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PREVENTABLE DISEASES
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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 Grad- uates College and University of Buffalo
BOSTON AND NEW YORK HOUGHTON MIFFLIN COMPANY Cambri&0e t
COPYRIGHT, 1907, 1908 AND 1909, BY THE CURTIS PUBLISHING COMPANY COPYRIGHT, 1909, BY WOODS HUTCHINSON
ALL RIGHTS RESERVED
Published November IQOQ
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 Physiognpmy 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, n 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
vi CONTENTS
XIII. Malaria: the Pestilence that walketh in Dark-
ness; the greatest Foe of the Pioneer 289
XIV. Rheumatism: what it Is, and particularly
what it Is n'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
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PEEVENTABLE DISEASES
CHAPTER I
THE BODY-REPUBLIC AND ITS DEFENSE
r I THE human body as a mechanism is far from per- _1_ feet. 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,
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but it must be capable, if needs be, of meeting extraor- dinary ones. It is' not enough for the body to be able to take care of itself, and preserve a fair degree of effi- ciency 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 medica- trix natures, 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
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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 unfa- vorable 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 de- vised, the group would destroy itself, and the experi- ment of cooperation, of colony-formation, of organiza- tion in fact, would be a failure.
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Hence, at a very early period we find the development of the rudiments of systems of body-sewerage, pro- viding 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 resource- ful 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 meth- ods 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 ir- ritating 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
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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 diarrhoea.
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 irra- tional than to stop a diarrhoea before it has accom- plished 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 antisep- tics, 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 de- fense. It was for a long time a puzzle why every drop
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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 pre- pared 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 bar- rier 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
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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 was n't work- ing at all, we should n'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 trdst 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 ma- jority 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 infec- tion of the body by more or less definitely recognized disease-germs or organisms. Fever is a complicated
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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 neutral- ized 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 tempera- ture 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 symp- toms. 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. Now- adays 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, tuberculo- sis, or pneumonia; knowing that not only they will not "catch cold," but that, as their hurried breathing in- dicates, they need all the oxygen they can possibly get, to burn up the poison poured out in the lungs and from
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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 flush- ing 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, co- operate 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 reliev- ing 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 antibody, 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.
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The treaty between these germs and the body, how- ever, 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 ab- solutely 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 be- tween 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
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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 intelli- gent cooperation. But it takes brains to do it and avoid doing more harm than good. It requires far more in- telligence 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 now- adays, and they are of 'use in the sickroom simply be- cause 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 re- covering 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 cer- tainly 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-
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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 cough- ing, 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 suffo- cation 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 in- fectious, 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
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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 reme- dies 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 doings anything toward removing the cause. In fact, on the contrary they make the situation worse by enabling the sufferer to keep right on repeat- ing 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
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relations to the general balance of activities of the or- ganism, 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 ap- proach 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 cen- turies 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 defi- nitions 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 indi-
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viduality and deadly concreteness, — nay, even a vindic- tive 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 patho- geny, and still holds well-nigh undisputed sway over the popular mind, and much more than could be de- sired 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 toss- ing and raving in the delirium of fever, or threatening to rupture his muscles and burst his eyes from their sockets in the convulsions of tetanus or uraemia, can wonder for a moment that the impression instinctively
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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 fol- lowed. The spirits which possessed the patient, al- though invisible, were supposed to be of like passions with ourselves, and to be affected by very similar in- fluences; hence dances, terrific noises, beatings and shakings of the unfortunate victim, and the adminis- tration 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 sug- gestion that there was any connection whatever be- tween 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
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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 treat- ment. Their chief virtue lay in their violence and re- pulsiveness. 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 pre- dominance 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
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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 incredi- bly late fullness it was, — under the great pioneer Virchow, who died less than a decade ago, was de- veloped the great cellular theory, a theory which has done more to put disease upon a rational basis, to sub- stitute 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 re-
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garded 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 demo- cracy have been as signal in biology as they have been in politics, and far more rapid. The sturdy little citi- zen-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 vefb, and even that may be over- ruled by the usual two-thirds vote.
In fact, if we dared to presume to criticise this mag- nificent 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 indi- vidual cells of any tissue may have become, they still
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retain most of the rights and privileges which they originally possessed in their free and imtrammeled amoeboid 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 alle- giance, 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 ab- sorbing 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 independ- ent organisms existing in animal communities out- side of the body. First of all, because furthest from
THE BODY-REPUBLIC 21
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 them- selves in a marble tomb. Like Esau, they have sold their birthright for a mess 6f "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
22 PREVENTABLE DISEASES
drama of coral-building. The coral polyp saturates it- self 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 amoeboid ancestral cell has transformed itself into tough, stringy bands and webs for the purpose of bind- ing together the more delicate tissues of the body. It has retained more of its rights and privileges, and con- sequently 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 con- siderable 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
THE BODY-REPUBLIC 23
as their power for good. From their ranks are re- cruited a whole army of those secessions from and re- bellions 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 ab- solutely necessary for the performance of the vital func- tion of the other cells. These they form first into pro- toplasm, 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
24 PREVENTABLE DISEASES
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 oesophagus, capable of con- taining 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 ex- cursions, and as the spoils are collected they are lite- rally 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 posi- tion 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 ordi- nary life activities until the next season's honey-gather- ing begins. It scarcely need be pointed out what an un- speakable 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
THE BODY-REPUBLIC 25
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 en- tirely free and unattached. They float at large in the blood-current, much as their original ancestor, the amoeba, 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- tele- graph system, and yet they are the most loyal and de- voted 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 hor- mones, 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 them- selves 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 in- jury is sounded in a part, all the vessels leading to it dilate, and their channels are crowded by swarms of the
26 PREVENTABLE DISEASES
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 them- selves 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-chan- nels, 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 rein- forcements 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
THE BODY-REPUBLIC 27
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 hesita- tion, 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.
28 PREVENTABLE DISEASES
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 re- tention 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 ques- tion 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 civil- ized 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 tern-
THE BODY-REPUBLIC 29
perature from the merest scratch, and yet either never develop any serious infection or display very high re- sisting 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 patrin moriuntur. Our whole alimentary canal is con- tinually 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,
30 PREVENTABLE DISEASES
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 I THE POWER OF HEREDITY IN THE PREVENTION OF DISEASE
evil in things always bulks large in our imagi- -L nations. It is no mere coincidence that the earli- est 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 is n'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
32 PREVENTABLE DISEASES
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 na- ture — 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 degen- eracy, 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 misconcep- tions 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
OUR LEGACY OF HEALTH 33
divided the scientific world : whether acquired charac- ters, changes occurring during the lifetime of the in- dividual, can be inherited. Disease is nine times out of ten an acquired character ; hence, instead of the proba- bilities being that it would be inherited, the balance of evidence to date points in exactly the opposite direc- tion. The burden of proof as to the inheritance of disease is absolutely upon those who believe in its pos- sibility.
Another fundamental fact which renders the inheri- tance of disease upon a priori grounds improbable and upon practical grounds obviously difficult, is that char- acters or peculiarities, m 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 in- jurious characters would rapidly go down in the strug- gle for survival and become extinct. An inherited dis- ease 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 dis- appearance and elimination by the stern, selective influence of environment.
Naturally, this great conservative tendency of na- ture 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 gener-
34 PREVENTABLE DISEASES
ations 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 re- vealed 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 difficul- ties overcome, significant and encouraging indications of what our body-machine is still capable of accom- plishing 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 thou- sands 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
OUR LEGACY OF HEALTH 35
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 de- fects in its machinery or gearing. Easily ninety-nine per cent of all our troubles through life are due to in- evitable 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 appar- ently hidebound conservatism on nature's part — are very much in the public eye at present, partly on ac- count 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
36 PREVENTABLE DISEASES
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 uncom- mon 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 as- sumption of the erect position and our incomplete ad- justment 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 fre- quency of hernia in the human species as compared with any of the animals.
Another fragment, of the impertinence of whose pres- ence 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 deli- cious 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
OUR LEGACY OF HEALTH 37
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 dis- turbances 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 pro- hibiting 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, harelip, due to a failure of the three parts of which our upper jaw is built to unite properly, — this triple construction
38 PREVENTABLE DISEASES
of the jaw being an echo of ancestral fishlike and rep- tilian 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 impres- sive 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 patho- logical 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 experi- mentation 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
OUR LEGACY OF HEALTH 39
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 adapt- able 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 safe- guard 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 im- mensely effective that a slash across the great artery of
40 PREVENTABLE DISEASES
the thigh in the groin of a dog will be closed completely before he can bleed to death. So delicate and so pur- poseful 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 sur- face 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 poi- sonous or offending substances out of the wound. This living, surgical cement, elastic, self-moulding, sooth- ing, 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 com- bination 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
OUR LEGACY OF HEALTH 41
brigade and are quickly followed by the heavy infantry of the line in the shape of cells born of the injured tis- sues 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 bud- ding 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 valu-
42 PREVENTABLE DISEASES
able 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 sala- mander. 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
OUR LEGACY OF HEALTH 43
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 experi- ences 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 pre- vention. 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 genera- tions. 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 Nature?" 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 destruc- tion of the living external causes of disease and the prevention of contagion, our most permanent and sub-
44 PREVENTABLE DISEASES
stantial victories are won by appealing to and increas- ing this long-descended and hard-won power of indi- vidual 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 vims 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.
OUR LEGACY OF HEALTH 45
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 any- where 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 chil- dren. This is strikingly brought out in the admirable work done by the Associated Dispensaries for Tuber- culosis 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 tubercu- losis an attendant nurse, whose duty it was to visit the patients at their homes and advise and instruct them as
46 PREVENTABLE DISEASES
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 re- sult 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 diarrhoea from tuberculo- sis of the bowels, or from a violent attack of distention. of the bowels due to tuberculous peritonitis. The favor- ite breeding-place of the tubercle bacillus is unfortu- nately in the home.
On the other hand, while the vast majority of cases of so-called hereditary tuberculosis are due to direct infec- tion, 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 tuber- culosis 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
OUR LEGACY OF HEALTH 47
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, under- feeding, overconfinement, or that form of gradual suffo- cation 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 propaga- tion 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
48 PREVENTABLE DISEASES
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 in- heritance, 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 compro- mise, 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, inas- much 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 nutri- tiousness or healthfulness of that blood may unfavor- ably influence the development of the offspring.
Disease cannot be inherited any more than a mutilat- ing 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
OUR LEGACY OF HEALTH 49
be expected that the development of the child will pro- ceed with the same perfection as it would under per- fectly 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 pre- ference, 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, reject- ing 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 trans- mitted only by direct infection, by permitting the more valuable cows to be saved alive for breeding purposes.
50 PREVENTABLE DISEASES
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 alto- gether 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 he- redity.
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 posi- tive 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 overwhelm- ing 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 dis- couraging 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
OUR LEGACY OF HEALTH 51
which quite conceivably might be transmitted to future generations, yet it is highly improbable, on both biologi- cal 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 fol- lowed 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 his- tory 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 aver- age distribution. Though possibly the offspring of a
52 PREVENTABLE DISEASES
cancerous individual may display a slightly greater ten- dency toward the development of that strange, curious process of "autonomy" than the offspring of the aver« age individual, this tendency is so small and occurs so infrequently as to be a factor of small practical import- ance 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 pre- vent his long surviving that epoch, will not, for me- chanical 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 sus- ceptibility 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 tuber- culosis would not last long, and in fact the whole pro- gress 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 pos-
OUR LEGACY OF HEALTH 53
sessor 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. How- ever, 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 com- munity, yet, on account of their fewness, this tendency probably does not account for more than a small frac- tion 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
54 PREVENTABLE DISEASES
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 prob- ably 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 pos- sibility 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 unbal- ance, 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 obvi- ously unstable, and careful hygienic treatment and training of the predisposed two per cent, insanity is almost as preventable as tuberculosis.
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.
1 The proportion of registered insane in civilized countries to-day ranges from two to three per 1000 of the population.
CHAPTER III
THE PHYSIOGNOMY OF DISEASE I 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 devel- opment, its indispensable basis, in fact, has been the invention of instruments of precision — the micro- scope, the fever thermometer, the stethoscope, the oph- thalmoscope, 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 re- garded — 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 ourfive senses. We should still avail ourselves of every particle of in- formation 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
56 PREVENTABLE DISEASES
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 sphygmo- manometer, 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 won- derful degree by the older physicians of the passing and past generations, has been almost lost by the new.
A healthful reaction has, however, set in ; and while we certainly do not love the Caesar of laboratory methods and accuracy the less, we are beginning to have a juster affection for the Rome of the rich harvest that may be gained from the careful, painstaking, de- tective-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 pro- per 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 examina- tion 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
THE PHYSIOGNOMY OF DISEASE 57
— 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 particu- lar 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 examina- tion in the laboratory, and get a prompt and decisive answer.
The observant physician begins to gather informa- tion 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'ceil, "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-ex- amination 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 ex- plain to you himself how he does it, what are the data that determine it ; yet not infrequently, three times out
58 PREVENTABLE DISEASES
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 de- partments 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 '11 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 can- cer, 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 thumb-
THE PHYSIOGNOMY OF DISEASE 59
print 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 puz- zle it out. And if this is true of the foundation struc- ture 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 pic- ture, 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 re- sponsive surface — half mirror, half sensitive plate — • the human countenance. The place where the moving finger of disease writes its clearest and most unmis- takable 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 ha- bitually 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 de- partments, the special senses, the nose, the eyes, and ears; while later, by an exceedingly clumsy device
60 PREVENTABLE DISEASES
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 ex- ternal 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-trans- parent skin, barely veiling the pulsating mesh of my- riad 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 rich- ness 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
THE PHYSIOGNOMY OF DISEASE 61
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 dis- ease, 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 im- pressions 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 care- ful and loving student of the genus humanum known as a doctor looks at first in the face of a patient. In- deed, 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
62 PREVENTABLE DISEASES
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 con- sultation-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 un- necessary questions, and finally stumbled upon it. After the patient had left the room, I, feeling rather proud of myself, expected his commendation, but I did n't get it. "My boy," he said, "you are not up to the mark yet. You should be able to recognize a dis- ease like that just as you know the face of an acquaint- ance on the street." A positive and full-blown diagno- sis 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, char- acter 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 text-
THE PHYSIOGNOMY OF DISEASE 63
books 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 expand- ing, the different orifices which, as we have seen, ap- pear upon the surface of the face. This naturally throws them into three great groups: those about and con- trolling the orifice of the alimentary canal, the mouth ; those surrounding th£ 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 com- bination, 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 differ- ent 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 open- ings, we get what a surveyor would call our " lines of
64 PREVENTABLE DISEASES
triangulation," and by following these to their con- verging 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 inti- mate 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, elimina- tion, 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 pain- ful 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
THE PHYSIOGNOMY OF DISEASE 65
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 con- traction 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 absorp- tion 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 anti- cipation of an early call for the admission of necessary nutriment, nor an instinctive desire to shut out any-
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thing that may be indigestible or undesirable, are now in their normal condition of peaceful, moderate con- traction; the face has a comfortable, well-fed, whole- some 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 con- trol ; 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, twitch- ing, 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 re- sultant 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.
THE PHYSIOGNOMY OF DISEASE 67
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 dis- turbance and pain, no more will be allowed to enter it at present under any conditions. And as our alimen- tary 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 addi- tion 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 does n't need it ; and the lines of weakness and irresolution are those of the nature which cannot resist either gastro- nomic 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
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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 circula- tion than it is to the lungs, especially in patients who are able to be up and about. If, in addition to the dan- ger 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 border- ing on dampness, red lips slightly parted, showing the teeth between, a painfully strong suspicion of consump- tion would arise unbidden.
This pathetic type of face has that fatal gift which the French clinicians, with their usual happiness of phrase, term La beauU dudiable. The eager eyes, di- lated nostrils, parted lips, give that weird air of exal- tation 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
THE PHYSIOGNOMY OF DISEASE 69
eyes and forehead. These are less reliable than either of the other two, for the reason that they are so sym- pathetic 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 signifi- cant; then they may be interpreted as one of three things : first, and commonest, eye strain ; second, dis- ease 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, be- cause — 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.
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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 tem- per, 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 complex- ion 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 mis- lead 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 ex- cess 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 in- stance, if our patient be of Southern blood, or tanned from the seashore, the good red blood in his arteries is
THE PHYSIOGNOMY OF DISEASE 71
pretty safe to show through at the normal blush area on the cheeks ; or, failing that, through the translucent epithelium of the lips and gums. If, on the other hand, this yellow tint be due to the escape of broken-down blood-pigments into the tissues, or a damming up of the bile, and a similar escape of its coloring matter, as in jaundice, then we turn to the whites of the eyes, and if a similar, but more delicate, yellowish tint confronts us there, we know we have to deal with a severe form of anaemia or jaundice, according to the tint. In ex- treme cases of the latter, the mucous membrane of the lips and of the gums will even show a distinctly yellow- ish hue. The frightfuf 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 tempo- rary anaemias of young girls, known for centuries past in the vernacular as " the green sickness." And a deli- cate lemon tint of this same origin, accompanied by a waxy pallor, is significant of the deadly, pernicious anaemia and the later stages of cancer.
The most significant single thing about the red flush, supposed to be indicative of health, is its location. If this be the normal " blush area," about the middle of each cheek, — which is one of nature's sexual orna- ments, 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
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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 defi- nite 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 com- monly 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 ap- pears, 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 cheek- bones, 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 consump- tive. But here we call for help upon another of the fea- tures of disease — the hand. If, instead of being cool, and elastic, this is either dry and hot, or clammy and
THE PHYSIOGNOMY OF DISEASE 73
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 ap- parent 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 uncon- scious of, the voice. These forms of expression are naturally not so frequent as those of the face, on ac- count 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 dis- tinctively localizing.
Next in importance to the face comes the hand, and volumes have been written upon this alone. Contain- ing, 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
74 PREVENTABLE DISEASES
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 no- thing 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
THE PHYSIOGNOMY OF DISEASE 75
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 ques- tion, " Did you not have a serious illness of some sort two, three, or six months ago ?" according to the posi- tion 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 does n't in- cline 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 club- bing 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 asso- ciated also with certain diseases of the heart. It seems to mean obstructed circulation through the lungs.
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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 trou- sers 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 relaxa- tion, 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 en- feeblement, he cannot even lie straight in bed, but col- lapses into a curled -up heap in the middle of the bed, the head even dropping from the pillow and falling on the chest. Between this debacle and the slight droop
THE PHYSIOGNOMY OF DISEASE 77
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, of 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 sig- nificant gait. For instance, if a patient comes in with a firm, rather precise, calculated sort of gait, " clump- ing" 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 sus- picion 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
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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 ex- tensor 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 expres- sion 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 suspect- ing 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 imagina- tion has got to have some physical basis as a starting- point. They may tell you much that is clearly and
THE PHYSIOGNOMY OF DISEASE 79
ludicrously irrelevant, or untrue, on account of inac- curacy 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 de- ductions, 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 exam- ination 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 symp- tom 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 sug- gestion 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 try- ing to mislead you, the very vigor of their efforts will often reveal their secret, just as the piteous broken- winged flutterings of the mother partridge reveal in- stantly to the eye of the bird-lover the presence of the
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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, in- cluding 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 fin- ish 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 con- tinue with the recital of your symptoms, and I will re- turn 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 ex- haustive 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 prosper- ity" 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 PHYSIOGNOMY OF DISEASE 81
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 luxurius loll of each group of muscles, and quietly draw your own conclu- sions 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 con- trol of the situation, and their restoration to comfort, if not health, which you could n'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 can- not 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 exqui-
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sitely responsive to every breath of change in his in- terior 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 dis- comfiture 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 de- lighted, was considerably puzzled with the gift, and explained to a friend of mine that she really did n't know what to feed it, and it was n'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 mam- moth, 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 memo- ries 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
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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 burrow- ing 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.
COLDS AND HOW TO CATCH THEM 85
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 actu- ally 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 thought- ful physicians may be graphically indicated by the flip- pant 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 major- ity of so-called "colds" have little or nothing to do with exposure to a low temperature, that they are en- tirely misnamed, and that a better term for them would befouls. 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
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are vastly more frequent in winter, and the other that when you sit in a draft until you feel chilly, you inevi- tably 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 an- other of the influenza and other bacilli. As the brilliant young English pulmonary expert, Dr. Leonard Wil- liams, puts it, " a constant succession of colds implies a mode of life in which all aerial microbes are afforded abundant opportunities." At the same time, we take less exercise and sit far less in the open air, thus lower- ing 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 compara- tively little more from colds in the winter-time than they do in summer; although, of course, the most vig- orous 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 in- fections to begin with a chill. The patient complains
COLDS AND HOW TO CATCH THEM 87
of shiverings up and down his spine, his finger-nails 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, be- cause 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 sneez- ing. 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 unani-
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mous 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
COLDS AND HOW TO CATCH THEM 89
a ship would touch there — usually not oftener than once a year. Then, within a week, half the popula- tion would be blowing and sneezing. The great Sam- uel commented upon the fact at length, and advanced the ingenious explanation that, as the harbor was so difficult of entry, the ships could beat in only when the wind was in a certain quarter, and that quarter was the nor'east. Hinc illae lacrima! (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 ap- parently 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 bac- teria, 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
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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 ba- cillus influenza of Pfeiffer) and one of the most con- tagious 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, be- ginning, as do nearly all our world-epidemics, — chol- era, 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 Rus- sia 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 dur- ing the search for the true bacillus of influenza: this was that a dozen other bacilli and cocci were discov- ered, each of which seemed capable of causing all the
COLDS AND HOW TO CATCH THEM 91
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 prob- ably 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 zoological gardens and circuses. I used often to drop in there to see if he had anything new, and he would come up
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to see me, to tell me his troubles and keep my dissect- ing-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 dis- eases 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 trium- phant. "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 "coldic" to try such heroic treatment offhand, for the pungency
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and painfulness of formalin vapor is something fero- cious, though the French physicians, with character- istic courage, are making extensive use of it for this purpose, with excellent results under careful super- vision.
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 sub- stances known as anti-bodies, which destroy or render harmless the invading germs. Flabby, under-venti- lated 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
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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 our- selves vigorous, clean, and well ventilated, we can prac- tically defy the " cold " devil and all his works.
Here is the leitmotif oi the whole fascinating drama of infection and immunity. We can study only one phrasing here. We shall, of course, catch cold occasion- ally, 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 would n'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
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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 its 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 defi- ance 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.
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Then we tried it in fear and trembling on our pa- tients, 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 appe- tite 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 im- ported "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 Sana- torium, "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 Cali- fornia is considered complete without them. The ideal bedroom is a small dressing-room, opening on
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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 '11 avoid two-thirds of your colds and three- fourths of your headaches. It may be necessary in win- ter 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
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of the breaths and perspiration of successive genera- tions. 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 ex- ternally 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 abun- dant 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 attend- ant 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 sec- ond 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 inven-
COLDS AND HOW TO CATCH THEM 99
tions 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 precipi- tate a cold is by temporarily lowering the vital resist- ance. 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 mem- branes 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 intes- tines, — 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
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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 run- ning 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 be- ginning of measles, scarlet fever, and diphtheria, and two-thirds of all cases of these would be sent home be- fore 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 '11 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 employ- ees comes to work shivering, give him three days' vaca- tion on full pay. If it runs through the force, you'll lose five times as much in enforced sick-leaves, slow- ness, and mistakes. Above all, don't go to any public
COLDS AND HOW TO CATCH THEM 101
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 them- selves, which are disagreeable and dangerous enough, but because mild infections of this sort are far the com- monest single means of making a breach in our body- ramparts through which more serious diseases like con- sumption, 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. Intelli- gently regarded and handled, they are the least harm- ful 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.
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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 I 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 ofwhat 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 pro- gress, is actually rated below silence, the attribute of the clod and of the dumb brute, the easy refuge of cow- ardice and of stupidity.
Easily eight-tenths of all speech is informing, educa- tive, 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,
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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 danger- ousness 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.
Asa matter of fact, there is exceedingly little evi- dence to show that pure, fresh, open air at any reason- able temperature and humidity ever did harm when in- haled 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 en- gaged 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.
ADENOIDS, OR MOUTH-BREATHING 105
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 at- tributed 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
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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 respi- ration 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 provid- ing 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 aban- don 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, wide- spread 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 neg-
ADENOIDS, OR MOUTH-BREATHING 107
lected 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 them- selves 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 school room. 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, moist- ened, 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 un- founded in fact. Fully two-thirds of these can be traced to the direct influence of the adenoids.
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These adenoids, it may briefly be stated, are the re- sult of an enlargement of a tonsil, or group of small ton- sils, 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 se- rious injurious effect, though not the earliest, — the impairment of the child's power of attention and intel- ligence. 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
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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 handi- cap. 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 pos- terior 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 prac- tical demonstrations of their existence, by the well- known sensation, when blowing your nose vigorously, of feeling something go "pop" in the ear. This sensa- tion 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
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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 lym- phoid 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 be- hind it, like the levers of a piano, becomes clogged, and the child becomes deaf, whether a chronic dis- charge be present or not.
This is the secret of his "inattention," his "indiffer- ence," — even of his apparent disobedience and re-
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belliousness. What other children hear without an effort he has to strain every nerve to catch. He mis- understands the question that is asked of him, makes an absurd answer, and is either scolded or laughed at. It is n'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 distin- guish 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
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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 expe- rience. 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 enrcoach upon and take advantage of it. Emer- son 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-breath- ing, 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.
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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 be- low, the horizontal partition between — the floor of the nose and the roof of the mouth — is kept compara- tively 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 diminu- tion 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
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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 ex- isting 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 in- creased.
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
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record of children with two, three, or even four genera- tions 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 re- move 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 cer- tainly 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 ex- plained by the desperate efforts that the little one makes to breathe through clogging nostrils, in which the dis- charges, 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 ade-
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noids, and how do they come to produce such serious disturbances ? This can be partially answered by say- ing that they are tonsils and with all a tonsil's suscep- tibility 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 sec- ond 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 dis- used canal, which performs the singular and appar- ently 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 ex- perience, but they serve as a port of entry for the germs of many serious diseases, such as tuberculosis, rheuma- tism, diphtheria, and possibly scarlet fever. They ap-
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pear 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 mis- chief 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 ex- quisitely 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 in- flames, 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 in- teresting, but troublesome, body. What its capabili- ties are in this respect may be gathered from the fact
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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, accord- ing 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 earli- est 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 child- hood. 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 par- ticular shape of nose and throat, — "the family nose,"
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as it has been called, — or from some peculiar spongi- ness and liability to inflammation and enlargement of all these tonsilar or lymphoid "glands" and " kernels" of the body generally — the old " lymphatic tempera- ment."
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 suc- cessive 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 nfouth-breathers, and who have on that account been sharply watched for the possible development of adenoids in early life, and these re- moved as soon as they appeared, and they have grown up with well-developed, wide nostrils, broad, flat pal- ates, and regular teeth, overcoming "hereditary de- fect" 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 pit- uitary body. This has been found to exert a profound influence over development and growth. Its enlarge- ment is attended by giantism and another curious giant disease in which the hands, feet, and jaws enlarge enor- mously, 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
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suggested by my distinguished friend, the late Dr. Harrison Allen, and myself, that some of the extraor- dinary dwarfing and growth-retarding effects of ade- noids 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 some- times 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.
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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 re- moval 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 freelfrom 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 teach- ers 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
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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
ONE of the darling habits of humanity is to dis- cover 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 her- alded 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 throwoff the disease. Nowhere is this truth more vividly illustrated than in the tuberculosis situa- tion. 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-seven!h 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 ap-
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parently 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 with- out destroying its cause and reverting to barbarism ? Yet this very apprehension was a sign of hope, a pro- mise 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 sys- tematic 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 ex- actly how many of the race were killed by it. It is one of the striking illustrations of the advantages of good bookkeeping. Boards and departments of health had just fairly got on their feet and started an accurate system of state accounts in matters of deaths and births. We were beginning to recognize national health as an asset, and to scrutinize its fluctuations with keen interest accordingly.
We may decry statistics as much as we like, but when we see the effects of a disease set down in cold columns of black and white we have no longer any idea of submitting to it as inevitable. We are going to get right up and do some fighting. "One-seventh of all the deaths" has literally become the war cry of our
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new Holy War against tuberculosis. Still another stir- ring phrase of inestimable value in rousing us from our torpor was that coined by the brilliant and lovable physician-philosopher, Oliver Wendell Holmes: "The Great White Plague of the North." This vivid epithet, abused as it may have been in later years, was of enor- mous service in fixing the public mind on consumption as a definite, individual disease, something to be fought and guarded against. Before that, we had been in- clined to look upon it as just a natural failing of the vital forces, a thing that came from within, and was in no sense caused frooorwithout. The fair young girl, or the delicate boy whose vitality was hardly sufficient to carry him through the stern battle of life, under some slight shock, or even mental disappointment, would sink into a decline, gradually waste away, and die. What could be done in such a case, except to bow in submission to the inscrutable ways of Providence ?
It seems incredible now, but such was the light in which smallpox was regarded by physicians of the Arabian and mediaeval schools : a natural oozing forth of "peccant humors" in the blood of the young, a dis- agreeable, but perfectly natural, and even necessary, process. For if the patient did not get rid of these hu- mors either he would die or his growth would be seri- ously impaired. Now smallpox has become little more than a memory in civilization, and consumption is due to follow its example.
Sanitary pioneers had already begun casting about eagerly for light upon the influence of housing, of drainage, of food, in the causation of tuberculosis,
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when a new and powerful weapon was suddenly placed in their hands by the infant science of bacteriology. This was the now world-famous discovery by Robert Koch that consumption and other forms of tuberculo- sis were due to the attack of a definite bacillus. No tubercle bacillus — no consumption.
At first sight this discovery appeared to be anything but encouraging. In fact, it seemed to make the situ- ation and the outlook even more hopeless. And when within a few years it was further demonstrated in rapid succession that most of the diseases of the spine in chil- dren, of the group of symptoms associated with en- larged glands or kernels in the neck and known as "scrofula" or struma, most cases of hip-joint disease, of white swelling of the knee, a large percentage of chronic ulcerations of the skin known as lupus, a com- mon form of fatal bowel disease in children, and many instances of peritonitis in adults, together with fully half of the fatal cases of convulsions in children, were due to the activity of this same ubiquitous bacillus, it looked as if the enemy were hopelessly entrenched against attack. And when it was further found that a similar bacillus was almost as common a cause of death and disease in cattle, particularly dairy cattle, and another in domestic fowls, it looked as if the heavens above and the earth beneath were so thickly strewn and so hopelessly infested with the germs that to war against them, or hope to escape from them, was like fighting back the Atlantic tides with a broom.
But this chill of discouragement quickly passed. Our foe had come down out of the clouds, and was
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spread out in battle array before us, in plain sight on the level earth. We were ready for the conflict, and proposed to " fight it out on this line if it takes all sum- mer." It was not long before we began to see joints in the enemy's armor and weaknesses in his positions. Then, when we lowered our field-glasses and turned to count our forces and prepare for the defense, we dis- covered with a shock of delighted relief that whole regiments of unexpected reinforcements had come up while we were studying the enemy's position. These new allies of ours were three of the great, silent forces of nature, which had fallen into line on either side and behind us, without hurry and without excitement, without even a bugle-blast to announce their coming.
The first was the great resisting power and vigor of the human organism, which we had gravely underes- timated. The second, that power of adaptation to new circumstances, including even the attack of infectious diseases, which we call "survival of the fittest." The third, that great, sustaining, conservative power of nature — heredity. More cheering yet, these forces came, not merely fully armed, but bearing new wea- pons fitted for our hands. The vigor and unconquer- able toughness of the human animal presented us with three glittering weapons, sunshine, food, and fresh air.
"If the deadly bacillus breaks through the lines, put me in the gap ! With these weapons, with this triad, I will engage to hurl him back, shattered and broken." " Equip your vanguard with them, and the enemy will never break the line."
The survival of the fittest held out to