these weeps!) The colds were caused by the
northeast wind of unsavory reputation! How often the wind got into the
northeast without bringing a ship or colds he apparently did not
speculate.
To come nearer yet, did you ever catch cold when camping out? I have
waked in the morning with the snow drifting across the back of my neck,
been wet to the skin all day, and gone to bed in my wet clothes, and
slept myself dry; and have lain out all day in a November gale, in a
hollow scooped in the half-frozen ground of the duck-marsh, and felt
never a hair the worse. Scores of similar experiences will rise up in
the minds of every camper, hunter, or fisherman. You _may_ catch cold
during the first day or two out, before you have got the foul city air,
with its dust and bacteria, out of your lungs and throat, but even this
rarely happens.
How seldom one catches cold from swimming, no matter how cold the water;
or from boating, or fishing,--even without the standard prophylactic; or
from picnicking, or anything that is done during a day in the open air.
So much for the negative side of the evidence, that colds are not often
caught where infectious materials are absent. Now for the positive side.
First of all, that typical cold of colds, influenza, or the grip, is now
unanimously admitted by authorities to be a pure infection, due to a
definite germ (the _bacillus influenzæ_ of Pfeiffer) and one of the most
contagious diseases known. Each of the great epidemics of it--1830-33,
1836-37, 1847-48, and, of most vivid and unblessed memory, 1889-90--can
be traced in its stately march completely across the civilized world,
beginning, as do nearly all our world-epidemics,--cholera, plague,
influenza, etc.,--in China, and spreading, _via_ India or Turkestan, to
Russia, Berlin, London, New York, Chicago. Moreover, its rate of
progress is precisely that of the means of travel: camel-train,
post-chaise, railway, as the case may be. The earlier epidemics took two
years to spread from Eastern Russia to New York; the later ones, forty
to sixty days. Soon it will beat Jules Verne or George Francis Train. So
intensely "catching" is it, that letters written by sufferers have been
known to infect the correspondents who received them in a distant town,
and become the starting-point of a local epidemic.
Of course, it may be urged that when we have proved the grip to be a
definite infection, we have taken it out of the class of "colds"
altogether, and that its bacterial origin proves nothing in regard to
the rest. But a rather interesting state of affairs developed during the
search for the true bacillus of influenza: this was that a dozen other
bacilli and cocci were discovered, each of which seemed capable of
causing all the symptoms of the _grip_, though in milder form. So that
the view of the majority of pathologists now is that these
"influenzoid," or "grip-like" attacks, under which come a majority of
all _common colds_, are probably due to a number of different milder
micro-organisms.
The next fact in favor of the infectious character of a cold is that it
begins with a chill, followed with a fever, runs a definite self-limited
course, and, barring complications, gets well of itself in a certain
time, just like the measles, scarlet fever, pneumonia, or any other
frank infection.
Colds are also followed by inflammations, or toxic attacks in other
organs of the body, lungs, stomach, bowels, heart, kidneys, nerves,
etc., just like diphtheria, scarlet fever, or typhoid, only, of course,
of milder form and less frequently.
Last, but not least practically convincing, colds may be traced from one
victim to another, may "run through" households, schools, factories, may
occur after attending church or theatre, may be checked by isolating the
sufferers; and are now most effectually treated by the inhalation of
non-poisonous germicidal or antiseptic vapors and sprays.
One of my first experiences with this last method occurred in a most
unexpected field. An old friend, a most interesting and intelligent
German, was the proprietor of a wild-animal depot, importing foreign
animals and birds and selling them to the zoölogical gardens and
circuses. I used often to drop in there to see if he had anything new,
and he would come up to see me, to tell me his troubles and keep my
dissecting-table supplied with interestingly diseased dead beasts and
birds.
One day he came up in a state of great excitement, with a very dead and
dilapidated parrot in his hand.
"Choost look, Dogdor; here's one of dose measley new pollies I god in
from Zingapore. De rest iss coffin' an' sneezin' to plow dere peaks off,
an' all de utter caitches iss kitchen him."
As parrots are worth from fifteen to thirty dollars apiece, "green" (not
in color, but training), and he had fifty or sixty in the store, the
situation was distinctly serious. Now, I was no specialist in the
peculiar diseases of parrots, but something had to be done, and, with a
boldness born of long practice, I drew my bow at a venture and let fly
this suggestion:--
"Try formalin; it's pretty fierce on the eyes and nose, but it won't
kill 'em; and, if you put a teaspoonful in the bottom of each cage, by
the time it evaporates no germ that gets into that cage will live long
enough to do any harm."
Five days later back he came, red-eyed but triumphant. "Dogdor, dot
vormaleen iss de pest shtuff I effer saw. It mos' shteenk me out of de
shtore, an' de pollies nearly sneeze dere fedders off, but it shtopt de
spret, an' _it's cureenall de seek ones_, an' I het a cold in de het,
_an' it's curt me_."
Before using it he had fourteen cases and three deaths; after, only
three new cases and no more deaths. I would, however, hardly advise any
human "coldie" to try such heroic treatment offhand, for the pungency
and painfulness of formalin vapor is something ferocious, though the
French physicians, with characteristic courage, are making extensive use
of it for this purpose, with excellent results under careful
supervision.
Another curious straw pointing in the direction of the infectious nature
of colds is the "annual cold," or "yearly sore throat," from which many
of us suffer. When we have had it we usually feel fairly safe from colds
for some months at least, often for a year. The only explanation that
seems in the least to explain is that colds, like other infections,
confer an immunity against another attack; only, unlike scarlet fever,
measles, smallpox, etc., this immunity, instead of for life, is only for
six months or a year. This immunity is due to the formation in the blood
of protective substances known as _anti-bodies_, which destroy or render
harmless the invading germs. Flabby, under-ventilated individuals, who
are always "catching cold," have such weak resisting powers that they
form hardly enough anti-bodies to terminate the first attack, without
having enough left to protect them from another for more than a few
weeks or months. Dr. Leonard Williams describes chronic cold-catchers as
"people who wear flannel next their skins, ... who know they are in a
draft because it makes them sneeze; who, in short, live thoroughly
unwholesome, coddling lives." Strong and vigorous individuals may form
enough to last them a year, or even two years.
Now comes the question, "What are we going to do about it?" Obviously,
we cannot "go gunning" for these countless billions of germs, of
fifteen or twenty different species. Nor can we quarantine every one who
has a cold. Fortunately, no such radical methods are necessary. All we
have to do is to take nature's hint of the anti-bodies and improve upon
it. Healthy cells can grow fat on a diet of such germs, and, if we keep
ourselves vigorous, clean, and well ventilated, we can practically defy
the "cold" devil and all his works.
Here is the _leitmotif_ of the whole fascinating drama of infection and
immunity. We can study only one phrasing here. We shall, of course,
catch cold occasionally, but will throw it off quickly, and probably
form anti-bodies enough to last us a year or more. How can this be done?
First and foremost, by living and sleeping as much as possible in the
open air. This helps in several different ways. First, by increasing the
vigor and resisting power of our bodies; second, by helping to burn up,
clean, and rid our tissues of waste products which are poisons if
retained; third, by greatly reducing the risks of infection.
You can't catch cold by sitting in a field exposed to the draft from an
open gate; though I understand that casuists of the old school of the
"chill-and-damp" theory of colds are still discussing the case of the
patient who "caught his death o' cold" by having his gruel served in a
damp basin.
The first thing to do is to get the outdoor habit. This takes time to
acquire, but, once formed, you wouldn't exchange it for anything else on
earth. The next thing is to learn to sit or sleep in a gentle current of
air all the time you are indoors. You ought to feel uncomfortable
unless you can feel air blowing across your face night and day. Then you
are reasonably sure it is fresh, and it is the only way to be sure of
it.
But drafts are so dangerous! As the old rhyme runs,
But when a draft blows through a hole,
Make your will and mend your soul.
Pure superstition! It just shows what's in a name. Call it a gentle
breeze, or a current of fresh air, and no one is afraid of it. Call it a
"draft," and up go hands and eyebrows in horror at once. One of our
highest authorities on diseases of the lungs, Dr. Norman Bridge, has
well dubbed it "The Draft Fetich." It is a fetich, and as murderous as
Moloch. The draft is a friend instead of an enemy. What converted most
of us to a belief in the beneficence of drafts was the open-air
treatment of consumption! Hardly could there have been a more
spectacular proof, a more dramatic defiance of the bogey. To make a
poor, wasted, shivering consumptive, in a hectic one hour and a
drenching sweat the next, lie out exposed to the November weather all
day and sleep in a ten-knot gale at night! It looked little short of
murder! So much so to some of us, that we decided to test it on
ourselves before risking our patients.
I can still vividly recall the astonishment with which I woke one frosty
December morning, after sleeping all night in a breeze across my head
that literally made
Each particular hair to stand on end,
Like quills upon the fretful porcupine,
not only without the sign of a sniffle, but feeling as if I'd been made
new while I slept.
Then we tried it in fear and trembling on our patients, and the delight
of seeing the magic it worked! That is an old story now, but it has
never lost its charm. To see the cough which has defied "dopes" and
syrups and cough mixtures, domestic, patent, and professional, for
months, subside and disappear in from three to ten days; the night
sweats dry up within a week; the appetite come back; the fever fall; the
strength and color return, as from the magic kiss of the free air of the
woods, the prairies, the seacoast. There's nothing else quite like it on
the green earth. Do you wonder that we become "fresh-air fiends"?
The only thing we dread in these camps is the imported "cold." Dr.
Lawrence Flick was the first to show us the way in this respect as in
several others. He put up a big sign at the entrance of White Haven
Sanatorium, "No persons suffering from colds allowed to enter," and
traced the only epidemic of colds in the sanatorium to the visit of a
butcher with the grip. I put up a similar sign at the gate of my Oregon
camp, and never had a patient catch cold from tenting out in the snow
and "Oregon mists" until the small son of the cook came back from the
village school, shivering and sneezing, when seven of the thirteen
patients "caught it" within a week.
What will cure a consumptive will surely not kill a healthy man. I am
delighted to say that it shows signs of becoming a fad now, and sleeping
porches are being put on houses all over the country. No house in
California is considered complete without them. The ideal bedroom is a
small dressing-room, opening on a wide screened porch, or balcony, with
a door wide enough to allow the bed to be rolled inside during storms or
in severest weather.
Sleep on a porch, or in a room with windows on two sides wide open, and
the average living-room or office begins to feel stuffy and "smothery"
at once. Apply the same treatment here. Learn to sit in a gentle draft,
and you'll avoid two-thirds of your colds and three-fourths of your
headaches. It may be necessary in winter to warm the draft, but don't
let any patent method of ventilation delude you into keeping your
windows shut any hour of the day or night.
On the other hand, don't fall into the widespread delusion that because
air is cold it is necessarily pure. Some of the vilest air imaginable is
that shut up in those sepulchres known as "best bedrooms," which chill
your very marrow. The rheumatism or snuffles you get from sleeping
between their icy sheets comes from the crop of bacilli which has lurked
there since they were last aired. The "no heat in a bedroom" dogma is
little better than superstition, born of those fecund parents which mate
so often, stinginess and puritanism. Practically, the room which will
_never_ have a window opened in it in winter is the one without any
heat.
Similarly, the air in an underheated church, hall, or theatre is almost
sure to be foul. The janitor will keep every opening closed in order to
get the temperature up. Some churches are never once decently ventilated
from December to May. The same old air, with an ever richer crop of
germs, is reheated and served up again every Sunday. The "odor of
sanctity" is the residue of the breaths and perspiration of successive
generations. Cleanliness may be next to godliness, but it is sometimes
an astonishingly long step behind it.
The next important step is to keep clean, both externally and
internally: externally, by cold bathing, internally, by exercise. The
only reason why a draft ever hurts us is because we are full of
self-poisons, or germs. The self-poisons can be best got rid of by
abundant exercise in the open air and plenty of pure, cold H2O,
internally and externally.
Food has very little to do with these autotoxins, and they are as likely
to form on one diet as another. In fact, they form normally and in
states of perfect health, and are poisonous only if retained too long.
It is simply a question of burning them up, and getting rid of them
quickly enough, by exercise, with its attendant deep breathing and
perspiration. The lungs are great garbage-burners. Exercise every day
till you puff and sweat.
A blast of cold air suddenly stops the escape of these poisons through
the skin and throws them on the lungs, liver, or kidneys. The resulting
disturbance is the second commonest form of a "cold," and covers perhaps
a third of all cases occurring. This is the cold that can be prevented
by the cold bath. Keep the skin hardened and toned up to such a pitch
that no reasonable chill will stop it from excreting, and you are safe.
Never depend on clothing. The more you pile on, the more you choke and
"flabbify" the skin and make it ready to "strike" on the first breath of
cold air. Too heavy flannels are cold-breeders, and chest-protectors
inventions of the evil one. Trust the skin; it is one of the most
important and toughest organs in the body, if only given half a chance.
But the most frequent way in which drafts precipitate a cold is by
temporarily lowering the vital resistance. This gives the swarms of
germs present almost constantly in our noses, throats, stomachs, bowels,
etc., the chance they have been looking for--to break through the cell
barrier and run riot in the body.
So long as the pavement-cells of our mucous membranes are healthy, they
can keep them out indefinitely. Lower their tone by cold, fatigue,
underfeeding, and their line is pierced in a dozen places at once. One
of the many horrifying things which bacteriology has revealed is that
our bodies are simply alive with germs, even in perfect health. One
enthusiastic dentist has discovered and described no less than
_thirty-three_ distinct species, each one numbering its billions, which
inhabit our gums and teeth. Our noses, our stomachs, our
intestines,--each boasts a similar population. Most of them do no harm
at all; indeed, some probably assist in the processes of digestion;
others are camp-followers, living on our leavings; others, captive
enemies which have been clubbed into peaceful behavior by our leucocyte
and anti-body police.
For instance, not a few healthy noses and throats contain the bacillus
of diphtheria and the diplococcus of pneumonia. We are beginning to find
that these last two groups will bear watching. Like camp-followers
elsewhere, they carry knives, and are not above using them on the
wounded after dark. In fact, they have a cheerful habit of taking a
hand in any disturbance that starts in their bailiwick, and usually on
the side against the body-cells.
Finally, while clearly realizing that the best defense is attack, and
that our chief reliance should be upon keeping ourselves in such
fighting trim that we can "eat 'em alive" at any time, there is no sense
in running easily avoidable risks, and we should keep away from
infection as far as possible. If a child comes to school heavy-eyed,
hoarse, and snuffling, the teacher should send him home at once. He will
only waste his time attempting to study in that trim, and may infect a
score of others. Moreover, it may be remarked, parenthetically, that
these are also symptoms of the beginning of measles, scarlet fever, and
diphtheria, and two-thirds of all cases of these would be sent home
before they could infect any one else if this procedure were the rule.
If your own child develops a cold, if mild, keep him playing
out-of-doors by himself; or if severe, keep him in bed, in a
well-ventilated room, for three or four days. He'll get better twice as
quick as if at school, and the rest of the household will escape.
When you wake with a stuffed head and aching bones, stay at home for a
few days if possible, out of regard for your customers, your
fellow-clerks, or your office force, as well as yourself. If one of your
employees comes to work shivering, give him three days' vacation on full
pay. If it runs through the force, you'll lose five times as much in
enforced sick-leaves, slowness, and mistakes. Above all, don't go to any
public gatherings,--to church, the theatre, or parties,--when you are
snuffling and coughing. You are not exactly a joy to your beholders,
even if you don't infect them. It is advisable, and well worth the
trifling trouble and expense, to fumigate thoroughly with formalin all
churches, theatres, and schoolrooms at least once a month. Reasonable
and public-spirited precautions of this sort are advisable, not only to
avoid colds themselves, which are disagreeable and dangerous enough, but
because mild infections of this sort are far the commonest single means
of making a breach in our body-ramparts through which more serious
diseases like consumption, pneumonia, and rheumatism may force an entry.
Colds do not "run into" consumption or pneumonia, but they bear much the
same relation to them that good intentions are said to do to the
infernal regions. They release the lid of a perfect Pandora's box of
distempers--tuberculosis, pneumonia, rheumatism, bronchitis, Bright's
disease, neuritis, endocarditis. A cold is no longer a joke. A
generation ago a prominent physician was asked by an anxious mother,
"Doctor, how would you treat a cold?"
"With contempt, madam," replied the great man.
That day is past, and has lasted too long. Intelligently regarded and
handled, they are the least harmful of diseases; neglected, one of the
most dangerous, because there are such legions of them. To sum up, if
you wish to revel in colds, all that is necessary is to observe the
following few and simple rules:--
Keep your windows shut.
Avoid drafts as if they were a pestilence.
Take no exercise between meals.
Bathe seldom, and in warm water.
Wear heavy flannels, chest-protectors, abdominal bandages, and electric
insoles.
Have no heat in your bedroom.
Never let anything keep you away from church, the theatre, or parties,
in winter.
Never go out-of-doors when it's windy, or rainy, or wet underfoot, or
cold, or hot, or looks as if it was going to be any of these.
Be just as intimate and affectionate as possible with every one you know
who has a cold. Don't neglect them on any account.
CHAPTER V
ADENOIDS, OR MOUTH-BREATHING: THEIR CAUSE AND THEIR CONSEQUENCES
In all ages it has been accounted a virtue to keep your mouth
shut--chiefly, of course, upon moral or prudential grounds, for fear of
what might issue from it if opened. Then came physiology to back up the
maxim, on the ground that the open mouth was also dangerous on account
of what might be inhaled into it. Oddly enough, in this instance, both
morality and science have been beside the mark to the degree that they
have been mistaking a symptom for a cause. This has led us to absurd and
injurious extremes in both cases. On the moral and prudential side it
has led to such outrageous exaggerations as the well-known and
oft-quoted proverb, "Speech is silver, but silence is golden."
Articulate speech, the chiefest triumph and highest single
accomplishment of the human species, the handmaid of thought and the
instrument of progress, is actually rated below silence, the attribute
of the clod and of the dumb brute, the easy refuge of cowardice and of
stupidity.
Easily eight-tenths of all speech is informing, educative, helpful in
some modest degree; while fully that proportion of silence is due to
lack of ideas, cowardice, or designs that can flourish only in darkness.
It is not the abundance of words, but the scarcity of ideas, that makes
us flee from "the plugless word-spout" and avoid the chatterbox.
Similarly, upon the physical side, because children who breathe through
the mouth are apt to have a vacant expression, to be stupid and
inattentive, undersized, pigeon-breasted, with short upper lip and
crowded teeth, we have leaped to the conclusion that it is a fearsome
and dangerous thing to breathe through your mouth. All sorts of stories
are told about the dangerousness of breathing frosty air directly into
the lungs. Invalids shut themselves scrupulously indoors for weeks and
even months at a stretch, for fear of the terrible results of a "blast
of raw air" striking into their bronchial tubes. All sorts of absurd
instruments of torture, in the form of "respirators" to tie over the
mouth and nose and "keep out the fog," are invented, and those who have
the slightest tendency to bronchial or lung disturbances are warned upon
pain of their life to wrap up their mouths whenever they go
out-of-doors.
As a matter of fact, there is exceedingly little evidence to show that
pure, fresh, open air at any reasonable temperature and humidity ever
did harm when inhaled directly into the lungs. In fact, a considerable
proportion of us, when swinging along at a lively gait on the country
roads, or playing tennis or football, or engaged in any form of active
sport, will be found to keep our lips parted and to inhale from a sixth
to a third of our breath in this way, and with no injurious results
whatever. Nine-tenths of all the maladies believed to be due to
breathing even the coldest and rawest of air are now known to be due to
invading germs.
Nevertheless, mouth-breathing in all ages has been regarded as a bad
habit, and with good reason. It was only about thirty years ago that we
began to find out why. A Danish throat surgeon, William Meyer, whose
death occurred only a few months ago, discovered, in studying a number
of children who were affected with mouth-breathing, that in all of them
were present in the roof of the throat curious spongy growths, which
blocked up the posterior opening of the nostrils. As this mass was made
up of a number of smaller lobules, and the tissue appeared to be like
that of a lymphatic gland, or "kernel," the name "adenoids" (gland-like)
was given to them. Later they were termed _post-nasal growths_, from the
fact that they lay just behind the rear opening of the nostrils; and
these two names are used interchangeably. Our knowledge has spread and
broadened from this starting-point, until we now know that adenoids are
the chief, yes, almost the sole primary cause, not merely of
mouth-breathing, but of at least two-thirds of the injurious effects
which have been attributed to this habit.
Mouth-breathing is not simply a bad habit, a careless trick on the part
of the child. We have come to realize that physical bad habits, as well
as many mental and moral ones, have a definite physical cause, and that
_no child ever becomes a mouth-breather as long as he can breathe
comfortably through his nose_.
This clears the ground at once of a considerable amount of useless
lumber in the shape of advice to train the child to keep his mouth shut.
I have even known mothers who were in the habit of going around after
their helpless offspring were asleep and gently but firmly pushing up
the little jaw and pressing the lips together until some sort of an
attempt at respiration was made through the nostrils. Advertisements
still appear of sling-like apparatuses for holding the jaws closed
during sleep.
To attempt to stop mouth-breathing before providing abundant air-space
through the nostrils is not only irrational, but cruel. Of course, after
the child has once become a mouth-breather, even after the nostrils have
been made perfectly free, it will not at once abandon its habit of
months or years, and disciplinary measures of some sort may then be
needed for a time. But the hundred-times-repeated admonition, "For
heaven's sake, child, shut your mouth! Don't go around with it hanging
open like that!" unless preceded by proper treatment of the nostrils,
will have just about as much effect upon the habit as the proverbial
water on a duck's back. No use trying to close his mouth by any amount
of opening of your own.
Fortunately, as does not always happen, with our discovery of the cause
has come the knowledge of the cure; and we are able to say with
confidence that, widespread and serious as are disturbances of health
and growth associated with mouth-breathing, they can be absolutely
prevented and abolished.
What, then, is the cause of this nasal obstruction, and when does it
begin to operate? The primary cause is catarrhal inflammation, with
swelling and thickening of the secretions, and it may begin to operate
anywhere from the seventh month to the seventh year. A neglected
attack, or series of attacks, of "snuffles," colds in the head,
catarrhs, in infants and young children, will set up a slow inflammation
of this glandular mass at the back of the nostrils--a tonsil, by the
way--and start its enlargement.
Whether we know anything about adenoids themselves or not, we are all
familiar with their handiwork. The open mouth, giving a vacant
expression to the countenance, the short upper lip, the pinched and
contracted nostrils, the prominent and irregular teeth, the listless
expression of the eyes, the slow response to request or demand, we have
seen a score of times in every schoolroom. Coupled with these facial
features are apt to be found on closer investigation a lack of interest
in both work and play, an impaired appetite, restless sleep, and a
curious general backwardness of development, both bodily and mental, so
that the child may be from one to four inches below the normal height
for his years, from five to fifteen pounds under weight, and from one to
three grades behind his proper school position. Very often, also, his
chest is inclined to be narrow, the tip of his breastbone to be sunken,
and his abdomen larger in girth than his chest. Is it possible that the
mere inhaling of air directly into the lungs, even though it be
imperfectly warmed, moistened, and filtered, as compared with what it
would be if drawn through the elaborate "steam-coils" in the nostrils
for this purpose, can have produced this array of defects? It is
incredible on the face of it and unfounded in fact. Fully two-thirds of
these can be traced to the direct influence of the adenoids.
These adenoids, it may briefly be stated, are the result of an
enlargement of a _tonsil_, or group of small tonsils, identical in
structure with the well-known bodies of the same name which can be seen
on either side of the throat. They have the same unfortunate faculty as
the other tonsils for getting into hot water, flaring up, inflaming, and
swelling on the slightest irritation. And, unfortunately, they are so
situated that their capacity for harm is far greater than that of the
other tonsils. They seem painfully like the chip on the shoulder of a
fighting man, ready to be knocked off at the lightest touch and plunge
the whole body into a scrimmage. Their position is a little difficult to
describe to one not familiar with the anatomy of the throat, especially
as they cannot be seen except with a laryngeal mirror; but it may be
roughly stated as in the middle of the roof of the throat, just at the
back of the nostrils, and above the soft palate. From this coign of
vantage they are in position to produce serious disturbances of two of
our most important functions,--respiration and digestion,--and three out
of the five senses,--smell, taste, and hearing.
We will begin with their most frequent and most serious injurious
effect, though not the earliest,--the impairment of the child's power of
attention and intelligence. So well known is their effect in this
respect that there is scarcely an intelligent and progressive teacher
nowadays who is not thoroughly posted on adenoids. Some of them will
make a snap diagnosis as promptly and almost as accurately as a
physician; and when once they suspect their presence, they will leave
no stone unturned to secure an examination of the child by a competent
physician, and the removal of the growths, if present. They consider it
a waste of time to endeavor to teach a child weighted with this
handicap. How keenly awake they are to their importance is typified by
the remark of a prominent educator five or six years ago:--
"When I hear a teacher say that a child is stupid, my first instinctive
conclusion is either that the child has adenoids, or that the teacher is
incompetent."
The lion's share of their influence upon the child's intelligence is
brought about in a somewhat unexpected and even surprising manner, and
that is by the _effects of the growths upon his hearing_. You will
recall that this third tonsil was situated at the highest point in the
roof of the pharynx, or back of the throat. The first effect of its
enlargement is naturally to block the posterior opening of the nostrils.
But it has another most serious vantage-ground for harm in its peculiar
position. Only about three-fourths of an inch below it upon either side
open the mouths of the Eustachian tubes, the little funnels which carry
air from the throat out into the drum-cavity of the ear. You have
frequently had practical demonstrations of their existence, by the
well-known sensation, when blowing your nose vigorously, of feeling
something go "pop" in the ear. This sensation was simply due to a bubble
of air being driven out through this tube from the back of the throat,
under pressure brought to bear in blowing the nose. The luckless
position of the third tonsil could hardly have been better planned if it
had been devised for the special purpose of setting up trouble in the
mouths of these Eustachian tubes.
Just as soon as the enlargements become chronic, they pour out a thick
mucous secretion, which quickly becomes purulent, or, in the vernacular,
"matter." This trickles down on both sides of the throat, and drains
right into the open mouth of the Eustachian tube. Not only so, but these
Eustachian tubes are the remains of the first gill-slits of embryonic
life, and, like all other gill-slits, have a little mass of this same
lymphoid or tonsilar tissue surrounding them. This also becomes infected
and inflamed, clogs the opening, and one fatal day the inflammation
shoots out along the tube, and the child develops an attack of earache.
At least two-thirds of all cases of earache, and, indeed, five-sixths of
all cases of deafness in children, are due to adenoids.
Earache is simply the pain due to acute inflammation in the small
drum-cavity of the ear. This in the large majority of cases will subside
and drain back again into the throat through the Eustachian tube. In a
fair percentage of instances, however, it will break in the opposite
direction, and we have the familiar ruptured drum and discharge from the
ear. In either case the drum becomes thickened, so that it can no longer
vibrate properly; the delicate little chain of bones behind it, like the
levers of a piano, becomes clogged, and the child becomes deaf, whether
a chronic discharge be present or not.
This is the secret of his "inattention," his "indifference,"--even of
his apparent disobedience and rebelliousness. What other children hear
without an effort he has to strain every nerve to catch. He
misunderstands the question that is asked of him, makes an absurd
answer, and is either scolded or laughed at. It isn't long before he
falls into the attitude: "Well, I can't get it right, anyhow, no matter
how I try, so I don't care." Up to five or ten years ago the puzzled and
distracted teacher would simply report the child for stupidity,
indifference, and even insubordination. In nine cases out of ten, when
children are naughty or stupid, they are really sick.
Not content with dulling one of the child's senses, these thugs of the
body-politic proceed to throttle two others--smell and taste. Obviously
the only way of smelling anything is to sniff its odor into your nose.
And if this be more or less, or completely, blocked up, and its delicate
mucous membranes coated with a thick, ropy discharge, you will not be
able to distinguish anything but the crudest and rankest of odors. But
what has this to do with taste? Merely that two-thirds of what we term
"taste" is really smell. Seal the nostrils and you can't "tell chalk
from cheese," not even a cube of apple from a cube of onion, as scores
of experiments have shown. We all know how flat tea, coffee, and even
our own favorite dishes taste when we have a bad cold, and this,
remember, is the permanent condition of the palate of the poor little
mouth-breather. No wonder his appetite is apt to be poor, and that even
what food he eats will not produce a flow of "appetite juice" in the
stomach, which Pavloff has shown to be so necessary to digestion. No
wonder his digestion is apt to go wrong, ably assisted by the continual
drip of the chronic discharge down the back of his throat; his bowels to
become clogged and his abdomen distended.
But the resources for mischief of this pharyngeal "Old Man of the Sea"
are not even yet exhausted. Next comes a very curious and unexpected
one. We have all heard much of "the struggle for existence" among plants
and animals, and have had painful demonstrations of its reality in our
own personal experience. But we hardly suspected that it was going on in
our own interior. Such, however, is the case; and when once one organ or
structure falls behind the others in the race of growth, its neighbors
promptly begin to encroach upon and take advantage of it. Emerson was
right when he said, "I am the Cosmos," the universe.
Now, the mouth and the nose were originally one cavity. As Huxley long
ago remarked, "When Nature undertook to build the skull of a land animal
she was too lazy to start on new lines, and simply took the old
fish-skull and made it over, for air-breathing purposes." And a clumsy
job she made of it!
It may be remarked, in passing, that mouth-breathing, as a matter of
history, is an exceedingly old and respectable habit, a reversion, in
fact, to the method of breathing of the fish and the frog. "To drink
like a fish" is a shameful and utterly unfounded aspersion upon a
blameless creature of most correct habits and model deportment. What the
poor goldfish in the bowl is really doing with his continual "gulp,
gulp!" is breathing--not drinking.
This remodeling starts at a very early period of our individual
existence. A horizontal ridge begins to grow out on either side of our
mouth-nose cavity, just above the roots of the teeth. This thickens and
widens into a pair of shelves, which finally, about the third month of
embryonic life, meet in the middle line to form the hard palate or roof
of the mouth, which forms also the floor of the nose. Failure of the two
shelves to meet properly causes the well-known "cleft-palate," and, if
this failure extends forward to the jaw, "hare-lip." In the growth of a
healthy child a balance is preserved between these lower and upper
compartments of the original mouth-nose cavity, and the nose above
growing as rapidly in depth and in breadth as the mouth below, the
horizontal partition between--the floor of the nose and the roof of the
mouth--is kept comparatively flat and level. In adenoids, however, the
nostrils no longer being adequately used, and consequently failing to
grow, and the mouth cavity below growing at the full normal rate, it is
not long before the mouth begins to encroach upon the nostrils by
pushing up the partition of the palate. As soon as this upward bulge of
the roof of the mouth occurs, then there is a diminution of the
resistance offered by the horizontal healthy palate to the continual
pressure of the muscles of the cheeks and of mastication upon the sides
of the upper jaw, the more readily as the tongue has dropped down from
its proper resting position up in the roof of the mouth. These are
pushed inward, the arch of the jaw and of the teeth is narrowed, the
front teeth are made to project, and, instead of erupting, with plenty
of room, in even, regular lines, are crowded against and overlap one
another.
When from any cause the lower jaw habitually hangs down, as in the open
mouth, it tends to be thrown slightly forward in its socket. Then, when
the jaws close again, the arches of the upper and lower teeth no longer
meet evenly. Instead of "locking" at almost every point, as they should,
they overlap, or fall behind, or inside, or outside, of each other. So
that instead of every tooth meeting its fellow of the jaw above evenly
and firmly, they strike at an angle, slip past or even miss one another,
and thus increase the already existing irregularity and overlapping.
Each individual tooth, missing its best stimulus to healthy growth and
vigor, firm and regular pressure and exercise against its fellow in the
jaw above or below, gets a twist in its socket, wears away irregularly,
and becomes an easy prey to decay, while from failure of the entire
upper and lower arches of the teeth to meet squarely and press evenly
and firmly against one another, the jaws fail to expand properly and the
tendency to narrowing of the tooth-arches and upward vaulting of the
palate is increased.
In short, we are coming to the conclusion that from half to two-thirds
of all cases of "crowded mouth," irregular teeth, and high-arched palate
in children are due to adenoids. Progressive dentists now are insisting
upon their little patients, who come to them with these conditions,
being examined for adenoids, and upon the removal of these, if found, as
a preliminary measure to mechanical corrective treatment. Cases are now
on record of children with two, three, or even four generations of
crowded teeth and narrow mouths behind them, but who, simply by being
sharply watched for nasal obstruction and the symptoms of adenoids, by
the removal of these latter as soon as they have put in an appearance,
have grown up with even, regular, well-developed teeth and wide, healthy
mouths and jaws. Unfortunately, attention to the adenoids will not
remove these defects of the jaws and teeth after they have been
produced. But, if the child be under ten, or even twelve, years of age,
their removal may yet do much permanently to improve the condition, and
is certainly well worth while on general principles.
Take care of the nose, and the jaws will take care of themselves. An
ounce of adenoids-removal in the young child is worth a pound of
_orthodontia_--teeth-straightening--in the boy or girl; though both are
often necessary.
The dull, dead tone of the voice in these children is, of course, an
obvious effect of the blocked nostrils. Similarly, the broken sleep,
with dreams of suffocation and of "Things Sitting on the Chest," are
readily explained by the desperate efforts that the little one makes to
breathe through clogging nostrils, in which the discharges, blown and
sneezed out in the daytime, dry and accumulate during sleep, until,
half-suffocated, it "lets go" and draws in huge gulps of air through the
open mouth. No child ever became a mouth-breather from choice, or until
after a prolonged struggle to continue breathing through its nose.
This brings us to the question, What are these adenoids, and how do
they come to produce such serious disturbances? This can be partially
answered by saying that they are tonsils and with all a tonsil's
susceptibility to irritation and inflammation. But that only raises the
further question, What is a tonsil? And to that no answer can be given
but Echo's. They are one of the conundrums of physiology. All we know of
them is that they are not true _glands_, as they have neither duct nor
secretion, but masses of simple embryonic tissue called _lymphoid_,
which has a habit of grouping itself about the openings of disused
canals. This is what accounts for their position in the throat, as they
have no known useful function. The two largest, or throat-tonsils,
surround the inner openings of the second gill-slits of the embryo; the
lingual tonsil, at the base of the tongue below, encircles the mouth of
the duct of the thyroid gland (the _goitre_ gland); and our own
particular Pandora's Box above, in the roof of the pharynx, is grouped
about the opening of another disused canal, which performs the singular
and apparently most uncalled-for office of connecting the cavity of the
brain with the throat. They can all of them be removed completely
without any injury to the general health, and they all tend to shrink
and become smaller--in the case of the topmost, or pharyngeal, almost
disappear--after the twelfth or fourteenth year.
Not only have they an abundant crop of troubles of their own, as most of
us can testify from painful experience, but they serve as a port of
entry for the germs of many serious diseases, such as tuberculosis,
rheumatism, diphtheria, and possibly scarlet fever. They appear to be a
strange sort of survival or remnant,--not even suitable for the
bargain-counter,--a hereditary leisure class in the modern democracy of
the body, a fertile soil for all sorts of trouble.
Here, then, we have this little bunch of idle tissue, about the size of
a small hazelnut, ready for any mischief which our Satan-bacilli may
find for its hands to do. A child kept in a badly ventilated room
inhales into his nostrils irritating dust or gases, or, more commonly
yet, the floating germs of some one or more of those dozen mild
infections which we term "a common cold." Instantly irritation and
swelling are set up in the exquisitely elastic tissues of the nostrils,
thick, sticky mucous, instead of the normal watery secretion, is poured
out, the child begins to sneeze and snuffle and "run at the nose," and
either the bacteria are carried directly to this danger sponge, right at
the back of the nostrils, or the inflammation gradually spreads to it.
The mucous membrane and tissues of the nose have an abundance of
vitality,--like most hard workers,--and usually react, overwhelm, and
destroy the invading germs, and recover from the attack; but the useless
and half-dead tissue of the pharyngeal tonsil has much less power of
recuperation, and it smoulders and inflames, though ultimately, perhaps,
it may swing round to recovery. Often, however, a new cold will be
caught before this has fully occurred, and then another one a month or
so later, until finally we get a chronically thickened, inflamed, and
enlarged condition of this interesting, but troublesome, body. What its
capabilities are in this respect may be gathered from the fact that,
while normally of the size of a small hazelnut, it is no uncommon thing
to find a mass which absolutely blocks up the whole of the upper part of
the pharynx, and may vary from the size of a robin's egg to that of a
large English walnut, or even a small hen's egg, according to the age of
the child and the size of the throat.
Dirt has been defined as "matter out of place," and the pharyngeal
tonsil is an excellent illustration. Nature is said never to make
mistakes, but she is apt to be absent-minded at times, and we are
tracing now not a few of the troubles that our flesh is heir to, to
little oversights of hers--scraps of inflammable material left lying
about among the cogs of the body-machine, such as the appendix, the
gall-bladder, the wisdom teeth, and the tonsils. One day a spark drops
on them, or they get too near a bearing or a "hot-box," and, in a flash,
the whole machine is in a blaze.
Never neglect snuffles or "cold in the head" in a young child, and
particularly in a baby. Have it treated at once antiseptically, by
competent hands, and learn exactly what to do for it on the appearance
of the earliest symptoms in the future, and you will not only save the
little ones a great deal of temporary discomfort and distress,--for it
is perfect torment to a child to breathe through its mouth at
first,--but you will ward off many of the most serious troubles of
infancy and childhood. We can hardly expect to prevent all development
of adenoids by these prompt and painless stitches in time, for some
children seem to be born peculiarly subject to them, either from the
inheritance of a particular shape of nose and throat,--"the family
nose," as it has been called,--or from some peculiar sponginess and
liability to inflammation and enlargement of all these tonsilar or
lymphoid "glands" and "kernels" of the body generally--the old
"lymphatic temperament."
We are, however, now coming to the opinion that this so-called
"hereditary" narrow nose, short upper lip, and high-arched palate are,
in a large percentage of cases, the _result of adenoids in infancy_ in
each successive generation of parents and grandparents. At all events,
there are now on record cases of children whose parents, grandparents,
and great-grandparents are known to have been mouth-breathers, and who
have on that account been sharply watched for the possible development
of adenoids in early life, and these removed as soon as they appeared,
and they have grown up with well-developed, wide nostrils, broad, flat
palates, and regular teeth, overcoming "hereditary defect" in a single
generation.
Curiously enough, their origin and ancestral relations may have an
important practical bearing, even in the twentieth century. At the upper
end of this curious _throat-brain_ canal lies another mass, the
so-called _pituitary body_. This has been found to exert a profound
influence over development and growth. Its enlargement is attended by
giantism and another curious giant disease in which the hands, feet, and
jaws enlarge enormously, known as _acromegaly_. It also pours into the
blood a secretion which has a powerful effect upon both the circulation
and the respiration. It is found shrunken and wasted in dwarfs. Some
years ago it was suggested by my distinguished friend, the late Dr.
Harrison Allen, and myself, that some of the extraordinary dwarfing and
growth-retarding effects of adenoids might be due to a reflex influence
exerted on their old colleague, the pituitary body. This view has found
its way into several of the textbooks. Blood is thicker than water, and
old ancestral vibrations will sometimes be set up in most unexpected
places.
Now comes the cheerful side of the picture. I should have hesitated to
draw at such full length and in such lugubrious detail the direful
possibilities and injurious effects of adenoids if its only result could
have been to arouse apprehensions which could not be relieved.
Fortunately, just the reverse is the case, and there are few conditions
affecting the child, so common and such a fertile source of all kinds of
mischief, and at the same time so completely curable, and whose cure
will be attended by such gratifying improvement on the part of the
little sufferer. In the first place, as has been said, their formation
may usually be prevented altogether by intelligent and up-to-date
hygienic care of the nose and the throat. In the second place, even
after they have occurred and developed to a considerable degree, they
can be removed by a trifling and almost painless operation, and, if
taken early enough, all their injurious effects overcome. If, however,
they have been neglected too long, so that the child has passed the
eighth or ninth year before any interference has been attempted, and
still more, of course, if it has passed the twelfth or thirteenth year,
then only a part of the disturbances that have been caused can be
remedied by their removal. So soft and pulpy are these growths, so
poorly supplied with blood-vessels or nerves, and so slightly connected
with the healthy tissues below them, that they may, in skilled hands, be
completely removed by simply scraping with a dull surgical spoon
(curette) or curved forceps, but never anything more knife-like than
this. In fact, in the first seven years of life, when their removal is
both easiest and will do most good, it is hardly proper to dignify the
procedure by the name of an operation. It is attended by about the same
degree of risk and of hemorrhage as the extraction of a tooth, and by
less than half the amount of pain.
But, trifling and free from danger as is the operation, there is nothing
in the entire realm of surgery which is followed by more brilliant and
gratifying results. It seems almost incredible until one has seen it in
half a dozen successive cases. Not merely doctors, but teachers and
nurses, develop a positive enthusiasm for it. This was the operation
that led to the comical, but pathetic, "Mothers' Riots" in the New York
schools. The word went forth, "The Krishts are cutting the throats of
your children"; and, with the shameful echoes of Kishineff ringing in
their ears, the Yiddish mothers swarmed forth to battle for the lives of
their offspring.
It is no uncommon thing to have a child of seven jump three to five
inches in height, six to twelve pounds in weight, and one to three
grades in his schooling, within the year following the operation. Ten
years more of intelligence and hygienic teaching should see this scourge
of childhood completely wiped out, or at least robbed of its
possibilities for harm. When this is done, at least two-thirds of all
cases of deafness, more than half of all cases of arrested development,
and three-fourths of those of backwardness in children will disappear.
CHAPTER VI
TUBERCULOSIS, A SCOTCHED SNAKE
I
One of the darling habits of humanity is to discover that we are facing
a crisis. One could safely offer a large prize for a group of ten
commencement orations, or political platforms, at least a third of which
did not announce this momentous fact. Either we are facing it or it
confronts us, and unutterable things will happen unless we "gird up our
loins," and vote the right ticket. An interesting feature about these
loudly heralded crises is that they hardly ever "crise." The real crisis
either strikes us so hard that we never know what hit us, or is over
before we recognize that anything was going to happen. And most of our
reflections about it are after ones--trying to explain what caused it.
In fact, in public affairs, as in medicine, a crisis is a sign of
recovery. Its occurrence is an indication that nature is preparing to
throw off the disease. Nowhere is this truth more vividly illustrated
than in the tuberculosis situation. When, about thirty years ago, the
world began to awake from its stupor of centuries, and to realize that
this one great disease alone was _killing one-seventh of all people born
under civilization_, and crippling as many more; that its killed and
wounded every year cast in the shade the bloodiest wars ever waged, and
that it was apparently caused by the civilization which it ravaged,--no
wonder that we were appalled at the outlook.
Here was a disease of civilization, caused by the conditions of that
civilization. Could it be cured without destroying its cause and
reverting to barbarism? Yet this very apprehension was a sign of hope, a
promise of improvement. That we were able to feel it was a sign that we
were shaking off the old fatalistic attitude toward disease,--as
inevitable or an act of Providence. It was brought about by the more
accurate and systematic study of disease. We had long been sadly
familiar with the fact that death by consumption, by "slow decline," by
"wasting" or "slow fever," was frightfully common. "To fall into a
decline" and die was one of the standard commonplaces of romantic
literature. But that was quite different from knowing in cold, hard
figures and inescapable percentages exactly how many of the race were
killed by it. It is one of the striking illustrations of the advantages
of good bookkeeping. Boards and departments of health had just fairly
got on their feet and started an accurate system of state accounts in
matters of deaths and births. We were beginning to recognize national
health as an asset, and to scr
Showing first 200,000 characters. Full text: gutenberg.org/ebooks/21965