There could be no more striking illustration, both of the dangerousness of "a little knowledge" and of the absurdity of applying rigid logic to premises which contain a large percentage of error. Too blind a confidence in the inerrancy of logic is almost as dangerous as superstition. Space will not permit us to enter into details, but suffice it to say:—

First, that expert statisticians are in grave doubt whether this increase is real or only apparent, due to more accurate diagnosis and more complete recording of all cases occurring. Certainly a large proportion of it is due to the gross imperfection of our records thirty years ago.

Second, that the apparent increase is little greater than that of deaths due to other diseases of later life, such as nervous, kidney, and heart diseases. Our heaviest saving of life so far is in the first five-year period, and more children are surviving to reach the cancer and Bright's disease age.

Third, that a disease, eighty per cent of whose death-rate occurs after forty-five years of age, is scarcely likely to threaten the continued existence of the race.

The nature of the process is a revolt of a group of cells. The cause of it is legion, for it embraces any influence which may detach the cell from its normal surroundings,—"isolate it," as one pathologist expresses it. The cure is early and complete amputation of not only the rebellious cells, but of the entire organ or region in which they occur.

A cancer is a biologic anomaly. Everywhere else in the cell-state we find each organ, each part, strictly subordinated, both in form and function, to the interests of the whole.

Here this relation is utterly disregarded. In the body-republic, where we have come to regard harmony and loyalty as the invariable rule, we find ourselves suddenly confronted by anarchy and revolt.

The process begins in one great class of cells, the epithelium of the secreting glands. This is a group of cell-citizens of the highest rank, descended originally from the great primitive skin-sheet, which have formed themselves into chemical laboratories, ferment-factories for the production of the various secretions required by the body, from the simplest watery mucus, as in the mouth, or the mere lubricant, as in the fat-glands of the hair-follicles, to the most complex gastric or pancreatic juice. They form one of the most active and important groups in the body, and their revolt is dangerous in proportion.

The movement of the process is usually somewhat upon this order: After forty, fifty, or even sixty years of loyal service, the cells lining one of the tubules of a gland—for instance, of the lip, or tongue, or stomach—begin to grow and increase in number. Soon they block up the gland-tube, then begin to push out in the form of finger-or root-like columns of cells into the surrounding tissues.

These columns appear to have the curious power of either turning their natural digestive ferments against the surrounding tissues, or secreting new ferments for the purpose, closely resembling pepsin, and thus literally eating their way into them. So rapidly do these cells continue to breed and grow and spread resistlessly in every direction, that soon the entire gland, and next the neighboring tissues, become packed and swollen, so that a hard lump is formed, the pressure upon the nerve-trunks gives rise to shooting pains, and the first act of the drama is complete.

But these new columns and masses, like most other results of such rapid cell-breeding in the body, are literally a mushroom growth. Scarcely are they formed before they begin to break down, with various results. If they lie near a surface, either external or internal, they crumble under the slightest pressure or irritation, and an ulcer is formed, which may either spread slowly over the surface, from the size of a shilling to that of a dinner-plate, or deepen so rapidly as to destroy the entire organ, or perforate a blood-vessel and cause death by hemorrhage. The cancer is breaking down in its centre, while it continues to grow and spread at its edge. Truly a "magnificent scheme of decay."

Then comes the last and strangest act of this weird tragedy. In the course of the resistless onward march of these rebel cell-columns some of their skirmishers push through the wall of a lymph-channel, or even, by some rare chance, a vein, and are swept away by the stream. Surely now the regular leucocyte cavalry have them at their mercy, and can cut them down at leisure. We little realize the fiendish resourcefulness of the cancer-cell. One such adrift in the body is like a ferret in a rabbit warren; no other cell can face it for an instant. It simply floats unmolested along the lymph-channels until its progress is arrested in some way, when it promptly settles down wherever it may happen to have landed, begins to multiply and push out columns in every direction, into and at the expense of the surrounding tissues, and behold, a new cancer, or "secondary nodule," is born (metastasis).

In fact, it is a genuine "animal spore," or seed-cell, capable of taking root and reproducing its kind in any favorable soil; and, unfortunately, almost every inch of a cancer patient's body seems to be such. It is merely a question of where the spore-cells happen to drift and lodge. The lymph-nodes or "settling basins" of the drainage area of the primary cancer are the first to become infected, probably in an attempt to check the invaders; but the spores soon force their way past them toward the central citadels of the body, and, one after another, the great, vital organs—the liver, the lungs, the spleen, the brain—are riddled by the deadly columns and choked by decaying masses of new cells, until the functions of one of them are so seriously interfered with that death results.

Obviously, this is a totally different process, not merely in degree, but in kind, from anything that takes place as a result of the invasion of the body by an infectious germ or parasite of any sort. There is a certain delusive similarity between the cancer process and an infection. But the more closely and carefully this similarity is examined the more superficial and unreal does it become. The invading germ may multiply chiefly at one point or focus, like cancer, and from this spread throughout the body and form new foci, and may even produce swarms of masses of cells resembling tumors, as, for instance, in tuberculosis and syphilis. But here the analogy ends.

The great fundamental difference between cancer and any infection lies in the fact that, in an infection, the inflammations and poisonings and local swellings are due solely and invariably to the presence and multiplication of the invading germs, which may be recovered in millions from every organ and region affected, while swellings or new masses produced are merely the outpouring of the body-cells in an attempt to attack and overwhelm these invaders. In cancer, on the contrary, the destroying organism is a group of perverted body-cells. The invasion of other parts of the body is carried out by transference of their bastard and abortive offspring. Most significant of all, the new growths and swellings that are formed in other parts of the body are composed, not of the outpourings of the local tissues, but of the descendants of these pirate cells. This is one of the most singular and incredible things about the cancer process: that a cancer starting, say, in the pancreas, and spreading to the brain, will there pile up a mass—not of brain-cells, or even of connective tissue-cells—but of gland-cells, resembling crudely the organ in which it was born. So far will this resemblance go that a secondary cancer of the pancreas found in the lung will yield on analysis large amounts of trypsin, the digestive ferment of the pancreas. Similarly a cancer of the rectum, invading the liver, will there pile up in the midst of the liver-tissue abortive attempts at building up glands of intestinal mucous membrane.

This fundamental and vital difference between the two processes is further illustrated by this fact: While an ordinary infection may be transferred from one individual to another, not merely of the same species, but of half a dozen different species, with perfect certainty, and for any number of successive generations, no case of cancer has ever yet been known to be transferred from one human being to another. In other words, the cancer-cell appears utterly unable to live in any other body except the one in which it originated.

So confident have surgeons and pathologists become of this that a score of instances are on record where physicians and pathologists, among them the famous surgeon-pathologist, Senn, of Chicago, only a few years ago, have voluntarily ingrafted portions of cancerous tissue from patients into their own arms, with absolutely no resulting growth. In fact, the cancer-cell behaves like every other cell of the normal body, in that, though portions of it can be grafted into appropriate places in the bodies of other human beings and live for a period of days, or even months, they ultimately are completely absorbed and disappear. The only apparent exception is the epithelium of the skin, which can be used in grafting or skinning over a wide raw surface in another individual. However, even here the probability appears to be that the taking root of the foreign cells is only temporary, and makes a preliminary covering or protection for the surface until the patient's own skin-cells can multiply fast and far enough to take its place.

A similarly reassuring result has been obtained in animals. Not a single authenticated case is on record of the transference of a human cancer to one of the lower animals; and of all the thousands and thousands of experiments that have been made in attempting to transfer cancers from one animal to another, only one variety of tumor with the microscopic appearance of cancer—the so-called Jensen's tumor of mice—has yet been found which can be transferred from one animal to another.

So we may absolutely disabuse our minds of the fear which some of our enthusiastic believers in the parasitic theory of cancer have done much to foster, that there is any danger of cancer "spreading," like an infectious disease. Disastrous and gruesome as are the conditions produced by this disease, they are absolutely free from danger to those living with or caring for the unfortunate victim. In the hundreds of thousands of cases of cancers which have been treated, in private practice, in general hospitals, and in hospitals devoted exclusively to their care, not a single case is on record of the transference of the disease to a husband, wife, or child, nurse or medical attendant. So that the cancer problem, like the Kingdom of Heaven, is within us.

This conclusion is further supported by the disappointing result of the magnificent crusade of research for the discovery of the cancer "parasite," whether vegetable or animal, which has been pursued with a splendid enthusiasm, industry, and ability by the best blood and brains of the pathological world for twenty years past. I say disappointing, because a positive result—the discovery and identification of a parasite which causes cancer—would be one of the greatest boons that could be granted to humanity; not so much on account of the actual loss of life produced by the disease as for the agonies of apprehension engendered by the fact of the absolute remorselessness and blindness with which it may strike, and our comparative powerlessness to cure. So far the results have been distressingly uniform and hopelessly negative.

Scores, yes, hundreds, of different organisms have been discovered in and about cancerous growths, and announced by the proud discoverer as the cause of cancer. Not one of these, however, has stood the test of being able to produce a similiar growth by inoculation into another body; and all which have been deemed worthy of a test-research by other investigators besides the paternal one have been found to be mere accidental contaminations, and present in a score of other diseases, or even in normal conditions. Many of them have been shown to be abnormal products of the cells of the body in the course of the cancer process, and some even such ludicrous misfits as impurities in the chemical reagents used, scrapings from the corks of bottles, dust from the air, or even air-bubbles. These "discoveries" have ranged the whole realm of unicellular life,—bacilli, bacteria, spirilla, yeasts, moulds, protozoa,—yet the overwhelming judgment of broad-minded and reputable experts the world over is the Scotch verdict of "not proven"; and we are more and more coming to turn our attention to the other aspect of the problem, the factors which cause or condition this isolation and assumption of autonomy on the part of the cells.

This is not by any means to say that there is no causative organism, and that this will not some day be discovered. Human knowledge is a blind and short-sighted thing at best, and it may be that some invading cell, which, from its very similarity to the body-cells, has escaped our search, will one day be discovered. Nor will the investigators diminish one whit of their vigor and enthusiasm on account of their failure thus far.

The most strikingly suggestive proof of the native-born character of cancer comes from two of its biologic characters. The first is that its habit of beginning with a mass formation, rapidly deploying into columns and driving its way into the tissues in a ghastly flying wedge, is simply a perfect imitation and repetition of the method by which glands are formed during the development of the body. The flat, or epithelial, cells of the lining of the stomach, for instance, begin to pile up in a little swarm, or mass, elongate into a column, push their way down into the deeper tissue, and then hollow out in their interior to form a tubular gland. The only thing that cancer lacks is the last step of forming a tube, and thereby becoming a servant of the body instead of a parasite upon it.

Nor is this process confined to our embryonic or prenatal existence. Take any gland which has cause to increase in size during adult life, as, for instance, the mammary gland, in preparation for lactation, and you will find massing columns and nests of cells pushing out into the surrounding tissue in all directions, in a way that is absolutely undistinguishable in its earlier stages from the formation of cancer. It is a fact of gruesome significance that the two organs—the mammary gland and the uterus—in which this process habitually takes place in adult life are the two most fatally liable to the attack of cancer.

Another biologic character is even more striking and significant. A couple of years ago it was discovered by Murray and Bashford, of the English Imperial Cancer Research Commission, that the cells of cancer, in their swift and irregular reproduction, showed an unexpected peculiarity. In the simplest form of reproduction, one cell cutting itself in two to make two new ones, known as mitosis, the change begins in the nucleus, or kernel. This kernel splits itself up into a series of threads or loops, known as the chromosomes, half of which go into each of the daughter cells. When, however, sex is born and a male germ-cell unites with a female germ-cell to form a new organism, each cell proceeds, as the first step in the process, to get rid of half of these chromosomes, so that the new organism has precisely the normal number of chromosomes, half of which are derived from the father and the other half from the mother germ-cell. This, by the way, is the mechanical basis of heredity.

It has been long known that the mitotic processes of cancer and the forming and dividing of the chromosomes were riotous and irregular, like the rest of its growth. But it was reserved for these investigators to discover the extraordinary fact that the majority of dividing and multiplying cancer-cells had, instead of the normal number of chromosomes, exactly half the quota. In other words, they had resumed the powers of the germ, or sexual, cells from which the entire body was originally built up, and were, like them, capable of an indefinite amount of multiplication and reproduction. How extraordinary and limitless this power is may be seen from the fact that a little group of cancer-cells grafted into a mouse to produce a Jensen tumor, from which a graft is again taken and transplanted into another mouse, and so on, is capable, in a comparatively few generations, of producing cancerous masses a thousand times the weight of the original mouse in which the tumor started!

In short, cancer-cells are obviously a small, isolated group of the body-cells, which in a ghastly fashion have found the fountain of perpetual youth, and can ride through and over the law-abiding citizens of the body-state with the primitive vigor of the dawn of life.

This brings us to the most practical and important questions of the problem: What are the influences which condition this isolation and outlawry of the cells? What can we do to prevent or suppress the rebellion? To the first of these science can only return a tentative and approximate answer. The subject is beset with difficulties, chief among which is the fact that we are unable to produce the disease with certainty in animals, with the single exception of the Jensen's tumors in mice referred to, nor is it transferred from one human being to another, so that we can make even an approximate guess at the precise time at, or conditions under, which the process began.

Many theories have been advanced, but most investigators who have studied the problem in a broad-minded spirit are coming gradually to agree to this extent:—

First of all, that one of the most powerful influences conditioning this isolation and revolt of the cells is age, both of the individual and of the organ concerned. Not only does far the heaviest cancer mortality fall between the ages of forty-five and sixty, but the organs most frequently and severely attacked are those which between these years are beginning to lose their function and waste away. First and most striking, the mammary gland and the uterus in women, and the shriveling lips and tongue of elderly men. To put it metaphorically, the mammary gland and the uterus, after the change of life, the lip, after the decay of the teeth, have done their work, outlived their usefulness, and are being placed upon a starvation pension by a grateful country. Nineteen out of twenty accept the situation without protest and sink slowly to a mere vegetative state of existence, but, in the twentieth, some little knot of cells rebel, revert to an ancestral power of breeding rapidly to escape extinction, begin to make ravages, and cancer is born.

The age-preferences are well marked. Cancer is emphatically a disease of senility, of age; but, as Roger Williams has pointed out in his admirable monograph, not of "completed" senility.

To express it in percentages, barely twenty per cent of the cases occur before forty years of age, sixty per cent between forty and sixty, and twenty per cent between sixty and eighty. Thus the early period of decline, the transition stage between full functional vigor and declared atrophy (wasting) of the glands, is clearly the period of greatest danger; precisely the period in which the gland-cells, though losing their function,—and income,—have still the strength to inaugurate a rebellion, and a sufficient supply of the sinews of war, either in their own possession or within easy striking distance in the tissues about them, to make it successful. Not less than sixty-five to seventy-five per cent of all cancers in women occur in atrophying organs, the uterus and mammary glands.

A rather alluring suggestion was made by Cohnheim, years ago, that cancers might be due to the sudden resumption of growth on the part of islands or rests of embryonic tissue, left scattered about in various parts of the body. But these are now believed to play but a small part, if indeed any, in the production of true cancer.

Finally, what can be done to prevent or cure this grotesque yet deadly process? So far as it is conditioned by age, it is, of course, obvious that little can be done, for not even the most radical vivisector would propose preventing in any way as large a proportion as possible of the human race from reaching fifty or sixty, or even seventy years, to avoid the barely six per cent liability to cancer after forty-five.

As regards the influence of chronic inflammations and irritation, much can be done, and here is our most hopeful field for prevention. Warts and birthmarks that are in any way subject to pressure or friction from clothing or movements should be promptly removed, as both show a distinctly greater tendency than normal tissue to develop into cancer. Cracks, fissures, chafes, and ulcers of all sorts, especially about the lips, tongue, mammary gland, uterus, and rectum, should be early and aseptically dealt with. Jagged remnants of teeth should be removed, all suppurative processes of the gums antiseptically treated, and the whole mouth-parts kept in a thoroughly aseptic condition.

Thorough and conscientious attention to this sort of surgical toilet work is valuable, not only for its preventive effect,—which is considerable,—but also because it will insure the bringing under competent observation at the earliest possible moment the beginnings of true cancer.

For the disease itself, after it has once started, there is, like treason in the body-politic, but one remedy—capital punishment. Parleying with the rebels is worse than useless. Pastes, caustics, X-rays, trypsin, radium,—all are fatally defective, because they suppress a symptom only and leave the cause untouched. Only in one form of surface-cancer, the so-called flat-celled or rodent ulcer, which has little or no tendency to form spore-cells and attack the deeper organs, are they effective.

Nothing is easier and nothing more idle than to destroy and break down cells which have actually become cancerous; but so long as there remains in the body a single nest, or even cell, of the organ in which the revolt started, so long the life of the patient is in danger.

Absolutely the only remedy which is of the slightest value is complete removal with the knife. The one superiority of the knife, shudder as we may at the name of it, over every other means of removal lies solely in this fact, that with it can be removed not merely the actual cancer, but the entire gland or group of surrounding cells in which this malignant, parricidal change has begun to occur.

The modern radical operations for cancer take not merely the tumor, but the entire diseased breast, for instance, and all the lymph-glands into which it drains, clear up into the armpit, with the muscles beneath it down to the ribs. Where this is done early enough, the disease does not recur. Such radical and complete amputation of an organ or region as this is possible in from two-thirds to three-fourths of all cases if seen reasonably early.

With watchfulness and courage, our attitude toward the cancer problem is one of hopeful confidence.



CHAPTER XVII

HEADACHE: THE MOST USEFUL PAIN IN THE WORLD

Greatness always has its penalties. Other ills besides death love a shining mark. Pain is one of them, and headache its best exemplar. If there be one thing about our bodies of which we are peculiarly and inordinately proud it is that expanded brain-bulb which we call the head. Yet it aches oftener than all the rest of us put together. Headache is the commonest of all pains, which fact gives the slight consolation that everybody can sympathize with you when you have it. One touch of headache makes the whole world kin, and the man or woman who has never had it would be looked upon as a creature abnormal and "a thing apart." It has even become incorporated into our social fabric as one of the sacred institutions of the game of polite society. How could we possibly protect ourselves against our instructors in youth and our would-be friends in later life if there were no such words as "a severe headache"?

What is a headache, and why does it ache the head? This is a wide and hotly disputed problem. But one fact, which is obvious at the first intelligent glance, becomes clearer and more important with deeper study, and that is that it is not the fault of the head. When the head aches, it is, nine times out of ten, simply doing a combination of scapegoat and fire-alarm duty for the rest of the body. Just as the brain is the servant of the body, rather than its master, so the devoted head meekly offers itself as a sort of vicarious atonement for the sins of the entire body. It is the eloquent spokesman of such "mute, inglorious Miltons" as the stomach, the liver, the muscles, and the heart. The humblest and least distinguished of all the organs of the body can order the lordly head to ache for it, and the head has no alternative but to obey.

To discuss the cause of headaches is like discussing the cause of the human species. It is one of the commonest facts of every-day observation, and can be demonstrated almost at will, that any one of a hundred different causes,—a stuffy room, a broken night's sleep, a troublesome letter, a few extra hours of work, eating something that disagrees, a cold, a glare of light in the eyes,—any and all of these may bring on a headache. The problem of avoiding headaches is the problem of the whole conduct of life.

Two or three broad generalizations, however, can be made from the confused and enormous mass of data at our disposal, which are of both philosophic interest and practical value. One of these is that, while headache is felt in the head, and particularly in those regions that lie over the brain, the brain has comparatively little to do with the pain. Headache is neither a mark of intellectuality, nor, with rare exceptions, a sign of cerebral disturbance. Indeed, it is far more a matter of the digestion, the muscles, and the ductless glands, than it is of the brain, or even of the nervous system. It is, therefore, idle to endeavor either to treat or try to prevent it by measures directed to the head, the brain, or even the nervous system as such.

Secondly, it is coming to be more and more clearly recognized that, while its causes are legion, a very large percentage of these practically and eventually operate by producing a toxic, or poisoned, condition of the blood, which, circulating through certain delicate and sensitive nerve-strands in the head and face, give rise to the sensation of pain.

Thirdly, the tissues which give out this pain-cry under the torture of the toxins in the blood are, in a large majority of cases, neither the brain, nor the nerves of the eye, nor other special senses, but the nerves of common sensation which supply the face, the scalp, and the structures of the head generally, most of them derived from one great pair of nerve-trunks, the so-called Trigeminus, or fifth pair of cranial nerves. Strange as it may seem, the brain substance is comparatively insensitive to pain, and the acutest pain of an operation upon it, such as for the removal of a tumor, is over when the skin and scalp have been cut through. These poisons, of course, go all over the body, wherever the circulation goes, but they produce their promptest and loudest pain outcry, so to speak, in the region where the nerves are most exquisitely sensitive. When your head aches, nine times out of ten your whole body is suffering, but other regions of it are not able to express themselves so promptly and so clearly.

These newer and clearer views of the nature of headache dispose at once of some of the most time-honored controversies in regard to its nature. In my student-days one of the most hotly debated problems in medicine was as to whether headaches were due to lack of blood (anaemia) or excess of blood (hyperaemia) in the brain. Few things could have been more natural for both the sufferer in, and the observer of, a case of throbbing, bursting headache, where every pulse-beat is registered as a thrill of agony, than to draw the conclusion that the pain was due to a huge engorgement and swelling of the brain with blood, resulting in agonizing pressure against its rigid, bony skull-walls.

One of the most naive and vivid illustrations of this conception of headache is the remedy adopted for generations past, in this all too familiar and distressing condition, by the Irish peasantry. It consists of a band or strip of tough cloth, or better, of twisted or plaited straw, which is tied around the head and then tightened vigorously by means of a stick inserted tourniquet fashion. This is believed to prevent the head, which is aching "fit to split," from actually bursting open, and is considered a cure of wondrous merit through many a countryside. Ludicrous as is the reason which is gravely assigned for its use, it does, in some cases, greatly relieve the pain, a fact which we were entirely at a loss to account for until our later knowledge showed us that the pain, instead of being inside the skull, was outside of it in the sensitive nerves supplying the scalp. By steady pressure of this sort upon the trunks of these nerves, pressing them against the bone, they can be gradually numbed into a condition of anaesthesia, when naturally the pain would diminish.

In politer circles a similar misapprehension has also given rise to a favorite form of treatment. That is the application of cold in the form of the classic wet cloth sprinkled with eau de Cologne. The mere mention of headache calls up in the minds of most of us memories of a darkened room, a pale face on the pillow with a ghastly bandage over the eyes, and a pervading smell of eau de Cologne. It was a perfectly natural conclusion that, because the head throbbed and felt hot and bursting, there must be some inflammation, or at least congestion, present, and that the application of cold would relieve this. The results seemed to justify this belief, for in many cases the sense of coolness to the aching head gives great relief; but this is apt to be only temporary, and in really severe cases makes the situation worse by adding another depressing influence—cold—to the toxin-burdens that are weighing upon the tortured nerves. The chief virtue in these cold cloths and handkerchiefs soaked in cologne was that you were compelled to lie down and keep perfectly still in order to keep them on, while at the same time they mechanically blindfolded you. Few better devices for automatically insuring that absolute rest, which is the best and only rational cure for a headache, have ever been invented.

We were not long in discovering that headaches, both of the mildest and the severest types, might be accompanied either by a rush of blood to the head, with flushing of the skin, reddening of the eyes, and a bursting sense of oppression in the head, or, on the other hand, by an absolute draining of the whole floating surplus of the blood into the so-called "abdominal pool," the huge network of vessels supplying the digestive organs, which, when distended, will contain nearly two-thirds of the entire blood of the body, leaving the face blanched, the eyes white and staring, and the brain so nearly emptied of blood as to cause loss of consciousness or swooning. Other headaches, again, will be accompanied by a fresh, natural color and a perfectly normal and healthy distribution of the blood-supply. In short, the amount of blood in the head, whether plus or minus, has practically nothing to do with the pain, but depends solely upon the effect of the poisons producing it upon the heart and great blood-vessels.

A good illustration of the full-blooded type of headache is that which so very frequently, indeed almost invariably, occurs in the early stage of a fever or other acute infection, such as typhoid, pneumonia, or blood-poisoning, Here the face is red, the eyes are bloodshot and abnormally bright, the pulse is rapid and full, the headache so severe as to become the first disabling symptom in the disease,—all because this is the effect of the poison (toxin) of the disease upon the heart, the temperature, and the surface blood-vessels. Fortunately for the sufferer, this head-pain, like most others in the course of severe infections, is only preliminary, for as soon as the tissues of the body have become thoroughly saturated with the toxins, the nerves become dulled and semi-narcotized, so that they no longer respond with the pain-cry. As the patient settles down into the depression and dullness of the regular course of the fever, the headache usually subsides into little more than a sense of heaviness, or oppression and vague discomfort.

Moral: It is a sign of health to be able to feel a headache, an indication that your body is still fighting vigorously against the enemy, whether traitor within or foe without.

On the other hand, many of our most agonizing, and particularly our most persistent and obstinate headaches, occur in individuals who are markedly anaemic, with a low, weak pulse, poor circulation, blanched lips, and dull, lackluster eyes. The one and only thing in common between these two classes of "head-achers" is that their blood and tissues are loaded with poisons. Whether produced by invading germs or by starvation and malnutrition of the body-tissues makes no difference to the headache nerves. Their business, like good watchdogs, is to bark every time they smell danger of any sort, whether it be bears or book-agents. One of the most valuable services rendered us by our priceless heads is aching.

This view of the nature of headache explains at once why it is so extraordinarily frequent and so extraordinarily varied in causation. It is not too much to say that any influence that injuriously affects the body may cause a headache. It would, of course, be idle even to attempt to enumerate the different causes and kinds of this pain, as it would involve a review of the entire environment of the human species, internal and external. It makes not the slightest difference how the poison gets into the blood, or where it starts. A piece of tainted meat or a salad made from spoiled tomatoes will produce a headache just as promptly and effectively as an over-exposure to the July sun or an attack of influenza. It is even practically impossible to pick out from such a wealth of origins two or three, or even a score of, conditions which are the most frequent, most important, or the most interesting causes. The most exasperating thing about dealing with a headache is that we never know, until its history has been most carefully examined, whether we have to do with a mere temporary expression of discomfort and unbalance, due to overfatigue, errors in diet, a stuffy room, lack of exercise, or what-not, which can be promptly relieved by removing the cause; or whether we have to deal with the first symptoms of a dangerous fever, the beginning of a nervous breakdown, or an early warning of some grave trouble in kidneys, liver, or heart.

The one thing, however, that stands out clearly is that headache always means something; that it should be promptly and thoroughly investigated with a view to finding and removing the cause,—never as something which is to be cured as quickly as possible, as the police cure social discontent, by clubbing it over the head, with some narcotic or other symptom-smotherer. Nor should it be regarded as a malady so trifling that it is best treated with contempt, and still less as a mere "thorn in the flesh," whose ignoring is to be counted a virtue, or whose patient endurance without sign a mark of saintship. Martyrdom is magnificent when it is necessary, but many forms of it are sheer stupidity. Don't either gulp down some capsule, or "grin and bear it." Look for the cause. The more trivial it is, the easier it will be to discover and remove before serious harm has been done. The less easy you find it to put your finger upon it, the more likely it is to be serious or chronic, and the more necessary it is to remove it.

Once, however, we have clearly recognized that no headache should be treated too lightly or indifferently, it may be frankly admitted that practically the vast majority of headaches in which we are keenly interested—that is, the kind that we individually or the members of our family habitually indulge in—do form a moderately uniform class among the hundreds of varieties, and are in the main due to some six or seven great groups of causes. We have learned by repeated and unpleasant experience that they are very apt to "come on" in about a certain way, after a certain set of circumstances; that they last about so long, that they are made worse by such and such things, that they are helped by other things, and that they generally get better after a good night's sleep.

One of the commonest causes of this group of recurrent and self-limited headaches is fatigue, whether bodily, mental, or emotional. This was long an apparent stumbling-block in the way of a poison theory of headache, but now it is one of its best illustrations. Physiologists years ago discovered that what produced not merely the sensation but also the fact of fatigue, or tiredness, was the accumulation in the muscles or nerves of the waste-products of their own activities. Simply washing these out with a salt solution would start the utterly fatigued muscle contracting again, without any fresh nourishment or even period for rest. It has become an axiom with physiologists that fatigue is simply a form of self-poisoning, or, as they sonorously phrase it, autointoxication. One of the reasons why we are so easily fatigued when we are already ill, or, as we say, "out of sorts," is that our tissues are already so saturated with waste-products or other poisons that the slightest addition of the fatigue poisons is enough to overwhelm them. This also explains why our pet variety of headache, which we may have clearly recognized to be due to overwork or overstrain of some sort, whether with eye, brain, or muscles, is so much more easily brought on by such comparatively small amounts of over-exertion whenever we are already below par and out of sorts. People who are "born tired," who are neurasthenic and easily fatigued and "ached," are probably in a chronic state of self-poisoning due to some defect in their body-chemistry. Further, the somewhat greater frequency and acuteness of headache in brain workers—although the difference between them and muscle workers in this regard has been exaggerated—is probably due in part to the greater sensitiveness of their nerves; but more so to the curious fact, discovered in careful experiments upon the nervous system, that the fatigue products of the nerve-cells are the deadliest and most powerful poisons produced in the body. Hence some brain workers can work only a few half-hours a day, or even minutes at a time; for instance, Darwin, Spencer, and Descartes.

A very frequent cause of these habitual headaches, really a subdivision of the great fatigue group, is eye-strain. This is due to an abnormal or imperfect shape of the eye, which is usually present from birth. Hence, the only possible way of correcting it is by the addition to the imperfect eye of carefully fitted lenses or spectacles which will neutralize this mechanical defect. To put it very roughly, if the eye is too flat to bring the light-rays to a focus upon the retina, which is far the commonest condition (the well-known "long sight," or hyperopia), we put a plus or bulging glass before the eye and thus correct its shape. But if the eye is too round and bulging, producing the familiar "short sight," or myopia, we put a minus or concave lens before the eye, and thus bring it back to the normal. By a curious paradox, however, it often happens that the headache due to eye-strain is caused not by the grosser defects, such as interfere with vision so seriously as absolutely to demand the wearing of glasses to see decently, but from slighter and more irregular degrees and kinds of misshapenness in the eye, most of which fall under the well-known heading of astigmatism. These interfere only slightly with vision, but keep the eye perpetually on the strain, on a twist, as it were, rasping the entire nervous system into a state of chronic irritation. Our motto now, in all cases of chronic headache, is, first examine the patient's habits of life, next his eyes.

Many forms of headache are really stomach-ache in disguise, due to digestive disturbances, the absorption of poisons from the food-tube, whether from tainted, spoiled, or decayed foods, as in the now familiar ptomaine poisoning, or from imperfect processes of digestion. The immediate effect, however, of diet in the causation of headache is not so great as we once believed. We have no adequate basis for believing that any particular kinds or amounts of food are especially likely to produce either headache or what we might call the headache habit, except in so far as they upset the digestion. In a certain number of susceptible individuals, however, it will be found that some particular kind of food, often perfectly wholesome and harmless in itself, will bring on an attack of headache whenever it is indulged in. Very frequently the disturbances of digestion which are put down as the cause of a headache are only symptoms of some general constitutional lack of balance, as eye-strain or neurasthenia, which is the cause of both these discomforts. Far fewer headaches can be cured by dieting than we at one time believed, and underfeeding is a more frequent cause than overeating.

By an odd bouleversement the one type of headache which we have almost unanimously in the past attributed to digestive disturbances, the famous, or, rather, infamous, "sick headache," is now known to have little or nothing to do with the stomach in its origin. In fact, incredible as it may seem at first sight, it is the headache that causes the sickness, not the sickness the headache. Stop the pain of a sick headache in the early stage, and the sickness will never develop at all. The vomiting of sick headache is an interesting illustration of vomiting due to disturbances of the brain and nervous system, technically known as central vomiting. Another illustration is the vomiting of seasickness, due solely to dizziness from the gross contradiction between the testimony of our eyes and of the balancing canals in the inner ear. The stomach or its contents has no more to do with seasickness than the water in a pump has with the plunger. Injuries to the head will bring on severe and uncontrollable vomiting, and the severer type of fevers is very frequently ushered in by this curious sign. As to what it means, we are as yet utterly in the dark, for in none of these conditions does the process do the slightest good, but simply adds to the discomfort of the situation. It would appear to be a curious echo of ancestral times, when the animal was pretty much all stomach, and hence emptying that organ would probably relieve two-thirds of his discomforts. Whatever the explanation, the fact remains that whenever our nervous system gets about so panic-stricken, it promptly begins throwing its cargo overboard, in the blind hope that this may somehow relieve the situation. The bile that we bring up at the end of these interesting acrobatic performances and which makes us feel so much better,—because we have now got the cause of the trouble out of our system,—is simply due to the prolonged vomiting, which has reversed the normal current and caused the perfectly healthy bile from our unoffending liver to pass upward into the stomach, instead of downward into the bowels.

In another great group of headaches natural poisons or waste-products are not burned up or got rid of through the body-sewers and pores as rapidly as they should be; for instance, the familiar headache from sitting too long in a stuffy room. Your well-known and well-earned discomfort is, of course, due in part to the irritating and often poisonous gases, dust, and bacteria, which are present in the air of an unventilated room; but it is also due to the steady piling up of the waste products of your own tissues. These poisons are normally oxidized in the muscles, burned up and exhaled through the lungs, and sweated out through the skin,—all three of which relief agencies are, of course, practically paralyzed, or working at lowest possible level, while you are sitting at your desk.

The well-known headache of sluggish bowels is an obvious case in point; and one of the early signs of beginning failure of the kidneys, as in Bright's disease, is a headache of a peculiar type due to accumulation in the system of the poisons which it is their duty to get rid of.

There are few things the head resents more keenly than loss of sleep. The pillow is the best headache medicine. If this loss of sleep be due to the encroachments of work or of amusements, then the mechanism of its production is obvious. The fatigue poisons produced during the day and normally completely neutralized and burned up during sleep are not entirely disposed of and remain in the tissues to torture the nerves. The headache of insomnia, or habitual sleeplessness, on the other hand, is not, strictly speaking, caused by loss of sleep. Paradoxical as it may sound, the fatigue poisons, which in moderate amounts will produce drowsiness and promote sleep, in excessive amounts will cause wakefulness and inability to sleep. Insomnia and headache are usually symptoms of this overfatigued, or poisoned, condition, and should both be regarded and treated as symptoms by the removal of their causes, not by the use of coal-tar products and hypnotics.

Another common cause of headache is nasal obstruction, such as may be due to adenoids or deformities of the septum, or chronic catarrhal conditions. These probably act by their interference with breathing and consequent imperfect ventilation of the blood, as well as by obstruction and inflammation of the great air-spaces in the bones of the skull, closely underlying the brain, which open and drain into the nose.

It may be remarked in passing that "sick headache," or migraine, though long and painfully familiar to us, is still a puzzle as to its cause. But the view which seems to come nearest to explaining its many eccentricities is that it is usually due to a congenital defect, not so much of the nervous system as of the entire body, by which the poisons normally produced in its processes fail to be neutralized and got rid of, and gradually accumulate until they saturate the system to such a degree as to produce a furious explosion of pain. This defect may quite possibly be in one of the ductless glands or in some of the internal secretions, rather than in the nervous system.

Obviously, after what has been said of the world-wide causation of headache, to attempt to discuss its treatment would be as absurd as to undertake to advise what should be done for the relief of hunger, for "that tired feeling," or for a pain in the knee. The treatment for a headache due to an inflammation or tumor of the brain would, of course, be wide as the poles from that which would relieve an ordinary fatigue or indigestion pain. Besides, it is utterly irrational and often harmful to attempt to treat any headache as such. That is the open road to the morphine habit and drug addictions of all sorts. Remedies—and there are plenty of them—which simply relieve the pain without doing anything to remove its cause, merely make the latter state of that individual worse than the first. Headache is always and everywhere nature's vivid warning that something is going wrong, like the shrieking of a wagon-axle or the clatter of a broken cog in machinery.

There is, however, fortunately one remedy which alone will cure ninety-nine per cent of all headaches, and that is rest. The first thing an intelligent machinist does when squeaking or rattling begins is to stop the machinery. This has the double advantage of preventing the damage from going any further and of enabling him to get at the cause. Headache, like pain anywhere, is nature's imperative order to Halt, at least long enough to find out what you are doing to yourself that you shouldn't. It makes little difference what you take for your headache, so long as you follow it up by lying down for an hour or two, or, better still, by going to bed for the remainder of the day and sleeping through until the next morning. If more headaches were treated in this way there would not only be fewer headaches, but two-thirds of the risks of nervous breakdown, collapse, insomnia, and chronic degenerative changes in the liver, kidneys, and blood-vessels would be avoided.

This, of course, is a counsel of perfection, and incapable of general application for the sternest of reasons; but it does indicate the rational attitude toward headache and its treatment, and one which is coming to be more and more adopted. No motorist would dream of pushing ahead with a shrieking axle or a scorching hot box, unless his journey were one of most momentous importance or a matter of life and death. Pain is nature's automatic speed regulator. It is often necessary to disregard it, to get the work of the world done and to discharge our sacred obligations to others; but this disregarding should not be exalted to too high a pinnacle of virtue, and least of all worshiped as inherently and everywhere a mark of piety and one of the insignia of saintship.

A business firm or a factory, for instance, which would send home for the day each of its employees who reported a genuine case of bad headache, would, in the long run, save money by avoiding accidents, mistakes, muddles, and confusions, often involving a whole department, due to the kind of work that is done by a man or woman who is physically unfit to attempt it. And the higher the type of work that has to be done, the more the elements of insight, grasp, and sound judgment enter into it, the graver and costlier are the mistakes that are likely to be made under such circumstances.

Of course, it will probably be objected at this point: "What is the use of wasting a day, or even half a day, when by taking two or three capsules of So-and-So's Headache Cure I can get rid of the pain and go right on with my work?" It is perfectly true that there are a number of remedies which will relieve the average headache; but there are two important things to be borne in mind. The first is that all of these are simply weaker or stronger nerve-deadeners; most of them actual narcotics. All that they do is to stop the pain and thus cheat you into the impression that you are better. You are just as tired and as unfit for work as you were before. Your nervous system is just as saturated with poisons, and the chances are ten to one that the quality of the work that you do will be just as bad as if you had taken no medicine. Further, like alcohol, when used as a "pick-me-up" under somewhat similar conditions, the remedy which you have taken, while producing a false sense of comfort and even exhilaration by deadening your pain and discomfort, in that very process itself takes off the finer edge of your judgment, the best keenness of your insight, and the highest balance of your control. In short, your nervous system has to struggle with all the poisons that were present before, with another one added to them!

After you have taken nature's wise advice, and obeyed her orders, and put yourself at rest, then there are a number of mild sedatives, with which every physician is familiar, one of which, according to the special circumstances of your case, it may be perfectly legitimate to take in moderate doses, with the approval of a physician, as a means of relieving the pain and helping to get that sleep which will complete the cure.

One other measure of relief, which, like rest, is also indicated by instinct, is worth mentioning, and that is gentle friction of the head. One of the most instinctive tendencies of most of us when suffering from a severe headache is to put the hands to the head, either for the purpose of frantically clutching at it, rubbing as if our lives depended upon it, or pressing hard over the aching region. The mere picture of a man with his head in his hands instantly suggests the idea of headache. Part of this is, of course, little more than a blind impulse to do something to or with the offending member. We would sometimes like to throw it away if we could, or at others to bang it against the wall. But part of it is due to the discovery, ages ago, that pressure and friction would give a certain amount of relief.

For some curious reason the nerves most frequently involved are those which are most readily accessible for this kind of treatment, namely, the long nerve-threads which run from the inner third of the eyebrow up the forehead and over the crown of the head (the so-called supraorbital or frontal branches). A corresponding pair run up the back of the neck, about half-way between the back of the ear and the spinal column, supplying the back of the head and the crown (these form the cervical plexus); and a smaller pair run up just in front of the ear into the temple, and from there on upward to join the other two pairs at the top of the head.

Broadly speaking, the position of the pain depends upon which pair of these nerves is lifting up its voice most vigorously in protest. If it be the front pair (supraorbitals) then we get the well-known frontal or forehead headache; if the back pair (known as the occipitals) then we have the deadly, constricting, band-around-the-head pain which clutches us across the back of the neck and base of the brain. If the lateral pair are chiefly affected then we get the classic throbbing temples. Practically all of these aches, however, are of the "fire-alarm" character; and while certain of these nerve-gongs show some tendency to respond more readily to calls coming in from certain regions of the body, as, for instance, the forehead nerves to eye-strain, the back-of-the-head nerves (occipital) to grave toxic states of the system, the tips of any of the nerves in the crown of the head to pelvic disturbances and anaemic conditions, the lateral branches in the temples to diseases of the teeth and throat, yet there is little fixed uniformity in these relations. Eye-strain, for instance, may cause either frontal or occipital headache; and, as every one knows from experience, the pain may be felt in all parts of the head at once.

Gentle and intelligent massage over the course of these nerves of the scalp, according to the location of the pain, will often do much to relieve the severity of the suffering.

Treat headache as a danger signal, by rest and the removal of its cause, and it will prevent at least ten times as much suffering and disability as it causes.



CHAPTER XVIII

NERVES AND NERVOUSNESS

Nerves are real things. In spite of their connection with imaginary diseases and mental disturbances, there is nothing imaginary or unsubstantial about them. There is no more genuine and obstinate malady on earth than a nervous disease. Because nerves lie in that twilight borderland between mind and matter, body and soul, the real and the ideal, the impression has got abroad that they are little better than figures of speech. Though their disturbances give rise to visions of all sorts there is nothing visionary about them; they are just as genuine and substantial a part of our bodily structure as our bones, muscles, and blood-vessels. In fact, it was this very substantiality that at the beginning prevented their proper recognition, and handicapped them with their present absurd and inappropriate name.

"Nerve" is from the Greek neuron, meaning tendon, or sinew, and was originally applied indiscriminately to all the different shining cords which run down the limbs and among the muscles. In fact the first recognition of nerves was an utter failure to recognize. The tendon cords, which are the ropes with which the muscles work the joint pulleys, were actually included under one head with the less numerous but almost equally large and tough cords of grayer color, flatter outline, and less glistening hue, which were afterwards found to be nerve-trunks. Cutting either paralyzed the limb below the cut,—and what more proof could you ask of their having the same function?

Such is the persistence of ancient memories, that any physician could tell you of scores of cases in which he has heard the naive remark, in reference most frequently to a deep gash across the wrist, that the "nerves" were cut, and the hand was paralyzed, when what had happened was simply that the tendons had been cut across. When, after centuries of blundering in every possible direction until the right one was finally stumbled upon (which is the mechanism of progress), it was realized that some of these "nerves," the grayer and flatter ones, carried messages instead of pulling ropes, they were still far from being properly understood.

It is an amusing illustration of the blissful ignorance and charming naivete which marked their study and discussion at this time, that nerves were for centuries regarded as hollow tubes, carrying a supply of "animal spirits" from the central reservoir of the brain to the different limbs. So seriously was this believed, that, in amputations, the cut nerve-trunks were carefully sought out and tied, for fear the vital spirits would leak out and the patient thus literally bleed to death. One can imagine how this must have added to the comfort of the luckless patient.

The term "nerves" still persists, in the old sense, in both botany and entomology, which speak of the "nerves" of a butterfly's wing, or the "nervation" of a leaf, meaning simply the branching, fibrous framework of each.

It comes in the nature of a surprise to most of us to learn that "nerves" are real things. I shall never forget the shock of my own first convincing demonstration of this fact. It was in one of the first surgical clinics that I attended as a medical student. A woman patient was brought in, with a history of suffering the tortures of the damned for a year past, from an uncontrollable sciatica.

It was a recognized procedure in those days (and is resorted to still), when all medical, electrical, and other remedial measures had failed to relieve a furious neuralgia, for the surgeon to cut down upon the nerve-trunk, free it from its surrounding attachments, and, slipping his tenaculum or finger under it, stretch the nerve with a considerable degree of force. Whether it acts by merely setting up some trophic change in the nerve-tissue, or by tearing loose inflammatory adhesions which are binding down the nerve-trunk, the procedure gives excellent results, nearly always temporary relief, and sometimes a permanent cure.

The patient was placed upon the table and anaesthetized, and the surgeon made a free, sweeping incision down the back of the thigh, exposing the sciatic nerve. He thrust his finger into the wound, loosened up the adhesions about the nerve, hooked two fingers underneath it, and, to my wide-eyed astonishment, heaved upward upon it, until he brought into view through the gaping wound a flattened, bluish-gray cord about twice the size of a clothesline, with which he proceeded to lift the hips of the patient clear of the table. In my ignorant horror, I expected every moment to see the thing snap and the patient go down with a bump, paralyzed for life; but I never doubted after that that nerves were real things. Though it has nothing to do with this discussion, for the benefit of those of my readers who cannot bear to have a story left unfinished, I will add that the operation was as successful as it was dramatic, and the patient left the hospital completely relieved of her sciatica.

When at last it was clearly recognized that the nerves were concerned in the sending of messages from the centre to the brain, known as sensory, or centripetal, and carrying back messages from the brain to the muscles and surface, known as motor, or centrifugal,—in other words that they were the organs of the mind,—still another source of confusion sprang up, and that was the determination on the part of some to regard them from a purely mental and, so to speak, spiritual point of view, and on the part of others to regard them from a physical and anatomical point of view. This confusion is of course in full riot at the present time.

The term "nerves," and its adjective, "nervous," are used in two totally distinct senses: one, that which is vague and unsubstantial, purely mental or subjective, and, in the realm of disease at least, imaginary; the other, purely anatomical, referring to certain strands of tissue devoted to the purpose of transmitting impulses, and the condition affecting these strands. I am not so rash as to raise the question here,—still less to attempt to settle it,—which of these two views is the right and rational one. Whether the brain secretes thought as the liver does bile, or whether the mind created the brain and nervous system, or, as it has been epigrammatically put in a recent work on psychology, "whether the mind has a body, or the body has a mind," I merely call attention to the fact that this confusion of meanings exists, and that its injection into the field of medicine and pathology, at least, has done an enormous amount of harm in the way of confusing problems and preventing a proper recognition of the actual facts.

The more carefully and exhaustively and dispassionately we study the disorders of the nervous system which come in the field of medicine, the more irresistibly we are drawn to the conclusion that from neurasthenia and hysteria to insanity and paralysis they are every one of them the result of some definite morbid change in some cell or strand of the nervous system. The man or woman who is nervous has poisoned nerve-cells, either from hereditary defect, or direct saturation of the tissues with toxic substances. The patient who has an imaginary disease is suffering from some kind of a hallucination produced by poison-soaked nerve-cells, such as in highest degree give rise to the delirium of fevers, and the horrid spectres of delirium tremens.

Even the man who is suffering from a "mind diseased," and confined in one of our merciful asylums for the insane, is in that condition and position on account of physical disease, not merely of his brain, but of his entire body. The lunatic is insane, in the for once correct derivative sense of unhealthy, to the very tips of his fingers. Not merely his mind and his brain, but his liver, his stomach, his skin, his hair and fingernails, the very sweat-glands of his surface which control his bodily odor, are diseased and have been so usually for years before his mind breaks down.

Tell a competent expert to pick out of a crowd of a thousand men and women the ten who are likely to become insane, and his selection will be found almost invariably to include the two or three who will actually become so.

In fact, from even the crudest and scantiest knowledge of the actual growth of our own bodies from the ovum to the adult, it will be difficult to conceive how this relation could be otherwise, The nerve-cells and their long processes, which form the nerve-trunks, are simply one of a score of different specialized cells which exist side by side in the body. Primarily all our body-cells had the power of responding to stimuli, of digesting and elaborating food, of moving by contraction, of reproducing their kind. The nerve-cells are simply a group which have specialized exclusively upon the power of receiving and transmitting impulses. They still take food, but it has to be prepared for them by the other cells; and here, as we shall see later, is one of the dangers to which they are exposed. They still reproduce their kind, but in very much smaller and more limited degree. They still, incredible as it may seem, probably have slight powers of movement or contraction, and can draw in their processes. But they have surrendered many of their rights and neglected some of their primitive accomplishments, in order to devote themselves more exclusively and perfectly to the carrying out of one or two things.

In spite of all this, however, they still remain blood-brothers and comrades to every other cell in the body. In the language of Shylock, "If you cut them, they will bleed; if you tickle them, they will laugh; if you starve them, they will die." In all this development, which continued up to a late hour last night, and is still going on, the nerve-tissue has lain side by side with every other tissue in the body, fed by the same blood, supplied with the same oxygen, saturated with the same body-lymph.

It is of course perfectly clear that any influence, whether beneficial or injurious, affecting the body, will also be likely to affect the nervous system, as a part of it; and this is precisely the fact, as we find it. If the body be well fed, well warmed, sufficiently exercised, without being overworked, and allowed a liberal allowance of that recharging of the human battery which we call sleep, then the nervous system will work smoothly and easily, at peace with itself and with all mankind. Its sense-organs will receive external impressions promptly and accurately. Its conducting fibres will transmit them to the centre with neither delay nor friction. The brain clearing-house will receive and dispose of them with ease and good judgment. And then, just because his nervous system is working to perfection, we say that such an individual "has no nerves."

If the triumph of art be to conceal art, then the nerves have achieved this. They have literally effaced themselves in the well-being of the body.

If on the other hand, the food-supply is inadequate, if the sleep allowance has been cut short, whether by the demands of work or by those of fashion, if the body has been starved of oxygen and deprived of sunlight, if the whole system has been kept on the rack, whether in the sweatshop, or in the furnace of affliction, what is the effect on the nervous system? Just what might have been expected. The sense-organs shy, like a frightened horse, at every shadow or fluttering leaf. The conducting wires break, and cross, and tangle in every imaginable fashion. The central exchange, half wild with hunger, or crazed with fatigue-toxins, shrieks out as each distorted message comes in, or sulks because it can't understand them. And then, with charming logicality, we declare that such an one is "all nerves."

The brain, by which we mean the biggest one near the mouth,—we have little brains, or ganglia all over our bodies,—so far from being an absolute monarch, is not even a constitutional one, or a president of a republic, but a mere house of congress of the modern type, which can do little but register and obey the demands of its constituents. The brain originates nothing. Impulses are brought to it from the sense-organs by the nerves. They set up in it certain vibrations, or chemical disturbances. It responds to these much as blue litmus paper turns red when a weak acid is dropped on it, or as lemonade fizzes when you put soda in it. If more than one of these vibrations are set up simultaneously, it "chooses" between them, by responding to the strongest. If the response differs from the stimulus, it is because of its huge deference to precedent as established by the records of previous stimuli with which its tissues are stored.

This brings us to the interesting and important question, What are the causes of these disturbances of the nerve-tissues? Probably the most important single result that has been reached in our study of nervous diseases in the last fifteen years, is that the cause of them in easily eighty per cent of all cases lies entirely outside of the nervous system.

The stomach burns, the nerve-tissues send in the fire alarm and order out the engines. The liver goes on a strike, and the body-garbage, which it has failed to burn to clean ashes and clear smoke, poisons the nerve-cells, and they remonstrate accordingly, on behalf of the other tissues. The heart, or blood-vessels, fails to supply a certain muscle with its due rations of blood and the nerves of the region cry out in the agony of cramp.

We have discovered, by half a century of careful study in the hospital and in the sick-room, not only that the nerve-tissues are usually poisoned by defect of other tissues of the body, but that they are among the very last of the body-stuffs to succumb to an intoxication. The complications of a given disease involving the nervous system are almost invariably the last of all to appear. This is one of the things that has given nervous diseases such a bad name for unmanageableness and incurableness, and that for years made us regard their study as so nearly hopeless, so far as any helpful results were concerned.

When a disease has, so to speak, soaked into the inmost core of the nerve-fibre, it has got a hold which it will take months and even years to dislodge. And before your remedies can reach it, it will often have done irreparable damage. An illustration of the care taken to spare the nervous system is furnished by its behavior in starvation. If a man or an animal has almost died of starvation, the tissues of the body will be found to have been wasted in very varying degrees, the fat, of course, most of all; in fact this will have almost entirely disappeared, all but three per cent. Then come the liver and great glands, which will have shrunk about sixty per cent; then the muscles, thirty per cent; then the heart and blood-vessels. Last of all, the nervous system, which will scarcely have wasted to any appreciable degree. In fact, it is an obvious instance of jettison on the part of the body, throwing overboard those tissues which it could most easily spare, and hanging on like grim death to those which were absolutely essential to its continued existence, viz., the heart and the nervous system. To use a cannibalistic and more correct illustration, it is killing and eating the less useful and valuable members of its family, in order that their flesh may keep alive the two or three most indispensable.

Another illustration is the actual behavior of the nerve-stuff in disease. This is most clearly shown in those clear-cut disturbances which are definitely known to be due to a specific infection; in other words, invasion of the body by a disease-organism, or germ.

First of all, it may be stated that physicians are now substantially agreed that two-thirds of the general diseases of the nervous system are due to the extension of one of these acute infections to the nerve-tissue; and this extension almost invariably comes late in the disease. The only exceptions to this rule in the whole list of infectious diseases are two, epidemic cerebro-spinal meningitis (spotted fever), and tetanus (lockjaw). Both of these have an extraordinary and deadly preference for the nervous system from the very start, and this is what gives them their frightful mortality and discouraging outlook. Even of this small number of exceptions, we are not altogether certain as to epidemic meningitis, inasmuch as we do not know how long the germ may have existed in the other tissues of the body before it succeeded in working its way to and attacking the brain and spinal cord.

The case of tetanus, however, is perfectly clear in this regard, and exceedingly interesting, inasmuch as it explains why a disease specially involving the nervous system from the start is so excessively hard to check or cure. The germ of the disease, long ago identified as one having its habitat in farm or garden soils,—particularly those which have been heavily fertilized with horse manure,—gets into the system through a cut or scratch upon the surface, into which the soil is rubbed. These infected cuts, for obvious reasons, are most frequently upon the hands or feet.

Small doses of the organism have been injected into animals; then, when they have recovered, larger ones, and so on, after the manner of the bacillus of diphtheria, until a powerful antitoxin can be obtained from their blood, very minute quantities of which will promptly kill the bacilli in a test-tube. For seven or eight years past we have been injecting this into every patient with tetanus that came under our observation, but so far with very limited benefit, even though the injections were made directly into the spinal cord, or brain substance. The problem puzzled us for years, until finally Cattani stumbled upon the explanation. While we had been supposing that the poison was carried, as almost every other known poison is, through the blood-vessels, or lymph-channels, to the heart and thence to the brain, he clearly proved that it ran up the central axis of the nerve-trunks, and consequently, when it had got once fairly started up this channel, was as safe from the attack of any antitoxin merely present in the general circulation and fluids of the body, as the copper of the Atlantic cable is from the eroding action of the sea-water. If, in his experimental animals, he carefully sought for the cut end of the nerve-trunk in the wound that had been infected, and injected the antitoxin directly into that, the disease was stopped. Or it might even be "headed off" by the crude method of cutting directly across the nerve-trunk at a point above that yet reached by the infection.

The commonest and most fatal of all forms of general diseases of the nervous system are those which are due to the later extensions of general infections.

First and foremost stands syphilis, due to the invasion of the blood by a clearly defined spirillum, the Treponema pallida of Schaudinn. This first attacks the mucous membranes of the throat and mouth, then the skin, then the great internal organs like the liver and stomach, then the bones, and, last of all, the nervous system. The length of time which the poison takes to reach the nervous system is something which at first sight is almost incredible, viz., from one and a half to fifteen years. It is true that in rare instances brain symptoms will manifest themselves within six or eight months; but these are usually due to pressure by inflammatory growths on the bones of the skull and its lining membrane (dura mater). It is not too much to say that this disease plays the greatest single role in nervous pathology. Three of the commonest and most fatal diseases of the spinal cord and brain, paresis (general paralysis of the insane), locomotor ataxia, and lateral sclerosis, are due to it.

Naturally, when a poison has taken a decade or a decade and a half to penetrate to the nerve-tissues, it does irreparable damage long before it can be dislodged or neutralized.

A similar aftermath may occur in almost all of the acute infectious diseases. Every year adds a new one to the list capable of causing cerebral complications. Tuberculosis, diphtheria, scarlet fever, typhoid, smallpox, influenza, have now well-recognized cerebral and nervous complications, some temporary, some permanent. A form of tuberculosis attacking the coverings (meninges) of the brain—hence known as meningitis—is far the commonest fatal brain-disease of infancy and childhood.

Perhaps the most striking illustration of just how acute affections attack the nervous system, is that furnished by diphtheria. A child develops an attack of this disease, passes the crisis safely, and begins to recover. A few days later, it is allowed to sit up in bed. Suddenly, after some slight exertion, or often without any apparent cause, the face blanches, the eyes stare widely, the child gasps two or three times, and is dead: sudden heart failure, due to the poisoning either of the heart muscle itself, or of the nerves supplying the heart, by the toxin of the disease. Moral: Keep diphtheria patients strictly at rest in bed for at least a week after the crisis is past. Another case will pass this period safely, though perhaps with a rapid and weak heart, for days or weeks; then one morning the child will choke when swallowing milk. The next time it is attempted, the milk, instead of going down the throat, comes back through the nostrils. Paralysis of the soft palate has developed, apparently from a local saturation of the nerves with the poison. This may go no further, or it may extend, as it commonly does, to the nerves of the eye, and the child squints and can no longer read, if old enough, because the muscle of accommodation also is paralyzed. The arms and limbs may be affected, and in extreme cases the nerves of respiration supplying the diaphragm may be involved, and the child dies of suffocation. In the majority of cases, however, fortunately, after this paralysis has lasted from three to six weeks, it gradually subsides, and may clear up completely, though not at all infrequently one or more muscles may remain permanently damaged by the attack, giving, for instance, a palatal tone to the voice, or interfering with the production of singing tones. Occasionally a permanent squint may follow.

It might be said in passing, that, with one of the charming logicalities of popular reasoning, these nerve complications have been said to be caused by antitoxin, simply because the use of the antitoxin saves more children alive to develop them.

The next group of nervous diseases may be roughly described as due to the failure of some part of the digestive system, like the stomach and intestines, properly to elaborate its food; or of one of the great glands, like the liver, thyroid, or suprarenal, properly to supply its secretion, which is needed to neutralize the poisons normally produced in the body. This class is very large and very important. It has long been known how surely a disordered liver "predicts damnation"; melancholia, or "black bilious condition," hypochondria, or "under the rib-cartilages" (where the liver lies), are every-day figures of speech. A thorough house-cleaning of the alimentary canal, together with proper stimulation of the skin and kidneys, and an intelligent regulation of diet, are our most important measures in the treatment of diseases of the nervous system, even in those extreme forms known as insanity.

Closely allied to these are those disturbances of the nervous system lumped together under the soul-satisfying designation of "neurasthenia," which are chiefly due to the accumulation in the system of the fatigue poisons, or substances due to prolonged overstrain, under-rest, or underfeeding of the system. Neurasthenia is the "fatigue neurosis," as a leading expert terms it. It may be due to any morbid condition under heaven. It is "that blessed word Mesopotamia" of the slipshod diagnostician. Nearly one-fourth of the cases which come into our sanatoria for tuberculosis have been diagnosed and treated for months and even years as "neurasthenia." It satisfies the patient—and it means nothing; though some experts contend for a distinct disease entity of this name but admit its rarity.

The intelligent neurologist, nowadays, has practically no known specific for any form of nervous disease, no remedy which acts directly and curatively upon the nervous system itself. He relies chiefly—and this applies to the asylum physician also—upon intestinal antisepsis, upon rest, upon baths, upon regulation diet, and habits of life.

A number of the more sudden and fatal disturbances of the nervous system, as for instance, the familiar "stroke of paralysis," or apoplexy, of later middle life, are due to a defect, not in the nervous system at all, but in the blood-vessels supplying the brain; rupture of a vessel, and consequent escape of blood, destroys so much of the surrounding brain-tissue as to produce paralysis, and, in extreme cases, death. Just why the blood-vessels of the brain in general, and of one part of the basal ganglia in particular (the Lenticulostriate artery in the internal capsule of the corpus striatum, the old jaw ganglion), are so liable to rupture we do not know; but it certainly is chiefly from a defect of the blood-vessels, and not of the brain. All of which brings us to the following important practical conclusions.

First of all, that every attack or touch, however light, of "nervousness," "nerves," "imagination," "neurasthenia," yes, hysteria, means something. It is the cry of protest of a smaller or larger part of the nervous system against underfed blood, under-ventilated muscles, lack of sunlight, lack of exercise, lack of sleep, excess of work, or bad habits. In other words, it is the danger signal, the red light showing the open switch, and we will disregard it at our peril. Unfortunately, by that power of esprit de corps of the entire system, known as "pluck" or "grit," or the veto-power, physiologically termed inhibition, we may ignore and for a time suppress the symptom, but this in the long run is just as rational as cutting the wire that rings a fire alarm, or blowing out the red light without closing the switch.

Nervousness is a symptom which should always have something done for it, especially in children. In fact, it has passed into an axiom both with intelligent teachers and with physicians who have much to do with the little ones, that crossness, fretfulness, laziness, lack of initiative, and readiness to weep, in children, are almost invariably the signs of physical disease. And this doctrine will apply to a considerable percentage of children of larger growth.

Unfortunately, one of the first and most decided tendencies on the part of the badly fed or poisoned nervous system, is to exaggerate the difficulties of the situation, and to minimize its good features. The individual "has lost his nerve," is afraid to undertake things, shrinks from responsibility, exaggerates the difficulties that may be in the way; hence the floods of tears, or outbursts of temper, with which nervous children will greet the suggestion of any task or duty, however trifling. If the nervous individual has reached that stage of maturity when she realizes that she is not merely "naughty," but sick, then this same process applies itself to her disease. She is sure that she is going to die, that another attack like that will end in paralysis; as a patient of mine once expressed it to me, "My heart jumps up in my mouth, I bite a couple of pieces off it, and it falls back again." In short, she so obviously and grossly exaggerates every symptom and phase of her disease, that the impression irresistibly arises that the disease itself is a fabrication. This view of her condition by her family or her physician is the tragedy of the neurasthenic.

Broadly speaking, no disease, even of the nervous system, is ever purely imaginary. Some part of the patient's nervous system is poisoned, or he would not imagine himself to be sick. We can all of us find trouble enough in some part of our complex bodily machinery, if we go around hunting for it; but this is precisely what the healthy man, or woman, never does. They have other things to occupy them, and are far more liable to run into danger by pushing ahead at full steam, and neglecting small creakings and jarrings until something important in the gear jams, or goes snap, and brings them to a halt, than they are to be wasting time and energy worrying over things that may never happen.

Worry, in fact, is a sign of disease instead of a cause. To put it very crudely, whenever the blood and fluids of a body become impoverished below a certain degree, or become loaded with fatigue poisons, or other waste products above a certain point, then the nervous system proceeds to make itself felt. Either the perceptive end-organs become color-blind and read yellow for blue, or are astigmatic and report oval for round; or the conducting nerve-strands tangle up the messages, or deliver them to the wrong centre; or the central clearing-house, puzzled by the crooked messages, loses its head, and begins to throw the inkstands about, or goes down in a sulk. In other words, the nervous system goes on a strike. But it is perfectly idle to endeavor to treat it with cheering words, or kindly meant falsehoods, to the effect that "nothing is really the matter." Like any other strike, it can be rationally dealt with only by improving the conditions under which the operatives have to work, and meeting their demands for higher wages, or shorter hours.