Our only resource in this form of the disease used to be by mechanical or surgical means, opening the windpipe below the level of the obstruction and inserting a curved silver tube—the so-called tracheotomy operation; or later, and less heroic, by pushing forcibly down into the larynx, and through and past the obstruction at the vocal cords, a small metal tube through which the child could manage to breathe. This was known as intubation. But these were both distressing and painful methods, and, what was far worse, pitifully broken reeds to depend upon. In spite of the utmost skill of our surgeons, from fifty to eighty per cent of cases that were tracheotomized, and from forty to sixty per cent of those that were intubated, died. In many cases they were enabled to breathe, their attacks of suffocation were relieved—but still they died.

This leads us to the most important single fact about the course of the disease, and that is that the chief source of danger is not so much from direct suffocation as from general collapse, and particularly failure of the heart.

This has given us two other data of great importance and value, namely, that while the immediate and greatest peril is over when the membrane has become loosened and the temperature has begun to subside, in both ordinary throat and in laryngeal forms of the disease, the patient is by no means out of danger. While the antitoxins poured out by his body have completely defeated the invading toxins in the open field of the blood, yet almost every tissue of the body is still saturated with these latter and has often been seriously damaged by them before their course was checked. For instance, nearly two-thirds of our diphtheria cases, which are properly examined, will show albumin in the urine, showing that the kidney-cells have been attacked and poisoned by the toxin. This may go on to a fatal attack of uremia; but fortunately, not commonly, far less so than in scarlet fever. The kidneys usually recover completely, but this may take weeks and months. Again, many cases of diphtheria will show a weak and rapid pulse, which will persist for weeks after the patient has apparently recovered; and if the little ones are allowed to sit up too soon, or to indulge in any sudden movements or muscular strains, this weak and rapid pulse will suddenly change into an attack of heart failure and, possibly, fatal collapse. This, again, illustrates the saturation of the poison, as these effects are now known to be due in part to a direct poisoning of the muscle of the heart itself, and later to serious damage done to the nerves controlling the heart, chiefly the pneumo-gastric. Moral: Keep the little patient in bed for at least two weeks or, better, three. He will have to spend a month or more in quarantine, anyway.

Last of all, and by no means least interesting, are the effects which are produced upon the nervous system. One day, while the child is recovering, and is possibly beginning to sit up in bed, a glass of milk is handed to him. The little one drinks it eagerly and attempts to swallow, but suddenly it chokes, half strangles, and back comes the milk, pouring out through the nostrils. Paralysis of the soft palate has occurred from poisoning of the nerves controlling it, caused by direct penetration of the toxin. Sometimes the muscles of the eye become paralyzed and the little one squints, or can no longer see to read.

Fortunately, most of these alarming results go only to a certain degree, and then gradually fade away and disappear; but this may take months or even longer. In a certain number, however, the nerves of respiration, or those controlling the heart-beat, become affected, and the patient dies suddenly from heart failure.

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

These effects of the diphtheria toxin are also of interest for a somewhat unexpected reason, since it has been claimed that they are effects of the antitoxin, by those who are opposed to its use. Every one of them was well recognized as a possible result of diphtheria long before the antitoxin was discovered, and every one of them can be readily produced by injections of diphtheria bacilli or their toxin into animals.

It is quite possibly true that there are more cases of nerve-poisoning (neuritis) and of paralysis following diphtheria than there were before the use of antitoxin, but that is for the simple and sufficient reason that there are more children left alive to display them! And between a child with a temporary squint and a dead child few mothers would hesitate long in their choice.



CHAPTER XI

THE HERODS OF OUR DAY: SCARLET FEVER, MEASLES, AND WHOOPING-COUGH

Why is a disease a disease of childhood? First and fundamentally, because that is the earliest period at which a human being can have it. But the problem goes deeper than this. There is no more interesting and important group of diseases in the whole realm of pathology than those which we calmly dub "the diseases of childhood," and thereby dismiss to the limbo of unavoidable accidents and discomforts, like flies, mosquitoes, and stubbed toes, which are best treated with a shrug of the shoulders and such stoic philosophy as we can muster. They are interesting, because the moment we begin to study them intelligently we stumble upon some of the profoundest and most far-reaching problems of resistance to disease; important, because, trifling as we regard them, and indeed largely just because we so regard them, they kill, or handicap for life, more children in civilized communities than the most deadly pestilence. Measles, for instance, according to the last United States census, causes yearly nearly thirteen thousand deaths, while smallpox causes so few that it is not listed among the important causes of death. Scarlet fever causes sixty-three hundred and thirty-three deaths, as compared with barely five thousand from appendicitis and the same number from rheumatism. Whooping-cough causes ninety-nine hundred and fifty-eight deaths, more than double the mortality from diabetes and nearly equal to that of malarial fever.

In medicine, as in war, the gravest and deadliest mistake that you can make is to despise your enemy. These trivial disorders, these trifling ailments, which every one takes as a matter of course, and expects to go through with, like teething, tight shoes, and learning to smoke, sweep away every year in these United States the lives of from forty to fifty thousand children, reaching the bad eminence of fifth upon our mortality lists, only consumption, pneumonia, heart disease, and diarrh[oe]al diseases ranking above them. Of course, it is obvious that these diseases outrank many other more serious ones among the "captains of the men of death," largely upon the familiar principle of the old riddle, whereby the white sheep eat more grass than the black, "because there are more of them."

While only a relatively small percentage of us ever have the bad luck to be attacked by typhoid fever, rheumatism, or appendicitis, to say nothing of cholera and smallpox, the vast majority of us have gone through two or more of these diseases of childhood; so that, though the death-rate of each and all of them is low, yet the number of cases is so enormous that the absolute total mounts high. But the pity and, at the same time, the practical importance of this heavy death-roll is that at least two-thirds of it is absolutely preventable, and by the exercise of only a very moderate amount of intelligence and vigilance. It is, of course, obvious that in a group of diseases which numbers its victims literally by the million every year there will inevitably occur a certain minute percentage of fatal results due to what might be termed unavoidable causes, like a badly nourished condition of the child attacked, unusual circumstances preventing proper shelter or nursing, or an exceptional virulence of the disease, such as will occur in two or three cases of every thousand in even the most trifling infectious malady. But even after making liberal allowance for what might be termed the unavoidable fatalities, at least two-thirds, and more probably nine-tenths, of the deaths from children's diseases might be prevented upon two grounds:—

First, that they are contagious and absolutely dependent upon a living germ, whose spread can be prevented; and secondly, and practically even more important, that more than half the deaths from them are due, not to the disease itself, but to complications occurring during the period of recovery, caused, for the most part, by gross carelessness on the part of the mother or nurse. A large majority, for instance, of the nearly thirteen thousand deaths attributed to measles are due to bronchitis, caught by letting the child go out-of-doors too soon after recovery, which means, of course, either a chill falling upon the irritated and weakened bronchial mucous membrane, or an infection by one of the score of disease-germs, such as those of influenza, pneumonia, bronchitis, and even tuberculosis, which are continually lying in wait for just such an emergency as this—just such a weakening of the vital resistance.

It is a sadly familiar statement in the history of fatal cases of tuberculosis that the trouble "began with an attack of measles," or whooping-cough, or a bad cold, and was mistaken for a mere "hanging on" of one of these milder maladies until it had gained a foothold that there was no dislodging. As breakers of the wall of the hollow square of the body-cells, drawn up to resist the cavalry charges of tuberculosis, pneumonia, and rheumatism, few can be compared in deadliness with the diseases of childhood and "common colds."

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

One of the English commissions which was investigating the alleged physical deterioration of city and town populations stumbled upon a singularly interesting and significant fact in this connection, while plotting the curves of the rate of growth of the children in a given district in Scotland during a series of years. They were struck with the fact that children born in certain years in the same families, neighborhoods, and presumably the same circumstances, grew more rapidly and had a lower death-rate than those born in other years; and that, on the other hand, children born in other years fell almost as far below the normal in their rate of growth. The only factor which they found to coincide with these differences was that in the years in which those children who made the slowest growth were born there had been unusually heavy epidemics of children's diseases and a high mortality; while, on the other hand, those years whose "crop" of children made the best growth had been unusually free from such epidemics and had a correspondingly low mortality, showing clearly that even the survivors of children's diseases were not only not benefited, but distinctly handicapped and set back in their growth by the energy, so to speak, wasted in resisting the onslaught.

This brings us to an aspect of these diseases which from both a philosophic and a practical point of view is most interesting and profoundly significant; and that is the question with which we opened: Why is a disease a disease of childhood? The old, primitive view was as guileless and as simple as the age in which the diseases occurred. They were regarded not merely by the laity but by grave and reverend physicians of the Dark Ages as a sort of necessary vital crisis peculiar and appropriate to each particular age of life,—a sort of sweating out and erupting of "peccant humors" of the blood, which must be got rid of or else the individual would not thrive. Incredible as it may seem, so far was this idea extended, that the great Arabian physician-philosopher, Rhazes, actually included smallpox in this group, as the last of the "crises of growth" which had to appear and have its way in young manhood or womanhood. Quaint little echoes of this simple faith still ring in the popular mind, as, for instance, in the widespread notion about the dangerousness of doing anything to check the eruption in measles and cause it to "strike in." Any mother in Israel will tell you, the first time you propose a bath or a wet pack to reduce the temperature in measles, that if you so much as touch water to the skin of that child it will "drive the rash in" and cause it to die in convulsions. And, of course, one of the commonest of a physician's memories is the expression of relief from the mother or aunt in any of these mild eruptive fevers, where the skin was well reddened and spotted: "Well, anyway, doctor, it is a splendid thing to get the rash so well out!" Until within the last ten or fifteen years it was no uncommon thing to hear the expression: "Well, I suppose we might just as well let Willie and Susie go on to school and get the measles and have done with it. It seems to be a real mild sort this time." Of course this view was scientifically shattered two or more decades ago by our recognition of the infectious nature of these diseases, but practically its hold on the public mind constitutes one of the most serious and vital obstacles in the way of the health-officer when he endeavors to attack and break up an epidemic of measles, whooping-cough, or chicken-pox.

It cannot be too strongly emphasized that, mild and in their immediate results trifling, as most of these "little diseases" are, they are genuine members of that class of pathologic poison-snakes, the germ-infections; that when they bite, they bite to kill; that two to five times in every hundred they do kill; that, like all other infections, they are capable of inflicting serious and permanent damage upon the great vital organs, the heart, the kidneys, the liver, and the brain; and that they are the very jackals of diseases, tracing down and pointing out the prey to the lions that work in partnership with them. With whatever we may treat measles and whooping-cough, never treat them with contempt!

The next conception of the "whyness" of children's diseases was that as one star differs from another in glory, so does one germ differ from another in virulence; that the germs of these particular diseases just happened to be from the beginning unusually mild and at the same time highly contagious, so that they remained permanently scattered about throughout the community, and attacked each successive brood of newborn children as quickly as they could conveniently get at them. Being so mild and so comparatively seldom fatal, little or no alarm was excited by them and few efforts made to check their spread, so that they continued to flourish, generation after generation. Upon this theory the germs of measles, chicken-pox, whooping-cough, mumps, would be in something like the same class as the numerous species of bacteria and other germs that normally inhabit the human mouth, stomach, and intestines; for the most part, comparatively harmless parasites, or what are technically now known as "symbiotes" (from two Greek words, bios, "life," and syn, "with"), a sort of little partners or non-paying boarders, for the most part harmless, but occasionally capable of making trouble. There are scores of species of such germs in our food-canals, some of which may be even slightly helpful in the process of digestion. Only a very small per cent of the bacilli of any sort in the world are harmful; the vast majority are exceedingly helpful.

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

My first direct experience with this feature of our "household pets" was on the Pacific Coast. All the old settlers told me of a dread pestilence which had preceded the coming of the main wave of invading civilization, sweeping down the Columbia River. Not merely were whole clans and villages swept out of existence, but the valley was practically depopulated; so that, as one of the old patriarchs grimly remarked, "It made it a heap easier to settle it up quietly." So swift and so fatal had been its onslaught that villages would be found deserted. The canoes were rotting on the river bank above high-water mark. The curtains of the lodges were flapped and blown into shreds. The weapons and garments of the dead lay about them, rusting and rotting. The salmon-nets were still standing in the river, worn to tatters and fringes by the current. Yet, from the best light that I was able to secure upon it, it appeared to have been nothing more than an epidemic of the measles, caught from the child of some pioneer or trapper and spreading like wildfire in the prairie grass. A little later I had an opportunity to see personally an epidemic of mumps in a group of Indians, and I have seldom seen fever patients, ill of any disease, who were more violently attacked and apparently more desperately ill than were sturdy young Indian boys attacked by this trifling malady. Their temperatures rose to one hundred and five or one hundred and six degrees, they became delirious, their faces were red and swollen, they ached in every limb, and the complications that occasionally follow mumps even in civilized patients were frequent and exceedingly severe. In like manner, influenza will slay its hundreds in a tribe of less than a thousand members. Chicken-pox will become so virulent as to be mistaken for smallpox. Several of the epidemics of alleged smallpox that have occurred among Indians and other savage tribes are now known to have been only measles. At first, pathologists were inclined to receive these reports with some degree of skepticism, and to regard them either as travelers' tales, or as instances of exceptional and accidental virulence in that particular tribe, the high death-rate due to bad nursing or horrible methods of voodoo treatment.

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

The probability is that both of these explanations are true. These diseases may originally have been comparatively severe and serious; but as generation after generation has been submitted to their attack, those who were most susceptible died or were so crippled as to be seriously handicapped in the race of life and have left fewer and less vigorous offspring. So that, by a gradual process of weeding out the more susceptible, the more resisting survived and became the resistant civilized races of to-day.

On the other hand, any disease which kills its victim so quickly that it has not time to make sure of its transmission to another one before his death, will not have so many chances of survival as will a milder and more chronic disorder. Hence, the milder and less fatal strains of germs would stand the better chance of survival. This, of course, is a very crude outline, but it probably represents something of the process by which almost all known diseases, except a few untamable hyenas, like the Black Death, the cholera, and smallpox, have gradually grown milder with civilization. If we escape the attack of these attenuated diseases of infancy until fifteen or sixteen years of age, we can usually defy them afterward; though occasionally an unusually virulent strain will attack an adult, with troublesome consequences.

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

If this view of the original character and taming of these diseases be correct, it also accounts for the extraordinary and otherwise inexplicable cases where they suddenly assume the virulence of cholera, or yellow fever, and kill within forty-eight or ninety-six hours, not merely in children but also in adults.

To group these three diseases together simply because they all happen to occur in children would appear scarcely a rational principle of classification. Yet, practically, widely different as they are in their ultimate results and, probably, in their origin, they have so many points in common as to their method of spread, prevention, and general treatment, that what is said of one will with certain modifications apply to all.

I said "probably" of widely different origin, because, by one of those strange paradoxes which so often confront us in real life, though the infectiousness and the method of spread of all these diseases is as familiar as the alphabet and as firmly settled, the most careful study and innumerable researches have failed to identify positively the germ in any one of them. There are a number of "suspects" against which a great deal of circumstantial evidence exists: a streptococcus in scarlet fever, a bacillus in whooping-cough, and a protozoan in measles; but none of these have been definitely convicted. The principal reason for our failure is a very common one in bacteriological research, whose importance is not generally known, and that is, that there is not a single species of the lower animals that is subject to the diseases or can be inoculated with them. This unfortunate condition is the greatest barrier which can now exist to our discovery of the causation of any disease. We were absolutely blocked, for instance, by it in smallpox and syphilis until we discovered that our nearest blood relatives, the ape and the monkey, are susceptible to them; and then the Cytoryctes Variolae and the Treponema pallida were discovered within comparatively a few months. Some lucky day, perhaps, we may stumble on the animal or bird which will take measles, scarlet fever, or whooping-cough, and then we will soon find out all about them.

But, fortunately, our knowledge of these little diseases, like Mercutio's wound, is "not so deep as a well, nor so wide as a church door; but 't is enough" for all practical purposes. The general plan of treatment in all of them might be roughly summed up as, rest in bed in a well-ventilated room; sponge-baths and packs for the fever; milk, eggs, bread, and fruit diet, with plenty of cool water to drink, either plain, or disguised as lemonade or "fizzy" mixtures; mild local antiseptic washes for nose and throat, and mild internal antiseptics, with laxatives, for the bowels and kidneys. There is no known drug which is specific in any one of them, though their course may be made milder and the patient more comfortable by the intelligent use of a variety of remedies, which assist nature in her fight against the toxin. Not knowing the precise cause, we have as yet no reliable antitoxin for any.

Now very briefly as to the earmarks of each particular member of this children's group. It may be said in advance that the "openings" of all of them (as chess-players call the first moves) are very much alike. All of them are apt to begin with a little redness and itching of the mucous membranes of the nose, the throat, and the eyes, with consequent snuffling and blinking and complaints of sore throat. These are followed, or in severe, swift cases may be preceded, by flushed cheeks, complaints of headache or heaviness in the head, fever, sometimes rising very quickly to from one hundred and four to one hundred and five degrees, backache, pains in the limbs, and, in very severe cases, vomiting. In fact, the symptoms are almost identical with those of an attack of that commonest of all acute infections, a bad cold, and probably for the same reason, namely, that the germs, whatever they may be, attack and enter the system by way of the nose and throat.

One of the most difficult practical points about the beginning of this group of diseases is to distinguish them from one another, or from a common cold. The important thing to remember is that, theoretically important as it may be to make this distinction, practically it isn't necessary at all, as they should all be treated exactly alike in the beginning. The only vital thing is to recognize that you are dealing with an infection of some sort, isolate promptly the little patient, put him to bed, and make your diagnosis later as the disease develops. Fortunately neither scarlet fever nor measles usually becomes acutely infectious until the rash appears, and as neither is particularly dangerous to adults, especially to such as have had them already, a one-room quarantine is sufficient for the first few days of any of these diseases. We will lose nothing and gain enormously by adopting this routine plan in all cases of snuffling noses, sore throats, headache, and fever in children, for these are the early symptoms of all their febrile diseases, from colds to diphtheria; all alike are infectious and all, even to the mildest, benefited by a few days of rest and seclusion.

After this first general blare of defiance on the part of the system to the enemy, whoever he may be, the battle begins to take on its characteristic form according to the nature of the invader. We will take first the campaign of scarlet fever, since this is the swiftest and first to disclose itself. After the preliminary snuffles and headache have lasted for a few hours, the temperature usually begins to rise; and when it does, by leaps and bounds often reaching one hundred and four or one hundred and five degrees within twelve hours, the skin becomes dry and hot, the throat sore, the tongue parched, and the little patient drowsy and heavy-eyed. Within from twenty-four to forty-eight hours a bright red or pinkish rash appears, first on the neck and chest, and then rapidly spreading all over the surface of the body within another twenty-four hours.

Meanwhile the throat becomes sore and swollen, ranging, according to the severity of the case, from a slight reddening and swelling to a furious ulcerative inflammation, with the formation of a thick membrane-like exudate, which sometimes is so severe as to raise a suspicion of possible diphtheria. The tongue becomes red and naked, with the papillae showing light against a red ground, so as to give rise to what has been known as "the strawberry tongue." The temperature is usually high, and the little patient when he drowses off to sleep is quite apt to become more or less delirious. In the vast majority of cases, after two to four days of this, the temperature goes down almost as swiftly as it came up, the rash begins to fade, the throat gets less sore, and the rebound toward recovery sets in. About this time the daily examination of the urine will begin to show traces of albumin, but this, under strict rest in bed and careful diet, will usually diminish and ultimately disappear. In the event of a relapse, however, or setback from any cause, the kidneys may become violently attacked, and a considerable per cent of the fatal cases die from suppression of the urine. After this crisis has occurred, however, in ninety-nine per cent of all cases it is comparatively plain sailing; the throat is still sore and troublesome, the skin itches and tickles, and the eyes smart, but the little patient steadily improves day by day. Anywhere from three to five days after the break in the fever the skin begins to get rough and scaly, and gradually peels off, until in some cases the entire coating of the body is shed, having been killed, as it were, by the violence of the eruption. These flakes and scales of the skin are exceedingly contagious, and no case should be regarded as fit to be released from isolation until every particle has been shed and got rid of. This constitutes one of the most tiresome and annoying periods of the disease, as complete shedding is seldom finished before two weeks, and sometimes may last from three to five.

However, this long period of contagiousness has been found to be really a blessing in disguise, inasmuch as we now know that even more strikingly than in the other children's diseases it is the period of recovery that is the period of greatest danger in scarlet fever. Like the Parthians of Greek history it is most dangerous when in retreat. Keeping the child at rest for the greater part of the time, in bed or on a lounge, in a well-ventilated room, or later on a porch or terrace, for five weeks from the beginning of the disease, is well worth all the trouble and inconvenience that it causes, for the sake of the almost absolute protection it gives against dangerous and even fatal complications, particularly of the kidneys, heart, or lungs.

This is a fair description of what might be termed an average case of the disease. We also have the sadly familiar type described as the fulminant or, literally, "lightning-stroke" variety. The child goes down as if struck by an invisible hand; vomiting is one of the first symptoms; delirium follows within ten or twelve hours; the eruption becomes not merely scarlet but purplish from hemorrhage under the skin, giving the name of "black" scarlet fever to this type. The throat becomes furiously swollen, the urine is absolutely suppressed, the child goes into convulsions, and dies within forty-eight hours from the beginning of the attack. Fortunately, this type is rare, but the important thing to remember is that it may develop in a child who caught the disease from one of the mildest of all possible cases! Hence every case should be treated with the strictest isolation, as if it were itself of the most malignant type.

Naturally, the mortality of scarlet fever varies according to the type. Not only may it assume a malignant form in individual cases, but whole epidemics may be of this character, with a mortality of from twenty to thirty per cent. Generally speaking, however, the death-rate is about one in twelve, ranging from as low as one in twenty-five to as high as one in five.

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

In measles we have to deal with a much more harmless and more nearly domesticated "beast of prey," but one of a prevalence to correspond. Though probably (exact data being as yet lacking) not more than one-third of all individuals are attacked by scarlet fever, it would be safe to say that not more than one-third, and possibly not more than one-fifth, of us escape measles. Hence, though its mortality is scarcely one-fourth that of scarlet fever, it more than holds its own in the Herod class, as grimly shown by its total death-roll of over twelve thousand, compared with only a little over six thousand to the credit of scarlet fever.

After the preliminary disturbances of snuffles, hot throat, headache, and feverishness, which it shares with all the other "little fevers," the first thing to mark off measles is usually that the itching and running at the nose and eyes become more prominent, the child begins to turn its face away from the light because it makes its eyes smart, and complains not so much of soreness as of a peppery, burning, itching sensation in its nose and throat. The tongue is coated, the stomach mildly upset; the little patient is more uncomfortable and fretful than seriously ill. This condition drags on, without apparently getting anywhere, for from two to four days, during which time it is often very difficult even for the most experienced physician to say positively what the sufferer has. But about the fourth day a rash begins to appear, typically first upon the cheeks or forehead in the shape of little widely separated dull-red blotches. These grow larger and deeper in color, rising in the middle and spreading at their edges, so that shortly the whole skin becomes puffed and swollen and of a mottled, pinkish-purple color. If the child's lower lip be pulled down, little red spots will be seen scattered over the lining membrane of the mouth, showing that the eruption is not confined to the skin. Indeed, these Koplik's spots (as they are called, after their discoverer) in the mouth will often appear a day or more before the eruption upon the skin and give the first clew to the nature of the disease. These are significant, because they probably illustrate the process of eruption, or, at least, irritation, which is taking place, not merely upon the skin, but also upon the mucous membranes of the eyes, nose, and throat, the windpipe and the bronchial tubes, and which is the cause of the burning, running, and, later, occasional serious inflammatory symptoms in all these regions.

When you look at the hot, angry-looking, swollen skin of the little victim of measles, the weeping eyes and running nose, and remember that this same sort of process is either going on or is likely to occur all over his entire lining, so to speak, from lungs to bowels, you can easily grasp how important it is to keep him absolutely at rest and protected from every possible risk in the way of chill, over-exertion, or injudicious feeding, until the whole process has completely subsided and been forgotten. Neglect of these precautions is the reason why so many cases of measles, on the least and most trifling exposure and overstrain during the two or three weeks following the disease, will blaze up into a fatal bronchitis or pneumonia.

The rash takes about two or three days to get out, then it begins to fade and the skin to peel off in tiny, branny scales, so small and thin as to be almost invisible—unlike the huge flakes of scarlet fever. At the same time all the other symptoms recede.

But, as in scarlet fever, all cases should be treated alike, by rest, sponging and packing for the fever, light diet with plenty of milk and fruit, and confinement to the room for at least ten days after the disappearance of the fever. The very mildest and most insignificant of attacks may be followed, through carelessness or exposure, by a fatal bronchitis. Indeed, in view of the distressing frequency with which our histories of tuberculosis in children contain the words, "Came on after measles," it is highly advisable to watch carefully every child as regards abundant feeding, avoidance of overwork or overstrain, and of all unnecessary exposure to infection, wind, or wet, for two months after an attack of measles instead of the customary two weeks. As the disease is acutely infectious, the little victim should be isolated for at least three weeks after the disappearance of the fever; but this again, as in the case of scarlet fever, is emphatically a blessing in disguise from his point of view, as well as a protection to the rest of the community.

Should the "little fever" prove to be whooping-cough, it will be later still in positively declaring its definite intentions. The cold or catarrhal stage will be much milder, the fever lower, the cough a trifle more marked, but will drag on for from a week to ten days before anything definite happens. Usually the child is supposed to be suffering with a slight cold, hence the prevailing impression that colds run into whooping-cough, if neglected. Then one day the child is suddenly seized with a coughing fit, consisting of from ten to fifteen short coughs in rapid succession of increasing intensity, until all the air seems literally pumped out of the lungs of the poor little patient; then, with a tremendous whoop, the youngster gets his breath again and the diagnosis is made. This distressing performance may occur only four or five times a day, or it may be repeated every half-hour or so. So violent is the paroxysm that the eyes of the child protrude, it becomes literally black in the face, and runs to its mother or nurse, or clutches a chair, to keep from falling.

As the same great nerves which supply the lungs supply the stomach, the irritation frequently "radiates," or spills over, from one division of it to the other, and the coughing fit is frequently followed by vomiting. Unexpectedly enough this may often become the most serious practical symptom of the disease, inasmuch as the stomach is emptied so frequently that the poor little victim is unable to retain any nourishment long enough to absorb it, and may waste away frightfully, and even literally starve to death, or have its resisting power so greatly lowered that an attack of bronchial trouble or bowel disturbance will prove rapidly fatal.

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

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

At all events, it is perfectly idle to treat the disease with cough mixtures or expectorants. The view toward which the majority of intelligent observers are inclined is that whooping-cough is an infection, the germ or toxin of which attacks the nervous system, and particularly the great "lung-stomach" (pneumo-gastric) nerve. At all events, the only remedies which appear to have any effect upon the disease are, in the early stages, mild local antiseptics in the nose and throat, and later those which diminish the irritability of the nerves without upsetting the appetite or depressing the general vigor. The disease is, for all its mildness, one of the most obstinate known.

A small percentage of cases run a violent course, in spite of the most intelligent and anxious care, both medical and household; but the vast majority of such complications as occur are either caused by carelessness or become serious only if neglected. Treating all children with whooping-cough as emphatically sick children, entitled to every care and excuse from exertion, every exemption and privilege that can be given them until the last whoop has been whooped, would prevent at least two-thirds of the almost ten thousand deaths from whooping-cough that yearly disgrace the United States.

To sum up in fine: intelligent, effective isolation of all cases, the mild no less than the severe, would stamp out these Herods of the twentieth century within ten years. In the meantime, six weeks' sick-leave, with all the privileges and care appertaining thereto, will rob them of two-thirds of their terrors.



CHAPTER XII

APPENDICITIS, OR NATURE'S REMNANT SALE

We were not made all at once, nor do we go to pieces all at once, like the "one-hoss shay." This is largely because we are not all of the same age, clear through. Some parts of us are older than other parts. We have always felt a difficulty, not to say a delicacy, in determining the age of a given member of the human species—especially of the gentler sex. Now we know the reason of it. From the biologic point of view, we are not an individual, but a colony; not a monarchy, but a confederacy of organ-states, each with its millions of cell-citizens. It is not merely editors and crowned heads who have a biologic right to say "We." Therefore, obviously, any statement that we make as to our age can be only in the nature of an average struck between the ages of our heart, lungs, liver, stomach; and as these vary in ancientness by thousands of years, the average must be both vague and misleading. The only reason why there is a mystery about a woman's age is that she is so intensely human and natural. The only statement as to our age that the facts would strictly justify us in making must partake of the vagueness of Mr. A. Ward's famous confession that he was "between twenty-three summers."

As we individually climb our own family-tree, from the first, one-celled droplet of animal jelly up, none of our organs is older than we are, but a number of them are younger. The appendix is one of these. Now, by some curious coincidence, explain it as we may, some of our oldest organs are youngest, in the sense of most vigorous, elastic, and resisting, while some of our youngest are oldest, in the sense of decrepit, feeble, and unstable. It is perhaps only natural that an organ like the stomach, for instance, which has a record of honorable service and active duty millions of years long, should be better poised, more reliable, and more resourceful than one which, like the lung or the appendix, has, as it were, a "character" of only about one-tenth of that length. However this may be, the curious fact confronts us that scattered about through the body are structures and fragments, the remains of organs which at one time in our ancestral career were, under the then existing circumstances, of utility and value, but have now become mere survivals, remnants,—in the language of the day, "back numbers." Some of these have still a certain degree of utility, though diminished and still diminishing in size and functional importance, like our third molars or "wisdom" teeth, our fifth or "little" toes, our gall-bladder, our coccyx or tail-bone, the hair-glands scattered all over the now practically hairless surface of our bodies, and our once movable ears, which can no longer be "pricked," or laid back. These, though of far less utility and importance than they obviously were at one time, still earn their salt, and, though all capable of causing us considerable annoyance on slight provocation, seldom give rise to serious trouble or inconvenience. There are, however, a few of these "oversights" which are of little or no known utility, and yet which, either by their structure or situation, may become the starting-point of serious trouble.

The best known members of this small group are the openings through the abdominal wall, which, originally placed at the strongest and safest position in the quadrupedal attitude, are now, in the erect attitude, at the weakest and most dangerous, and furnish opportunity for those serious and sometimes fatal escapes of portions of the intestines which we call hernia; the tonsils; and our friend the appendix vermiformis.

For once its name expresses it exactly. It is an "appendix," an afterthought; and it is "vermiformis," a worm-like creature,—and, like the worm, will sometimes turn when trodden on. Its worm-likeness is significant in another sense also, in that it is this very diminutiveness in size—the coils into which it is thrown, the spongy thickness of its walls, and the readiness with which its calibre or its circulation is blocked—that is the fundamental cause of its tendency to disease.

The cause of appendicitis is the appendix.

"Despise not the day of small things" is good pathology as well as Scripture. Here we have a little, worm-shaped tag, or side branch, of the food-tube, barely three or four inches long, of about the diameter of a small quill and of a calibre that will barely admit an ordinary knitting needle. And yet we speak of it with bated breath. When we remember that this little, twisted, blind tube opens directly out of one of the largest pouches of the intestines (the caecum), and that it is easy for anything that may be present in the large pouch—food, irritating fragments of waste matter, or bacteria—to find its way into this fatal little trap, but very difficult to find the way out again, we can form some idea of what a literal death-trap it may become.

How did such a useless and dangerous structure ever come to develop in a body in which for the most part there is mutual helpfulness, utility, and perfect smoothness of working through all the great machine? To attempt to answer this would carry us very far back into ancient history. But to make such backward search is absolutely the only means of reaching an answer.

"But," some one will object, "how perfectly irrational, not to say absurd, to propose to go back hundreds of thousands of years into ancient history, to account for a disease which has been discovered—according to some, invented—within the past twenty-five years!"

Appendicitis is a mark, not a result, of a high grade of civilization. To have had an operation for it is one of the insignia of modern rank and culture. Our new biologic aristocracy, the "Appendix-Free," look down with gentle disdain upon their appendiciferous fellows who still bear in their bodies this troublesome mark of their lowly origin. In short, the general impression prevails that appendicitis is a new disease, a disease which has become common, or perhaps occurred at all, only within the last quarter of a century, and which therefore—with the usual flying leap of popular logic—is a serious menace to our future, if it keeps on increasing in frequency and ferocity at anything like the same rate which it has apparently shown for the past fifteen years.

As this feeling of apprehension is in many minds quite genuine, it may be well to say briefly, before proceeding further, first, that, if there be any disease which absolutely and almost exclusively depends upon definite peculiarities of structure, it is appendicitis, and that these structural peculiarities of this tiny, cramped tag of the food-canal have existed from the earliest infancy of the race. So it is almost unthinkable that man should not have been subject to fatal disturbances of this organ from the very earliest times. On the post-mortem table, the appendix of the lowest savage is the same useless, shriveled, and inflammable worm as that of the most highly civilized Aryan, though perhaps an inch or so longer. Secondly, there is absolutely no adequate proof that appendicitis is increasing in frequency among civilized races. It is only about twenty-five years ago that it was first definitely described, and barely fifteen that the profession began at all generally to recognize it.

But all of us whose memory extends backward a quarter of a century can clearly recall that, while we did not see any cases of "appendicitis," we saw dozens of cases of "acute enteritis," "idiopathic (self-caused) peritonitis," "acute inflammation of the bowels," "acute obstruction of the bowels," of which patients died both painfully and promptly, and which we now know were really appendicitis.

In short, from a careful study of all the data, including the claims so frequently made of freedom from appendicitis on the part of Oriental races, colored races, less civilized tribes, vegetarians, and others, we are tending toward the conclusion that the percentage of appendicitis in a given community is simply the percentage of its recognition,—in other words, of the intelligence and alertness, first of its physicians, and then of its laity. As an illustration, my friend Dr. Bloodgood kindly had the statistics of the surgical patients treated in the great Johns Hopkins Hospital at Baltimore investigated for me, and found almost precisely the same percentage of cases of appendicitis among colored patients as among white patients.

The earlier impression, first among physicians and now in the laity, that appendicitis is an almost invariably fatal disease, is not well founded, and we now know that a large percentage of cases recover, at least from the first attack; so that it is quite possible for from half to two-thirds of the cases of appendicitis actually occurring in a given community to escape recognition, unless promptly reported, carefully examined, and accurately diagnosed. Thirdly, in spite of the remarkable notoriety which the disease has attained, the general dread of its occurrence,—which has been recently well expressed in a statement that everybody either has had it, or expects to have it, or knows somebody who has had it,—the actual percentage of occurrence of grave appendicitis is small. In the United States census of 1900, which was the first census in which it was recognized as a separate cause of death, it was responsible for only 5000 deaths in the entire United States for the ten years preceding, or about one death in two hundred. This rate is corroborated by the data, now reaching into thousands, from the post-mortem rooms of our great hospitals, which report an average of between a half and one per cent. A disease which, in spite of the widespread terror of it, kills only one in two hundred of those who actually die—or about one in every ten thousand of our population—is certainly nothing to become seriously excited over from a racial point of view.

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

The satirical proposal that a "closed season" should be established by law for appendicitis as for game birds, during which none might be taken, would apply almost as often to the laity as to the profession, even the surgical half.

Since the chief cause of appendicitis is the appendix, the first question for disposal is, How did the appendix become an appendix? To this biology can render a fairly satisfactory answer. It is the remains of one of Mother Nature's experiments with her 'prentice hand upon the mammalian food-tube. As is now generally known, the food-canal in animals was originally a comparatively straight tube, running the length of the body from mouth to anus. It early distends into a moderate pouch, about a third of the way down from the mouth, forming a stomach, or storage and churning-place for the food. Below this, it lengthens into coils (the so-called small intestine), which, as the body becomes more complex, increase in number and length until they reach four to ten times the length of the body. Later, the lower third of the tube distends and sacculates out into a so-called large intestine, in which the last remnants of nutritive material and of moisture are extracted from the food-residues before they are discharged from the body. Just at the junction of this large intestine with the small intestine, nature took it into her head to develop a second pouch, a sort of copy of the stomach. This pouch, from the fact that it ends in a blind sac, is known as the caecum (or "blind" pouch), and is apparently simply a means of delaying the passage of the foodstuffs until all the nutriment and moisture have been absorbed out of them for the service of the body. Naturally, it has developed to the largest degree and size in those animals which have lived upon the bulkiest and grassiest of foods, the so-called Herbivora, or grass-eaters. In the Carnivora, or flesh-eaters, it is usually small, and in one family, the bears, entirely absent. This pouch is no mere figure of speech, as may be gathered from the fact that in certain of the rodent Herbivora, like the common guinea-pig, it may have a capacity equal to all of the rest of the alimentary canal, and in the horse it will hold something like four times as much as the stomach. Oddly enough, among the grass-eaters, for some reason which we do not understand, it appears to occur in a sort of inverse proportion to the stomach; those which have large, sacculate, pouched stomachs, like the cow, sheep, and the ruminants generally, having smaller caeca. In other Herbivora with small stomachs, like the rabbit and the horse, it develops greater size.

Our primitive ancestors were mixed feeders, and, though probably more largely herbivorous than we are to-day, had a medium-sized caecum, and maintained it up to the point at which the anthropoid apes began to branch off from our family-tree. But at about this point, for some reason, possibly connected with the increasing variety and improved quality and concentration of the food, due to greater intelligence and ability to obtain it, this large caecum became unnecessary, and began to shrivel.

Here, however, is where nature makes her first afterthought mistake. Instead of allowing this pouch to contract and shrivel uniformly throughout its entire length, she allowed the farther (or distal) two-thirds of it to shrivel down at a much faster rate than the central (or proximal) third; so that the once evenly distended sausage-shaped pouch, about six to eight inches long and two inches in diameter, has become distorted down into a narrow, contracted end portion, about a quarter of an inch in diameter, and a distended first portion, for all the world like a corncob pipe with a crooked stem and an unusually large bowl. And behold—the modern appendix vermiformis, with all its fatal possibilities!

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

The most strikingly and distinctly human thing about us is not our brain, but our appendix. And, while recognizing its power for mischief, it is only fair to remember that it is an incident and a mark of progress, of difficulties overcome, of dangers survived. In all probability, it was our change to a more carnivorous diet, and consequently predatory habits, which enabled our ancestors to step out from the ruck of the "Bandar-Log," the Monkey Peoples. An increase in carnivorousness must have been a powerful help to our survival, both by widening our range of diet, so that we could live and thrive on anything and everything we could get our hands on, and by inspiring greater respect in the bosoms of our enemies. Let us therefore respect the appendix as a mark and sign of historic progress and triumph, even while recognizing to the full its unfortunate capabilities for mischief.

But what has this ancient history to do with us in the twentieth century? Much in every way. First, because it furnishes the physical basis of our troubles; and second, and most important, because, like other history, it is not merely repeating itself, but continuing. This process of shriveling on the part of the appendix is not ancient history at all, but exceedingly modern; indeed, it is still going on in our bodies, unless we are over sixty-five years of age.

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

At the first appearance of the caecum, or blind pouch, in our prenatal life, it is of the same calibre as the rest of the intestine, and of uniform size from base to tip. About three weeks later the tip begins to shrivel, and from this on the process steadily continues, until at birth it has contracted to about one-fifteenth of the bulk of the caecum. But the process doesn't stop here, though its progress is slower. By about the fifth year of life the stem of the caeco-appendix pipe has diminished to about one-thirtieth of the size of the bowl, which is the proportion that it maintains practically throughout the rest of adult life. For a long time we concluded that the process was here finished, and that the appendix underwent no further spontaneous changes during life; but, after appendicitis became clearly recognized, a more careful study was made of the condition of the appendix in bodies coming to the post-mortem table, dead of other diseases, at all ages of life. This quickly revealed an extraordinary and most significant fact, that, while the appendix was no longer decreasing in apparent size, its internal capacity or calibre was still diminishing, and at such a rate that by the thirty-fifth year it had contracted down so as to become cut off from the cavity of the caecum in about twenty-five to thirty per cent of all individuals. By the forty-fifth year, according to the anatomist Ribbert (who has made the most extensive study of the subject), nearly fifty per cent of all appendices are found to be cut off, and by the sixty-fifth year nearly seventy per cent.

This explains at once why appendicitis is so emphatically a disease of young life, the largest number of cases occurring before the twenty-fifth year (fifty per cent of all cases occur between ten and thirty years of age), and becoming distinctly rarer after the thirty-fifth, only about twenty per cent occurring after this age. As soon as the cavity of the appendix is cut off from that of the intestine, it is of course obvious that infectious or other irritating materials can no longer enter its cavity to cause trouble, although, of course, it is still subject to accidents due to kinks, or twists, or interference with its blood-supply; but these are not so dangerous, providing there be no infectious germs present.

Here, then, we have a clear and adequate physical basis for appendicitis. A small, twisted, shriveling spur or side twig of the intestine, opening from a point which has become a kind of settling basin in the food-tube, its mouth gaping, as it were, to admit any poisonous or irritating food, infectious materials, disease-germs, the ordinary bacteria which swarm in the alimentary canal, or irritating foreign bodies, like particles of dirt, sand, hairs, fragments of bone, pins, etc., which may have been accidentally swallowed. Once these irritating and infectious materials have entered it, spasm of its muscular coat is promptly set up, their escape is blocked, and a violent inflammation easily follows, which may end in rupture, perforation, or gangrene.

Not only may any infection which is sweeping along the alimentary canal, thrown off and resisted by the vigorous, full-sized, well-fed intestine, find a point of lowered resistance and an easy victim for its attack in the appendix, but there is now much evidence to indicate that the ordinary bacteria which inhabit the alimentary canal, particularly that first cousin of the typhoid bacillus, the colon bacillus, when once trapped in this cul-de-sac, may quickly acquire dangerous powers and set up an acute inflammation. It is not necessary to suppose that any particular germ or infection causes appendicitis. Any one which passes through, or attacks, the alimentary canal is quite capable of it, and probably does cause its share of the attacks.

Numerous attempts have been made to show that appendicitis is particularly likely to follow typhoid fever, rheumatism, influenza, tonsilitis, and half a dozen other infectious or inflammatory processes. But about all that has been demonstrated is that it may follow any of them, though in none with sufficient frequency or constancy to enable it to be regarded as one of the chief or even one of the important causes of the disease.

One dread, however, we may relieve our anxious souls of, and that is the famous grape-seed or cherry-stone terror. To use a Hibernianism, one of our most positive conclusions in regard to the cause of appendicitis is a negative one: that it is not chiefly, or indeed frequently, due to the presence of foreign bodies. This was a most natural conclusion in the early days of the disease, since, given a tiny blind pouch with a constricted opening gaping upon the cavity of the food-canal, nothing could be more natural than to suppose that small irritating food remnants or foreign bodies, slipping into it and becoming lodged, would block it and give rise to serious inflammation. And, moreover, this a priori expectation was apparently confirmed by the discovery, in many appendices removed by operation, of small oval or rounded masses, closely resembling the seed of some vegetable or fruit. Whereupon anxious mothers promptly proceeded to order their children to "spit out," with even more religious care than formerly, every grape-seed and cherry-stone. The increased use of fresh and preserved fruits was actually gravely cited, particularly by our Continental brethren, as one of the causes of this new American disease. Barely ten years ago I was spending the summer in the Adirondacks, and was bitterly reproached by the host of one of the Lake hotels, because the profession had so terrified the public about the dangers of appendicitis from fruit-seeds that he was utterly unable to serve upon his tables a large stock of delicious preserved and canned raspberries, blackberries, and grapes which he had put up the previous years. "Why," he said, "more than half the people that come up here will no more eat them than they would poison, for fear that some of the seeds will give 'em appendicitis." This dread, however, has been deprived of all rational basis, first, by finding that many inflamed appendices removed, after the operation became more common, contained no foreign body whatever; secondly, that many perfectly healthy appendices examined on the post-mortem table, death being due to other diseases, contain these apparently foreign bodies; and thirdly, that when these "foreign bodies" were cut into, they were found to be not seeds or pits of any description, but hardened and, in some cases, partially calcareous masses of the faeces.

We are in a nearly similar position in regard to the third alleged cause of appendicitis, and that is food. Many are the accusations which have been made in this field. On the one hand, meat and animal foods generally have been denounced, on account of their supposed "heating" or "uric-acid-forming" properties; while on the other, vegetables and fruits have been equally hotly incriminated, on account of their seeds, fibres, husks, and irritating substances, and the danger of their being contaminated by bacteria and other parasites from the soil. These charges appear to have little adequate foundation, and, so far as we are in a position now to judge, the only way a food can give, or be accessory to, appendicitis is by its being taken in such excessive amounts as to set up fermentive or putrefactive changes in the alimentary canal, or by its being in an unsound, decaying, or actually diseased condition. Any amounts or quality of food which are capable of giving rise to an attack of acute indigestion may secondarily lead to an attack of appendicitis. The only single article of diet whose ingestion is declared by Osler to be rather frequently followed by an attack of appendicitis is the peanut.

Therefore, the best thing to do in the way of taking precautions against the occurrence of appendicitis is, in the language of the day, to "forget it" as completely as possible, reassuring ourselves that, in spite of its extraordinary notoriety and popularity, it is a comparatively rare disease in its fatal form, responsible for not more than one-half of one per cent of the deaths, and that the older we grow, the better become our chances of escaping it.

Whatever we may have decided in regard to our brains, by the time we reach fifty, we may feel reasonably sure we've no appendix.

But the question will at once arise, if the appendix be so tiny in size, so insignificant in capacity, and so devoid of useful function, what is the use of disturbing ourselves over the question of what may become of it? If it is going to decay and drop off, why not permit it to do so, with the philosophic indifference with which we would sacrifice the tip of our little fingers in a planing-mill? Here, however, is just the rub, and the fact that gives to appendicitis all its terrors, and to the question of what to do in each particular case its difficulties and perplexities.

The appendix does not, unfortunately, hang out from the surface of the body, where it could peacefully decay and drop off without prejudice to the rest of the body, or be quickly lopped off in the event of its giving trouble. On the contrary, it projects its stubby and insignificant length right into the midst of the most delicate and susceptible cavity of the body, the general cavity of the abdomen, or peritoneum. The thin, sensitive sheet of peritoneum which lines this cavity covers every fold and part of the food-tube, from the stomach down to the rectum. And when once infection or inflammation has occurred at any point in it, there is nothing to prevent its spreading like a prairie fire, all over the entire abdominal cavity from diaphragm to pelvis. If this wretched little remnant were a coil of explosive fuse within the brain-cavity itself, which any jar might set off, it could hardly be richer in possibilities of danger.

A redeeming feature of appendicitis is that the appendix lies—so to speak—in a corner, or wide-mouthed pouch, of the great peritoneal cavity; and if the inflammation set up in it can be "walled off" from the rest of the peritoneal cavity, and limited strictly to this little corner or pouch, all will be well. This is what occurs in those cases of severe appendicitis which spontaneously recover. If, however, this disturbance bursts its barriers, and lights up an inflammation of the entire peritoneal cavity, then the result is likely to be a fatal one. Just how far nature can be trusted in each particular case to limit and stamp out the process in this manner is the core of the problem that confronts us, as attending physicians.

In the majority of cases, fortunately, the peritoneal fire brigade acts promptly, pours out a wall of exudate, and locks up the appendix in a living prison, to fight out its own battles and sink or swim by itself. But unfortunately, in a minority of cases, by a wretched sort of "senatorial courtesy" which exists in the body, the appendix is given its ancestral or traditional rights and allowed to inflict its petty troubles upon the entire abdominal cavity, and include the body in its downfall.

Lastly come the two most pertinent and appealing questions:—

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

In regard to the first of these, it is safe to say that our answer is much less alarming than it was in the earlier stage of our knowledge. Naturally enough, in the beginning, only the severest and most unmistakable forms of the disease and those which showed no tendency to localization, were recognized, or at least came under the eye of the surgeon; and as a large percentage of these resulted fatally, the conclusion was reached, both in the medical profession and by the laity, that appendicitis was an exceedingly dangerous disease, with a high fatality in all cases. As, however, physicians became more expert in the recognition of the disease, it was discovered to be vastly more common, while side by side came the consoling knowledge that a considerable percentage of cases got well of themselves, in the sense of the inflammation being limited to the lower right-hand corner of the abdominal cavity, though, of course, with the possibility of leaving a smouldering fuse which might light up another explosion under any stress in future.

Further, as the attention of the post-mortem investigators at our large hospitals was directed to the subject, it was found that a very considerable percentage of all bodies, ranging from twenty to—according to some estimates—as high as sixty per cent, showed changes in the appendix and its neighborhood which were believed to be due to old inflammations; so that, while it is possible to speak only with great caution and reserve, the balance of opinion among clinicians and pathologists of wide experience and the more conservative surgeons appears to be that from one-half to two-thirds of all cases of appendicitis will recover of themselves, in the sense of subsiding more or less permanently, without causing death.

On the other hand, it must be remembered that the appendix is an organ which, so far as any evidence has been adduced, is entirely without useful function; that it is in process of shriveling and disappearance, if left entirely alone, and that the best result which can be expected from a self-cured attack of appendicitis is the destruction of the appendix and its elimination as a further possible cause of mischief. By avoiding an operation in appendicitis, we may be practically certain that we save nothing that is worth saving—except the fee. Moreover, even though only from one-fourth to one-third of all cases develop serious complications, you never can be quite sure in which division your particular case will fall.

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

"What is the height of the building, gentlemen?"

The number of feet was given.

"How much is that above that of any surrounding structures?"

The data were supplied.

"It is a church, you say?"

"Yes."

"Well," said the great man, "on the whole, I should advise you to put on a lightning-rod. Providence is apt to be, at times, a trifle absent-minded."

The chances are in favor of your recovery, but—put on a lightning-rod, in the shape of the best and most competent doctor you know, and be guided entirely by his opinion. An attack of appendicitis is like shooting the Grand Lachine Rapids. Probably you will come through all right; but there is always the possibility of landing at a moment's notice on the rocks or in the whirlpools. With a good pilot your risk doesn't exceed a fraction of one per cent. And fortunately this condition has been not merely theoretically but practically reached already; for the later series of case-groups of appendicitis treated in this intelligent way by cooeperation between the physician and surgeon from the start, with prompt interference in those cases which to the practiced eye show signs of making trouble, has reduced the actual recorded mortality of the disease to between two and five per cent. Even of those cases which come to operation now, the death-rate has been reduced as low as five per cent, in series of from 400 to 600 successive operations. When we contrast this with the first results of operation, when the cases as a rule were seen too late for the best time of interference, and from twenty per cent to thirty per cent died; and with the intermediate stage, when surgeons as a rule were inclined to advise operation at the earliest possible moment that the disease could be recognized, and from ten per cent to fifteen per cent died, we can see how steady the improvement has been, and how encouraging the outlook is for the future.

Cases which have weathered one attack of appendicitis are of course by no means free from the risk of another. Indeed, at one time it was believed that a recurrence was almost certain to occur. Later investigations, based upon larger numbers of cases, now running up into the thousands, give the reassuring result that though this danger is a real one, it is not so great as it was at one time supposed, as the average number in whom a second attack occurs appears to be about twenty per cent. This, however, is a large enough risk to be worthy of serious consideration; and in view of the fact that the mortality of operations done between attacks is less than one per cent, it is generally the feeling of the profession that, where there is any appreciable soreness, or tenderness, or liability to attacks of pain in the right iliac region, in an individual who has had one attack of appendicitis, the really conservative and prudent procedure is to have the source of the trouble removed once and for all.

The four principal symptoms of appendicitis are: pain, which is usually felt most keenly somewhere between the umbilicus and the right groin, though this is by no means invariable; tenderness in that same region upon pressure; rigidity of the muscles of the abdominal wall on the right side; and temperature, or fever.

No matter how much and how variegated pain you may have in the abdomen, or how high your temperature may run, if you are not distinctly sore on firm pressure down in this right lower or southwest quadrant of the abdomen,—but be careful not to press too hard, it isn't safe,—you may feel fairly sure that you haven't got appendicitis. If you are, you may still not have it, but you'd better send for the doctor, to be sure.



CHAPTER XIII

MALARIA: THE PESTILENCE THAT WALKETH IN DARKNESS; THE GREATEST FOE OF THE PIONEER

Malaria has probably killed more human beings than all the wars that have ever devastated the globe. Some day the epic of medicine will be written, and will show what a large and unexpected part it has played in the progress of civilization. Valuable and essential to that progress as were the classic great discoveries of fire, ships, wheeled carriages, steam, gunpowder, and electricity, they are almost paralleled by the victories of sanitary science and medicine in the cure and prevention of that greatest disrupter of the social organism—disease. No sooner does the primitive human hive reach that degree of density which is the one indispensable condition of civilization, than it is apt to breed a pestilence which will decimate and even scatter it. Smallpox, cholera, and bubonic plague have blazed up at intervals in the centres of greatest congestion, to scourge and shatter the civilization that has bred them. No civilization could long make headway while it incurred the dangers from its own dirtiness; and to-day the most massive and imposing remains of past and gone empires are their aqueducts, their sewers, and their public baths. What chance has a community of building up a steady and efficient working force, or even an army large enough for adequate defense, when it has a constant death-rate of ten per cent per annum, and an ever recurrent one of twenty to thirty per cent, by the sweep of some pestilence? The bubonic plague alone is estimated to have slain thirty millions of people within two centuries in Mediaeval Europe, and to have turned whole provinces into little better than deserts.

In malaria, however, we have a disease enemy of somewhat different class and habits. While other great infections attack man usually where he is strongest and most numerous, malaria, on the contrary, lies in wait for him where he is weakest and most scattered, upon the frontiers of civilization and the borders of the wilderness. It is only of late years that we have begun to realize what a deadly and persistent enemy of the frontiersman and pioneer it is. We used to hear much of climate as an obstacle to civilization and barrier to settlement. Now, for climate we read "malaria." Whether on the prairies or even the tundras of the North, or by the jungles and swamps of the Equator, the thing that killed was eight times out of ten the winged messenger of death with his burden of malaria-infection. The "chills and fever," "fevernager," "mylary," that chattered the teeth and racked the joints of the pioneer, from Michigan to Mississippi, was one and the same plague with the deadly "jungle fever," "African fever," "black fever" of the tropics, from Panama to Singapore. Hardly a generation ago, along the advancing front of civilization in the Middle West, the whole life of the community was colored with a malarial tinge and the taste of quinine was as familiar as that of sugar. To this day, over something like three-quarters of the area of these United States, the South, Middle West, and Far West, if you feel headachy and bilious and "run down," you sum it all up by saying that you are feeling "malarious." Dwellers upon the rich bottom-lands expected to shake every spring and fall with almost the same regularity as they put on and shed their winter clothing. Readers of Frank Stockton will remember the gales of merriment excited by his quaint touch of the incongruous in making the prospective bridegroom of the immortal Pomona change the date of their wedding day from Tuesday to Monday, because, on figuring the matter out, he had discovered that Tuesday was his "chill-day."

Though the sufferer from ague seldom received very much sympathy at the time, but was considered a fair butt for genial ridicule and chaff, yet even there the trouble had its serious side. Through all those communities there stalked a well-known and dreaded spectre, the so-called "congestive chill," what is now known in technical language as the pernicious malarial paroxysm. These were like the three warnings of death in the old parable. You would probably survive the first and might never have another; but if you had your second, it was considered equivalent to a notice to quit the country promptly and without counting the cost. In my boyhood days in the Middle West, I can recall hearing old pioneers tell of little groups of one or more families moving out on to some particularly rich and virgin bottom-land and losing two or three or more members out of each family by congestive chills within the first year, and in some cases being driven in from the outpost and back to civilization by the fearful death-loss.

A pall of dread hangs over the whole west coast of Africa. The factories and trading-posts are haunted by the ghosts of former agents and explorers who have died there. Some years ago one German company had the sinister record that of its hundreds of agents sent out to the Gold Coast under a three years' contract, not one had fulfilled the term! All had either died, or been invalided and returned home. It was malaria more than any other five influences combined that thwarted the French in their attempt to dig the Panama Canal and that made the Panama Railroad bear the ghastly stigma of having built its forty miles of track with a human body for every tie.

Malaria ever has been, and is yet, the great barrier against the invasion of the tropics by the white races; nor has its injurious influence been confined to the deaths that it causes, for these gaps in the fighting line might be filled by fresh levies drawn from the wholesome North. Its fearfully depressing and degenerating effects upon even those who recover from its attacks have been still more injurious. It has been held by careful students of tropical disease and conditions that no small part of that singular apathy and indifference which steal over the mind and body of the white colonist in the tropics, numbing even his moral sense, and alternating with furious outbursts of what the French have termed "tropical wrath," characterized by unnatural cruelty and abnormal disregard for the rights of others, is the deadly work of malaria. It is the most powerful cause, not merely of the extinction of the white colonist in the tropics, but of the peculiar degeneracy—physical, mental, and moral—which is apt to steal over even the survivors who succeed in retaining a foothold. Two particularly ingenious investigators have even advanced the theory that the importation of malaria into the islands of Greece and the Italian peninsula by soldiers returning from African and Southern Asiatic conquests had much to do with accelerating, if not actually promoting, the classic decay of both of these superb civilizations.