Preventable Diseases Part 13

In measles we have to deal with a much more harmless and more nearly domesticated "beast of prey," but one of a prevalence to correspond.

Though probably (exact data being as yet lacking) not more than one-third of all individuals are attacked by scarlet fever, it would be safe to say that not more than one-third, and possibly not more than one-fifth, of us escape measles. Hence, though its mortality is scarcely one-fourth that of scarlet fever, it more than holds its own in the Herod cla.s.s, as grimly shown by its total death-roll of over twelve thousand, compared with only a little over six thousand to the credit of scarlet fever.

After the preliminary disturbances of snuffles, hot throat, headache, and feverishness, which it shares with all the other "little fevers,"

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

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

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

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

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

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

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

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

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

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

To sum up in fine: intelligent, effective isolation of all cases, the mild no less than the severe, would stamp out these Herods of the twentieth century within ten years. In the meantime, six weeks'

sick-leave, with all the privileges and care appertaining thereto, will rob them of two-thirds of their terrors.

CHAPTER XII

APPENDICITIS, OR NATURE'S REMNANT SALE

We were not made all at once, nor do we go to pieces all at once, like the "one-hoss shay." This is largely because we are not all of the same age, clear through. Some parts of us are older than other parts. We have always felt a difficulty, not to say a delicacy, in determining the age of a given member of the human species--especially of the gentler s.e.x.

Now we know the reason of it. From the biologic point of view, we are not an individual, but a colony; not a monarchy, but a confederacy of organ-states, each with its millions of cell-citizens. It is not merely editors and crowned heads who have a biologic right to say "We."

Therefore, obviously, any statement that we make as to our age can be only in the nature of an average struck between the ages of our heart, lungs, liver, stomach; and as these vary in ancientness by thousands of years, the average must be both vague and misleading. The only reason why there is a mystery about a woman's age is that she is so intensely human and natural. The only statement as to our age that the facts would strictly justify us in making must partake of the vagueness of Mr. A.

Ward's famous confession that he was "between twenty-three summers."

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

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

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

The cause of appendicitis is the appendix.

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

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

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

Appendicitis is a mark, not a result, of a high grade of civilization.

To have had an operation for it is one of the insignia of modern rank and culture. Our new biologic aristocracy, the "Appendix-Free," look down with gentle disdain upon their appendiciferous fellows who still bear in their bodies this troublesome mark of their lowly origin. In short, the general impression prevails that appendicitis is a new disease, a disease which has become common, or perhaps occurred at all, only within the last quarter of a century, and which therefore--with the usual flying leap of popular logic--is a serious menace to our future, if it keeps on increasing in frequency and ferocity at anything like the same rate which it has apparently shown for the past fifteen years.

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

But all of us whose memory extends backward a quarter of a century can clearly recall that, while we did not see any cases of "appendicitis,"

we saw dozens of cases of "acute enteritis," "idiopathic (self-caused) peritonitis," "acute inflammation of the bowels," "acute obstruction of the bowels," of which patients died both painfully and promptly, and which we now know were really appendicitis.

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

The earlier impression, first among physicians and now in the laity, that appendicitis is an almost invariably fatal disease, is not well founded, and we now know that a large percentage of cases recover, at least from the first attack; so that it is quite possible for from half to two-thirds of the cases of appendicitis actually occurring in a given community to escape recognition, unless promptly reported, carefully examined, and accurately diagnosed. Thirdly, in spite of the remarkable notoriety which the disease has attained, the general dread of its occurrence,--which has been recently well expressed in a statement that everybody either has had it, or expects to have it, or knows somebody who has had it,--the actual percentage of occurrence of grave appendicitis is small. In the United States census of 1900, which was the first census in which it was recognized as a separate cause of death, it was responsible for only 5000 deaths in the entire United States for the ten years preceding, or about one death in two hundred.

This rate is corroborated by the data, now reaching into thousands, from the post-mortem rooms of our great hospitals, which report an average of between a half and one per cent. A disease which, in spite of the widespread terror of it, kills only one in two hundred of those who actually die--or about one in every ten thousand of our population--is certainly nothing to become seriously excited over from a racial point of view.

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

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

Since the chief cause of appendicitis is the appendix, the first question for disposal is, How did the appendix become an appendix? To this biology can render a fairly satisfactory answer. It is the remains of one of Mother Nature's experiments with her 'prentice hand upon the mammalian food-tube. As is now generally known, the food-ca.n.a.l in animals was originally a comparatively straight tube, running the length of the body from mouth to a.n.u.s. It early distends into a moderate pouch, about a third of the way down from the mouth, forming a _stomach_, or storage and churning-place for the food. Below this, it lengthens into coils (the so-called _small intestine_), which, as the body becomes more complex, increase in number and length until they reach four to ten times the length of the body. Later, the lower third of the tube distends and sacculates out into a so-called _large intestine_, in which the last remnants of nutritive material and of moisture are extracted from the food-residues before they are discharged from the body. Just at the junction of this large intestine with the small intestine, nature took it into her head to develop a second pouch, a sort of copy of the stomach. This pouch, from the fact that it ends in a blind sac, is known as the _caec.u.m_ (or "blind" pouch), and is apparently simply a means of delaying the pa.s.sage of the foodstuffs until all the nutriment and moisture have been absorbed out of them for the service of the body.

Naturally, it has developed to the largest degree and size in those animals which have lived upon the bulkiest and gra.s.siest of foods, the so-called _Herbivora_, or gra.s.s-eaters. In the _Carnivora_, or flesh-eaters, it is usually small, and in one family, the bears, entirely absent. This pouch is no mere figure of speech, as may be gathered from the fact that in certain of the rodent _Herbivora_, like the common guinea-pig, it may have a capacity equal to all of the rest of the alimentary ca.n.a.l, and in the horse it will hold something like four times as much as the stomach. Oddly enough, among the gra.s.s-eaters, for some reason which we do not understand, it appears to occur in a sort of inverse proportion to the stomach; those which have large, sacculate, pouched stomachs, like the cow, sheep, and the ruminants generally, having smaller _caeca_. In other _Herbivora_ with small stomachs, like the rabbit and the horse, it develops greater size.

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

Here, however, is where nature makes her first afterthought mistake.

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

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

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

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

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

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

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

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

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

Numerous attempts have been made to show that appendicitis is particularly likely to follow typhoid fever, rheumatism, influenza, tonsilitis, and half a dozen other infectious or inflammatory processes.

But about all that has been demonstrated is that it may follow any of them, though in none with sufficient frequency or constancy to enable it to be regarded as one of the chief or even one of the important causes of the disease.

One dread, however, we may relieve our anxious souls of, and that is the famous grape-seed or cherry-stone terror. To use a Hibernianism, one of our most positive conclusions in regard to the cause of appendicitis is a negative one: that it is not chiefly, or indeed frequently, due to the presence of foreign bodies. This was a most natural conclusion in the early days of the disease, since, given a tiny blind pouch with a constricted opening gaping upon the cavity of the food-ca.n.a.l, nothing could be more natural than to suppose that small irritating food remnants or foreign bodies, slipping into it and becoming lodged, would block it and give rise to serious inflammation. And, moreover, this _a priori_ expectation was apparently confirmed by the discovery, in many appendices removed by operation, of small oval or rounded ma.s.ses, closely resembling the seed of some vegetable or fruit. Whereupon anxious mothers promptly proceeded to order their children to "spit out," with even more religious care than formerly, every grape-seed and cherry-stone. The increased use of fresh and preserved fruits was actually gravely cited, particularly by our Continental brethren, as one of the causes of this new American disease. Barely ten years ago I was spending the summer in the Adirondacks, and was bitterly reproached by the host of one of the Lake hotels, because the profession had so terrified the public about the dangers of appendicitis from fruit-seeds that he was utterly unable to serve upon his tables a large stock of delicious preserved and canned raspberries, blackberries, and grapes which he had put up the previous years. "Why," he said, "more than half the people that come up here will no more eat them than they would poison, for fear that some of the seeds will give 'em appendicitis."