WOODS HUTCHINSON, A.M., M.D.
Author of "Studies in Human and Comparative Pathology," "Instinct and Health," etc., etc. Clinical Professor of Medicine, New York Polyclinic, late Lecturer in Comparative Pathology, London Medical Graduates College and University of Buffalo
BOSTON AND NEW YORK HOUGHTON MIFFLIN COMPANY The Riverside Press Cambridge
COPYRIGHT, 1907, 1908 AND 1909, BY THE CURTIS PUBLISHING COMPANY COPYRIGHT, 1909, BY WOODS HUTCHINSON
ALL RIGHTS RESERVED
Published November 1909
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By Woods Hutchinson
THE CONQUEST OF CONSUMPTION. Illustrated. 12mo, $1.00 net. Postage extra.
PREVENTABLE DISEASES. 12mo, $1.50 net. Postage 13 cents.
HOUGHTON MIFFLIN COMPANY BOSTON AND NEW YORK
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I. The Body-Republic and its Defense 1
II. Our Legacy of Health: the Power of Heredity in the Prevention of Disease 31
III. The Physiognomy of Disease: what a Doctor can tell from Appearances 55
IV. Colds and how to catch Them 83
V. Adenoids, or Mouth-Breathing: their Cause and their Consequences 103
VI. Tuberculosis, a Scotched Snake. I 123
VII. Tuberculosis, a Scotched Snake. II 140
VIII. The Unchecked Great Scourge: Pneumonia 174
IX. The Natural History of Typhoid Fever 198
X. Diphtheria: the Modern Moloch 222
XI. The Herods of Our Day: Scarlet Fever, Measles, and Whooping-Cough 243
XII. Appendicitis, or Nature's Remnant Sale 267
XIII. Malaria: the Pestilence that walketh in Darkness; the greatest Foe of the Pioneer 289
XIV. Rheumatism: what it Is, and particularly what it Isn't 311
XV. Germ-Foes that follow the Knife, or Death under the Finger-Nail 331
XVI. Cancer, or Treason in the Body-State 350
XVII. Headache: the most useful Pain in the World 367
XVIII. Nerves and Nervousness 387
XIX. Mental Influence in Disease, or how the Mind affects the Body 411
THE BODY-REPUBLIC AND ITS DEFENSE
The human body as a mechanism is far from perfect. It can be beaten or surpassed at almost every point by some product of the machine-shop or some animal. It does almost nothing perfectly or with absolute precision. As Huxley most unexpectedly remarked a score of years ago, "If a manufacturer of optical instruments were to hand us for laboratory use an instrument so full of defects and imperfections as the human eye, we should promptly decline to accept it and return it to him. But," as he went on to say, "while the eye is inaccurate as a microscope, imperfect as a telescope, crude as a photographic camera, it is all of these in one." In other words, like the body, while it does nothing accurately and perfectly, it does a dozen different things well enough for practical purposes. It has the crowning merit, which overbalances all these minor defects, of being able to adapt itself to almost every conceivable change of circumstances.
This is the keynote of the surviving power of the human species. It is not enough that the body should be prepared to do good work under ordinary conditions, but it must be capable, if needs be, of meeting extraordinary ones. It is not enough for the body to be able to take care of itself, and preserve a fair degree of efficiency in health, under what might be termed favorable or average circumstances, but it must also be prepared to protect itself and regain its balance in disease.
The human automobile in its million-year endurance-run has had to learn to become self-repairing; and well has it learned its lesson. Not only, in the language of the old saw, is there "a remedy for every evil under the sun," but in at least eight cases out of ten that remedy will be found within the body itself. Generations ago this self-balancing, self-repairing power was recognized by the more thoughtful fathers in medicine and even dignified by a name in their pompous Latinity—the vis medicatrix naturae, the healing power of nature.
In the new conception of disease, our drugs, our tonics, our prescriptions and treatments, are simply means of rousing this force into activity, assisting its operations, or removing obstacles in its way. This remedial power does not imply any gift of prophecy on nature's part, nor is it proof of design, or beneficent intention. It is rather one of those blind reactions to certain stimuli, tending to restore the balance of the organism, much as that interesting, new scientific toy, the gyroscope car, will respond to pressure exerted or weight placed upon one side by rising on that side, instead of tipping over. Let the onslaught of disease be sufficiently violent and unexpected, and nature will fail to respond in any way.
Moreover, we and our intelligences are a product of nature and a part of her remedial powers. So there is nothing in the slightest degree irrational or inconsistent in our attempting to assist in the process.
However, a great, broad, consoling and fundamental fact remains: that in a vast majority of diseases which attack humanity, under ninety per cent of the unfavorable influences which affect us, nature will effect a cure if not too much interfered with. As the old proverb has it, "A man at forty is either a fool or a physician"; and nature is a good deal over forty and has never been accused of lacking intelligence.
In the first place, nature must have acquired a fair knowledge of practical medicine, or at least a good working basis for it, from the fact that the body, in the natural processes of growth and activity, is perpetually manufacturing poisons for its own tissues.
In this age of sanitary reform, we are painfully aware that the most frequent causes of human disease are the accumulations about us of the waste products of our own kitchens, barns, and factories. The "bad air" which we hear so frequently and justly denounced as a cause of disease, is air which we have ourselves polluted. This same process has been going on within the body for millions of years. No sooner did three or four cells begin to cling together, to form an organism, a body, than the waste products of the cells in the interior of the group began to form a source of danger for the others. If some means of getting rid of these could not be devised, the group would destroy itself, and the experiment of cooeperation, of colony-formation, of organization in fact, would be a failure.
Hence, at a very early period we find the development of the rudiments of systems of body-sewerage, providing for the escape of waste poisons through the food-tube, through the kidneys, through the gills and lungs, through the sweat glands of the skin. So that when the body is confronted by actual disease, it has all ready to its hand a remarkably effective and resourceful system of sanitary appliances—sewer-flushing, garbage-burning, filtration. In fact, this is precisely what it does when attacked by poisons from without: it neutralizes and eliminates them by the same methods which it has been practicing for millions of years against poisons from within.
Take, for instance, such a painfully familiar and unheroic episode as an attack of colic. It makes little difference whether the attack is due to the swallowing of some mineral poison, like lead or arsenic, or the irritating juice of some poisonous plant or herb, or to the every-day accident of including in the menu some article of diet which was beginning to spoil or decay, and which contained the bacteria of putrefaction or their poisonous products. The reaction of defense is practically the same, varying only with the violence and the character of the poison. If the dose of poisonous substances be unusually large or virulent, nature may short-circuit the whole attack by causing the outraged stomach to reject its contents. The power of "playing Jonah" is a wonderful safety-valve.
If the poison be not sufficiently irritating thus to short-circuit its own career, it may get on into the intestines before the body thoroughly wakes up to its presence. This part of the food-tube being naturally geared to discharge its contents downward, the simplest and easiest thing is to turn in a hurry call and cut down the normal schedule from hours to minutes, with the familiar result of an acute diarrh[oe]a.
Both vomiting and purging are defensive actions on nature's part, remedies instead of diseases. Yet we are continually regarding and treating them as if they were diseases in themselves. Nothing could be more irrational than to stop a diarrh[oe]a before it has accomplished its purpose. Intelligent physicians now assist it instead of trying to check it in its early stages; and paradoxical as it may sound, laxatives are often the best means of stopping it. It is only the excess of this form of nature's house-cleaning which needs to be checked. Many of the popular Colic Cures, Pain-Relievers, and "Summer Cordials" contain opium which, while it relieves the pain and stops the discharge, simply locks up in the system the very poisons which it was trying to get rid of. Laxatives, intestinal antiseptics, and bowel irrigations have almost taken the place of opiates in the treatment of these conditions in modern medicine. We try to help nature instead of thwarting her.
Supposing that the poison be of more insidious form, a germ or a ptomaine, for instance, which slips past these outer "firing-out" defenses of the food-tube and arouses no suspicion of its presence until it has been partially digested and absorbed into the blood. Again, resourceful nature is ready with another line of defense. It was for a long time a puzzle why every drop of the blood containing food and its products absorbed from the alimentary food-canal had to be carried, often by a most roundabout course, to and through the liver, before it could reach any part of the general system. Here was the largest and most striking organ in the body, and it was as puzzling as it was large. We knew in some crude way that it "made blood," that it prepared the food-products for use by the body-cells, and that it secreted the bile; but this latter secretion had little real digestive value, and the other changes seemed hardly important enough to demand that every drop of the blood coming from the food-tube should pass through this custom-house. Now, however, we know that in addition to its other actions, the liver is a great poison-sponge or toxin-filter, for straining out of the blood poisonous or injurious materials absorbed from the food, and converting them into harmless substances. It is astonishing what a quantity of these poisons, whether from the food or from germs swallowed with it, the liver is capable of dealing with—destroying them, converting them, and acting as an absolute barrier to their passage into the general system. But sometimes it is overwhelmed by appalling odds; some of the invaders slip through its lines into the general circulation, producing headache, backache, fever, and a "dark-brown taste in the mouth"; and, behold, we are bilious, and proceed to blame the poor liver. We used to pour in remedies to "stir it up," to "work on it"—which was about as rational as whipping a horse when he is down, instead of cutting his harness or taking his load off. Nowadays we stop the supply of further food-poisons by stopping eating, assist nature in sweeping out or neutralizing the enemies that are still in the alimentary canal, flush the body with pure water, put it at rest—and trust the liver. Biliousness is a sign of an overworked liver. If it wasn't working at all, we shouldn't be bilious: we should be dead, or in a state of collapse.
Moral: Don't rush for some remedy with which to club into insensibility every symptom of disease as soon as it puts in an appearance. Give nature a little chance to show what she intends to do before attempting to stop her by dosing yourself with some pain-reliever or colic cure. Don't trust her too blindly, for the best of things may become bad in extremes, and the body may become so panic-stricken as to keep on throwing overboard, not merely the poisons, but its necessary daily food, if the process be allowed to continue too long.
This is where the doctor comes in. This is the point at which it takes brains to succeed in the treatment of disease—to decide just how far nature knows what she is doing, even in her most violent expulsive methods, and is to be helped; and just when she has lost her head, or got into a bad habit, and must be thwarted. This much we feel sure of, and it is one of the keynotes of the attitude of modern medicine, that a large majority of the symptoms of disease are really nature's attempts to cure it.
This is admirably shown in our modern treatment of fevers. These we now know to be due to the infection of the body by more or less definitely recognized disease-germs or organisms. Fever is a complicated process, and we are still in the dark upon many points in regard to it, but we are coming more and more firmly to the conclusion that most of its symptoms are a part of, or at least incidents in, the fight of the body against the invading army. The flushed and reddened skin is due to the pumping of large quantities of blood through its mesh, in order that the poisons may be got rid of through the perspiration. The rapid pulse shows the vigor with which the heart is driving the blood around the body, to have its poisons neutralized in the liver, burned up in the lungs, poured out by the kidneys and the skin. The quickened breathing is the putting on of more blast in the lung poison-crematory. It is possible that even the rise of temperature has an injurious effect upon the invading germs or assists the body in their destruction.
In the past we have blindly fought all of these symptoms. We shut our patients up in stove-heated rooms with windows absolutely closed, for fear that they would "catch cold." We took off the sheets and piled blankets upon the bed, setting a special watch to see that the wretched sufferer did not kick them off. We discouraged the drinking of water and insisted on all drinks that were taken being hot or lukewarm. Nowadays all this is changed. We throw all the windows wide-open, and even put our patients out of doors to sleep in the open air, whether it be typhoid, tuberculosis, or pneumonia; knowing that not only they will not "catch cold," but that, as their hurried breathing indicates, they need all the oxygen they can possibly get, to burn up the poison poured out in the lungs and from the skin. We encourage the patient to drink all the cool, pure water he will take, sometimes gallons in a day, knowing that his thirst is an indication for flushing and flooding all the great systems of the body sewers. Instead of smothering him in blankets, we put him into cold packs, or put him to soak in cool water.
In short, we trust nature instead of defying her, cooeperate with her in place of fighting her,—and we have cut down the death-rate of most fevers fifty to seventy-five per cent already. Plenty of pure, cool water internally, externally, and eternally, rest, fresh air, and careful feeding, are the best febrifuges and antipyretics known to modern medicine. All others are frauds and simply smother a symptom without relieving its cause, with the exception of quinine in malaria, mercury, and the various antitoxins in their appropriate diseases, which act directly upon the invading organism.
Underneath all this storm and stress of the fever paroxysm, nature is quietly at work elaborating her antidote. In some marvelous fashion, which we do not even yet fully understand, the cells of the body are producing in ever-increasing quantities an anti-body, or antitoxin, which will unite with the toxin or poison produced by the hostile germs and render it entirely harmless. By a curious paradox of the process, it does not kill the germs themselves. It may not even stop their further multiplication. Indeed, it utilizes part of their products in the formation of the antitoxin; but it domesticates them, as it were—turns them from dangerous enemies into harmless guests.
The treaty between these germs and the body, however, is only of the "most-favored-nation" class; for let these tamed and harmless friends of the family escape and enter the body of another human being, and they will attack it as virulently as ever.
Now, where and how did nature ever succeed in getting the rehearsal and the practice necessary to build up such an extraordinary and complicated system of defense as this? Take your microscope and look at a drop of fluid from the mouth, the gums, the throat, the stomach, the bowels, and you will find it simply swarming with bacteria, bacilli, and cocci, each species of which numbers its billions. There are thirty-three species which inhabit the mouth and gums alone! We are literally alive with them; but most of them are absolutely harmless, and some of them probably slightly helpful in the processes of digestion. In fevers and infections the body merely applies to disease-germs the tricks which it has learned in domesticating these millions of harmless vegetable inhabitants.
Still more curious—there is a distinct parallel between the method in which food-materials are split up and prepared for assimilation by the body, and the method adopted in breaking up and neutralizing the toxins of disease-germs. It is now known that poisons are formed in the process of digesting and absorbing the simplest and most wholesome foods; and the liver uses the skill which it has gained in dealing with these "natural poisons" in disposing of the toxins of germs.
When a fever has run its course, as we now know nearly all infections do, within periods ranging from three or four days to as many weeks, it simply means that it has taken the liver and the other police-cells this length of time to handle the rioters and turn them into peaceable and law-abiding, even though not well-disposed citizens. In this process the forces of law and order can be materially helped by skillful and intelligent cooeperation. But it takes brains to do it and avoid doing more harm than good. It requires far more intelligence on the part of the doctor, the nurse, or the mother, skillfully to help nature than it did blindly to fight her.
This is what doctors and nurses are trained for nowadays, and they are of use in the sick-room simply because they have devoted more time and money to the study of these complicated processes than you have. Don't imagine that calling in the doctor is going to interfere with the natural course of the disease, or rob the patient of some chance he might have had of recovering by himself. On the contrary, it will simply give nature and the constitution of the patient a better chance in the struggle, probably shorten it, and certainly make it less painful and distressing.
If these symptoms of the summer fevers and fluxes are indicative of nature's attempts to cure, those of the winter's coughs and colds are no less clearly so. As we walk down the streets, we see staring at us in large letters from a billboard, "Stop that Cough! It is Killing you!" Yet few things could be more obvious to even the feeblest intelligence, than that this "killing" cough is simply an attempt on the part of the body to expel and get rid of irritating materials in the upper air-passages. As long as your larynx and windpipe are inflamed or tickled by disease-germs or other poisons, your body will do its best to get rid of them by coughing, or, if they swarm on the mucous membrane of the nose, by sneezing. To attempt to stop either coughing or sneezing without removing the cause is as irrational as putting out a switch-light without closing the switch. Though this, like other remedial processes, may go to extremes and interfere with sleep, or upset the stomach, within reasonable limits one of the best things to do when you have a cold is to cough. When patients with severe inflammations of the lungs become too weak or too deeply narcotized to cough, then attacks of suffocation from the accumulation of mucus in the air-tubes are likely to occur at any time. Young children who cannot cough properly, not having got the mechanism properly organized as yet, have much greater difficulty in keeping their bronchial tubes clear in bronchitis or pneumonia than have grown-ups. Most colds are infectious, like the fevers, and like them run their course, after which the cough will subside along with the rest of the symptoms. But simply stopping the cough won't hasten the recovery. Most popular "Cough-Cures" benumb the upper throat and stop the tickling; smother the symptoms without touching the cause. Many contain opium and thus load the system with two poisons instead of one.
Lastly, in the realm of the nervous system, take that commonest of all ills that afflict humanity—headache. Surely, this is not a curative symptom or a blessing in disguise, or, if so, it is exceedingly well disguised. And yet it unquestionably has a preventive purpose and meaning. Pain, wherever found, is nature's abrupt command, "Halt!" her imperative order to stop. When you have obeyed that command, you have taken the most important single step towards the cure. A headache always means something—overwork, under-ventilation, eye-strain, underfeeding, infection. Some error is being committed, some bad physical habit is being dropped into. There are a dozen different remedies that will stop the pain, from opium and chloroform down to the coal-tar remedies (phenacetin, acetanilid, etc.) and the bromides. But not one of them "cures," in the sense of doing anything toward removing the cause. In fact, on the contrary they make the situation worse by enabling the sufferer to keep right on repeating the bad habit, deprived of nature's warning of the harm that he is doing to himself. As the penalties of this continued law-breaking pile up, he requires larger and larger doses of the deadening drug, until finally he collapses, poisoned either by his own fatigue-products or by the drugs which he has been taking to deaden him against their effect.
In fine, follow nature's hints whenever she gives them: treat pain by rest, infections by fresh air and cleanliness, the digestive disturbances by avoiding their cause and helping the food-tube to flush itself clean; keep the skin clean, the muscles hard, and the stomach well filled—and you will avoid nine-tenths of the evils which threaten the race.
The essence of disease consists, not in either the kind or the degree of the process concerned, but only in its relations to the general balance of activities of the organism, to its "resulting in discomfort, inefficiency, or danger," as one of our best-known definitions has it. Disease, then, is not absolute, but purely relative; there is no single tissue-change, no group even of changes or of symptoms, of which we can say, "This is essentially morbid, this is everywhere and at all times disease."
Our attainment of any clear view of the essential nature of disease was for a long time hindered, and is even still to some degree clogged, by the standpoint from which we necessarily approached and still approach it, not for the study of the disease itself, but for the relief of its urgent symptoms. Disease presents itself as an enemy to attack, in the concrete form of a patient to be cured; and our best efforts were for centuries almost wasted in blind, and often irrational, attempts to remove symptoms in the shortest possible time, with the most powerful remedies at our disposal, often without any adequate knowledge whatever of the nature of the underlying condition whose symptoms we were combating, or any suspicion that these might be nature's means of relief, or that "haply we should be found to fight against God." There was sadly too much truth in Voltaire's bitter sneer, "Doctors pour drugs of which they know little, into bodies of which they know less"; and I fear the sting has not entirely gone out of it even in this day of grace.
And yet, relative and non-essential as all our definitions now recognize disease to be, it is far enough (God knows) from being a mere negative abstraction, a colorless "error by defect." It has a ghastly individuality and deadly concreteness,—nay, even a vindictive aggressiveness, which have both fascinated and terrorized the imagination of the race in all ages. From the days of "the angel of the pestilence" to the coming of the famine and the fever as unbidden guests into the tent of Minnehaha; from "the pestilence that walketh in darkness" to the plague that still "stalks abroad" in even the prosaic columns of our daily press, there has been an irresistible impression, not merely of the positiveness, but even of the personality of disease. And no clear appreciation can possibly be had of our modern and rational conceptions of disease without at least a statement of the earlier conceptions growing out of this personifying tendency. Absurd as it may seem now, it was the legitimate ancestor of modern pathogeny, and still holds well-nigh undisputed sway over the popular mind, and much more than could be desired over that of the profession.
The earliest conception of disease of which we have any record is, of course, the familiar Demon Theory. This is simply a mental magnification of the painfully personal, and even vindictive, impression produced upon the mind of the savage by the ravages of disease. And certainly we of the profession would be the last to blame him for jumping to such a conclusion. Who that has seen a fellow being quivering and chattering in the chill-stage of a pernicious malarial seizure, or tossing and raving in the delirium of fever, or threatening to rupture his muscles and burst his eyes from their sockets in the convulsions of tetanus or uraemia, can wonder for a moment that the impression instinctively arose in the untutored mind of the Ojibwa that the sufferer was actually in the grasp, and trying to escape from the clutch, of some malicious but invisible power? And from this conception the treatment logically followed. The spirits which possessed the patient, although invisible, were supposed to be of like passions with ourselves, and to be affected by very similar influences; hence dances, terrific noises, beatings and shakings of the unfortunate victim, and the administration of bitter and nauseous messes, with the hope of disgusting the demon with his quarters, were the chief remedies resorted to. And while to-day such conceptions and their resultant methods are simply grounds for laughter, and we should probably resent the very suggestion that there was any connection whatever between the Demon Theory and our present practice, yet, unfortunately for our pride, the latter is not only the direct lineal, historic descendant of the former, but bears still abundant traces of its lowly origin. It will, of course, be admitted at once that the ancestors of our profession, historically, the earliest physicians, were the priest, the Shaman, and the conjurer, who even to this day in certain tribes bear the suggestive name of "medicine men." Indeed, this grotesque individual was neither priest nor physician, but the common ancestor of both, and of the scientist as well. And, even if the history of this actual ancestry were unknown, there are scores of curious survivals in the medical practice of this century, even of to-day, which testify to the powerful influence of this conception. The extraordinary and disgraceful prevalence of bleeding scarcely fifty years ago, for instance; the murderous doses of calomel and other violent purges; the indiscriminate use of powerful emetics like tartar emetic and ipecac; the universal practice of starving or "reducing" fevers by a diet of slops, were all obvious survivals of the expulsion-of-the-demon theory of treatment. Their chief virtue lay in their violence and repulsiveness. Even to-day the tendency to regard mere bitterness or distastefulness as a medicinal property in itself has not entirely died out. This is the chief claim of quassia, gentian, calumbo, and the "simple bitters" generally, to a place in our official lists of remedies. Even the great mineral-water fad, which continues to flourish so vigorously, owed its origin to the superstition that springs which bubbled or seethed were inhabited by spirits (of which the "troubling of the waters" in the Pool of Bethesda is a familiar illustration). The bubble and (in both senses) "infernal" taste gave them their reputation, the abundant use of pure spring water both internally and externally works the cure, assisted by the mountain air of the "Bad," and we sapiently ascribe the credit to the salts. Nine-tenths of our cells are still submarine organisms, and water is our greatest panacea.
Then came the great "humoral" or "vital fluid" theory of disease which ruled during the Middle Ages. According to this, all disease was due to the undue predominance in the body of one of the four great vital fluids,—the bile, the blood, the nervous "fluid," and the lymph,—and must be treated by administering the remedy which will get rid of or counteract the excess of the particular vital fluid in the system. The principal traces of this belief are the superstition of the four "temperaments," the bilious, the sanguine, the nervous, and the lymphatic, and our pet term "biliousness," so useful in explaining any obscure condition.
Last of all, in the fullness of time,—and an incredibly late fullness it was,—under the great pioneer Virchow, who died less than a decade ago, was developed the great cellular theory, a theory which has done more to put disease upon a rational basis, to substitute logic for fancy, and accurate reasoning for wild speculation, than almost any discovery since the dawn of history. Its keynote simply is, that every disturbance to which the body is liable can be ultimately traced to some disturbance or disease of the vital activities of the individual cells of which it is made up. The body is conceived of as a cell-state or cell-republic, composed of innumerable plastid citizens, and its government, both in health and disease, is emphatically a government "of the cells, by the cells, for the cells." At first these cell-units were regarded simply as geographic sections, as it were, sub-divisions of the tissues, bearing much the same relation to the whole body as the bricks of the wall do to the building, or, from a little broader view, as the Hessians of a given regiment to the entire army. They were merely the creatures of the organism as a whole, its servants who lived but to obey its commands and carry out its purposes, directed in purely arbitrary and despotic fashion by the lordly brain and nerve-ganglia, which again are directed by the mind, and that again by a still higher power. In fact, they were regarded as, so to speak, individuals without personality, mere slaves and helots under the ganglion-oligarchy which was controlled by the tyrant mind, and he but the mouthpiece of one of the Olympians. But time has changed all that, and already the triumphs of democracy have been as signal in biology as they have been in politics, and far more rapid. The sturdy little citizen-cells have steadily but surely fought their way to recognition as the controlling power of the entire body-politic, have forced the ganglion-oligarchy to admit that they are but delegates, and even the tyrant mind to concede that he rules by their sufferance alone. His power is mainly a veto, and even that may be overruled by the usual two-thirds vote.
In fact, if we dared to presume to criticise this magnificent theory of disease, we would simply say that it is not "cellular" enough, that it hardly as yet sufficiently recognizes the individuality, the independence, the power of initiative, of the single constituent cell. It is still a little too apt to assume, because a cell has donned a uniform and fallen into line with thousands of its fellows to form a tissue in most respects of somewhat lower rank than that originally possessed by it in its free condition, that it has therefore surrendered all of its rights and become a mere thing, a lever or a cog in the great machine. Nothing could be further from the truth, and I firmly believe that our clearest insight into and firmest grasp upon the problems of pathology will come from a recognition of the fact that, no matter how stereotyped, or toil-worn, or even degraded, the individual cells of any tissue may have become, they still retain most of the rights and privileges which they originally possessed in their free and untrammeled am[oe]boid stage, just as in the industrial community of the world about us. And, although their industry in behalf of and devotion to the welfare of the entire organism is ever to be relied upon, and almost pathetic in its intensity, yet it has its limits, and when these have been transgressed they are as ready to "fight for their own hand," regardless of previous conventional allegiance, as ever were any of their ancestors on seashore or rivulet-marge. And such rebellions are our most terrible disease-processes, cancer and sarcoma. More than this: while, perhaps, in the majority of cases the cell does yeoman service for the benefit of the body, in consideration of the rations and fuel issued to it by the latter, yet in many cases we have the curious, and at first sight almost humiliating, position of the cell absorbing and digesting whatever is brought to it, and only turning over the surplus or waste to the body. It would almost seem as if our lordly Ego was living upon the waste-products, or leavings, of the cells lining its food-tube.
Let us take a brief glance at the various specializations and trade developments, which have taken place in the different groups of cells, and see to what extent the profound modifications which many of them have undergone are consistent with their individuality and independence, and also whether such specialization can be paralleled by actually separate and independent organisms existing in animal communities outside of the body. First of all, because furthest from the type and degraded to the lowest level, we find the great masses of tissue welded together by lime-salts, which form the foundation masses, leverage-bars, and protection plates for the higher tissues of the body. Here the cells, in consideration of food, warmth, and protection guaranteed to themselves and their heirs for ever by the body-state, have, as it were, deliberately surrendered their rights of volition, of movement, and higher liberties generally, and transformed themselves into masses of inorganic material by soaking every thread of their tissues in lime-salts and burying themselves in a marble tomb. Like Esau, they have sold their birthright for a mess of "potash," or rather lime; and if such a class or caste could be invented in the external industrial community, the labor problem and the ever-occurring puzzle of the unemployed would be much simplified. And yet, petrified and mummified as they have become, they are still emphatically alive, and upon the preservation of a fair degree of vigor in them depends entirely the strength and resisting power of the mass in which they are embedded, and of which they form scarcely a third. Destroy the vitality of its cells, and the rock-like bone will waste away before the attack of the body-fluids like soft sandstone under the elements. Shatter it, or twist it out of place, and it will promptly repair itself, and to a remarkable degree resume its original directions and proportions.
So little is this form of change inconsistent with the preservation of individualism, that we actually find outside of the body an exactly similar process, occurring in individual and independent animals, in the familiar drama of coral-building. The coral polyp saturates itself with the lime-salts of the sea-water, much as the bone-corpuscles with those of the blood and lymph, and thus protects itself in life and becomes the flying buttress of a continent in death.
In the familiar connective-tissue, or "binding-stuff," we find a process similar in kind but differing in the degree, so to speak, of its degradation.
The quivering responsiveness of the protoplasm of the am[oe]boid ancestral cell has transformed itself into tough, stringy bands and webs for the purpose of binding together the more delicate tissues of the body. It has retained more of its rights and privileges, and consequently possesses a greater amount of both biological and pathological initiative. In many respects purely mechanical in its function, fastening the muscles to the bones, the bones to each other, giving toughness to the great skin-sheet, and swinging in hammock-like mesh the precious brain-cell or potent liver-lobule, it still possesses and exercises for the benefit of the body considerable powers of discretion and aggressive vital action. Through its activity chiefly is carried out that miracle of human physiology, the process of repair. By the transformation of its protoplasm the surplus food-materials of the times of plenty are stored away within its cell-wall against the time of stress.
Whatever emergency may arise, nature, whatever other forces she may be unable to send to the rescue, can always depend upon the connective-tissues to meet it; and, of course, as everywhere the medal of honor has its reverse side, their power for evil is as distinguished as their power for good. From their ranks are recruited a whole army of those secessions from and rebellions against the body at large—the tumors, from the treacherous and deadly sarcoma, or "soft cancer," to the harmless fatty tumor, as well as the tubercle, the gumma of syphilis, the interstitial fibrosis of Bright's disease. They are the sturdy farmers and ever ready "minute-men" of the cell-republic, and we find their prototype and parallel in the external world, both in material structure and degree of vitality, in the well-known sponge and its colonies.
Next in order, and, in fact, really forming a branch of the last, we find the great group of storage-tissues, the granaries or bankers of the body-politic, distinguished primarily, like the capitalist class elsewhere, by an inordinate appetite, not to say greed. They sweep into their interior all the food-materials which are not absolutely necessary for the performance of the vital function of the other cells. These they form first into protoplasm, and then by a simple degenerative process it is transformed, "boiled down" as it were, into a yellow hydrocarbon which is capable of storage for practically an indefinite period. Not a very exalted function, and yet one of great importance to the welfare of the entire body, for, like the Jews of the Middle Ages, the fat-cells, possessing an extraordinary appetite for and faculty of acquiring surplus wealth in times of plenty, can easily be robbed of it and literally sucked dry in times of scarcity by any other body-cell which happens to need it, especially by the belligerent military class of muscle-cells. In fever or famine, fat is the first element of our body-mass to disappear; so that Proudhon would seem to have some biological basis for his demand for the per capita division of the fortunes of millionaires. And yet, rid the fat-cell of the weight of his sordid gains, gaunt him down, as it were, like a hound for the wolf-trail, and he becomes at once an active and aggressive member of the binding-stuff group, ready for the repair of a wound or the barring out of a tubercle-bacillus.
And this form of specialization has also its parallel outside of the body in one of the classes in a community of Mexican ants, whose most distinguishing feature is an enormously distended [oe]sophagus, capable of containing nearly double the weight of the entire remainder of the body. They are neither soldiers nor laborers, but accompany the latter in their honey-gathering excursions, and as the spoils are collected they are literally packed full of the sweets by the workers. When distended to their utmost capacity they fall apparently into a semi-comatose condition, are carried into the ant-hill, and hung up by the hind legs in a specially prepared chamber, in which (we trust) enjoyable position and state they are left until their contents are needed for the purposes of the community, when they are waked up, compelled to disgorge, and resume their ordinary life activities until the next season's honey-gathering begins. It scarcely need be pointed out what an unspeakable boon to the easily discouraged and unlucky the introduction of such a class as this into the human industrial community would be, especially if this method of storage could be employed for certain liquids.
Another most important class in the cell-community is the great group of the blood-corpuscles, which in some respects appear to maintain their independence and freedom to a greater degree than almost any other class which can be found in the body. While nearly all other cells have become packed or felted together so as to form a fixed and solid tissue, these still remain entirely free and unattached. They float at large in the blood-current, much as their original ancestor, the am[oe]ba, did in the water of the stagnant ditch. And, curiously enough, the less numerous of the two great classes, the white, or leucocytes, are in appearance, structure, pseudopodic movements, and even method of engulfing food, almost exact replicas of their most primitive ancestor.
There is absolutely no fixed means of communication between the blood-corpuscles and the rest of the body, not even by the tiniest branch of the great nerve-telegraph system, and yet they are the most loyal and devoted class among all the citizens of the cell-republic. They are called hither and thither partly by messenger-substances thrown into the blood, known as hormones, partly by the "smell of the battle afar off," the toxins of inflammation and infection as they pour through the blood.
The red ones lose their nuclei, their individuality, in order to become sponges, capable of saturating themselves with oxygen and carrying it to the gasping tissues. The white are the great mounted police, the sanitary patrol of the body. The moment that the alarm of injury is sounded in a part, all the vessels leading to it dilate, and their channels are crowded by swarms of the red and white hurrying to the scene. The major part of the activity of the red cells can be accounted for by the mechanism of the heart and blood-vessels. They are simply thrown there by the handful and the shovelful, as it were, like so many pebbles or bits of chalk.
But the behavior of the white cells goes far beyond this. We are almost tempted to endow them with volition, though they are of course drawn or driven by chemical and physical attractions, like iron-filings by a magnet, or an acid by a base. Not only do all those normally circulating in the blood flowing through the injured part promptly stop and begin to scatter themselves through the underbrush and attack the foe at close quarters, but, as has been shown by Cabot's studies in leucocytosis, the moment that the red flag of fever is hoisted, or the inflammation alarm is sounded, the leucocytes come rushing out from their feeding-grounds in the tissue-interspaces, in the lymph-channels, in the great serous cavities, and pour themselves into the blood-stream, like minute-men leaving the plough and thronging the highways leading towards the frontier fortress which has been attacked. Arrived at the spot, if there be little of the pomp and pageantry of war in their movements, their practical devotion and heroism are simply unsurpassed anywhere, even in song and story. They never think of waiting for reinforcements or for orders from headquarters. They know only one thing, and that is to fight; and when the body has brought them to the spot, it has done all that is needed, like the Turkish Government when once it has got its sturdy peasantry upon the battlefield: they have not even the sense to retreat. And whether they be present in tens, or in scores, or in millions, each one hurls himself upon the toxin or bacillus which stands directly in front of him. If he can destroy the bacillus and survive, so much the better; but if not, he will simply overwhelm him by the weight of his body-mass, and be swept on through the blood-stream into the great body-sewers, with the still living bacillus literally buried in his dead body. Like Arnold Winkelried, he will make his body a sheath for a score of the enemy's spears, so that his fellows can rush in through the gap that he has made. And it makes no difference whatever if the first ten or hundred or thousand are instantly mowed down by the bacillus or its deadly toxins, the rear ranks sweep forward without an instant's hesitation, and pour on in a living torrent, like the Zulu impis at Rorke's Drift, until the bacilli are battered down by the sheer impact of the bodies of their assailants, or smothered under the pile of their corpses. When this has happened, in the language of the old surgeon-philosophers, "suppuration is established," and the patient is saved.
Or if, as often happens, an antitoxin is formed, which protects the whole body, this is largely built out of substances set free from the bodies of slain leucocytes. And the only thing that dims our vision to the wonder and beauty of this drama, is that it happens every day, and we term it prosaically "the process of repair," and expect it as a matter of course. Every wound-healing is worthy of an epic, if we could only look at it from the point of view of these citizens of our great cell-republic. And if we were to ask the question, "Upon what does their peculiar value to the body-politic depend?" we should find that it was largely the extent to which they retained their ancestral characteristics. They are born in the lymph-nodes, which are simply little islands of tissue of embryonic type, preserved in the body largely for the purpose of breeding this primitive type of cells. They are literally the Indian police, the scavengers, the Hibernians, as it were, of the entire body. They have the roving habits and fighting instincts of the savage. They cruise about continually through the waterways and marshes of the body, looking for trouble, and, like their Hibernian descendants, wherever they see a head they hit it. They are the incarnation of the fighting spirit of our ancestors, and if it were not for their retention of this characteristic in so high a degree, many classes of our fixed cells would not have been able to subside into such burgher like habits.
Although even here, as we shall see, it is only a question of quickness of response, for while the first bands of the enemy may be held at bay by the leucocyte cavalry, and a light attack repelled by their skirmish-line, yet when it comes to the heavy fighting of a fever-invasion, it is the slow but substantial burgher-like fixed cells of the body which form the real infantry masses of the campaign. And I believe that upon the proportional relation between these primitive and civilized cells of our body-politic will depend many of the singular differences, not only in degree but also in kind, in the immunity possessed by various individuals. While some surgeons and anatomists will show a temperature from the merest scratch, and yet either never develop any serious infection or display very high resisting power in the later stages, others, again, will stand forty slight inoculations with absolute impunity, and yet, when once the leucocyte-barrier is broken down, will make apparently little resistance to a fatal systemic infection. And this, of course, is only one of a score of ways in which the leucocytes literally pro patria moriuntur. Our whole alimentary canal is continually patrolled by their squadrons, poured into it by the tonsils above and Peyer's patches below; if it were not for them we should probably be poisoned by the products of our own digestive processes.
If, then, the cells of the body-republic retain so much of their independence and individuality in health, does it not seem highly probable that they do also in disease? This is known to be the case already in many morbid processes, and their number is being added to every day. The normal activities of any cell carried to excess may constitute disease, by disturbing the balance of the organism. Nay, most disease-processes on careful examination are found to be at bottom vital, often normal to the cells concerned in them. The great normal divisions of labor are paralleled by the great processes of degeneration into fat, fibrous tissue, and bone or chalk. A vital chemical change which would be perfectly healthy in one tissue or organ, in another may be fatal.
Ninety-nine times out of a hundred any group of cells acts loyally in the interests of the body; once in a hundred some group acts against them, and for its own, and disease is the result. There is a perpetual struggle for survival going on between the different tissues and organs of the body. Like all other free competition, as a rule, it inures enormously to the benefit of the body-whole. Exceptionally, however, it fails to do so, and behold disease. This struggle and turmoil is not only necessary to life—it is life. Out of the varying chances of its warfare is born that incessant ebb and flow of chemical change, that inability to reach an equilibrium, which we term "vitality." The course of life, like that of a flying express train, is not a perfectly straight line, but an oscillating series of concentric curves. Without these oscillations movement could not be. Exaggerate one of them unduly, or fail to rectify it by a rebound oscillation, and you have disease.
Or it is like the children's game of shuttlecock. So long as the flying shuttle keeps moving in its restless course to and fro, life is. A single stop is death. The very same blow which, rightly placed, sends it like an arrow to the safe centre of the opposing racket, if it fall obliquely, or even with too great or too little force, drives it perilously wide of its mark. It can recover the safe track only by a sudden and often violent lunge of the opposing racket. The straight course is life, the tangent disease, the saving lunge recovery.
One and the same force produces all.
In the millions of tiny blows dealt every minute in our body-battle, what wonder if some go wide of the mark!
OUR LEGACY OF HEALTH: THE POWER OF HEREDITY IN THE PREVENTION OF DISEASE
The evil in things always bulks large in our imaginations. It is no mere coincidence that the earliest gods of a race are invariably demons. Our first conception of the great forces of nature is that they are our enemies. This misconception is not only natural, but even necessary on the sternest of physical bases. The old darky, Jim, in Huckleberry Finn, hit upon a profound and far-reaching truth when he replied in answer to Huck's question whether among all the signs and portents with which his mind was crammed—like black cats and seeing the moon over your left shoulder and "harnts"—some were not indications of good luck instead of all being of evil omen:—
"Mighty few—an' dey ain't no use to a body. What fur you want to know when good luck's a-comin'? Want to keep it off?"
It isn't the good, either in the forces of nature or in our fellows, that keeps us watchful, but the evil. Hence our proneness to declare in all ages that evil is stronger than good and that "all men are liars." One injury done us by storm, by sunstroke, by lightning-flash, will make a more lasting impression upon our memories than a thousand benefits conferred by these same forces. Besides, evil has to be sharply looked out for and guarded against. Well enough can be safely let alone.
The conviction is steadily growing, among both physicians and biologists, that this attitude has caused a serious, if not vital, misconception of the influence of that great conservative and preservative force of nature—heredity. We hear a great deal of hereditary disease, hereditary defect, hereditary insanity, but very little of hereditary powers of recovery, of inherited vigor, and the fact that ninety-nine and seven-tenths per cent of us are sane.
One instance of hereditary defect, of inherited degeneracy, fills us with horror and stirs us to move Heaven and earth to prevent another such. The inheritance of vigor, of healthfulness, and of sanity we placidly accept as a matter of course and bank upon it in our plans for the future, without so much as a thank you to the force that underlies it.
When once we clear away these inherited misconceptions and look the facts of the situation squarely in the face, we find that heredity is at least ten times as potent and as frequently concerned in the transmission and securing of health and vigor as of disease and weakness; that its influence on the perpetuation of bodily and mental defects has been enormously exaggerated and that there are exceedingly few hereditary diseases.
It is not necessary for our present purpose to enter into a discussion of the innumerable theories of that inevitable tendency of like to beget like, of child to resemble parent, which we call heredity. One reference, however, may be permitted to the controversy that has divided the scientific world: whether acquired characters, changes occurring during the lifetime of the individual, can be inherited. Disease is nine times out of ten an acquired character; hence, instead of the probabilities being that it would be inherited, the balance of evidence to date points in exactly the opposite direction. The burden of proof as to the inheritance of disease is absolutely upon those who believe in its possibility.
Another fundamental fact which renders the inheritance of disease upon a priori grounds improbable and upon practical grounds obviously difficult, is that characters or peculiarities, in order to be inherited certainly for more than a few generations, must be beneficial and helpful in the struggle. A moment's reflection will show this to be mathematically necessary, in that any family or race which tended to inherit defects and injurious characters would rapidly go down in the struggle for survival and become extinct. An inherited disease of any seriousness could not run for more than two or three generations in any family, simply for the reason that by the end of that time there would be no family left for it to run in. A slight defect or small peculiarity of undesirable character might run for a somewhat longer period, but even this would tend toward disappearance and elimination by the stern, selective influence of environment.
Naturally, this great conservative tendency of nature has, like all other influences, "the defects of its virtues," as the French say. It has no gifts of prophecy, and in the process of handing down to successive generations those mechanisms and powers which have been found useful in the long, stern struggle of the past, it will also hand down some which, by reason of changes in the environment, are not only no longer useful, but even injurious. As the new light of biology has been turned on the human body and its diseases, it has revealed so many of these "left-overs," or remnants in the body-machine—some of most dramatic interest—that they at first sight have done much to justify the popular belief in the malignant tendencies of heredity.
Yet, broadly considered, the overwhelming majority of them should really be regarded as honorable scars, memorials of ancient victories, monuments to difficulties overcome, significant and encouraging indications of what our body-machine is still capable of accomplishing in the way of further adjustment to conditions in the future. The really surprising thing is not their number, but the infrequency with which they give rise to serious trouble.
The human automobile is not only astonishingly well built, with all the improvements that hundreds of thousands of generations of experience have been able to suggest, but it is self-repairing, self-cleaning, and self-improving. It never lets itself get out of date. If only given an adequate supply of fuel and water and not driven too hard, it will stand an astonishing amount of knocking about in all kinds of weather, repairing itself and recharging its batteries every night, supplying its own oil, its own paint and polish, and even regulating its own changes of gear, according to the nature of the work it has to do. Simply as an endurance racer it is the toughest and longest-winded thing on earth and can run down and tire out every paw, pad, or hoof that strikes the ground—wolf, deer, horse, antelope, wild goat. This is only a sample of its toughness and resisting power all along the line.
These wide powers of self-support and adjustment overbalance a hundred times any little remnant defects in its machinery or gearing. Easily ninety-nine per cent of all our troubles through life are due to inevitable wear and tear, scarcity of food-fuel, of water, of rest, and external accidents—injuries and infectious diseases. Still, it occasionally happens that these little defects may furnish the point of least resistance at which external stresses and strains will cause the machine to break down. They are often the things which prevent us from living and "going to pieces all at once, all at once and nothing fust, just as bubbles do when they bust," like the immortal One-Hoss Shay. It is just as well that they should, for, of all deaths to die, the loneliest and the most to be dreaded is that by extreme old age.
These vestigia or remnants—instances of apparently hidebound conservatism on nature's part—are very much in the public eye at present, partly on account of their novelty and of their exceptional and extraordinary character. Easily first among these trouble-breeding remnants is that famous, or rather notorious, scrap of intestine, the appendix vermiformis, an obvious survival from that peaceful, ancestral period when we were more largely herbivorous in our diet and required a longer and more complicated food-tube, with larger side pouches in the course of it, to dissolve and absorb our food. Its present utility is just about that of a grain of sand in the eye. Yet, considering that it is present in every human being born into the world, the really astonishing thing is not the frequency with which it causes trouble, but the surprisingly small amount of actual damage that arises from it. Never yet in even the most appendicitis-ridden community has it been found responsible for more than one half of one per cent of the deaths.
Then there is that curious and by no means uncommon tendency for a loop of the intestine to escape from the abdominal cavity, which we call hernia. This is one of a fair-sized group of dangers clearly due to the assumption of the erect position and our incomplete adjustment thereto. In the quadrupedal position this necessary weak spot—a partial opening through the abdominal wall—was developed in that region which was highest from the point of view of gravity and least exposed to strain. In the bipedal position it becomes lowest and most exposed; hence the much greater frequency of hernia in the human species as compared with any of the animals.
Another fragment, of the impertinence of whose presence many of us have had painful proof, is the third or last molar, so absurdly misnamed the wisdom tooth. If there be any wisdom involved in its appearance it is of the sort characterized by William Allen White's delicious definition: "That type of ponderous folly of the middle-aged which we term 'mature judgment.'" The last is sometimes worst as well as best, and this belated remnant is not only the last to appear, but the first to disappear. In a considerable percentage of cases it is situated so far back in the jaw that there is no room for it to erupt properly, and it produces inflammatory disturbances and painful pressure upon the nerves of the face and the jaw.
Even when it does appear it is often imperfectly developed, has fewer cusps and fewer roots than the other molars, is imperfectly covered with enamel and badly calcified. In no small percentage of cases it does not meet its fellow of the jaw below and hence is almost useless for purposes of mastication. But it comes in every child born into the world, simply because at an earlier day, when our jaws were longer—to give our canine teeth the swing they needed as our chief weapons of defense—there was plenty of room for it in the jaw and it was of some service to the organism. If the Indiana State Legislature would only pass a law prohibiting the eruption of wisdom teeth in future, and enforce it, it would save a large amount of suffering, inconvenience, and discomfort, with little appreciable lack of efficiency!
In this list of admitted charges against heredity must also come the gall-bladder, that curious little pouch budded out from the bile ducts, which has so little known utility as compared with its possibility as a starting-point for inflammations, gall-stones, and cancer.
Then there is that disfiguring facial defect, hare-lip, due to a failure of the three parts of which our upper jaw is built to unite properly,—this triple construction of the jaw being an echo of ancestral fishlike and reptilian times when our jaws were built in five pieces to permit of wide distention in the act of swallowing our prey alive. All over the surface of the body are to be found innumerable little sebaceous glands originally intended to lubricate hairs, which have now atrophied and disappeared. These useless scraps, under various forms of irritation, both external and internal, become inflamed and give rise to pimples, acne, or "a bad complexion."
And so the list might be drawn out to most impressive length. But this length would be no indication of its real importance, inasmuch as the vast majority of entries upon it would come under the head of pathological curiosities, or conditions which were chiefly interesting on account of their rareness and unusual character. With the exception of the appendix, the gall-bladder, and hernia, these vestigial conditions may be practically disregarded as factors in the death-rate.
In the main, when the fullest possible study and recognition have been made of all the traces of experimentation and even of ancient failure that are to be found in this Twentieth Century body-machine of ours, the resulting impression is one of enormously increased respect for and confidence in the machine and its capabilities. While they are of great interest as indicating what the past history and experiences of the engine have been, and of highest value as enabling us to interpret and even anticipate certain weak spots in its construction and joints in its armor, their most striking influence is in the direction of emphasizing the enormous elasticity and resourcefulness of the creature.
Not only has it met and survived all these difficulties, but it is continuing the selfsame processes to-day. So far as we are able to judge, it is as young and as adaptable as it ever was, and just as ready to "with a frolic welcome greet the thunder and the sunshine" as it ever was in the dawn of history.
These ancestral and experimental flaws, even when unrecognized and unguarded against, have probably not at any time been responsible for more than one or two per cent of the body's breakdowns; while, on the other hand, every process with which it fights disease, every trick of strategy which it uses against invading organisms, every step in the process of repair after wounds or injury, is a trick which it has learned in its million-year battle with its surroundings.
Take such a simple thing as the mere apparently blind habit possessed by the blood of coagulating as soon as it comes in contact with the edges of a cut or torn blood-vessel, and think what an enormous safeguard this has been and is against the possibility of death by hemorrhage. So well is it developed and so rapidly does it act that it is practically impossible to bleed some animals to death by cutting across any vessel smaller than one of the great aortic trunks. The rapidity and toughness of the clotting, combined with the other ancestral tricks of lowering the blood pressure and weakening down the heart, are so immensely effective that a slash across the great artery of the thigh in the groin of a dog will be closed completely before he can bleed to death. So delicate and so purposeful is this adjustment that the blood will continue as fluid as milk for ten, twenty, forty, eighty years—as long as it remains in contact with healthy blood-vessels. But the instant it is brought in contact with a broken or wounded piece of a vessel-wall, that instant it will begin to clot. So inevitable is this result that it gives rise to some of the sudden forms of death by bloodclot in the brain or lung (apoplexy, "stroke"), the clot having formed upon the roughened inner surface of the heart or of one of the blood-vessels and then floated into the brain or lung.
Then take that matchless and ingenious process of the healing of wounds, whose wondrousness increases with every step that we take into the deeper details of its study. First, the quick outpouring and clotting of the blood after enough has escaped to wash most poisonous or offending substances out of the wound. This living, surgical cement, elastic, self-moulding, soothing, not only plugs the cut or torn mouths of the blood-vessels, but fills the gap of the wound level with the surface. Here, by contact with the air and in combination with the hairs of the animal it forms a tough, firm, protective coating or scab, completely shutting out cold, heat, irritants, or infectious germs.
Into the wedge-shaped, elastic clot which now fills the wound from bottom to top like jelly in a mould, the leucocytes or white blood-cells promptly migrate and convert it into a mesh of living cells. They are merely the cavalry and skirmishers of the repair brigade and are quickly followed by the heavy infantry of the line in the shape of cells born of the injured tissues on either side of the wound. These join hands across the gap, the engineer corps and the commissariat department move up promptly to their support in the form of little vein-construction switches, which bud out from the wounded blood-vessels. The clot is transformed into what we term granulation tissue and begins to organize. A few days later this granulation tissue begins to contract and pull the lips of the wound together. If the gap has not been too wide the wound will be completely closed, its lips and deeper parts drawn together in nearly perfect line, separated only by a thin scar on the surface with a vertical keel of scar tissue descending from it. If the lips cannot be drawn together and there be no surgical skill at hand to assist them with stitches or bandages, then the gap will be filled up by the fibrous transformation of this granulation tissue and a thick, heavy scar result. Meanwhile, the skin-cells of the surface have not been idle, but are budding out on either side of the healing wound, pushing a little line of colonists forward across the raw surface. In longer or shorter time, according to the width of the gap, these two lines meet, and the site of our wound or the scar that it has left is perfectly coated over with a layer of healthy skin. This drama has occurred so many score of times in every one of us that custom has blinded our eyes to its ingenious perfection, but it took a million years to bring it to its present finish.
It may be a healthy corrective to our overweening conceit to remind ourselves that, remarkable and valuable as it is, it is a mere infant in arms compared to the superb powers of replacement and repair possessed by our more remote ancestors. Most invertebrates and many of the lowest two classes of backboned animals, the fishes and the amphibians, cannot merely stop up a rent, but renew an entire limb, fin,—yes, even eye or head. Cut an earthworm in two and the rear half will grow a new head and the front half a new tail. It may even be cut in four or five segments, each of which will proceed to form a head at one end and a tail at the other. The lobster can regrow a complete gill and any number of claws or an eye. A salamander will reproduce a foot and part of a limb. Take out the crystalline lens in the eye of a salamander and the edge of the iris, or colored part of the eye, will grow another lens. Take out both the lens and the iris and the choroid coat of the eye will reproduce both.
We are in the A, B, C class in powers of repair by comparison with the angleworm, the lobster, or the salamander. Yet we are not without gruesome echoes of this lost power of regeneration in that our whole brood of tumors, including the deadly cancer and sarcoma, are due to a strange resumption, on the part of some little knot of our body-cells, of the power of reproducing themselves or the organ in which they are situated, without any regard to the welfare of the rest of the body. Cancer is, in one sense, a throwing off of the allegiance to the body-state and a resumption of amphibian powers of independent growth on the part of certain groups of our body-cells—literally, a "rebellion of the cells."
These are but a handful of scores of instances that could be adduced, showing that the majority of the processes upon which we rely in combating disease and preserving life are the result of the hereditary experiences of our cells. Intelligent physicians are receding completely from that curiously warped and jaundiced view which led us to regard heredity chiefly as a factor in the production of disease. It was, perhaps, natural enough, since it was inevitably only its injurious, or, so to speak, malicious, effects which were brought to our attention to be corrected. But, just as in the growth of our ethnic religions it is Evil that is worshiped first as strongest and most aggressive, and the recognition of the greater power of good comes only at a later stage, so it has been in pathology.
Not only do we regard heredity as a comparatively small and steadily receding factor in the production of disease, but we fully and frankly recognize it as the strongest and most important single force in its prevention. All our processes of repair, all the reactions of the body against the attack of accident or of disease, are hereditary endowments, worked out with infinite pains and labor through tens of thousands of generations. The utmost that we can do with our drugs and remedies is to appeal to and rouse into action the great healing power of nature, the classic "Vis medicatrix Naturae," an incarnation of our past experiences handed down by heredity. Enormously valuable and important as are the services to human welfare, health, and happiness which can be rendered by the destruction of the living external causes of disease and the prevention of contagion, our most permanent and substantial victories are won by appealing to and increasing this long-descended and hard-won power of individual resistance.
"But," says some one at once, "I thought there were a large number of hereditary diseases." Fifty years ago there were a score of such, twenty years ago the score had sunk to five or six. Now there is scarcely one left. There is no known disease which is directly inherited as such. There is scarcely even a disease in which we now regard heredity as playing a dominant or controlling part. Among the few diseases in which there is serious dispute as to this are tuberculosis, insanity, epilepsy, and cancer.
Then there are diseases which for a long time puzzled us as to the possibility of their inheritance, but which have now resolved themselves clearly into instances of the fact that a mother who happens to contract an acute infectious disease of any sort may communicate that disease to the unborn child. If this occurs at an early stage of development the child will naturally be promptly killed. In fact, this is the almost invariable result in smallpox and yellow fever. If, on the other hand, development be further advanced or the infection be of a milder character, like scarlet fever or syphilis, the child may be born suffering with the disease or with the virus in its blood, which will cause the disease to develop within a few days after birth. This, however, is clearly not inheritance at all, but direct infection. We no longer use the term hereditary syphilis but have substituted for it the word congenital, which simply means that a child is born with the disease.
There is no such thing as this disease extending "unto the third and fourth generation," like the wrath of Jehovah. One fact must, of course, be remembered, which has probably proved a source of confusion in the popular mind, and that is its extraordinary "long-windedness." It takes not merely two or three weeks or months to develop its complete drama, but anywhere from three to thirty years, so that it is possible for a child to be born with the taint in its blood and yet not exhibit to the non-expert eye any sign of the disease until its eighth, twelfth, or even fifteenth year.
The case of tuberculosis is almost equally clear-cut. In all the thousands of post-mortem examinations which have been held upon newborn children and upon mothers dying in or shortly after childbirth, the number of instances of the actual transference of the bacilli of tuberculosis from mother to child could be counted upon the fingers of two hands. It is one of the rarest of pathologic curiosities and, for practical purposes, may be entirely disregarded. When tuberculosis appears in several members of a family, in eight cases out of ten it is due to direct infection from parents or older children. This is strikingly brought out in the admirable work done by the Associated Dispensaries for Tuberculosis of the Charity Organization Society of New York.
One of the first steps in advance which they took was to establish in connection with every clinic for tuberculosis an attendant nurse, whose duty it was to visit the patients at their homes and advise and instruct them as to improvements in their methods of living, ventilation, food, and the prevention of infection.
It was not long before these intelligent women began to bring back reports of other cases in the same family. Now the procedure is regularly adopted, whenever a case presents itself, of rounding up the remainder of the family group for examination, with the astounding result that where a mother or father is tuberculous, from twenty to sixty per cent of the children will be found to be suffering from some form of the infection. Instances of three infected children out of five living in the same room with a tuberculous mother are actually on record.
No one can practice long in any of our great climatic health resorts for tuberculosis, like Colorado or the Pacific Slope, without coming across scores of painful and distressing instances of children of tuberculous parents dying suddenly in convulsions from tuberculous meningitis, or by a wasting diarrh[oe]a from tuberculosis of the bowels, or from a violent attack of distention of the bowels due to tuberculous peritonitis. The favorite breeding-place of the tubercle bacillus is unfortunately in the home.
On the other hand, while the vast majority of cases of so-called hereditary tuberculosis are due to direct infection, and may be prevented by proper disposal of the sputum and other methods for avoiding contagion, there is probably a hereditary element in the spread of tuberculosis to this degree: that, inasmuch as all of us have been exposed to the attack and invasion of the tubercle bacillus, not merely scores, but hundreds of times, and have been able to resist or throw off that attack without apparent injury, the development of an invasion of the tubercle bacillus sufficiently extensive to endanger life is, in nine cases out of ten, in itself a proof of lowered resisting power on the part of the patient. This may be, and often is, only temporary, due to overwork, underfeeding, overconfinement, or that form of gradual suffocation which we politely term inadequate ventilation.
In a certain percentage of cases, however, it is due to a chronic lack of vigor and vitality; a lowering of the whole systemic tone, which may have existed from birth. In that case it is hardly to be expected that such an individual, becoming a parent, will be able to transmit to his or her offspring more vigor than he originally possessed. It is therefore probable that the children of a considerable percentage of tuberculous parents would not possess the same degree of resisting power against tuberculosis, or any other infection, as the average individual.
It is doubtful whether this factor of inherited lowered resistance plays any very important part in the propagation of tuberculosis, partly because it is comparatively seldom that consumptive marries consumptive, and such tendencies to lowered vigor and vitality as may be transmitted by one parent will be neutralized by the other; partly also because, by the superb and beneficent logic of nature, the pedigree of any disease is of the most mushroom and insignificant length, while the pedigree of health stretches back to the very dawn of time. In the struggle for dominance which takes place between the germ cells of the father and those of the mother, the chances are at least ten to one in favor of the old ancestral traits of vigor, of resisting power, and of survival. How deeply this idea is implanted in the convictions of the scientific world, the bitterly and widely debated biologic question whether acquired characters or peculiarities can under any circumstances be inherited clearly shows. Victory for the present rests with those who deny the possibility of such inheritance, and disease is emphatically an acquired character.
Truth here, as everywhere, probably lies between the extremes, and both biologists and the students of disease have arrived at practically the same working compromise, namely, that while no gross defect, such as a mutilation, nor definite disease factor, such as a germ, nor even a cancer, can possibly be inherited, yet, inasmuch as the two cells, which by their development form the new individual, are nourished by the blood of the maternal body, influences which affect the nutritiousness or healthfulness of that blood may unfavorably influence the development of the offspring.
Disease cannot be inherited any more than a mutilating defect, but the results of both, in so far as they affect the nutrition of the offspring in the process of formation, may be transmitted, though to a very much smaller extent than we formerly believed. In the case of tuberculosis, if the mother, during the months that she is building up the body and framework of a child, is in a state of reduced or lowered nutrition on account of consumption or any other disease, or has her tissues saturated with the toxins of this disease, it is hardly to be expected that the development of the child will proceed with the same perfection as it would under perfectly normal maternal surroundings.
However, even this influence is comparatively small; for one of the most marvelous things in nature is the perfection of the barrier which she has erected between the child before birth and any injurious conditions which may occur in the body of the mother. Here preference, so to speak, is given to the coming life, and whenever there is a contest for an adequate supply of nutrition, as, for instance, in cases of underfeeding or of famine, it is the mother who will suffer in her nutrition rather than the child. The unborn child, biologically considered, feeds upon the best she has to offer, rejecting all that is inferior, doing nothing and giving nothing in return.
How perfectly the coming generation is protected under the most unfavorable circumstances we have been given a striking object-lesson in one family of the lower animals. In the effective crusade against tuberculosis in dairy cattle waged by the sanitary authorities in Denmark, it was early discovered that the greatest practical obstacle to the extermination of tuberculosis in cattle was the enormous financial sacrifice involved in killing all animals infected. The disease was at that time particularly rife among the high-bred Jersey, Holstein, and other milking breeds. It was determined as a working compromise to test the truth of the modern belief that tuberculosis was transmitted only by direct infection, by permitting the more valuable cows to be saved alive for breeding purposes. They were isolated from the rest of the herd and given the best of care and feeding. The moment that their calves were born they were removed from them altogether and brought up on the milk of perfectly healthy cows. The milk of the infected cows was either destroyed or sterilized and used for feeding pigs.
The results were brilliantly successful. Scarcely one of the calves thus isolated developed tuberculosis in spite of their highly infected ancestry. And not only were they not inferior in vigor and perfection of type to the remainder of their breed, but some of them have since become prize-winners. The additional care and more abundant feeding that they received more than compensated for any problematic defect in their heredity.
As to the heredity of cancer, all that can be said is that the burden of proof rests upon those who assert it. It is really curious how widespread the belief is that cancer "runs in families," and how exceedingly slender is the basis of evidence for such a belief. There are so many things that we do not know about cancer that any positive statement of any kind would be unbecoming. It would be absurd to declare that a disease, of which the cause is still unknown, either is or is not inherited. And this is our position in regard to cancer. An overwhelming majority of the evidence so far indicates that it is not a parasite; if it were, of course, we could say positively that it is not inherited. Although we are getting a discouraging degree of familiarity with the process and clearly recognize that it consists chiefly in the sudden revolt or rebellion of some group of cells, a tendency which quite conceivably might be transmitted to future generations, yet it is highly improbable, on both biological and pathological grounds, that such is the case. If this rebellious tendency were transmitted we should at least have the right to expect that it would appear in the cells of the same organ or region of the body. It is a singular fact that in all the hundreds of cases in which cancer has appeared in the child of a cancerous parent it has almost invariably appeared in some different organ from that affected in the parent.
For instance, cancer of the lip in the father may be followed by cancer of the liver in the son or daughter, while cancer of the breast in the mother will be followed by cancer of the lip in a son. Further than this, the percentage of instances in which cancer appears in more than one member of a family is decidedly small, considering the frequency of the disease.
I took occasion to look into the matter carefully from a statistical point of view some ten or twelve years ago, and out of a collection of some fifty thousand cases of cancer less than six per cent were found to give any history of cancer in the family. And this, of course, simply means that some one of the relatives of the patient had at one time developed the disease.
In fact, the consensus of intelligent expert opinion upon the subject of heredity of cancer is, that though it may occur, we have comparatively little proof of the fact; that the percentage of cases in which there is cancer in the family is but little larger than might be expected on the doctrine of probabilities from the average distribution. Though possibly the offspring of a cancerous individual may display a slightly greater tendency toward the development of that strange, curious process of "autonomy" than the offspring of the average individual, this tendency is so small and occurs so infrequently as to be a factor of small practical importance in the propagation and spread of the disease.
In insanity and epilepsy we have probably the last refuge and almost only valid instance of the old belief in the remorseless heredity of disease. But even here the part played by heredity is probably only a fraction of that which it is popularly, and even professionally, believed to play. It is, of course, obvious that diseases which tend quickly to destroy the life of the patient, especially those which kill or seriously cripple him before he has reached the age of reproduction, or prevent his long surviving that epoch, will not, for mechanical reasons, become hereditary. The Black Death, or the cholera, for instance, could not "run in a family." Supposing that children were born with a special susceptibility to this disease, there would obviously soon be no family left.
The same is true in a lesser degree of milder or more chronic diseases. The family which was hereditarily predisposed to scarlet fever, measles, smallpox, or tuberculosis would not last long, and in fact the whole progress of civilization has been a continuous process of the weeding out of those who were most susceptible and the survival of those who were least so.
But when we come to deal with certain conditions, fortunately rare, such as functional disturbances of the nervous system, which neither seriously unfit their possessor for the struggle of life nor prevent him from reproducing his kind, then it becomes possible that a tendency to such disease may be transmitted through several successive generations.
Such is the case with insanity, with epilepsy, with hemophilia, or "bleeders," and with certain rare and curious disturbances of the nervous system, such as the hereditary ataxias and "tics" of various sorts. However, even here the only conditions on which these diseases can continue to run in a family for more than one or two generations is either that they shall be mild in form or that only a comparatively small percentage of the total family shall be affected by them. If, for instance, two-thirds, one-half, or even a third of the descendants of a mentally unsound individual were to become insane, it would only need a few generations for that family to be crushed to the wall.
While the descendants of insane persons are distinctly more liable to become insane than the rest of the community, yet, on account of their fewness, this tendency probably does not account for more than a small fraction of the total insanity. We should, by all means, prevent the marriage of the insane and discourage that of their children, and the development of any well-defined form of insanity should act at once, ipso facto, as a ground and cause of divorce.
But the consoling fact remains that even of such children, providing, of course, as usually happens, that the other parent—husband or wife—is sound and sane, not more than ten or fifteen per cent would probably become insane. In other words, insanity is acquired and the result of individual stress and strain at least five times as frequently as it is inherited. We have absolutely no rational or statistical basis for gloomy predictions that, at present rates, within a couple of centuries more, we shall all be shut up in asylums with nobody left to support us and pay the taxes. The apparent increase of insanity of recent decades is probably only "on paper," due to better registration.
To put it very roughly, probably ninety-eight per cent of us are so born, thanks to heredity, that the possibility of our becoming insane, even under the severest stress, is almost infinitesimal. Of the two per cent born with this taint, this possible tendency to mental unbalance, only about one-tenth now become completely insane, and this percentage might be greatly diminished by general sanitary improvements. Our alienists now claim that, by checking the reproduction of the obviously unstable, and careful hygienic treatment and training of the predisposed two per cent, insanity is almost as preventable as tuberculosis.
[Footnote 1: The proportion of registered insane in civilized countries to-day ranges from two to three per 1000 of the population.]
In fine, from all the broad field of pathology, the mists of tradition which have dimmed the fair name and reputation of heredity are slowly but surely lifting, until we now behold it, not as our worst enemy, but as our best friend in the prevention of disease and the upbuilding of the race.
THE PHYSIOGNOMY OF DISEASE: WHAT A DOCTOR CAN TELL FROM APPEARANCES
It is our pride that medicine, from an art, and a pretty black one at that, originally, is becoming a science. And the most powerful factor in this development, its indispensable basis, in fact, has been the invention of instruments of precision—the microscope, the fever thermometer, the stethoscope, the ophthalmoscope, the test-tube, the culture medium, the triumphs of the bacteriologist and of the chemist. Any man who makes a final diagnosis in a serious case without resorting to some or all of these means is regarded—and justly—as careless and derelict in his duty to his patient.
At the same time, priceless and indispensable as are these laboratory methods of investigation, they should not be allowed to make us too scornful and neglectful of the evidence gained by the direct use of our five senses. We should still avail ourselves of every particle of information that can be gained by the trained eye, the educated ear, the expert touch,—the tactus eruditus of the medical classics,—and even the sense of smell. There is, in fact, a general complaint among the older members of the profession that the rising generation is being trained to neglect and even despise the direct evidence of the senses, and to accept no fact as a fact unless it has been seen through the microscope or demonstrated by a reaction in the test-tube. As one of our keenest observers and most philosophic thinkers expressed it a few months ago:—
"I fear that certain physicians on their rounds are most careful to take with them their stethoscope, their thermometer, their hemoglobin papers, their sphygmomanometer, but leave their eyes and their brains at home."
And it is certain that the art of sight diagnosis, which seems like half magic, possessed in such a wonderful degree by the older physicians of the passing and past generations, has been almost lost by the new.
A healthful reaction has, however, set in; and while we certainly do not love the Caesar of laboratory methods and accuracy the less, we are beginning to have a juster affection for the Rome of the rich harvest that may be gained from the careful, painstaking, detective-like exercise of our eye, ear, and hand.
As a matter of fact, the conflict between the two methods is only apparent. Not only is each in its proper sphere indispensable, but they are enormously helpful one to the other. Instead of our being able to tell less by the careful, direct eye-and-hand examination of our patients than the doctor of a century ago, we can tell three to five times as much. Signs that he could interpret only by the slow and painful method of two-thirds of a lifetime of plodding experience, or by occasional flashes of half-inspired insight, we are now able to interpret absolutely upon a physiological—yes, a chemical—basis from the revelations of the microscope, the test-tube, and the culture medium. His only way of determining the meaning of a particular tint of the complexion, or line about the mouth, or eruption on the skin, was by slowly and laboriously accumulating a long series of similar cases in which that particular symptom was found always to occur, and deducing its meaning. Now, we simply take a drop of our patient's blood, a scraping from his throat, a portion of some one of his secretions, a little slice of a tumor or growth, submit them to direct examination in the laboratory, and get a prompt and decisive answer.
The observant physician begins to gather information about a patient from the moment he enters the sick-room or the patient steps into his consulting-room; and the value of the information obtained in the first thirty seconds, before a word has been spoken, is sometimes astonishingly great. While no intelligent man would dream of depending upon this first coup d'[oe]il, "stroke of the eye" as the French so graphically call it, for his final diagnosis, or accept its findings until he had submitted them to the most ruthless cross-examination with the stethoscope and in the laboratory, yet it will sometimes give him a clew of almost priceless value. It is positively uncanny to see the swift, intuitive manner in which an old, experienced, and thoughtful physician will grasp the probable nature of a case in one keen look at a patient. Often he can hardly explain to you himself how he does it, what are the data that determine it; yet not infrequently, three times out of five, your most elaborate and painstaking study of the case with all the modern methods will bring you to the same conclusion as that sensed within forty-five seconds by this keen-eyed old sleuth-hound of the fever trails. Time and again, in my interne days, have I gone the rounds of the wards or the out-patient departments with some kindly-faced, keen-eyed old Sherlock Holmes of the profession, and seen him point to a new case across the ward with the question: "When did that pneumonia come in?" or pick out a pain-drawn, ashy mask in the waiting line, with an abrupt, "Bring me that case of cancer of the stomach. He's in pain. I'll take him first."
And, in later years, I have had colleagues with whom it was positively painful to walk down a crowded street, from the gruesome habit that they had of picking out, and condemning to lingering deaths, the cases of cancer, of Bright's disease, or of locomotor ataxia, that we happened to meet. Of course, they would be the first to admit that this was only what they would term a "long shot," a guess; but it was a guess based upon significant changes in the patient's countenance or gait, which their trained eye picked out at once, and it was surprising how often this snapshot diagnosis turned out to be correct.
The first thing that a medical student has to learn is that appearances are not deceptive—except to fools. Every line of the human figure, every proportion of a limb, every detail of size, shape, or relation in an organ, means something. Not a line upon any bone in the skeleton which was not made by the hand-grip or thumbprint of some muscle, tendon, or ligament; no bump or knuckle which is not a lever or hand-hold for the grip of some muscle; not a line or a curve or an opening in that Chinese puzzle, the skull, which was not made to protect the brain, to accommodate an eye, to transmit a blood-vessel, or to allow the escape of a nerve. Every minutest detail of structure means something to the man who will take the pains to puzzle it out. And if this is true of the foundation structure of the body, is it to be expected that the law ceases to run upon the surface?