Reading Salisbury, Part 7: The Disease Nobody Could Hear

The yeast-pot

Salisbury divides consumption into four stages, and the first one is not in the lungs at all. It is in the gut, and it can last for most of a life.

“The first, or incubative stage of consumption, is the fermentation of vegetable food, fruits, sweets and fats in the stomach and bowels,” by which “the digestive apparatus becomes a veritable ‘yeast-pot,’ and all its follicles become filled with alcohol and the sour yeasts.” The cells that line the gut, he says, are slowly paralyzed by the gas, lose their “normal selective power,” and begin to “gobble up” what they should have refused.

Then he lists what the patient feels during those years. “A gradual increase of lassitude, with a tendency to tire and get out of breath, even in ordinary labors and exertions. There is a tendency to cold feet, to palpitation of the heart, dizzy head with, often, nervous, wakeful nights. This stage may continue from one to many years, depending upon the manner of living, the drinks, exercise, and other habits.”

Tired. Winded on the stairs. Cold feet. A heart that flutters. A head that is never quite clear. Nights that will not settle. One to many years. Not one of those is a symptom a doctor in 1888 would have called disease, and not one of them is a symptom a doctor in 2026 will call disease either. They are the ordinary complaints of ordinary adults, the things a man mentions at a checkup and is told are stress, or age, or nothing. Salisbury called them the first stage of the thing that would kill him.

He is wrong about the yeast. He is not wrong that the years of feeling vaguely bad are the disease, and that by the time it has a name it is old.

Feeling better while getting worse

The first stage, he says, runs in three periods.

In the first period the fermentation is confined to the stomach, held there by a pyloric valve that has “closed with unusual force” to keep the poison out of the bowels below. The stomach is bloated and sour; the patient is uncomfortable and knows it. Then the valve itself tires and relaxes, the fermenting mass drops into the small intestine, and “in this period the patient experiences great relief in the stomach, the acidity and gases not being retained in that organ, and expresses himself as being greatly improved.”

Greatly improved. The disease has advanced one full stage, from the organ built to contain it into the organ built to absorb from it, and the patient feels better and says so. Salisbury then explains why this is the worst place to be. With the fermenting products held in the small bowel, the paralyzed lining begins to pass them into the blood, and from there to the lungs. A patient whose gut instead flushes them out in chronic diarrhoea “may survive from one to twenty years,” miserable but alive. The one who feels relieved, whose bowels are quiet, is the one whose lungs are being seeded, and who dies, in Salisbury’s telling, “usually within three years.”

The physiology is his own invention. The shape of it is not. The body has a way of adapting to an insult so that the insult stops hurting, and the adaptation is read as recovery when it is the opposite. The man whose heartburn stopped when he stopped noticing it. The drinker who no longer feels the drink. The blood sugar that comes down after a meal not because the meal was handled but because the body has started storing the excess somewhere it does not belong. Relief is not evidence. Salisbury knew that in 1867, and he knew it because he had watched men say they felt fine while he looked at their blood.

Dough

The third period, when the fermentation reaches the colon, is chronic diarrhoea, which he calls consumption of the bowels, and here he reaches for two comparisons from outside the sickroom. The disease, he says, is “represented in animals, in a marked degree, in the diarrhoea of the so-called ‘hog cholera,’ and in man in the ‘chronic diarrhoea’ of armies,” and both are “nothing more or less than a well-established yeast pot in the colon.” Then: “These discharges will ferment dough as well as will the sour yeast of the mash tub or the old yeast pot.”

He had tested it. There is no other way to write that sentence. Somewhere in the 1860s a physician took the stool of a man dying of diarrhoea, mixed it into flour and water, and watched it rise, because he wanted to know whether what he saw under the microscope would do what yeast does. It is the same man who fed six hired men beans and dissected two thousand hogs. Whatever else is said about his theory, nobody can say he did not check.

Along the way he ties two more diseases to the same pathway. If the fermenting stomach sits long enough, he says, the heart, liver, and spleen grow sluggish and “more or less paralyzed,” and when their vitality falls too far, “nature, to prevent dissolution of the elements of the organs, infiltrates fat into them, by means of which they are preserved.” Fat in the heart and the liver as a preservative, a body packing its failing organs in grease to keep them from dissolving. And if the liver’s sugar-making portion is congested, it makes “more animal sugar than the system requires,” the kidneys are called on to dump it, “and we have then the disease known as diabetes.”

Both mechanisms are wrong. Both arrive at the right destination from the same starting point, a diet of fermentable food and a sedentary life, and land on fatty heart, fatty liver, and diabetes as stations on a single line. A modern physician drawing the course of metabolic disease would draw that line, and would put those three stations on it, and would start it in the same place.

The year nobody can see

The second stage, which Salisbury calls transmission, is when the products of the gut pass into the blood. He says it lasts about a year, sometimes three, and then he says the sentence that gives Chapter XV its title: “This second stage cannot be determined by the usual physical signs, but can readily be made out, or unmistakably indicated, by careful microscopic examination of the blood.”

What he saw in that blood was corpuscles gone “softened, sticky, stringy,” fibrin filaments shortened and thickened, clots that would not hold, the whole picture taking on “a more and more (so to speak) ‘rotten’ condition.” He was looking at the blood of people who were sick, and he was describing what sick blood looks like, and some of what he describes is real and some of it is what a man sees when he already knows what he is looking for. The yeast masses he reports lodging in the capillaries were not there.

But set the yeast aside and look at what he is claiming about time. A full year, sometimes three, during which the patient has no sign a physician can find by the ordinary means, and during which the disease is doing its most consequential work. He thought the microscope could see it. He was wrong about what the microscope would show. He was right that the window existed, and that the instruments in general use were pointed at the wrong end of it.

Dying faster than living

The third stage is the tubercle itself, which he treats as “a secondary product,” a deposit around a blockage, growing by accretion until its own vitality fails and it softens and breaks down. One to three years. The fourth stage is the breaking down, and here, for the first time, his description and the disease agree completely, because he is describing what every physician of his century saw at a consumptive’s bedside: “variable, chilly feelings during the early part of the day, followed by more or less fever in the middle and after-part, and by cold, more or less profuse sweating at night.” Chills, fever, night sweats. That is tuberculosis, and nothing else in these chapters is.

Then:

“During this stage the patient is dying faster than he is living. Decay is making greater inroads than his materials suffice to repair.”

Dying faster than living. He means it as arithmetic. Every day a body is being broken down and every day it is being rebuilt, and the only question that matters is which column is larger. In the fourth stage, decay is winning. But, he says, “if at any time the digestion and assimilation so far improve that blood is made faster than it is used up, lung repair goes on more rapidly than does the breaking-down process, and the chills, fever and sweats, growing lighter by degrees, soon cease entirely.” The ledger flips. And once it has flipped, “his cure is then merely a question of time and of continuance in right doing, with soul and body, in carrying on the good work.”

Merely a question of time and of continuance in right doing. He is writing about a man coughing up pieces of his own lung, and he is saying that the moment repair outruns decay, by however little, the outcome is decided, and the rest is patience. He was wrong about how often that moment could be reached in tuberculosis; the bacillus did not care how much beef a man ate once it had the upper hand. He was right about the arithmetic, and the arithmetic is the whole of chronic disease. A body is never standing still. It is always being made or unmade a little faster than the other, and the direction is set, mostly, at the table.

The stethoscope

Chapter XV is a page long and it is an argument against the instrument every doctor carried. “In the incubative and transmissive stages of consumption, it is seldom that auscultation and percussion afford any clue to the condition of the patient. These means are only of service in throwing light upon the state of the lungs after deposits have begun to take place.”

Listening to the chest and tapping it, the two skills a nineteenth-century physician was proudest of, found consumption only in its third stage, when something was already lodged in the lung. Before that there was “a period of considerable duration, when no outward physical signs of the disease present themselves,” and Salisbury lists what the patient does present, which the stethoscope cannot hear: he “becomes readily fatigued”; the pulse is “in all cases weak”; the breathing is quick and shallow, “the patient complaining that he cannot breathe deeply enough, and hence taking frequently a long breath”; there is an ache near the heart and under the left shoulder blade, a tightness in the chest, ropy mucus in the throat, “a marked tendency to take cold on the least exposure, with cold feet and hands.”

A man sighing at his desk because he cannot get a full breath. Cold hands in a warm room. Catching every cold that goes around. These were not findings. They were complaints, the kind a doctor nods at while reaching for the stethoscope that will tell him nothing is wrong.

In 1886, two years before Salisbury published, Tolstoy published a short novel about exactly this. Ivan Ilyich, a successful judge, begins with a strange taste in his mouth and a vague discomfort in his left side, the sort of thing a man mentions and is told is nothing. The celebrated doctor examines him, taps and listens, and delivers a learned opinion about whether the trouble is the appendix or a floating kidney, and Ivan Ilyich realizes, lying there, that the only question he cares about, whether his life is in danger, is one the doctor regards as beside the point. The doctor is weighing organs. The patient is dying. Neither of them can hear it.

Salisbury’s answer was the microscope, “our unerring guide during these two prior stages.” It was the wrong instrument; what he saw in the blood was not what was killing his patients. But his complaint about the stethoscope was exactly right and has not aged a day. The standard tools detect the disease when it is established and miss it when it is forming, and the years in between are filled with symptoms that are real, that the patient reports, and that the tools cannot register, so they are called nothing.

That is still the arrangement. The ordinary blood panel finds diabetes when the sugar has been high for years and calls everything before that normal, while the fatigue and the cold hands and the two-in-the-afternoon fog and the waist that will not stop growing go on being complaints rather than findings. The instruments that would see it earlier exist, as Salisbury’s microscope existed, and they are not the ones in general use. The patient, meanwhile, knows. He has known for years. He simply has nothing a doctor can tap.

What survives

Nearly all of the mechanism in these five chapters is wrong. The yeast does not migrate, the valves are not paralyzed by gas, the tubercle is not a plug of spores, and the microscope did not show what he thought it showed. Tuberculosis has its own stages, latent and active, and they are not his.

What he got right is the shape of a chronic disease, and he got it right because he was not really looking at tuberculosis. He was looking at the slow decline of people who ate badly and sat still, and he mapped that decline onto the disease that happened to kill them. The map is wrong for the bacillus and right for the thing that fills the clinics now. A long first stage of ordinary complaints, lasting years. A middle stage where the patient feels better and is worse. Fat packed into the organs, sugar spilling into the urine, as stations on one line. A long window during which the usual instruments see nothing. And then a visible disease that everyone agrees is a disease, which is treated as if it had begun that morning.

Underneath all of it, the ledger. A body is being made or unmade every day, and the balance can be read, if a person is willing to read it, long before any instrument confirms it. The stairs that got harder. The breath that got shorter. The cold feet. Salisbury’s patients had those signs for years, and the stethoscope said they were well.

The arithmetic runs both ways. The same slow balance that takes a man down over twenty years will bring him back, more slowly than he wants and faster than he fears, from the day the column of repair pulls ahead of the column of decay. After that, in the old doctor’s words, it is merely a question of time and of continuance in right doing. Nobody needs a microscope to know which way the ledger is running. The stairs will tell him.

Read along

The book is in the public domain, and the Internet Archive has the complete scan free of charge, in PDF, EPUB, and plain text:

The Relation of Alimentation and Disease (Internet Archive)

Part 8 takes Chapters XVI through XIX, consumption of the bowels: the chronic diarrhoea that killed more soldiers than bullets, what Salisbury found when he put their stool under the microscope, and what he found when he opened the bodies.