Part 16

One of the most remarkable features of modern protective medicine is the widespread interest that has been aroused in the crusade against tuberculosis. What has already been accomplished warrants the belief that the hopes of even the most enthusiastic may be realized. A positive decline in the prevalence of the disease has been shown in many of the larger cities during the past ten years. In Massachusetts, which has been a hot-bed of tuberculosis for many years, the death-rate has fallen from forty-two per ten thousand inhabitants in 1853 to twenty-one and eight-tenths per ten thousand inhabitants in 1895. In the city of Glasgow, in which the records have been very carefully kept, there has been an extraordinary fall in the death-rate from tuberculosis, and the recent statistics of New York City show, too, a similar remarkable diminution.

In fighting the disease our chief weapons are: First, education of the public, particularly of the poorer classes, who do not fully appreciate the chief danger in the disease. Secondly, the compulsory notification and registration of all cases of tuberculosis. The importance of this relates chiefly to the very poor and improvident, from whom, after all, comes the greatest danger, and who should be under constant surveillance in order that these dangers may be reduced to a minimum. Thirdly, the foundation in suitable localities by the city and by the State of sanatoria for the treatment of early cases of the disease. Fourthly, provision for the chronic, incurable cases in special hospitals.

_Diphtheria._—Since the discovery of the germ of this disease and our knowledge of the conditions of its transmission, and the discovery of the antitoxin, there has been a great reduction in its prevalence and an equally remarkable reduction in the mortality. The more careful isolation of the sick, the thorough disinfection of the clothing, the rigid scrutiny of the milder cases of throat disorder, a more stringent surveillance in the period of convalescence, and the routine examination of the throats of school-children—these are the essential measures by which the prevalence of the disease has been very markedly diminished. The great danger is in the mild cases, in which the disease has perhaps not been suspected, and in which the child may be walking about and even going to school. Such patients are often a source of widespread infection. The careful attention given by mothers to the teeth and mouth of children is also an important factor. In children with recurring attacks of tonsillitis, in whom the tonsils are enlarged, the organs should be removed. Through these measures the incidence of the disease has been very greatly reduced.

_Pneumonia._—While there has been a remarkable diminution in the prevalence of a large number of all the acute infections, one disease not only holds its own, but seems even to have increased in its virulence. In the mortality bills, pneumonia is an easy second to tuberculosis. It attacks particularly the intemperate, the feeble, and the old, though every year a large number of robust, healthy individuals succumb. So frequent is pneumonia at advanced periods of life that to die of it has been said to be the natural end of old men in this country. In many ways, too, it is a satisfactory disease, if one may use such an expression. It is not associated with much pain, except at the onset, the battle is brief and short, and a great many old persons succumb to it easily and peacefully.

We know the cause of the disease; we know only too well its symptoms, but the enormous fatality (from twenty to twenty-five per cent.) speaks only too plainly of the futility of our means of cure, and yet in no disease has there been so great a revolution in treatment. The patient is no longer drenched to death with drugs, or bled to a point where the resisting powers of nature are exhausted. We are not without hope, too, that in the future an antidote may be found to the toxins of the disease, and of late there have been introduced several measures of great value in supporting the weakness of the heart, a special danger in the old and debilitated.

_Hydrophobia._—Rabies, a remarkable, and in certain countries a widespread, disease of animals, when transmitted to a man by the bite of rabid dogs, wolves, etc., is known as hydrophobia. The specific germ is unknown, but by a series of brilliant observations Pasteur showed (1) that the poison has certain fixed and peculiar properties in connection with the nervous system; (2) that susceptible animals could be rendered refractory to the disease, or incapable of taking it, by a certain method of inoculation; and (3) that an animal unprotected and inoculated with a dose of the virus sufficient to cause the disease may, by the injection of proper anti-rabic treatment, escape. Supported by these facts, Pasteur began a system of treatment of hydrophobia in man, and a special institute was founded in Paris for the purpose. When carried out promptly the treatment is successful in an immense majority of all cases, and the mortality in persons bitten by animals proved to be rabid, who have subsequently had the anti-rabic treatment, has been reduced to less than one-half per cent. The disease may be stamped out in dogs by careful quarantine of suspected animals, and by a thoroughly carried out muzzling order.

_Malaria._—Among the most remarkable of modern discoveries is the cause of malarial fever, one of the great maladies of the world, and a prime obstacle to the settlement of Europeans in tropical regions. Until 1880 the cause was quite obscure. It was known that the disease prevailed chiefly in marshy districts, in the autumn, and that the danger of infection was greatest in the evening and at night, and that it was not directly contagious. In 1880 a French army surgeon, Laveran, discovered in the red blood-corpuscles small bodies which have proved to be the specific germ of the disease. They are not bacteria, but little animal bodies resembling the amœba—tiny little portions of protoplasm. The parasite in its earliest form is a small, clear, ring-shaped body inside the red blood-corpuscle, upon which it feeds, gradually increasing in size and forming within itself blackish grains out of the coloring matter of the corpuscle. When the little parasite reaches a certain size it begins to divide or multiply, and an enormous number of these breaking up at the same time give off poison in the blood, which causes the paroxysms of fever. During what is known as the chill, in the intermittent fever, for example, one can always find these dividing parasites. Several different forms of the parasites have been found, corresponding to different varieties of malaria. Parasites of a very similar nature exist abundantly in birds. Ross, an army surgeon in India, found that the spread of this parasite from bird to bird was effected through the intervention of the mosquito. The parasites reach maturity in certain cells of the coats of the stomach of these insects, and develop into peculiar thread-like bodies, many of which ultimately reach the salivary glands, from which, as the insect bites, they pass with the secretion of the glands into the wound. From this as a basis, numerous observers have worked out the relation of the mosquito to malaria in the human subject.

Briefly stated, the disease is transmitted chiefly by certain varieties of the mosquito, particularly the _Anopheles_. The ordinary _Culex_, which is present chiefly in the Northern States, does not convey the disease. The _Anopheles_ sucks the blood from a person infected with malaria, takes in a certain number of parasites, which undergo development in the body of the insect, the final outcome of which is numerous small, thread-like structures, which are found in numbers in the salivary glands. From this point, when the mosquito bites another individual, they pass into his blood, infect the system, and in this way the disease is transmitted. Two very striking experiments may be mentioned. The Italian observers have repeatedly shown that _Anopheles_ which have sucked blood from patients suffering from malaria, when sent to a non-malarial region, and there allowed to bite perfectly healthy persons, have transmitted the disease. But a very crucial experiment was made a short time ago. Mosquitoes which had bitten malarial patients in Italy were sent to London and there allowed to bite Mr. Manson, son of Dr. Manson, who really suggested the mosquito theory of malaria. This gentleman had not lived out of England, and there is no acute malaria in London. He had been a perfectly healthy, strong man. In a few days following the bites of the infected mosquitoes he had a typical attack of malarial fever.

The other experiment, though of a different character, is quite as convincing. In certain regions about Rome, in the Campania, malaria is so prevalent that in the autumn almost every one in the district is attacked, particularly if he is a new-comer. Dr. Sambron and a friend lived in this district from the 1st of June to the 1st of September, 1900. The test was whether they could live in this exceedingly dangerous climate for the three months without catching malaria, if they used stringent precautions against the bites of mosquitoes. For this purpose the hut in which they lived was thoroughly wired, and they slept with the greatest care under netting. Both of these gentlemen at the end of the period had escaped the disease.

The importance of these studies cannot be overestimated. They explain the relation of malaria to marshy districts, the seasonal incidence of the disease, the nocturnal infection, and many other hitherto obscure problems. More important still, they point out clearly the way by which malaria may be prevented: First, the recognition that any individual with malaria is a source of danger in a community, so that he must be thoroughly treated with quinine; secondly, the importance of the draining of marshy districts and ponds in which mosquitoes breed; and, thirdly, that even in the most infected regions persons may escape the disease by living in thoroughly protected houses, in this way escaping the bites of mosquitoes.

_Venereal Diseases._—These continue to embarrass the social economist and to perplex and distress the profession. The misery and ill-health which they cause are incalculable, and the pity of it is that the cross is not always borne by the offender, but innocent women and children share the penalties. The gonorrhœal infection, so common, and often so little heeded, is a cause of much disease in parts other than those first affected. Syphilis claims its victims in every rank of life, at every age, and in all countries. We now treat it more thoroughly, but all attempts to check its ravages have been fruitless. Physicians have two important duties: the incessant preaching of continence to young men, and scrupulous care, in every case, that the disease may not be a source of infection to others, and that by thorough treatment the patient may be saved from the serious late nervous manifestations. We can also urge that in the interests of public health venereal diseases, like other infections, shall be subject to supervision by the State. The opposition to measures tending to the restriction of these diseases is most natural: on the one hand, from women, who feel that it is an aggravation of a shocking injustice and wrong to their sex; on the other, from those who feel the moral guilt in a legal recognition of the evil. It is appalling to contemplate the frightful train of miseries which a single diseased woman may entail, not alone on her associates, but on scores of the innocent—whose bitter cry should make the opponents of legislation feel that any measures of restriction, any measures of registration, would be preferable to the present disgraceful condition, which makes of some Christian cities open brothels and allows the purest homes to be invaded by the most loathsome of all diseases.

_Leprosy._—Since the discovery of the germ of this terrible disease systematic efforts have been made to improve the state of its victims and to promote the study of the conditions under which the disease prevails. The English Leprosy Commission has done good work in calling attention to the widespread prevalence of the disease in India and in the East. In this country leprosy has been introduced into San Francisco by the Chinese, and into the Northwestern States by the Norwegians, and there are foci of the disease in the Southern States, particularly Louisiana, and in the province of New Brunswick. The problem has an additional interest since the annexation of Hawaii and the Philippine Islands, in both of which places leprosy prevails extensively. By systematic measures of inspection and the segregation of affected individuals the disease can readily be held in check. It is not likely ever to increase among native Americans, or again gain such a foothold as it had in the Middle Ages.

_Puerperal Fever._—Perhaps one of the most striking of all victories of preventive medicine has been the almost total abolition of so-called child-bed fever from the maternity hospitals and from private practice. In many institutions the mortality after child-birth was five or six per cent., indeed sometimes as high as ten per cent., whereas to-day, owing entirely to proper antiseptic precautions, the mortality has fallen to three-tenths to four-tenths per cent. The recognition of the contagiousness of puerperal fever was the most valuable contribution to medical science made by Oliver Wendell Holmes. There had been previous suggestions by several writers, but his essay on the “Contagiousness of Puerperal Fever,” published in 1843, was the first strong, clear, logical statement of the case. Semmelweis, a few years later, added the weight of a large practical experience to the side of the contagiousness, but the full recognition of the causes of the disease was not reached until the recent antiseptic views had been put into practical effect.

THE NEW DISPENSATION IN TREATMENT

The century has witnessed a revolution in the treatment of disease, and the growth of a new school of medicine. The old schools—regular and homœopathic—put their trust in drugs, to give which was the alpha and the omega of their practice. For every symptom there were a score or more of medicines—vile, nauseous compounds in one case; bland, harmless dilutions in the other. The new school has a firm faith in a few good, well-tried drugs, little or none in the great mass of medicines still in general use. Imperative drugging—the ordering of medicine in any and every malady—is no longer regarded as the chief function of the doctor. Naturally, when the entire conception of the disease was changed, there came a corresponding change in our therapeutics. In no respect is this more strikingly shown than in our present treatment of fever—say, of the common typhoid fever. During the first quarter of the century the patients were bled, blistered, purged and vomited, and dosed with mercury, antimony, and other compounds to meet special symptoms. During the second quarter, the same, with variations in different countries. After 1850 bleeding became less frequent, and the experiments of the Paris and Vienna schools began to shake the belief in the control of fever by drugs. During the last quarter sensible doctors have reached the conclusion that typhoid fever is not a disease to be treated with medicines, but that in a large proportion of all cases diet, nursing, and bathing meet the indications. There is active, systematic, careful, watchful treatment, but not with drugs. The public has not yet been fully educated to this point, and medicines have sometimes to be ordered for the sake of the friends, and it must be confessed that there are still in the ranks _antiques_ who would insist on a dose of some kind every few hours.

The battle against poly-pharmacy, or the use of a large number of drugs (of the action of which we know little, yet we put them into bodies of the action of which we know less), has not been fought to a finish. There have been two contributing factors on the side of progress—the remarkable growth of the skeptical spirit fostered by Paris, Vienna, and Boston physicians, and, above all, the valuable lesson of homœopathy, the infinitesimals of which certainly could not do harm, and quite as certainly could not do good; yet nobody has ever claimed that the mortality among homœopathic practitioners was greater than among those of the regular school. A new school of practitioners has arisen which cares nothing for homœopathy and less for so-called allopathy. It seeks to study, rationally and scientifically, the action of drugs, old and new. It is more concerned that a physician shall know how to apply the few great medicines which all have to use, such as quinine, iron, mercury, iodide of potassium, opium, and digitalis, rather than a multiplicity of remedies the action of which is extremely doubtful.

The growth of scientific pharmacology, by which we now have many active principles instead of crude drugs, and the discovery of the art of making medicines palatable, have been of enormous aid in rational practice. There is no limit to the possibility of help from the scientific investigation of the properties and action of drugs. At any day the new chemistry may give to us remedies of extraordinary potency and of as much usefulness as cocaine. There is no reason why we should not even in the vegetable world find for certain diseases specifics of virtue fully equal to that of quinine in the malarial fevers.

One of the most striking characteristics of the modern treatment of disease is the return to what used to be called the natural methods—diet, exercise, bathing, and massage. There probably never has been a period in the history of the profession when the value of _diet_ in the prevention and the cure of disease was more fully recognized. Dyspepsia, the besetting malady of this country, is largely due to improper diet, imperfectly prepared and too hastily eaten. One of the great lessons to be learned is that the preservation of health depends in great part upon food well cooked and carefully eaten. A common cause of ruined digestion, particularly in young girls, is the eating of sweets between meals and the drinking of the abominations dispensed in the chemists’ shops in the form of ice-cream sodas, etc. Another frequent cause of ruined digestion in business men is the hurried meal at the lunch-counter. And a third factor, most important of all, illustrates the old maxim, that more people are killed by over eating and drinking than by the sword. Sensible people have begun to realize that alcoholic excesses lead inevitably to impaired health. A man may take four or five drinks of whiskey a day, or even more, and thinks perhaps that he transacts his business better with that amount of stimulant; but it only too frequently happens that early in the fifth decade, just as business or political success is assured, Bacchus hands in heavy bills for payment, in the form of serious disease of the arteries or of the liver, or there is a general breakdown. With the introduction of light beer there has been not only less intemperance, but a reduction in the number of the cases of organic disease of the heart, liver, and stomach caused by alcohol. While temperance in the matter of alcoholic drinks is becoming a characteristic feature of Americans, intemperance in the quantity of food taken is almost the rule. Adults eat far too much, and physicians are beginning to recognize that the early degenerations, particularly of the arteries and of the kidneys, leading to Bright’s disease, which were formerly attributed to alcohol, are due in large part to too much food.

_Nursing._—Perhaps in no particular does nineteenth-century practice differ from that of the preceding centuries more than in the greater attention which is given to the personal comfort of the patient and to all the accessories comprised in the art of nursing. The physician has in the trained nurse an assistant who carries out his directions with a watchful care, and who is on the lookout for danger-signals, and with accurate notes enables him to estimate the progress of a critical case from hour to hour. The intelligent, devoted women who have adopted the profession of nursing, are not only in their ministrations a public benefaction, but they have lightened the anxieties which form so large a part of the load of the busy doctor.

_Massage and Hydrotherapy_ have taken their places as most important measures of relief in many chronic conditions, and the latter has been almost universally adopted as the only safe means of combating the high temperatures of the acute fevers.

Within the past quarter of a century the value of _exercise_ in the education of the young has become recognized. The increase in the means of taking wholesome out-of-door exercise is remarkable, and should show in a few years an influence in the reduction of the nervous troubles in young persons. The prophylactic benefit of systematic exercise, taken in moderation by persons of middle age, is very great. Golf and the bicycle have in the past few years materially lowered the average incomes of the doctors in this country as derived from persons under forty. From the senile contingent—those above this age—the average income has for a time been raised by these exercises, as a large number of persons have been injured by taking up sports which may be vigorously pursued with safety only by those with young arteries.

Of three departures in the art of healing, brief mention may be made. The use of the extracts of certain organs (or of the organs themselves) in disease is as old as the days of the Romans, but an extraordinary impetus has been given to the subject by the discovery of the curative powers of the extract of the thyroid gland in the diseases known as cretinism and myxœdema. The brilliancy of the results in these diseases has had no parallel in the history of modern medicine, but it cannot be said that in the use of the extracts of other organs for disease the results have fulfilled the sanguine expectations of many. There was not, in the first place, the same physiological basis, and practitioners have used these extracts too indiscriminately and without sufficient knowledge of the subject.

Secondly, as I have already mentioned, we possess a sure and certain hope that for many of the acute infections antitoxins will be found.