To come nearer home, there can be little question that the baneful, persistent influence of malaria, together with the hookworm disease, has had much to do both with the degeneracy of the Southern "cracker," or "mean white," and with those wild outbursts of primitive ferocity in all classes which take the form of White Cap raids and lynching mobs.

However this may be, the disease and the colonization habit brought in a crude way their own remedy. The Spanish conquerors of Peru were told by the natives that a certain bark which grew upon the slopes of the Andes was a sovereign remedy for those terrible ague seizures. Indian remedies did not stand as high in popular esteem as they do now; but they were in desperate straits and jumped at the chance. To their delight, it proved a positive specific, and a Spanish lady of rank, the Countess Chincona, was so delighted with her own recovery that she carried back a package of the precious Peruvian bark on her return to Europe, and endeavored to introduce it. So furious was the opposition of the Church, however, to this "pagan" remedy that she was completely defeated in her praiseworthy attempt and was obliged to confine her ministrations to those who belonged to her, the peasantry on her own estate. About half a century later, the new remedy excited so much discussion by the numerous cures that it effected, that it was considered worthy of a special council of the Jesuits, who formally pronounced it suitable for the use of the faithful, thereby attaching to it for many years the name of "Jesuit's bark." Virtue, however, is sometimes rewarded in this world, and the devoted and enlightened countess has, all unknown to herself, attained immortality by attaching her name, Chincona, softened into cinchona, and hardened into quinine, to the greatest therapeutic gift of the gods to mankind. It is not too much to say that the modern colonization of the tropics and subtropics by Northern races, which is one of the greatest and most significant triumphs of our civilization, would have been almost impossible without it. Its advance depended upon two powders, one white and the other black,—quinine and gunpowder.

For nearly three centuries we rested content with the knowledge that in quinine we had a remedy for malaria, which, if administered at the proper time and in adequate doses, would break up and cure ninety per cent of all cases. Just how it did it we were utterly in the dark, and many were the speculations that were indulged in. It was not until 1880, that Laveran, a French army surgeon stationed in Algeria, announced the discovery in the blood of malarial patients of an organism which at first bore his name, the Hematozoon-Laveran, now known as the Plasmodium malariae. This organism, of all curious places, burrowed into and found a home in the little red corpuscles of the blood. At periods of forty-eight hours it ripened a crop of spores, and would burst out of the corpuscles, scattering throughout the blood and the tissues of the body, and producing the famous paroxysm. This accounted for the most curious and well-marked feature of the disease, namely, its intermittent character, chill and fever one day, and then a day of comparative health, followed by another chill day and so on, as long as the infection continued. One problem, however, was left open, and that was why certain forms of the disease had their chills every fourth day and so were called quartan ague. This was quickly solved by the discovery of another form of the organism, which ripened its spores in three days instead of two. So the whole curious rhythm of the disease was established by the rate of breeding or ripening of the spores of the organism. Later still another form was discovered, which had no such regular period of incubation and gave rise to the so-called irregular, or autumnal, malarial fevers. That form of the fever which had a paroxysm every day, the classic quotidian ague, remained a puzzle for a little longer, but was finally discovered to be due chiefly to the presence of two broods, or infections, of the organism, which ripened on alternate days and hence kept the entire time of the unfortunate patient occupied.

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

But here will challenge some twentieth-century Gradgrind: "This is all very pretty from the point of view of abstract science, but what is the practical value of it? The discovery of the plasmodium and its peculiarities has merely shown us the how and the why of a fact that we had known well and utilized for centuries, namely, that quinine will cure malaria." Just listen to what follows. The story of the plasmodium is one of the most beautiful illustrations of the fact that there is no such thing as useless or unpractical knowledge. The only thing that makes any knowledge unpractical is our more or less temporary ignorance of how to apply it. The first question which instantly raised itself was, "How did the plasmodium get into human blood?" The very sickle-shape of the plasmodium turned itself into an interrogation mark. The first clew that was given was the new and interesting one that this organism was a new departure in the germ line in that it was an animal, instead of a plant, like all the other hitherto known bacilli, bacteria, and other disease-germs.

It may be remarked in passing that its discovery had another incidental practical lesson of enormous value, and that was that it paved the way for the identification of a whole class of animal parasites causing infectious diseases, which already includes the organisms of Texas fever in cattle, dourine in horses, the tsetse fly disease, the dreaded sleeping sickness, and finally such world-renowned plagues as syphilis and perhaps smallpox.

Being an animal, the plasmodium naturally would not grow upon culture-media like the vegetable bacilli and bacteria, and this very fact had delayed its recognition, but raised at once the probability that it must be conveyed into the human body by some other animal. Obviously, the only animals that bite our human species with sufficient frequency and regularity to act as transmitters of such a common disease are those Ishmaelites of the animal world, the insects. As all the evidence pointed toward malaria being contracted in the open air, attested by its popular though unscientific name mal-aria, "bad air," and as of all forms of "bad air" the night air was incomparably the worst, it must be some insect which flew and bit by night; which by Sherlock Holmes's process promptly led the mosquito into the dock as the suspected criminal. It wasn't long before he was, in the immortal language of Mr. Devery, "caught with the goods on"; and in 1895 Dr. Ronald Ross, of the Indian Medical Service, discovered and positively identified the plasmodium undergoing a cycle of its development in the body of the mosquito. He attempted to communicate the disease to birds and animals by allowing infected mosquitoes to bite them, but was unsuccessful. Two Italian investigators, Bignami and Grassi, saw that the problem was one for human experiment and that nothing less would solve it. Volunteers were called for and promptly offered themselves. Their blood was carefully examined to make sure that they were not suffering from any latent form of malaria. They then allowed themselves to be bitten by infected mosquitoes, and within periods varying from six to ten days, eight-tenths of them developed the disease. It may be some consolation to our national pride to know that although the organism was first identified in the mosquito by an Englishman and its transmission to human beings in its bite by Italians, the first definite and carefully worked-out statement of the relation of the mosquito to malaria was made by an American, King of Washington, in 1882; though it is only fair to say that suggestions of the possible connection between mosquitoes and malaria had, so to speak, been in the air and been made from scores of different sources, from the age of Augustus onward.

Another mystery was solved—and what a flood of light it did pour upon our speculations as to the how and wherefore of the catching of malaria! In some respects it curiously corroborated and increased our respect for popular beliefs and impressions. While "bad air" had nothing to do with causing the disease, except in so far as it was inhabited by songsters of the Anopheles genus, yet it was precisely the air of marshy places which was most likely to be "bad" in this sense. So that, while in one sense those local wiseacres, who would point out to you the pearly mists of evening as they rose over low-lying meadows and bottom-lands, and inform you that there before your very eyes was the "mylary just a-risin' out of the ground," were ludicrously mistaken, in another their practical conclusion was absolutely sound; for it is in just such air, at such levels above the surface of the water, that the Anopheles most delights to disport himself. Furthermore, while all raw or misty air is "bad," the night air is infinitely more so than that of the day, because this is the time at which mosquitoes are chiefly abroad. In fact, there can be little doubt that this is part of the foundation for that rabid and unreasonable dread of the night air which we fresh-air crusaders find the bitterest and most tenacious foe we have to fight. We have literally discovered the Powers of Darkness in both visible and audible form, and they have wings and bite, just like the vampire.

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

Of course, a number of popular causes, such as bad drainage, the drinking of water from shallow surface wells, damp subsoils under the houses, and especially that peculiarly widespread and firmly held article of belief that new settlements, where large areas of prairie sod were being freshly upturned by the plough, were peculiarly liable to the attack and spread of malaria, had to go by the board,—with this important reservation, however, that almost every one of these alleged causes either implied or was pretty safe to be associated with pools or swamps of stagnant water in the neighborhood, which would furnish breeding-spots for the mosquitoes.

The discovery explains at once a score of hitherto puzzling facts as to the distribution of malaria. Why, for instance, in all tropical or other malarious countries, those who slept in second and third story bedrooms were less likely to contract the disease, supposedly because "bad air didn't rise to that height," is clearly seen to be due to the fact that the mosquito seldom flies more than ten or twelve feet above the level of the ground or marsh in which he breeds, except when swept by prevailing winds. It also explained why in our Western and Southwestern states the inhabitants of the houses situated on the south bank of a river, though but a short distance back from the stream, would suffer very slightly from malaria, while those living upon the north bank, half a mile back, or even upon bluffs fifteen or twenty feet above the water level, were simply plagued with it. The prevailing winds during the summer are from the south and mosquitoes cannot fly a foot against the wind, but will fly hundreds of yards, and even the best part of a mile, with it. The well-known seasonal preference of the disease for warm spring and summer months, and its prompt subsidence after a killing frost, were seen simply to be due to the influence of the weather upon the flight of mosquitoes. Shakespeare's favorite reference to "the sun of March that breedeth agues" has been placed upon a solid entomological basis by the discovery that, like his pious little brother insect, the bee, the one converted and church-going member of a large criminal family, the mosquito hies himself abroad on his affairs at the very first gleam of spring sunshine, and will even reappear upon a warm, sunny day in November or December. Perhaps even some of the popular prejudice against "unseasonable weather" in winter may be traceable to this fact.

Granted that mosquitoes do cause and are the only cause of malaria, what are you going to do about it? At first sight any campaign against malaria which involves the extermination of the mosquito would appear about as hopeless as Mrs. Partington's attempt to sweep back the rising Atlantic tide with her broom. But a little further investigation showed that it is not only within the limits of possibility, but perfectly feasible, to exterminate malaria absolutely from the mosquito end. In the first place, it was quickly found that by a most merciful squeamishness on the part of the plasmodium, it could live only in the juices of one particular genus of mosquito, the Anopheles; and as nowhere, not even in the most benighted regions of Jersey, has this genus been found to form more than about four or five per cent of the total mosquito population, this cuts down our problem to one-twentieth of its apparent original dimensions at once. The ordinary mosquito of commerce (known as Culex) is any number of different kinds of a nuisance, but she does not carry malaria.

Here the trails of the extermination party fork, one of them taking the perfectly obvious but rather troublesome direction of protecting houses and particularly bedrooms with suitable screens and keeping the inhabitants safely behind them from about an hour before sundown on. By this simple method alone, parties of explorers, of campers, of railroad-builders going through swamps, of the laborers on our Panama Canal, have been enabled to live for weeks and months in the most malarious regions with perfect impunity, so long as these precautions were strictly observed. The first experiment of this sort was carried out by Bignami upon a group of laborers in the famous, or rather infamous, Roman Campagna, whose deadly malarial fevers have a classic reputation, and has achieved its latest triumphs in the superb success of Colonel Gorgas at Panama. While this procedure should never be neglected, it is obvious that it involves a good deal of irksome confinement and interferes with freedom of movement, and it will probably be carried out completely only under military or official discipline, or in tropical regions where the risks are so great that its observance is literally a matter of life or death.

The other division of malaria-hunters pursued the trail of the Anopheles to her lair. There they discovered facts which give us practically the whip-hand over malarial and other tropical fevers whenever we choose to exercise it. It had long been known that the breeding-place of mosquitoes was in water; that their eggs when deposited in water floated upon the surface like tiny boats, usually glued together into a raft; that they then turned into larvae, of which the well-known "wigglers" in the water-butt or the rain-barrel are familiar examples; and that they finally hatched into the complete insect and rose into the air.

Obviously, there were two points at which the destroyers might strike, the egg and the larvae. It was first found that, while the eggs required no air for their development, the larvae wiggled up to the surface and inhaled it through curious little tubes developed for this purpose, oddly enough from their tail-ends. If some kind of film could be spread over the surface of the water, through which the larvae could not obtain air, they would suffocate. The well-known property of oil in "scumming over" water was recalled, two or three stagnant pools were treated with it, and to the delight of the experimenters, not a single larva was able to develop under the circumstances. Here was insecticide number one. The cheapest of oils, crude petroleum, if applied to the pool or marsh in which mosquitoes breed, will almost completely exterminate them. Scores of regions and areas to-day, which were once almost uninhabitable on account of the plague of mosquitoes, are now nearly completely free from these pests by this simple means. An ounce to each fifteen square feet of water-surface is all that is required, though the oiling needs to be repeated carefully several times during the season.

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

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

Finally, most consoling of all, it was discovered that, while the ordinary Culex mosquito can breed, going through all the stages from the egg to the complete insect, in about fourteen days, so that any puddle which will remain wet for that length of time, or even such exceedingly temporary collections of water as the rain caught in a tomato-can, in an old rubber boot, in broken crockery, etc., will serve her for a breeding-place, the Anopheles on the other hand takes nearly three months for the completion of her development. So that, while a region might be simply swarming with ordinary mosquitoes, it would frequently be found that the only places which fulfilled all the requirements for breeding-homes for the Anopheles, that is, isolation from running water or larger streams, absence of fish, and persistence for at least three months continuously, would not exceed five or six to the square mile. Drain, fill up, or kerosene these puddles,—for they are often little more than that,—and you put a stop to the malarial infection of that particular region. Incredible as it may seem, places in such a hotbed of fevers as the west coast of Africa, which have been thoroughly investigated, drained, and cleaned up by mosquito-brigades, have actually been freed from further attacks of fever by draining and filling not to exceed twenty or thirty of these breeding-pools.

In short, science is prepared to say to the community: "I have done my part in the problem of malaria. It is for you to do the rest." There is literally no neighborhood in the temperate zone, and exceedingly few in the tropics, which cannot, by intelligent cooeperation and a moderate expense, be absolutely rid first of malaria, and second of all mosquito-pests. It is only a question of intelligence, cooeperation, and money. The range of flight of the ordinary mosquito is seldom over two or three hundred yards, save when blown by the wind, and more commonly not more than as many feet, and thorough investigation of the ground within the radius of a quarter of a mile of your house will practically disclose all the danger you have to apprehend from mosquitoes. It is a good thing to begin with your own back yard, including the water-butt, any puddles or open cesspools or cisterns, and any ornamental water gardens or lily-ponds. These latter should be stocked with fish or slightly oiled occasionally. If there be any accumulations of water, like rain-barrels or cisterns, which cannot be abolished, they should either be kept closely covered or well screened with mosquito netting.

It might be remarked incidentally in passing, that the only really dangerous sex in mosquitodom, as elsewhere, is the female. The male mosquito, if he were taxed with transmitting malaria, would have a chance to reecho Adam's cowardly evasion in the Garden of Eden, "It was the woman that thou gavest me." Both sexes of mosquitoes under ordinary conditions are vegetable feeders, living upon the juices of plants. But when the female has thrown upon her the tremendous task of ripening and preparing her eggs for deposition, she requires a meal of blood—which may be a comfort to our vegetarian friends, or it may not. Either she requires a meal of blood to nerve her up to her criminal deed, or, when she has some real work to do, she has to have some real food.

The mosquito-brigade have still another method of checking the spread of malaria, at first sight almost a whimsical one,—no less than screening the patient. The mosquito, of course, criminal as she is, does not hatch the parasites de novo in her own body, but simply sucks them up in a meal of blood from some previous victim. Hence by careful screening of every known case of malaria, mosquitoes are prevented from becoming infected and transmitting the disease. Instead of the screens protecting the victims from the mosquitoes, they protect the mosquitoes against the victim.

This explains why hunters, trappers, and Indians may range a region for years, without once suffering from malaria, while as soon as settlers begin to come in in considerable numbers, it becomes highly malarious. It had to be infected by the coming of a case of the disease.

The notorious prevalence of malaria on the frontier is due to the introduction of the plasmodium into a region swarming with mosquitoes, where there are few window-screens or two-story houses.

No known race has any real immunity against malaria. The negro and other colored races, it is true, are far less susceptible; but this we now know applies only to adults, as the studies of Koch in Africa showed that a large percentage of negro children had the plasmodium in their blood. No small percentage of them die of malaria, but those who recover acquire a certain degree of immunity. Possibly they may be able to acquire this immunity more easily and with less fatality than the white race, but this is the extent of their superiority in this regard. The negro races probably represent the survivors of primitive men, who were too unenterprising to get away from the tropics, and have had to adjust themselves as best they might.

The serious injury wrought in the body by malaria is a household word, and a matter of painfully familiar experience. Scarcely an organ in the body escapes damage, though this may not be discovered till long after the "fever-and-ague" has been recovered from.

As the parasite breeds in the red cells of the blood, naturally its first effect is to destroy huge numbers of these, producing the typical malarial anaemia, or bloodlessness. Instead of 5,000,000 to the cubic centimetre of blood the red cells may be reduced to 2,000,000 or even 1,500,000. The breaking down of these red cells throws their pigment or coloring-matter afloat in the blood; and soaking through all the tissues of the body, this turns a greenish-yellow and gives the well-known sallow skin and yellowish whites of the eyes of swamp-dwellers and "river-rats."

The broken-down scraps of the red blood-cells, together with the toxins of the parasite, are carried to the liver and spleen to be burned up or purified in such quantities that both become congested and diseased, causing the familiar "biliousness," so characteristic of malaria.

The spleen often becomes so enormously enlarged that it can be readily felt with the hand in the left side below the ribs, so that it is not only relied upon as a sign of malaria in doubtful cases, but has even received the popular name of the "ague-cake" in malarious districts.

So full is the blood of the parasites, that they may actually choke up the tiny blood-vessels and capillaries in various organs, so as to block the circulation and cause serious and even fatal congestions. Obstructions of this sort may occur in the brain, the liver, the coats of the stomach, or intestines, and the kidneys; and they are the chief cause of the deadly "congestive chills," or pernicious malarial paroxysms, which we have alluded to.

The kidneys are particularly liable to be attacked in this way; indeed, one of their involvements is so serious and fatal in the tropics as to have been given a separate name, "Blackwater fever," from the quantities of broken-down blood which appear in and blacken the urine.

The vast majority of attacks of malaria are completely recovered from, like any other infection, but it can easily be seen what an injurious effect upon the system may be produced by successive attacks, keeping the entire body saturated with the poison; while there is serious risk of the parasite sooner or later finding some weak spot in the body,—kidney, liver, nervous system,—where its incessant battering works permanent damage.

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

Altogether, malaria is a remarkably bad citizen in any community, and its stamping-out is well worth all it costs.



CHAPTER XIV

RHEUMATISM: WHAT IT IS, AND PARTICULARLY WHAT IT ISN'T

What's in a name? All the aches and pains that came out of Pandora's box, if the name happens to be rheumatism. It is a term of wondrous elasticity. It will cover every imaginable twinge in any and every region of the body—and explain none of them. It is a name that means just nothing, and yet it is in every man's vocabulary, from proudest prince to dullest peasant. Its derivative meaning is little short of an absurdity in its inappropriateness, from the Greek reuma (a flowing), hence, a cold or catarrh. It is still preserved for us in the familiar "salt rheum" (eczema) and "rheum of the eyes" of our rural districts. But this very indefiniteness, absurdity if you will, is a comfort both to the sufferer and to the physician. Moreover, incidentally, to paraphrase Portia's famous plea,—

It blesseth him that has and him that treats; 'T is mightier than the mightiest. It doth fit the throned monarch closer than his crown.

To the patient it is a satisfying diagnosis and satisfactory explanation in one; to the doctor, a great saving of brain-fag. When we call a disease rheumatism, we know what to give for it—even if we don't know what it is. As the old German distich runs,—

Was man kann nicht erkennen, Muss er Rheumatismus nennen.[2]

[Footnote 2: What one cannot recognize he must call rheumatism.]

However, in spite of the confusion produced by this wholesale and indiscriminate application of the term to a host of widely different, painful conditions, many of which have little else in common save that they hurt and can be covered by this charitable name-blanket, a few definite facts are crystallizing here and there out of the chaos. The first is, that out of this swarm of different conditions there can be isolated one large and important central group which has the characters of a well-defined and constant disease-entity. This is the disease known popularly as rheumatic fever, and technically as acute rheumatism or acute articular rheumatism. In fact, the commonest division is to separate the "rheumatisms" into two great groups: acute, covering the "fever" form, and chronic, containing all the others. From a purely scientific point of view, this classification has rather an undesirable degree of resemblance to General Grant's famous division of all music into two tunes: one of which was Old Hundred, and the other wasn't. But for practical purposes it has certain merits and may pass.

Every one has seen, or known, or had, the acute articular form of rheumatism, and when once seen there is no difficulty in recognizing it again. It is one of the most striking and most abominable of disease-pictures, beginning with high fever and headache, then tenderness, quickly increasing to extreme sensitiveness in one or more of the larger joints, followed by drenching sweats of penetrating acid odor. The joint attacked becomes red, swollen, and glossy, so tender that merely pointing a finger at it will send a twinge of agony through the entire body, and the patient lies rigid and cramped for fear of the agony caused by the slightest movement. The tongue becomes coated and foul, the blood-cells are rapidly broken down, and the victim becomes ashy pale. He is worn out with pain and fever, yet afraid to fall asleep for fear of unconsciously moving the inflamed joint and waking in tortures; and altogether is about as acutely uncomfortable and completely miserable as any human being can well be made in so short a time.

Fortunately, as with its twin brother, the grip, the bark of rheumatism is far worse than its bite; and a striking feature of the disease is its low fatality, especially when contrasted with the fury of its onslaught and the profoundness of the prostration which it produces. Though it will torture its victim almost to the limits of his endurance for days and even weeks at a stretch, it seldom kills directly. Its chief danger lies in the legacies which it bequeaths. Though, like nearly all fevers, it is self-limited, tends to run its course and subside when the body has manufactured an antitoxin in sufficient amounts, it is unique in another respect, and that is in the extraordinary variability of the length of its "course." This may range anywhere from ten days to as many weeks, the "average expectation of life" being about six weeks. The agonizing intensity of the pain and acute edge of the discomfort usually subside in from five to fifteen days, especially under competent care. When the temperature falls, the drenching sweats cease, the joints become less exquisitely painful, and the patient gradually begins to pull himself together and to feel as if life were once more worth living. He is not yet out of the woods, however, for while the pain is subsiding in the joints which have been first attacked, another joint may suddenly flare up within ten or twelve hours, and the whole distressing process be repeated, though usually on a somewhat milder and shorter scale. This uncertainty as to how many joints in the body may be attacked, is, in fact, one of the chief elements in making the duration of the disease so irregular and incalculable.

Even when the frank and open progress of the disease through the joints of the body has come to an end, the enemy is still lying in wait and reserving his most deadly assault. Distressing and crippling as are the effects of rheumatism upon the joints and tendons, its most deadly and permanent damage is wrought upon the heart. Fortunately, this vital organ is not attacked in more than about half the cases of acute rheumatism, and in probably not more than one-third of these are the changes produced either serious or permanent, especially if the case be carefully watched and managed. But it is not too much to say that, of all cases of serious or "organic" heart disease, rheumatism is probably responsible for from fifty to seventy per cent. The same germ or toxin which produces the striking inflammatory changes in the joints may be carried in the blood to the heart, and there attack either the lining and valves of the heart (endocardium), which is commonest, or the covering of the heart (pericardium), or the heart-muscle. So intense is the inflammation, that parts of the valves may be literally eaten away by ulceration, and when these ulcers heal with formation of scar-tissue as everywhere else in the body, the flaps of the valves may be either tied together or pulled out of shape, so that they can no longer properly close the openings of the heart-pump. This condition, or some modification of it, is what we usually mean when we speak of "heart disease," or "organic heart disease." The effect upon the heart-pump is similar to that which would be produced by cutting or twisting the valve in the "bucket" of a pump or in a bulb syringe.

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

Now comes another redeeming feature of this troublesome disease, and that is the comparatively small permanent effects which it produces upon the joints in the way of crippling, or even stiffening. To gaze upon a rheumatic knee-joint, for instance, in the height of the attack,—swollen to the size of a hornet's nest, hot, red, throbbing with agony, and looking as if it were on the point of bursting,—one would almost despair of saving the joint, and the best one would feel entitled to expect would be a roughening of its surfaces and a permanent stiffening of its movements.

On the contrary, when once the fury of the attack has passed its climax, especially if another joint should become involved, the whole picture changes as if by magic. The pain fades away to one-fifth of its former intensity within twenty-four, or even within twelve hours; three-fourths of the swelling follows suit in forty-eight hours; and within three or four days' time the patient is moving the joint with comparative ease and comfort. After he gets up at the end of his six weeks, the knee, though still weak and stiff and sore, within a few weeks' time "limbers up" completely, and usually becomes practically as good as ever. In short, the violence and swiftness of the onset are only matched by the rapidity and completeness of the retreat. It would probably be safe to say that not more than one joint in fifty, attacked by rheumatism, is left in any way permanently the worse.

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

Obviously, the picture of acute rheumatism carries upon its face a strong suggestion of its real nature and causation. The high temperature, the headache, the sweats, the fierce attack and rapid decline, the self-limited course, the tendency to spread from one joint to another, from the joints to the heart, from the heart to the lungs and the kidneys, all stamp it unmistakably as an infection, a fever. On the other hand, there are two rather important elements lacking in the infection-picture: one, that, although it does at times occur in epidemics, it is very seldom transmitted to others; the other, that one attack does not produce immunity or protect against another. The majority of experts are now practically agreed that acute rheumatism, or rheumatic fever, is probably due to the invasion of the system by some microoerganism or germ. When, however, we come to fixing upon the particular bacillus, or micrococcus, there is a wide divergence of opinion, some six or seven different eminent investigators having each his favorite candidate for the doubtful honor. In fact, it is our inability as yet positively to identify and agree upon the causal germ that makes our knowledge of the entire subject still so regrettably vague, and renders either a definite classification or successful treatment so difficult.

The attitude of the most careful and experienced physicians and broad-minded bacteriologists may be roughly summed up in the statement that acute rheumatism is probably due to some germ or germs, but that the question is still open which particular germ is at fault, and even whether the group of symptoms which we call rheumatism may not possibly be produced by a number of different organisms, acting upon a particular type of constitution or susceptibility. There is no difficulty in finding germs of all sorts, principally micrococci, in the blood, in the tissues about the joints, and on the heart-valves of patients with rheumatism, and these germs, when injected into animals, will not infrequently produce fever and inflammatory changes in the joints, roughly resembling rheumatism. But the difficulty so far has been, first, that these organisms are of several different kinds and distinct species; and second, and even more important, that almost any of the organisms of the common infectious diseases are capable at times of producing inflammation of the joints and tendons. For instance, the third commonest point of attack of the tubercle bacillus, after the lungs and the glands, is the bones and joints, as illustrated in the sadly familiar "white-swelling of the knee" and hip-joint disease. All the so-called septic organisms, which produce suppuration and blood-poisoning in wounds and surgery, may, and very frequently do, attack the joints; while nearly all the common infections, such as typhoid, scarlet fever, pneumonia, and even measles, influenza, and tonsillitis, may be followed by severe joint symptoms.

In fact, we are coming to recognize that diseases of the joints, like diseases of the nervous system, are among the frequent results of any and all of the acute infectious diseases or fevers; and we now trace from fifty to seventy-five per cent of both joint troubles and degenerations of the nervous system to this cause. Two-thirds, for instance, of our cases of hip-joint disease and of spinal disease (caries) are due to tuberculosis.

The puzzling problem now before pathologists is the sorting out of these innumerable forms of joint inflammations and the splitting off of those which are clearly due to certain specific diseases, from the great, central group of true rheumatism. Most of these joint inflammations which are due to recognized germs, such as the pus-organisms of surgical fevers, tuberculosis, and typhoid, differ from true rheumatism in that they go on to suppuration (formation of "matter") and permanently cripple the joint to a greater or less degree. So that there is probably a germ or group of germs which produces the swift attack and rapid subsidence and other characteristic features of true rheumatism, even though we have not yet succeeded in sorting them out of the swarm. So confident do we feel of this, that although, as will be shown, there are probably other factors involved, such as exposure, housing, occupation, food, and heredity, yet the best thought of the profession is practically agreed that none of these would alone produce the disease, but that they are only accessory causes plus the micrococcus. In practically all our modern textbooks of medicine, rheumatism is included under the head of infections.

This theory of causation, confessedly provisional and imperfect as it is, helps us to harmonize the other known facts about the disease; it has already greatly improved our treatment and given us a foothold for attacking the problem of prevention. For instance, it has long been known that rheumatism was very apt to follow tonsillitis or other forms of sore throat; indeed, many of the earlier authorities put down tonsillitis as one of the great group of "rheumatic" disturbances, and persons of rheumatic family tendency were supposed to have tonsillitis in childhood and rheumatism in later life. Not more than ten or fifteen per cent of all cases gave a history of tonsillitis; but since we have broadened our conception of infection and begun to inquire, not merely for symptoms of tonsillitis, but also for those of influenza, "common colds," measles, whooping-cough, and the like, we reach the most significant result of finding that forty to sixty per cent of our cases of rheumatism have been preceded, anywhere from one to three weeks before, by an attack of some sort of "cold," sore throat, catarrhal fever, cough, bronchitis, or other group of disturbances due to a mild infection. Further, it has long been notorious that when a rheumatic individual "catches cold" it is exceedingly apt to "settle in the joints," and, if these cases happen to come under the eye of a physician, they are recognized as secondary attacks of true rheumatism. In other words, the "cold" may simply be a second dose of the same germ which caused the primary attack of rheumatism.

This brings us to the widespread article of popular belief that rheumatism is most commonly due to cold, exposure, chill, or damp. Much of this is found on investigation to be due to the well-known historic confusion between "cold," in the sense of exposure to cold air, and "cold," in the sense of a catarrh or influenza, with running at the nose, coughing, sore throat, and fever, a group of symptoms now clearly recognized to be due to an infection. In short, the vast majority of common colds are unmistakably infections, and spread from one victim to another, and this is the type of "cold" which causes the majority of rheumatic attacks.

The chill, which any one who is "coming down" with a cold experiences, and usually refers to a draft or a cold room, is, in nine cases out of ten, the rigor which precedes the fever, and has nothing whatever to do with the external temperature. The large majority of our cases of rheumatism can give no clear or convincing history of exposure to wet, cold, or damp. But popular impression is seldom entirely mistaken, and there can be no question that, given the presence of the infectious germ, a prolonged exposure to cold, and particularly to wet, will often prove to be the last straw which will break down the patient's power of resistance, and determine an attack of rheumatism.

This climatic influence, however, is probably not responsible for more than fifteen or twenty per cent of all cases, and, popular impression to the contrary notwithstanding, the liability of outdoor workers who are subject to severe exposure, such as lumbermen, fishermen, and sailors, is only slightly greater than that of indoor workers. The highest susceptibility, in fact, not merely to the disease, but also to the development of serious heart involvements, is found among domestic servants, particularly servant girls, agricultural laborers and their families (in districts where wages are low and cottages bad), and slum-dwellers; in fact, those classes which are underfed, overworked, badly housed, and crowded together. Diet has exceeding little to do with the disease, and, so far from meat or high living of any sort predisposing to it, it is most common and most serious in precisely those classes which get least meat or luxuries of any sort, and are from stern necessity compelled to live upon a diet of cereals, potatoes, cheap fats, and coarse vegetables.

Even its relations to the weather and seasons support the infection theory. Its seasonal occurrence is very similar to that of pneumonia,—rarest in summer, commonest in winter, the highest percentage of cases occurring in the late fall and in the early spring; in other words, just at those times when people are first beginning to shut themselves up for the winter, light fires, and close windows, and at the end of their long period of winter imprisonment, when both their resisting power has been reduced to the lowest ebb in the year and infections of all sorts have had their most favorable conditions of growth for months.

The epidemics of rheumatism, which occasionally occur, probably follow epidemics of influenza, tonsillitis, or other mild infections, and instances of two or more cases of rheumatism in one family or household are most rationally explained as due to the spread of the precedent infection from one member of the family to the other. Instances of the direct transmission of the disease from one patient to another are exceedingly rare.

Our view of the infectious causation of rheumatism, vague as it is, has given us already our first intelligent prospect of prevention. Whatever may be the character of a germ or germs, the vast majority of them agree in making the nose and throat their first point of attack and of entry into the system. Hence, vigorous antiseptic and other rational treatment of all acute disturbances of the nose and throat, however slight, will prove a valuable preventive and diminisher of the percentage of rheumatism. This simply emphasizes again the truth and importance of the dictum of modern medicine, "Never neglect a cold," since we are already able to trace, not merely rheumatism, but from two-thirds to three-fourths of our cases of heart disease, of kidney trouble, and of inflammations of the nervous system, to those mild infections which we term "colds," or to other definite infectious diseases.

Not only is this good a priori reasoning, but it has been demonstrated in practice. One of our largest United States army posts had acquired an unenviable reputation from the amount of rheumatism occurring in the troops stationed there. A new surgeon coming to take charge of the post set about investigating the cause of this state of affairs, and came to the conclusion that the disease began as, or closely followed, tonsillitis and other forms of sore throat. He accordingly saw to it that every case of tonsillitis, of cold in the head, or sore throat was vigorously treated with local germicides and with intestinal antiseptics and laxatives, until it was completely cured; with the result that in less than a year he succeeded in lowering the percentage of cases of rheumatism per company nearly sixty per cent.

At some of our large health-resorts, where great numbers of cases of rheumatism are treated, it has been discovered that if a case of common cold, or tonsillitis, happens to come into the establishment, and runs through the inmates, nearly half of the rheumatic patients attacked will have a relapse or new seizure of their rheumatism. Accordingly, a rigorous and hawk-like watch is kept for every possible case of cold, tonsillitis, or sore throat entering the house; the patient is promptly isolated and treated on rigidly antiseptic principles, with the result that epidemics of relapses of rheumatism in the inmates have greatly diminished in frequency.

If every case of cold or sore throat were promptly and thoroughly treated with antiseptic sprays and washes such as any competent physician can direct his patients to keep in the house, in readiness for such an emergency, combined with laxatives and intestinal antiseptic treatment, and, above all, with rest in bed as long as any rise of temperature is present, there would be a marked diminution in both the frequency and the severity of rheumatism. If to this were added an abundant and nutritious dietary, good ventilation and pure air, an avoidance of overwork and overstrain, we should soon begin to get the better of this distressing disease. In fact, while positive data are lacking, on account of the small fatality of rheumatism and its consequent infrequent appearance among the causes of death in our vital statistics, yet it is the almost unanimous opinion of physicians of experience that the disease is distinctly diminishing, as a result of the marked improvement in food, housing, wages, and living conditions generally, which modern civilization has already brought about.

So much for acute rheumatism. Vague and unsatisfactory as is our knowledge of it, it is, unfortunately, clearness and precision itself when contrasted with the welter of confusion and fog which covers our ideas about the chronic variety. The catholicity of the term is something incredible. Every chronic pain and twinge, from corns to locomotor ataxia, and from stone-in-the-kidney to tic-douloureux, has been put down as "rheumatism." It is little better than a diagnostic garbage-dump or dust-heap, where can be shot down all kinds of vague and wandering pains in joints, bones, muscles, and nerves, which have no visible or readily ascertainable cause. Probably at least half of all the discomforts which are put down as "rheumatism" of the ankle, the elbow, the shoulder, are not rheumatism at all, in any true or reasonable sense of the term, but merely painful symptoms due to other perfectly definite disease conditions of every imaginable sort. The remaining half may be divided into two great groups of nearly equal size. One of these, like acute rheumatism, is closely related to, and probably caused by, the attack of acute infections of milder character, falling upon less favorable soil. The other is of a vaguer type and is due, probably, to the accumulation of poisonous waste-products in the tissues, setting up irritative and even inflammatory changes in nerve, muscle, and joint. Either of these may be made worse by exposure to cold or changes in the weather. In fact, this is the type of rheumatism which has such a wide reputation as a barometer and weather prophet, second only to that of the United States Signal Service. When you "feel it in your bones," you know it is going to snow, or to rain, or to clear up, or become cloudy, or whatever else may happen to follow the sensation, merely because all poisoned and irritated nerves are more sensitive to changes in temperature, wind-direction, moisture, and electric tension, than sound and normal ones. The change in the weather does not cause the rheumatism. It is the rheumatism that enables us to predict the change in the weather, though we have no clear idea what that change will be.

Probably the only statement of wide application that can be made in regard to the nature of chronic rheumatism is that a very considerable percentage of it is due to the accumulation of poisons (toxins) in the nerves supplying joints and muscles, setting up an irritation (neurotoxis), or, in extreme cases, an inflammation of the nerve (neuritis), which may even go on to partial paralysis, with wasting of the muscles supplied. The same broad principles of causation and prevention, therefore, apply here as in acute rheumatism.

The most important single fact for rheumatics of all sorts, whether acute or chronic, to remember is that they must avoid exposure to colds, in the sense of infections of all sorts, as they would a pestilence; that they must eat plenty of rich, sound, nourishing food; live in well-ventilated rooms; take plenty of exercise in the open air, to burn up any waste poisons that may be accumulating in the tissues; dress lightly but warmly (there is no special virtue in flannels), and treat every cold or mild infection which they may be unfortunate enough to catch, according to the strictest rigor of the antiseptic law.

The influence of diet in chronic rheumatism is almost as slight as in the acute form. Persons past middle age who can afford to indulge their appetites and are inclined to eat and drink more than is good for them, and, what is far more important, to exercise much less, may so embarrass their liver and kidneys as to create accumulations of waste products in the blood sufficient to cause rheumatic twinges. The vast majority, however, of the sufferers from chronic rheumatism, like those from the acute form, are underfed rather than overfed, and a liberal and abundant dietary, including plenty of red meats, eggs, fresh butter, green vegetables, and fresh fruits, will improve their nutrition and diminish their tendency to the attacks.

There appears to be absolutely no rational foundation for the popular belief that red meats cause rheumatism, either from the point of view of practical experience, or from that of chemical composition. We now know that white meats of all sorts are quite as rich in those elements known as the purin bodies, or uric-acid group, as red meats, and many of them much richer. It may be said in passing, that this last-mentioned bugbear of our diet-reformers is now believed to have nothing whatever to do with rheumatism, and probably very little with gout, and that the ravings of Haig and the Uric-Acid School generally are now thoroughly discredited. Certainly, whenever you see any remedy or any method of treatment vaunted as a cure for rheumatism, by neutralizing or washing out uric acid, you may safely set it down as a fraud.

One rather curious and unexpected fact should, however, be mentioned in regard to the relation of diet to rheumatism, and that is that many rheumatic patients have a peculiar susceptibility to some one article of food. This may be a perfectly harmless and wholesome thing for the vast majority of the species, but to this individual it acts as a poison and will promptly produce pains in the joints, redness, and even swelling, sometimes accompanied by a rash and severe disturbances of the digestive tract. The commonest offenders form a curious group in their apparent harmlessness, headed as they are by strawberries, followed by raspberries, cherries, bananas, oranges; then clams, crabs, and oysters; then cheese, especially overripe kinds; and finally, but very rarely, certain meats, like mutton and beef. What is the cause of this curious susceptibility we do not know, but it not infrequently occurs with this group of foods in rheumatics and also in asthmatics.

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

As to principles of treatment in a disease of so varied and indefinite a character, due to such a multitude of causes, obviously nothing can be said except in the broadest and sketchiest of outline. The prevailing tendency is, for the acute form, rest in bed, the first and most important, also the second, the third, and the last element in the treatment. This will do more to diminish the severity of the attack and prevent the occurrence of heart and other complications than any other single procedure.

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

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

In short, there is no disease under heaven in which so much depends upon a careful study of each individual case and adaptation of treatment to it personally, according to its cause and the patient in whom it occurs. Rheumatism, unfortunately, does tend to "run in families." Apparently some peculiar susceptibility of the nervous system to influences which would be comparatively harmless to normal nerves and cells is capable of being inherited. But this inheritance is almost invariably "recessive," in Mendelian terms, and a majority of the children of even the most rheumatic parent may entirely escape the disease, especially if they live rationally and vigorously, feed themselves abundantly, and avoid overwork and overcrowding.



CHAPTER XV

GERM-FOES THAT FOLLOW THE KNIFE, OR DEATH UNDER THE FINGER-NAIL

Our principal dread of a wound is from fear that it may fester instead of healing quickly. We don't exactly enjoy being shot, or stabbed, or scratched, though, as a matter of fact, in what Mulvaney calls the "fog av fightin'" we hardly notice such trifles unless immediately disabling. But our greatest fear after the bleeding has stopped is lest blood-poisoning may set in. And we do well to dread it, for in the olden days,—that is, barely fifty years ago,—in wounds of any size or seriousness, two-thirds of the risk remained to be run after the bleeding had been stopped and the bandages put on. Nowadays the danger is only a fraction of one per cent, but till half a century ago every wound was expected to form "matter" or pus in the process of healing, as a matter of course. Most of us can recall the favorite and brilliant repartee of our boyhood days in answer to the inquisitive query, "What's the matter?" "Nuthin': it hasn't come to matter yet. It's only a fresh cut!"

Even surgeons thought it a necessary part of the process of healing, and the approving term "laudable pus" was applied to a soft, creamy discharge, without either offensive odor or tinge of blood, upon the surfaces of the healing wound; and the hospital records of that day noted with satisfaction that, after an operation, "suppuration was established." So strongly was this idea intrenched, that a free discharge or outpouring of some sort was necessary to the proper healing of the wound, that in the Middle Ages it was regarded as exceedingly dangerous to permit wounds to close too quickly. Wounds that had partially united were actually torn apart, and liquids like oil and wine and strong acids, which tended to keep them from closing and to set up suppuration, were actually poured into them; and in some instances their sides were actually burned with hot irons. There was a solid basis of reason underlying even these extraordinary methods, viz., the "rule of thumb" observation, handed down from one generation to another, that wounds that discharged freely and "sweetly," while they were slow in healing and left disfiguring scars, usually did not give rise to serious or fatal attacks of blood-poison or wound-fever. And of two evils they chose the less. Plenty of pus and a big ugly scar in preference to an attack of dangerous blood-poisoning. Even if it didn't kill you, it might easily cripple you for life by involving a joint. The trouble was with their logic, or rather with their premises. They were firmly convinced that the danger came from within, that there was a sort of morbid humor which must be allowed to escape, or it would be dammed up in the system with disastrous results.

One day a brilliant skeptic by the name of Lister (who is still living) took it into his head that perhaps the fathers of surgery and their generations of imitators might have been wrong. He tried the experiment, shut germs out of his wounds, and behold, antiseptic surgery, with all its magnificent line of triumphs, was born!

Now a single drop of pus in an operation wound is as deep a disgrace as a bedbug on the pillow of a model housekeeper, and calls for as vigorous an overhauling of equipment, from cellar to skylight; while a second drop means a commission of inquiry and a drumhead court-martial. This is the secret of the advances of modern surgery,—not that our surgeons are any more skillful with the knife, but that they can enter cavities like those of the skull, the spinal cord, the abdomen, and the chest, remove what is necessary, and get out again with almost perfect safety; whereas these cavities were absolutely forbidden ground to their forefathers, on account of the twenty, forty, yes, seventy per cent death risk from suppuration and blood-poison.

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

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

Surgeons, ignorant of antisepsis, and careless nurses, spread the infection along, until in some instances it reached a virulence which burst into the dreaded "hospital gangrene." This dread disease was the scourge of all hospitals, especially military ones, all over the civilized world, as recently as our War of Secession. In some wards of our military hospitals, from thirty to fifty per cent of all the wounded received were attacked, and over five thousand cases were formally reported during the war, of which nearly fifty per cent died. This plague was born solely of those two great mothers of evils, ignorance and dirt, and is to-day, in civilized lands, as extinct as the dodo. Then the dread that the community had of hospitals, as places that "help the poor to die," in Browning's phrase, had a certain amount of foundation; and cases operated upon in a farmhouse kitchen, where no one in the family happened to have had a boil or a catarrh or a festering cut within a month or so, and where the knife happened to be clean or new, would recover with less suppuration than hospital cases. Nowadays, from incessant and eternal vigilance, a hospital is surgically the cleanest and safest place in the world for an operation, so that most surgeons decline to operate outside of one, except in emergencies; and some will not even operate except in one with which they are personally connected, so that they know every step in the process of protection.

It was this terrible risk of the surgeon carrying infection from one case to another, that made the coroner of London declare, barely sixty years ago, that he would hold an inquest upon the next case of death after ovariotomy that was reported to him, on account of the fearful pus-mortality that followed this serious operation, which now has a possible death-rate from all causes connected with the operation of only a fraction of one per cent.

The brusque reply is still remembered of Lawson Tait, the great English ovariotomist, to a distinguished German colleague, who had inquired the secret of his then marvelously low death-rate: after a glance at the bands of mourning on the ends of the other's fingers, he said, "I keep my fingernails clean, sir!" There was sadly too much truth in the saying of another eminent surgeon, that in the pre-Listerian days many a poor woman's death warrant was written under the fingernails of her surgeon. This reproach has been wiped out, thank Heaven! but the labor, pains, and persistence after heart-breaking failures which it took to do it! Never was there a more vivid illustration of the declaration that genius is the capacity for taking pains, than antiseptic surgery! Not a loophole must be left unstopped, not a possibility unconsidered, not a thing in, or about, or connected with, the operating-room left unsterilized, except the patient and the surgeon; and these are brought as near to it as is possible without danger to life.

In the first place, the operating-room itself must be like a bath room, or, more accurately, the inside of a cistern. Walls, floor, and ceiling are all waterproof and capable of being washed down with a hose. There must be no casings or cornices of any sort to catch dust; and in the best appointed hospitals no one is permitted to enter, under any pretext, whose hands and garments have not been sterilized.

In the second place, everything that is brought into the room for use in, or during, the operation, is first thoroughly sterilized. The knives, instruments, and other operative objects are sterilized by boiling, or by the use of superheated steam; and the towels, dressings, bandages, sheets, etc., by boiling, baking, or superheated steam. Then begins the preparation of the surgeon and the nurse. Dressing-rooms are provided, in which the outer garments are removed, and the hands given an ordinary wash. Then the scrubbing-room is entered, where, at a series of basins provided with running hot and cold water, whose faucets are turned by pressure with the foot so as to avoid any necessity for touching them with the hand, the hands are thoroughly scrubbed with hot water, boiled soap, and a boiled nail-brush. Then they are plunged into, and thoroughly soaked in, some strong antiseptic solution, then washed again; then plunged into another antiseptic solution, containing some fat solvent like ether or alcohol, to wash off any dirt that may have been protected by the natural oil of the skin. Then they are thoroughly scrubbed with soap and hot water again, to remove all traces of the antiseptics, most of which are irritating to wounded tissues; then washed in absolute alcohol, then in boiled or distilled water. Then the nurse, whose hands are already sterilized, takes out of the original package in which it came from the sterilizing oven, a linen surgical gown or suit which covers the operator from neck to toes. A sterilized linen or cotton cap is placed upon his head and pulled down so that the scales or germs of any sort may not fall into the wound. Some surgeons of stout and comfortable habit, who are apt to perspire in the high temperature of an operating-room, will tie a band of gauze around their foreheads, to prevent any unexpected drops of perspiration from falling into the wound; while some purists muffle up the mouth and lower part of the face lightly in a similar comforter.

You would think that by this time the hands were clean enough to go anywhere with safety, but no risks are going to be taken. A pair of rubber or cotton gloves, the former taken right out of a strong antiseptic solution, the latter out of the sterilizing oven, are pulled carefully on by the nurse. Holding his sacred hands spread out rigidly before him, like the front paws of a kangaroo, the surgeon carefully edges his way into the operating-room, waiting for any doors that he may have to pass through to be opened by the nurse, or awkwardly pushing them with his elbow. In that attitude of benediction, the hands are maintained until the operation is ready to begin.

Then comes the patient! If his condition will in any wise permit, he has been given a boiling hot bath and scrub the night before, and put to bed in a sterilized nightgown between sterilized sheets. The region which is to be operated upon has, at the same time, been scrubbed and rubbed and flushed with hot water, germicides, alcohol, soap,—in fact, has gone through the same sacred ceremonial of cleansing through which the surgeons' hands have passed; and a large, closely fitting antiseptic dressing, covering the whole field, has been applied and tightly bound. He is brought into a waiting-room and put under ether by an anaesthetist, through a sterilized mask; he is then wheeled into the operating-room, the dressing is removed, a thorough double scrub is again given, for "good measure," to the whole area in which the wound is to be made. A big sheet is thrown over the lower part of his body, another over the upper part, a third, with an oval opening in the centre of it, thrown over the region to be operated upon. The instrument nurse takes a boiled knife out of a sterilized dish of distilled water, hands it to the surgeon, who takes it in his gloved hand, and the operation begins.

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

The intruders against whom all these preparations are made are two in number: Streptococcus pyogenes and Staphylococcus pyogenes—cousins, as you see, by their names. Their last (not family) name really means something, and is not half so alarming as it sounds, as it is Greek for "pus-making." Their real family name, Coccus, which means a berry, was suggested, by their rounded shape under the microscope, to some poetically minded microscopist. Undesirable citizens, both of them! But the older, or Strepto, cousin is by far the more dangerous character and desperate individual, giving rise to and being concerned in nearly all the civilized and dangerous wound-fevers—septicaemia, erysipelas, etc. Staphylococcus is a milder and less harmful individual, seldom going farther than to produce the milder forms of festering, discharging, refusing to heal, pustules, etc. He is not to be given a yard of leeway, however, for if he can get a sufficient number of dirty wounds to run through, he can work himself up to a high degree of virulence and poisoning power. Indeed, this faculty of his may possibly furnish a clew as to how these pus-makers developed their power of living in wounds, and almost nowhere else. There is another cousin also, in the group, called Staphylococcus pyogenes albus, to distinguish him (albus, "white") from the other two, who have the tag name aureus (golden). He is an almost harmless denizen of the surfaces of our bodies, particularly the mouths of the sweat-ducts, and the openings of the hair follicles. Under peculiarly favorable circumstances, such as a very big wound, an aggravated chafe, or the application of that champion "bug-breeder," a poultice, he may summon up courage enough to attack some half-dead skin-cells and make a few drops of pus on his own account. He is the criminal concerned in the so-called stitch-abscesses, or tiny points of pus which form around the stitches of a big wound and in some of the smaller pimples which turn to "matter." It is conceivable that this feeble and harmless white coccus may at some time have been accelerated under favorable circumstances to where he was endowed with "yellow" powers, and even, upon another turn of the screw, with strepto-virulence. But this is a mere academic question. Practically the only thing needful is to keep all the rascals out of every wound.

Now comes the question, how is this to be done? Fortunately it is not necessary to hunt out and destroy the pus-germs in their breeding-places outside of the human body. As we have seen, they do not long retain their vitality out of doors, or as a rule even in the dust of rooms and dirt of houses, unless the latter have been recently contaminated with the dressings of, or discharges from, wounds. There are two main things to be watched: first, the wound itself, and second, any unwashed or unsterilized part of your own or some other living body. Dirt of all sorts is a mighty good thing to keep absolutely out of the wound, but practically a whole handful of ordinary soil or dust rubbed into a wound might not, unless it happened to contain fertilizer of some sort, be half so dangerous as a single touch with a finger which had been dressing a wound, picking a scab out of the nose, rubbing an ulcerated gum, or scratching an itching scalp. If it be a cut on the finger, or scratch on the hand, for instance, don't suck it, or lick it, unless you can give an absolutely clean bill of health to your gums and teeth. If not thoroughly brushed three or four times a day, they are sure to be swarming with germs of twenty or thirty different species, which not infrequently include one or both of the pus-germs. Indeed, the real reason why the bite of certain animals, and above all of a man, particularly of a "blue-gum nigger," is regarded as so dangerous is on account of the swarms of germs that breed in any remnants of food left between the teeth or in the pockets of ulcerating gums. Many a human bite is almost as dangerous as a rattlesnake's. The devoted hero who sucks the poison of the dagger out of the wound may be conferring a doubtful benefit, if he happens to be suffering from Rigg's disease.

Don't try to stop the bleeding unless it comes in spurts or the flow is serious. The loss of a few teaspoonfuls, tablespoonfuls, or, for the matter of that, cupfuls, of blood won't do you any harm, and its free flow will wash out the cut from the bottom, and carry out most of the germs that may happen to be present on the knife or nail. If water and dressings are not accessible, let the blood cake and dry over the wound without disturbing it, even though it does look rather gory.

A slight cut with a clean knife, or other instrument, into which no dirt has been rubbed, will often require no other dressing than its own blood-scab. If, however, as oftener happens, you cannot be sure of the cleanness of the knife, tool, or nail, hold the wound under running water from a pump or tap (this is not germ-free, but practically never contains pus-germs), until the wound has been thoroughly washed out, wiping any gravel or dirt out of the cut with soft rags which have been recently washed, or baked in the oven; then dry with a small piece of linen, or white goods, put on a dressing of absorbent cotton such as can be purchased for a few cents an ounce at any drug store. Absorbent or surgical cotton makes a good dressing, because it both sucks up any fluids which might leak out of the wound, and forms a mesh-filter through which no germs can penetrate.

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

If the cut or scratch is of any depth or seriousness whatever, or the knife, tool, or other instrument be dirty, or if any considerable amount of street-dust or garden-soil has got into the wound, then it is, by all means, advisable to go to a physician, have the wound thoroughly cleaned on antiseptic principles, and put up in antiseptic dressing. A single treatment of this sort, in a comparatively trifling wound which has become in any way contaminated, may save weeks of suffering and disability, and often danger of life, and will in eight cases out of ten shorten the time of healing from forty to sixty per cent. The rapidity with which a wound in a reasonably healthy individual, cleaned and dressed on modern surgical principles, will heal, is almost incredible, until it has actually been seen.

The principal danger of garden-soil or street-dust in a wound is not so much from pus-germs, though these may be present, as from another "bug"—the tetanus or lockjaw bacillus. This deadly organism lives in the alimentary canal of the horse, and hence is to be found in any dirt or soil which contains horse manure. It is, fortunately, not very common, or widely spread, but enough so to make it the part of prudence to have thoroughly asepticized and dressed any wound into which considerable amounts of garden-soil, or street-dust, have been rubbed. The reason why wounds of the feet and hands have had such a bad reputation, both for festering and giving rise to lockjaw, is that it is precisely in these situations that they are most likely to get garden-soil, or stable manure, into them. The classic rusty nail does not deserve the bad reputation as a wound-maker which it enjoys, its bad odor being chiefly due to the fact already referred to, that injuries inflicted by it are most apt to be in the palm of the hand, or in the sole of the foot, and hence peculiarly liable to contamination by the tetanus and other soil bacilli.

For some reason or other which we don't as yet thoroughly understand, burns from a toy pistol in particular, and Fourth of July fireworks in general, seem to be peculiarly liable to be followed by tetanus. The fulminate used in the cap of a toy pistol, and the paper and explosives of several of the brands of firecrackers, have been thoroughly examined bacteriologically, but without finding any tetanus germs in them. So many cases of lockjaw used to follow the Fourth of July celebrations a few years ago, that Boards of Health became alarmed, and not only forbade outright the sale of deadly toy pistols, but provided supplies of the tetanus antitoxin at various depots throughout the cities, so that all patriotic wounds of this description could have it dropped into them when they were dressed. Since then, the lockjaw penalty which we pay for our highly intelligent method of celebrating the Fourth, has diminished considerably. It is probable that the mortality was chiefly due to infection of the ugly, slow-healing, dirty little wounds with city-dust, a large percentage of which, of course, is dried horse manure. What with the tetanus bacillus and the swarms of flies which breed chiefly in stable manure, and carry summer diseases, typhoid, diphtheria, and tuberculosis in every direction, it will not be long before the keeping of horses within city limits will be as strictly forbidden as pigpens now are.

So definite is the connection between the tetanus bacilli and the soil, that tetanus fields or lockjaw gardens are now recognized and listed by the health authorities, on account of their having given rise to several successive cases of the disease. Workers in such fields or gardens, who scratch or cut themselves, are warned to report themselves promptly for treatment with the tetanus antitoxin.

Apart from the tetanus germ, however, the problem of the treatment of wounds—while there should be perfect cleanliness, the spotlessness of the model housekeeper multiplied fivefold—is yet not so much a matter of keeping dirt in general out of the wound, as of keeping out that particular form of dirt which consists of or contains, discharges from some previous wound, sore, ulcer, or boil!

While both these pus-organisms can breed and flourish freely only in wounds or sores, this is but their starting-point where they gather strength to invade the entire organism. We used to make a distinction between those cases in which their toxins or poison-products got into the blood, with the production of fever, headache, backache, delirium, sweats, etc., which we term septicaemia, and other cases in which the cocci themselves were carried into the blood and swept all over the body by forming fresh foci, or breeding-places, which resulted in abscesses all over the body, which we call pyaemia. But now we know that there is no hard and fast line to be drawn, and that the germs get into the blood much more easily than we supposed; and the degree and dangerousness of the fever which they set up depend, first, upon their virulence, or poisonousness, and, second, upon the resisting power of the patient at the time. Anything which lowers the general health and strength and weakens the resisting power of the body will make it much easier for pus-germs to get an entrance into it, and overwhelm it; so that, after prolonged famines for instance, or among the population of besieged cities, or in armies or exploring expeditions which have been deprived of food and exposed to great hardship, the merest scratch will fester and inflame, and give rise to a serious and even fatal attack of blood-poisoning, erysipelas, hospital gangrene, etc. Famines and sieges in fact are not infrequently followed by positive epidemics of blood-poisoning, often in exceedingly severe and fatal forms.

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

As the invading germs pass into the body, they travel most commonly through the lymph-channels and skin; are arrested and threatened with destruction by the so-called lymphatic glands, or lymph-nodes. This is why, if you have a festering wound or boil on your hand or wrist, the "kernels" or lymph-nodes up in your armpit will swell and become painful. If the lymph-nodes can conquer the germs and eat them up, the swelling goes down and the pain disappears. But if the germs, on the other hand, succeed in poisoning and killing the cells of the body, these latter melt down and turn to pus, and we get what we call a "secondary abscess."

The next commonest point of attack of these pus-germs, if they once get into the body, and by far the most dangerous, is the heart, as in rheumatism and other fevers. Some will also attack the kidneys, giving rise to albumin in the urine, while others attack the membranes of the joints (synovia) and cause suppuration of one or more joints in the body, which is very apt to be followed by very serious stiffening or crippling. So that, common, and, in many instances, comparatively mild as they are, the pus-germs in the aggregate are responsible for a very large amount of damage to the human body.

This is the way the streptococcus and staphylococcus behave in an open wound, or sore; but they have two other methods of operating which are somewhat special and peculiar. One of these is where the germ digs and burrows, as it were, underground, in a limited space, resulting in that charming product known as a boil, or a carbuncle. The other, where it spreads rapidly over the surface just under the skin, after the fashion of the prairie fire, producing erysipelas. In the first of these he behaves like the famous burrowing owl of our Western plains, who forms, with the prairie-dog, the so-called "happy family." He never makes his own burrow, he simply uses one which is already provided for him by nature, and that is the little close-fitting pouch surrounding the root of a hair. Whether the criminal is a harmless native white coccus which has suddenly developed anti-social tendencies, or a Mongolian immigrant who has been accidentally introduced, is still an open question. The probabilities are that it is more frequently the latter, as, while boils are absolutely no respecters, either of persons or places, and may rear their horrid heads in every possible region of the human form divine, yet they display a very decided tendency to appear most frequently in regions like the back of the neck, the wrist, the hips, and the nose. One thing that these areas have in common is that they are liable to a considerable amount of chafing and scratching as by collars and stocks on the neck, and cuffs on the wrists, or of friction from belts, or pressure or chafing from chairs or saddles. When the tissues have been bruised or chafed after such fashion, especially if the surface of the skin has been at the same time broken, and any pus-organism is either present in the hair-follicle, like the white coccus, or rubbed into it by a finger or finger-nail which has just been sucked in the mouth, used to pick the nose, or possibly engaged in dressing some wound, or cutting meat, or handling fertilizer, then all the materials for an explosion are at hand.



CHAPTER XVI

CANCER, OR TREASON IN THE BODY-STATE

The imagination of the race has ever endowed Cancer with a peculiar individuality of its own. Although it has vaguely personified in darkest ages other diseases, like the Plague, the Pestilence, and Maya (the Smallpox), these have rapidly faded away in even the earliest light of civilization, and have never approached in concreteness and definiteness the malevolent personality of Cancer. Its sudden appearance, the utter absence of any discoverable cause, the twinges of agonizing pain that shoot out from it in all directions, its stone-like hardness in the soft, elastic flesh of the body, the ruthless way in which it eats into and destroys every organ and tissue that come in its way, make this impression, not merely of personality, but of positive malevolence, almost unescapable.

Its very name is instinct and bristling with this idea: Krebs, in German, Cancer, in Latin, French, and English, Carcinoma, in Greek, all alike mean "Crab," a ghastly, flesh-eating parasite, gnawing its way into the body. The simile is sufficiently obvious. The hard mass is the body of the beast; the pain of the growth is due to his bite; the hard ridges of scar tissue which radiate in all directions into the surrounding skin are his claws.

The singular thing is that, while brushing aside, of course, all these grotesque similes, the most advanced researches of science are developing more and more clearly the conception of the independent individuality—as they term it, the autonomy—of cancer.

More and more decidedly are they drifting toward the unwelcome conclusion that in cancer we have to deal with a process of revolt of a part of the body against the remainder, "a rebellion of the cells," as an eminent surgeon-philosopher terms it. Unwelcome, because a man's worst foes are "they of his own household." Successful and even invigorating warfare can be waged against enemies without, but a contest with traitors within dulls the spear and paralyzes the arm. Against the frankly foreign epidemic enemies of the race a sturdy and, of late years, a highly successful battle has been fought. We have banished the plague, drawn the teeth of smallpox, riddled the armor of diphtheria, and robbed consumption of half its terrors. In spite of the ravings and gallery-play of the Lombroso school anent "degeneracy," our bills of mortality show a marked diminution in the fatality of almost every important disease of external origin which afflicts humanity.

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

There is absolutely no adequate ground for the tone of lamentation and the Cassandra-like prophecy which pervade all popular, and a considerable part of medical, discussion of the race aspects of the cancer problem. The reasoning of most of these Jeremiahs is something on this wise: That, inasmuch as the deaths from cancer have apparently nearly trebled in proportion to the population within the last thirty years, it only needs a piece of paper and a pencil to be able to figure out with absolute certainty that in a certain number of decades, at this geometric ratio, there will be more deaths from cancer than there are human beings living.