Disease and Its Causes by William Thomas Councilman

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Diseases of the nervous system have a special interest in that they so
often interfere with man in his relations with his fellows. In
diseases of other organs the disturbances set up concern the
individual only. Thus, others need not be disturbed save by the
demands made on their sympathies by an individual with a cold in the
head or a cancer of the stomach. Disease of the nervous system is
another affair, instead of those reactions and expressions of activity
to which we are accustomed and to which society is adjusted, the
reactions and activities are unusual and the individual in consequence
does not fit into the social state and is said to be anti-social.
There are all possible grades of this, from mere unpleasantness in the
social relations with such an individual, to states in which he is
dangerous to society and must be isolated from it. Insanity is an
extreme case. There is no disease signified in the expression, but it
is merely a legal term to designate those individuals whose actions
are opposed to the social state and who are not responsible for them.
In insanity there is falsity in impressions, in conceptions, in
judgment, a defective power of will and an uncontrollable violence of
emotion. The individual is prevented from thinking the thoughts or
feeling the feelings and doing the duties of the social body in the
community in which he lives. The insane are out of harmony with their
social environment, but not necessarily in opposition to it.

There is no very sharp line between insanity and criminality. The
criminal is in direct antagonism to the laws of social life. An insane
person may cause the same injury to society as a criminal, but his
actions are not voluntary, whereas the criminal is one who can control
his actions, but does not. Mentally degenerated persons, however, can
be both insane and criminal. Whatever the state of society, this
reprobates the actions of one opposed to it; in a society in which it
were usual to appropriate the possessions of others or to devour
unpleasant or useless relatives, virtue and lack of appetite would be
reprobated as unsocial.

The symptoms of insanity or the manner in which the defective action
of the brain expresses itself and the various underlying pathological
changes vary, and by combining these it has been possible to subdivide
insanity into a number of distinct forms. There are both intrinsic and
extrinsic causes of insanity. The intrinsic are the structural
differences in the brain as compared with the normal or usual, whether
these are due to imperfection in development or to defective heredity
or to the injury of disease; the extrinsic causes are those which come
from without and bring the intrinsic into activity. Syphilis is a
frequent cause of insanity, and probably the only cause of the
condition known as general paralysis of the insane, acting by means of
the injury which it produces in the cortex of the brain. The abuse of
alcohol is another fertile cause, but the changes produced in this are
not so obvious as in the case of syphilis. Tumors of the brain are not
infrequently a cause, and the same is true of infections, even those
not located in the brain. How susceptible the brain is to the effects
of the toxines of the infectious diseases is shown in the frequency of
delirium in these diseases. There is an interesting relation between
this and alcoholism. Alcohol abuse may produce injury, but not
sufficient to manifest itself under ordinary conditions; when,
however, the action of toxic substance is superadded to the effect of
the alcohol the delirium of fever is more marked.

Probably of greater importance than the acquired pathological
conditions of the brain in producing insanity is a congenital
condition in which the nervous system is defective. The most fertile
cause of insanity lies in the inheritance; by this it must not be
understood that insane parents produce insane offsprings, but that
conditions inherited from immediate or remote ancestors appear in a
diminished resistance of the nervous system which is sooner or later
expressed as insanity. Given such a defective nervous system,
extrinsic conditions which would have no effect on another individual
or would be felt in different ways may produce insanity. In these
cases occupation plays a great role. The excitement and privations of
war especially in the tropics and the ennui of camps leads to insanity
in soldiers; occupations such as that of the baker in which there is
loss of sleep and the mental strain of students can all act in the
same way. A woman who gives no sign of nervous defect may become
insane under the strain of pregnancy.

Although insanity is determined by the social relations of man, that
part of the social organization which is termed _Society_, and
which has been developed by the idle as a diverting game, is a fertile
source of nervous disease and even of insanity, affecting particularly
females. The strenuosity of the life, the nervous excitement
alternating with ennui, the lack and improper times of sleep, the lack
of rest and particularly of restful occupation, the not infrequent use
of alcohol in injurious amounts, are all factors calculated to make a
defect operative. The so-called "coming out" of young girls is an
important element in the game, and their headlong plunge into such a
life at a period under any conditions full of danger to the nervous
system is especially to be reprobated. If we consider the influence of
the game in other respects as conducing to lack of moral sense, to
alcoholic abuse (for without the seeming stimulation, but which is
really the blunting of impressions which alcohol brings, the game
would not be possible), to discontent, to mental enfeeblement, it is
all bad. Curiously enough the game is one which in all periods has
been played by the idle, but its evil influence is greater now than
before when it was the game of royalty chiefly, because there are now
more people living from the work of others.

The unusual mental action of the insane not infrequently expresses
itself by suicide. The analysis of three hundred deaths from suicide
showed pathological changes in the brain in forty-three per cent, and
when we think that mental disturbances are very often without
recognizable anatomical changes after death, the percentage is very
large. In another analysis of one hundred and twenty-four suicides
forty-four of these were mentally affected to various degrees. Five of
the men and seven women were epileptics, in ten of the families there
was hysteria, twenty-four of the men and four of the women were
chronic alcoholics.

It is extremely difficult at the present time to say whether insanity
is increasing. Statistics in all lands giving the numbers committed to
insane hospitals show on their face a great increase, but so many
factors enter into these statistics that their value is uncertain.
There is now an ever-increasing provision for the care of the insane.
Owing to the recognition of insanity as a part of nervous disease and
its separation from criminality there is no longer the same attempt to
conceal it as was formerly the case, and hospitals for the insane are
no longer associated with ideas of Bedlam. It is generally believed
that modern conditions in the hurry and excitement of life, and the
extreme social differences, the greater urban life, the greater
extension of factory life, all tend to an increase in insanity, but
there is no absolute proof that this is true. We know very little
about insanity in the Middle Ages, but the conditions then were not
conducive to a quiet life. There prevailed then as now excess and
want, luxury and poverty, enjoyment and deprivations, balls and dinner
parties and other features of the social game. There were factions in
the cities, public executions, not infrequent sieges, scenes of
horror, epidemics, famines, and all these combined with religious
superstition and the often unjust and cruel laws should have been
factors for insanity. There were actual epidemics of insanity
affecting masses of the population, as shown in the children's
crusade, the Jewish massacres and the dancing mania in the Rhine
provinces. Where civilization seems to be the highest, statistics show
the most insane, but this most probably depends upon better
recognition of the condition and better provision for asylum care.

The so-called functional diseases have a close relation with diseases
of the nervous system, for they chiefly concern the reactions of nerve
tissue. Disease expressing itself in disturbance of function only,
does not seem to fit in with the conceptions of disease which have
been expressed, nor can we imagine a disturbance of function which
does not depend upon a change of material. Living matter does not
differ intrinsically from any other sort of matter; like other matter
its reactions depend upon its composition structure[1] and the
character of the action exerted upon it. By functional disease there
is expressed merely that no anatomical or chemical change is
discoverable in the material which gives the unusual reaction. The
further our researches into the nature of disease extend, particularly
the researches into the physiology and chemistry of disease, the
smaller is the area of functional disease. In functional disease there
may be either vague discomfort or actual pain under conditions when
usually such would not be experienced, and on examination no condition
is found which in the vast majority of cases would alone give rise to
that impression on the nervous system which is interpreted as pain. In
the production of the sensations of disease there can be change at any
place along the line, in the sense organs, in the conducting paths or
in the central organ. Thus there may be false visual impressions which
may be due to changes in the retina or in the optic nerve or in the
brain matter to which the nerve is distributed. It is perfectly
possible that substances of an unusual character or an excess or
deficiency of usual substances in the fluids around brain cells may so
change them that such unusual reactions appear. There may be, of
course, very marked individual susceptibility, which may be congenital
or acquired. The perception of every stimulus involves activity of the
nerve cells, and it is possible that the constant repetition of
stimuli of an ordinary character may produce sufficient change to give
rise to unusual reactions, and this particularly when there is lack of
the restoration which repose and sleep bring. We know into what a
condition one's nervous system may be thrown by the incessant noise
attending the erection of a building in the vicinity of one's house or
the pounding of a plumber working within the house, this being
accentuated in the latter case by the thought of impending financial
disaster. Even the confused and disagreeable sound due to the clatter
of high-pitched women's voices at teas and receptions may, when
frequently repeated, be productive of changes in the nerve cells
sufficiently marked to give rise to the unusual reactions which are
evidence of disease.

In the condition known as neurasthenia, which is often taken as a type
of a functional disease, the basal and intrinsic cause is activity of
the nervous system with the using up of material which is not
compensated for by the renewal which comes in repose and sleep.
Neurasthenia is one of the common conditions of our civilization,
found among children and adults, the poor and rich, the idle and the
factory worker; it is rife in the scholastic professions and among
those who earn their living by brain work. It seems to be more common
in the upper classes and particularly in the women, but this is
because these are more subject to medical care and the condition is
more in evidence. There are all sorts of symptoms attached to the
condition, for the unusual mental action can be variously expressed.
The cerebral form has been thus described by a well-known medical
writer: "One of the most characteristic features of cerebral
neurasthenia is a weary brain. The sensation is familiar enough to any
fagged man, especially if he fall short of sleep. Impressions seem to
go half into one's head and there sink into a woolly bed and die.
Voices sound far off, the lines of a book run into one another and the
meaning of them passes unperceived. Doors bang and windows rattle as
they never did before; if a shoestring breaks, an imprecation is upon
the lips. Business matters are in a conspiracy to go wrong. Letters
are left unopened partly from want of will, partly from a senseless
dread lest they contain bad news. At night the patient tosses on his
bed possessed by all the cares which blacken with darkness. Headache
is common, loss of memory is distressing, and in severe cases it is
wider and deeper than mere inattention can explain. There is often the
torture of acute hearing, or an inability to suppress attention; the
hater of clocks and crowing cocks is a neurasthenic." The disease is
especially common in the women players of the social game, and its
unhappy victims too often seek relief from the nervous irritability
which is a common early symptom in still greater nervous excitement.
It is a sad commentary on our civilization that one of the means of
treatment for these persons which has been found efficacious is to
supply them with some restful household occupation such as knitting or
plain sewing, and there are institutions which combine refuge from
social activities, often called duties, with simple occupation.

FOOTNOTE:
[1] By structure as used in this wide sense, there must be
understood not merely the anatomical structure, which is revealed by
the dissecting knife and microscope, but molecular structure, or the
manner in which elements are arranged to form the molecule, as well.

CHAPTER XII

THE RAPID DEVELOPMENT OF MEDICINE IN THE LAST FIFTY YEARS.--THE
INFLUENCE OF DARWIN.--PREVENTIVE MEDICINE.--THE DISSEMINATION OF
MEDICAL KNOWLEDGE.--THE DEVELOPMENT OF CONDITIONS IN RECENT YEARS
WHICH ACT AS FACTORS OF DISEASE.--FACTORY LIFE.--URBAN LIFE.--THE
INCREASE OF COMMUNICATION BETWEEN PEOPLES.--THE INTRODUCTION OF PLANT
PARASITES.--THE INCREASE IN ASYLUM LIFE.--INFANT MORTALITY.--WEALTH
AND POVERTY AS FACTORS IN DISEASE.

Certain conditions have arisen in the past fifty years which have
profoundly affected the thoughts, the beliefs and the activities of
man. Within this period what is generally known as Darwinism,
including under this evolution, has developed. Unlike theories which
came from philosophical speculation only, the theory of evolution was
one which could be subjected to observation and experiment. It freed
man's mind from dogmas, it stimulated the imagination, it enlarged the
territory in which it seemed possible to extend knowledge by the
methods of science, and has resulted in an enormous increase of
knowledge. This has been more striking in medical science than
elsewhere, and in this of more far-reaching influence. Evolution
coincided with another important development. History shows that all
great periods of civilization have at their back sources of energy. In
the civilizations of the past such sources of energy have come from
the enslavement of conquered peoples or from commerce, or more direct
forms of robbery, which have enabled a favored class to appropriate
for its purposes the results of the work of others. While these
sources have not been absent in the development of our civilization,
the great source of energy has come from the rapid, and usually
wasteful and reckless, utilization of the stored energy of the earth.
The almost incredible advance in medical and other forms of scientific
knowledge and the utilization of this knowledge is largely due to the
greater forces which we have become possessed of.

Disease plays such a large part in the life of man and is so closely
related to all of his activities that the changes in this period must
have exerted an influence on disease. We have already seen that within
the period we have obtained knowledge of the causes of disease and the
conditions under which these causes became operative. The mystery
which formerly enveloped disease is gone; disease is recognized as due
to conditions which for the most part are within the control of man,
and like gravity and chemical attraction it follows the operation of
definite laws. There has been developed within the period what is
known as preventive medicine, which aims rather at prevention than
cure, and the resources of prevention are capable of much greater
extension.

Have there been new conditions developed within the period, or an
increase of existing conditions which can be regarded as disease
factors and which counterbalance the results which have come from the
knowledge of prevention and cure? There has been an increase of
certain factors of immense importance in the extension of disease.
These are:

1. The increase in industrialism, involving as this does an increase
in factory life. In many ways this is a factor in disease. (_a_) By
favoring the extension of infection, particularly in such diseases as
tuberculosis. (_b_) The life indoors, and frequently with the
combination of insufficient air and space, produces a condition of
malnutrition and deficient general resistance. (_c_) The family life
is interfered with by the mothers, whose primary duty is the care of
home and children, working in factories, and the too frequent
conversion of the house into a factory. (_d_) The influence of factory
life is towards a loss of moral stamina rendering more easy of
operation the conditions of alcoholism and general immorality. How
great has been this increase in industrialism, fostered as it has been
by conditions both natural and artificially created by unwise
legislation, is shown in the figures from the last census. The number
of factory operatives increased forty per cent between 1899 and 1909
and the total population of the country in the period between 1900 and
1910 increased twenty per cent. It is probable that the future will
see an extension rather than a diminution of mass labor.

2. The increase in urban life is as conspicuous as the increase in
industrialism. In 1880, twenty-nine and five-tenths per cent of the
population was urban and seventy and five-tenths per cent was rural;
in 1910, forty-six and three-tenths per cent was urban and fifty-three
and seven-tenths was rural, the increase being most marked in cities
of over five hundred thousand inhabitants. Of the total increase in
population between 1900 and 1910, seven-tenths per cent was in the
cities and three-tenths per cent in the country. City life in itself
is not necessarily unhealthy and there are many advantages associated
with it. The conditions which have chiefly fostered it are the
immigration of people who are accustomed to community life, the
increase in factory life and the increased number of people of wealth
who seek the advantages which the city gives them. The city has always
been the favored playground for the social game. The unhealthy
conditions of city life are due to the crowding, the more uncertain
means of livelihood, the greater influence of vice and alcoholism.
Prostitution and the sexual diseases are almost the prerogatives of
the cities.

3. All means of transportation have increased and communication
between peoples has become more extended and more rapid. In the past
isolation was one of the safeguards of the people against disease.
With the increase and greater rapidity of communication there is a
tendency not only to loss of individuality in nations as expressed in
dress, customs, traditions and beliefs, but many diseases are no
longer so strictly local as formerly--pellagra, for example. Only
those diseases which are transmitted by insects which have a strictly
local habitat remain endemic, although the region of endemic
prevalence may become greatly extended, as is seen in the distribution
of sleeping sickness. Diseases of plants and of animals have become
disseminated. Any plants desirable for economic use or for beauty of
foliage and flower become generally distributed, their parasites are
removed from the regions where harmonious parasitic inter-relations
have been established, and in new regions the parasites may not find
the former restrictions to their growth. There have been many examples
of this, such as the ravages of the brown-tail and gypsy moths which
were introduced into New England and of the San Jose scale which was
introduced into California. There have been many other examples of the
almost incredible power of multiplication of an animal or plant when
taken into a new environment, removed from conditions which held it in
check, as the introduction of the mongoose into Jamaica, the rabbit
into Australia, the thistle into New South Wales and the water-plant
chara into England.

It is very difficult to say, but it seems as though there is an
increasing unevenness in the distribution of wealth, an increase in
the number of persons who live at the expense of the laboring class.
Mass labor, effective though it be, makes it easier to divert the
proceeds of labor from the laborers. The evidence of this is seen in
the increase in number and the prosperity of those pursuits which
purvey to luxury, as the automobile industry and the florists' trade
and the greatly increased scope and activity of the social game. On
the other hand, there is an increase in the number of people who are
to a greater or less extent dependent upon extraneous aid, evinced
among other ways by the increase in the asylum populations. Both these
conditions, wealth and poverty, are important disease factors.
Tuberculosis is now a disease of the proletariat chiefly. The measures
both of prevention and cure can be and are carried out by the
well-to-do, but the disease must remain where there are the conditions
of the slums. Of all the conditions favoring infant mortality poverty
comes first. In Erfurt, a small city of Germany, of one thousand
infants born in each of the different classes, there died of the
illegitimate children three hundren and fifty-two; of those of the
laboring class, three hundred and five; of those in the medium station
(official class largely), one hundred and seventy-three; of those in
higher station, eighty-nine. The same relation of infant mortality to
poverty becomes apparent when estimated in other ways. In Berlin, with
an average infant mortality of one hundred and ninety-six per
thousand, the deaths in the best districts of the city were fifty-two
and in the poorer quarters four hundred and twenty. The effect of
poverty is seen particularly in the bottle-fed infants; with natural
nursing the child of poverty has almost as good a chance as the child
of wealth. From reasons which are almost self-evident, the mortality
in illegitimate infants is almost double that of the legitimate. The
greater infant mortality in poverty is due to the more numerous
children preventing individual care, the separation of the mother from
the nursing child in consequence of the demand made upon her earning
capacity, and the decline in breast nursing. Wealth is on the whole
more advantageous from the narrow point of view of disease than is
poverty, but if we regard its influence on the race its advantages are
not so evident. Nothing can be worse for a race than that it should
die out, and wealthy families have never reproduced themselves.
Conditions always tending to destruction are a necessary part of the
environment of poverty; wealth voluntarily creates these conditions,
and chiefly by the pernicious influence of its amusements on the
young.

A new and in many respects a nobler conception of medicine has been
developed. Formerly medical practice was almost exclusively a personal
service to the sick individual, and measures looking toward the
general relief of disease and its prevention received scanty
consideration. The idea of a wider service to the city, to the state,
to the nation, to humanity rather than the personal service to the
individual, is becoming dominant in medicine. This is seen in the
establishment of laboratories by boards of health in cities and states
in which knowledge obtained by exact investigations can be made of
direct service to the people; in the medical inspection of schools and
factories; in promulgating laws directed against conditions which
affect health, in the extension of hospitals, and in divers other
ways. The idea of public service and of returning to the people in an
effective way some of the results of their labor also underlies the
large donations which have been given for the creation of special
laboratories and institutes in which, through research, greater
knowledge of disease may be obtained and made available. The
researches which have been made on the nutrition of man and the
nutritive value of different foods are of great importance, and this
knowledge has not yet begun to be applied as it should be.

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