Preventable Diseases Part 14

This dread, however, has been deprived of all rational basis, first, by finding that many inflamed appendices removed, after the operation became more common, contained no foreign body whatever; secondly, that many perfectly healthy appendices examined on the post-mortem table, death being due to other diseases, contain these apparently foreign bodies; and thirdly, that when these "foreign bodies" were cut into, they were found to be not seeds or pits of any description, but hardened and, in some cases, partially calcareous ma.s.ses of the faeces.

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

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

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

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

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

A redeeming feature of appendicitis is that the appendix lies--so to speak--in a corner, or wide-mouthed pouch, of the great peritoneal cavity; and if the inflammation set up in it can be "walled off" from the rest of the peritoneal cavity, and limited strictly to this little corner or pouch, all will be well. This is what occurs in those cases of severe appendicitis which spontaneously recover. If, however, this disturbance bursts its barriers, and lights up an inflammation of the entire peritoneal cavity, then the result is likely to be a fatal one.

Just how far nature can be trusted in each particular case to limit and stamp out the process in this manner is the core of the problem that confronts us, as attending physicians.

In the majority of cases, fortunately, the peritoneal fire brigade acts promptly, pours out a wall of exudate, and locks up the appendix in a living prison, to fight out its own battles and sink or swim by itself.

But unfortunately, in a minority of cases, by a wretched sort of "senatorial courtesy" which exists in the body, the appendix is given its ancestral or traditional rights and allowed to inflict its petty troubles upon the entire abdominal cavity, and include the body in its downfall.

Lastly come the two most pertinent and appealing questions:--

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

In regard to the first of these, it is safe to say that our answer is much less alarming than it was in the earlier stage of our knowledge.

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

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

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

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

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

The number of feet was given.

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

The data were supplied.

"It is a church, you say?"

"Yes."

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

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

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

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

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

CHAPTER XIII

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

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

In malaria, however, we have a disease enemy of somewhat different cla.s.s and habits. While other great infections attack man usually where he is strongest and most numerous, malaria, on the contrary, lies in wait for him where he is weakest and most scattered, upon the frontiers of civilization and the borders of the wilderness. It is only of late years that we have begun to realize what a deadly and persistent enemy of the frontiersman and pioneer it is. We used to hear much of climate as an obstacle to civilization and barrier to settlement. Now, for climate we read "malaria." Whether on the prairies or even the tundras of the North, or by the jungles and swamps of the Equator, the _thing that killed_ was eight times out of ten the winged messenger of death with his burden of malaria-infection. The "chills and fever," "fevernager,"

"mylary," that chattered the teeth and racked the joints of the pioneer, from Michigan to Mississippi, was one and the same plague with the deadly "jungle fever," "African fever," "black fever" of the tropics, from Panama to Singapore. Hardly a generation ago, along the advancing front of civilization in the Middle West, the whole life of the community was colored with a malarial tinge and the taste of quinine was as familiar as that of sugar. To this day, over something like three-quarters of the area of these United States, the South, Middle West, and Far West, if you feel headachy and bilious and "run down," you sum it all up by saying that you are feeling "malarious." Dwellers upon the rich bottom-lands expected to shake every spring and fall with almost the same regularity as they put on and shed their winter clothing. Readers of Frank Stockton will remember the gales of merriment excited by his quaint touch of the incongruous in making the prospective bridegroom of the immortal Pomona change the date of their wedding day from Tuesday to Monday, because, on figuring the matter out, he had discovered that Tuesday was his "chill-day."

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

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

Malaria ever has been, and is yet, the great barrier against the invasion of the tropics by the white races; nor has its injurious influence been confined to the deaths that it causes, for these gaps in the fighting line might be filled by fresh levies drawn from the wholesome North. Its fearfully depressing and degenerating effects upon even those who recover from its attacks have been still more injurious.

It has been held by careful students of tropical disease and conditions that no small part of that singular apathy and indifference which steal over the mind and body of the white colonist in the tropics, numbing even his moral sense, and alternating with furious outbursts of what the French have termed "tropical wrath," characterized by unnatural cruelty and abnormal disregard for the rights of others, is the deadly work of malaria. It is the most powerful cause, not merely of the extinction of the white colonist in the tropics, but of the peculiar degeneracy--physical, mental, and moral--which is apt to steal over even the survivors who succeed in retaining a foothold. Two particularly ingenious investigators have even advanced the theory that the importation of malaria into the islands of Greece and the Italian peninsula by soldiers returning from African and Southern Asiatic conquests had much to do with accelerating, if not actually promoting, the cla.s.sic decay of both of these superb civilizations.

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

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

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

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

But here will challenge some twentieth-century _Gradgrind_: "This is all very pretty from the point of view of abstract science, but what is the practical value of it? The discovery of the plasmodium and its peculiarities has merely shown us the how and the why of a fact that we had known well and utilized for centuries, namely, that quinine will cure malaria." Just listen to what follows. The story of the plasmodium is one of the most beautiful ill.u.s.trations of the fact that there is no such thing as useless or unpractical knowledge. The only thing that makes any knowledge unpractical is our more or less temporary ignorance of how to apply it. The first question which instantly raised itself was, "How did the plasmodium get into human blood?" The very sickle-shape of the plasmodium turned itself into an interrogation mark.

The first clew that was given was the new and interesting one that this organism was a new departure in the germ line in that it was an animal, instead of a plant, like all the other hitherto known bacilli, bacteria, and other disease-germs.

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

Being an animal, the plasmodium naturally would not grow upon culture-media like the vegetable bacilli and bacteria, and this very fact had delayed its recognition, but raised at once the probability that it must be conveyed into the human body by some other animal.

Obviously, the only animals that bite our human species with sufficient frequency and regularity to act as transmitters of such a common disease are those Ishmaelites of the animal world, the insects. As all the evidence pointed toward malaria being contracted in the open air, attested by its popular though unscientific name _mal-aria_, "bad air,"

and as of all forms of "bad air" the night air was incomparably the worst, it must be some insect which flew and bit by night; which by Sherlock Holmes's process promptly led the mosquito into the dock as the suspected criminal. It wasn't long before he was, in the immortal language of Mr. Devery, "caught with the goods on"; and in 1895 Dr.

Ronald Ross, of the Indian Medical Service, discovered and positively identified the plasmodium undergoing a cycle of its development in the body of the mosquito. He attempted to communicate the disease to birds and animals by allowing infected mosquitoes to bite them, but was unsuccessful. Two Italian investigators, Bignami and Gra.s.si, saw that the problem was one for human experiment and that nothing less would solve it. Volunteers were called for and promptly offered themselves.

Their blood was carefully examined to make sure that they were not suffering from any latent form of malaria. They then allowed themselves to be bitten by infected mosquitoes, and within periods varying from six to ten days, eight-tenths of them developed the disease. It may be some consolation to our national pride to know that although the organism was first identified in the mosquito by an Englishman and its transmission to human beings in its bite by Italians, the first definite and carefully worked-out statement of the relation of the mosquito to malaria was made by an American, King of Washington, in 1882; though it is only fair to say that suggestions of the possible connection between mosquitoes and malaria had, so to speak, been in the air and been made from scores of different sources, from the age of Augustus onward.

Another mystery was solved--and what a flood of light it did pour upon our speculations as to the how and wherefore of the catching of malaria!

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

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

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

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