TUBERCULOSIS, A SCOTCHED SNAKE
II
Closely allied to the discovery that sunlight and fresh air are fatal to
the microörganisms of tuberculosis came the consoling fact that these
bacilli, though most horribly ubiquitous and apparently infesting both
the heavens above and the earth beneath, had neither wings nor legs, and
were absolutely incapable of propelling themselves a fraction of an
inch. They do not move--_they have to be carried_. More than this, like
all other disease-germs, while incredibly tiny and infinitesimal, they
have a definite weight of their own, and are subject to the law of
gravity. They do not flit about hither and thither in the atmosphere,
thistledown fashion, but rapidly fall to the floor of whatever room or
receptacle they may be thrown in. And the problem of their transference
is not that of direct carrying from one victim to the next, but the
intermediate one of infected materials, such as are usually associated
with visible dust or dirt. In short, keep dust or dirt from the floor,
out of our food, away from our fingers or clothing or anything that can
be brought to or near the mouth, and you will practically have abolished
the possibility of the transference of tuberculosis. The consumptive
himself is not a direct source of danger. It is only his filthy or
unsanitary surroundings. Put a consumptive, who is careful of his sputum
and cleanly in his habits, in a well-lighted, well-ventilated room, or,
better still, out of doors, and there will be exceedingly little danger
of any other member of his family or of those in the house with him
contracting the disease. Wherever there is dirt or dust there is danger,
and there almost only. Thorough and effective house-reform--not merely
in tenements, alas! but in myriads of private houses as well--would
abolish two-thirds of the spread of tuberculosis.
It is not necessary to isolate every consumptive in order to stop the
spread of the disease. All that is requisite is to prevent the bacilli
in his sputum from reaching the floor or the walls, to have both the
latter well lighted and aired, and, if possible, exposed to direct
sunlight at some time during the day, and to see that dust from the
floor is not raised in clouds by dry sweeping so as to be inhaled into
the lungs or settle upon food, fingers, or clothing, and that children
be not allowed to play upon such floors as may be even possibly
contaminated. These precautions, combined with the five-to-one resisting
power of the healthy human organism, will render the risk of
transmission of the disease an exceedingly small one. To what
infinitesimal proportions this risk can be reduced by intelligent and
strict sanitation is illustrated by the fact, already alluded to, of the
almost complete germ-freeness of the dust from walls and floors of
sanitorium cottages, and by the even more convincing and conclusive
practical result, that scarcely a single case is on record of the
transmission of this disease to a nurse, a physician, or a servant, or
other employee in an institution for its cure.
There is absolutely no rational basis for this panic-stricken dread of
an intelligent, cleanly consumptive, or for the cruel tendency to make
him an outcast and raise the cry of the leper against him: "Unclean!
Unclean!"
It cannot be too strongly emphasized that consumption is transmitted _by
way of the floor_; and if this relay-station be kept sterile there is
little danger of its transmission by other means.
Practically all that is needed to break this link is the absolute
suppression of what is universally and overwhelmingly regarded as not
merely an unsanitary and indecent, but a filthy, vulgar, and disgusting
habit--promiscuous expectoration. There is nothing new or unnatural in
this repression, this _tabu_ on expectoration. In fact, we are already
provided with an instinct to back it. In every race, in every age, in
every grade of civilization, the human saliva has been regarded as the
most disgusting, the most dangerous and repulsive of substances, and the
act of spitting as the last and deepest sign of contempt and hatred; and
if directed toward an individual, the deadliest and most unbearable
insult, which can be wiped out only by blood. Primitive literature and
legend are full of stories of the poisonousness of human saliva and the
deadliness of the human bite. It was the "bugs" in it that did it. It is
most interesting to see how science has finally, thousands of years
afterward, shown the substantial basis of, and gone far to justify, this
instinctive horror and loathing.
Not merely are the fluids of the human mouth liable to contain the
tubercle bacillus, and that of diphtheria, of pneumonia, and half a
dozen other definite disorders, but they are in perfectly healthy
individuals, especially where the teeth are in poor condition, simply
swarming with millions of bacteria of every sort, some of them harmless,
others capable of setting up various forms of suppuration and septic
inflammation if introduced into a wound, or even if taken into the
stomach. Even if there were no such disease as tuberculosis a campaign
to stamp out promiscuous expectoration would be well worth all it cost.
Of course, as a counsel of perfection, the ideal procedure would be
promptly to remove each consumptive, as soon as discovered, from his
house and place him in a public sanatorium, provided by the state, for
the sake of removing him from the conditions which have produced his
disease, of placing him under those conditions which alone can offer a
hopeful prospect of cure, and of preventing the further infection of his
surroundings. The only valid objections to such a plan are those of the
expense, which, of course, would be very great. It would be not merely
best, but kindest, for the consumptive himself, for his immediate
family, and for the community. And enormous as the expense would be,
when we have become properly aroused and awake to the huge and almost
incredible burden which this disease, with its one hundred and fifty
thousand deaths a year, is now imposing upon the United States,--five
times as great as that of war or standing army in the most military-mad
state in Christendom,--the community will ultimately assume this
expense. So long, however, as our motto inclines to remain, "Millions
for cure, but not one cent for prevention," we shall dodge this issue.
There can be no question but that each state and each municipality of
more than ten thousand inhabitants ought to provide an open-air camp or
colony of sufficient capacity to receive all those who are willing to
take the cure but unable to meet the expense of a private institution;
and, also, some institution of adequate size, to which could be sent, by
process of law, all those consumptives who, either through perversity,
or the weakness and wretchedness due to their disease, or the apathy of
approaching dissolution, fail or are unable to take proper precautions.
When we remember that the careful investigations of the various
dispensaries for the treatment of tuberculosis in our larger cities, New
York, Boston, Cleveland, report that on an average twenty to thirty per
cent of all children living in the same room or apartment with a
consumptive member of their family are found to show some form of
tuberculosis, it will be seen how well worth while, from every point of
view, this provision for the removal and sanatorium treatment of the
poorer class of these unfortunates would be. These dispensaries now
have, as a most important part of their campaign against the disease,
one or more visiting nurses, who, whenever a patient with tuberculosis
is brought into the dispensary, visit him in his home, show him how to
ventilate and light his rooms as well as may be, give practical
demonstrations of the methods of preventing the spread of the disease,
advise him as to his food, and see that he is supplied with adequate
amounts of milk and eggs, and, finally, round up all the children of the
family and any adults who are in a suspicious condition of health, and
bring them to the dispensary for examination. Distressing as are these
findings, reaching in some cases as high as fifty and sixty per cent of
the children, they have already saved hundreds of children, and
prevented hundreds of others from growing up crippled or handicapped.
It must be remembered that the tubercle bacillus causes not merely
disease of the lungs in children but also a large majority of the
crippling diseases of the bones, joints, and spine, together with the
whole group of strumous or scrofulous disorders, and a large group of
intestinal diseases and of brain lesions, resulting in convulsions,
paralysis, hydrocephalus, and death. The battle-ground of the future
against tuberculosis is the home.
We speak of the churchyard as "haunted," and we recoil in horror from
the leper-house or the cholera-camp. Yet the deadliest known hotbed of
horrors, the spawning ground of more deaths than cholera, smallpox,
yellow fever, and the bubonic plague combined, is the dirty floor of the
dark, unventilated living-room, whether in city tenement or village
cottage, where children crawl and their elders spit.
It is scarcely to the credit of our species that for convincing, actual
demonstrations of what can be done toward stamping out tuberculosis, by
measures directed against the bacillus alone, we are obliged to turn to
the lower animals. By a humiliating paradox we are never quite able to
put ourselves under those conditions which we know to be ideal from a
sanitary point of view. There are too many prejudices, too many vested
interests, too many considerations of expense to be reckoned with. But
with the lower animals that come under our care we have a clear field,
free from obstruction by either our own prejudices or those of others.
In this realm the stamping out of tuberculosis is not merely a rosy
dream of the future but an accomplished fact, in some quarters even an
old story. Two illustrations will suffice, one among domestic animals,
the other among wild animals in captivity. The first is among pure-bred
dairy cattle, the pedigreed Jerseys and Holsteins. No sooner did the
discovery of the bacillus provide us with a means of identification,
than the well-known "_perlsucht_" of the Germans, or "grapes" of the
English veterinarians--both names being derived from the curious rounded
masses or nodules of exudate found in the pleural cavity and the
peritoneum (around the lungs and the bowels), and supposed to resemble
pearls and grapes respectively--were identified as tuberculosis, and
cows were found very widely infected with it. This unfortunately still
remains the case with the large mass of dairy cattle. But certain of the
more intelligent breeders owning valuable cattle proceeded to take steps
to protect them.
The first step was to test their cows with tuberculin, promptly weeding
out and isolating all those that reacted to the disease. It was at first
thought necessary to slaughter all these at once. But it was later found
that, if they were completely isolated and prevented from communicating
the disease to others, this extreme measure was necessary only with
those extensively diseased. The others could be kept alive, and if their
calves were promptly removed as soon as born, and fed only upon
sterilized or perfectly healthy milk, they would be free from the
disease. And thus the breeding-life of a particularly valuable and
high-bred animal might be prolonged for a number of years. They must,
however, be kept in separate buildings and fields, and preferably upon a
separate farm from the rest of the herd.
Those cows found healthy were given the best of care, including a marked
diminution of the amount of housing or confinement in barns, and were
again tested at intervals of six months, several times, to weed out any
others which might still have the infection in their systems. In a short
time all signs of the disease disappeared, and no other cases developed
in these herds unless fresh infection was introduced from without. To
guard against this, each farm established a quarantine station, where
all new-bought animals, after having been tested with tuberculin and
shown to be free from reaction, are kept for a period of at least a
year, for careful observation and study, before being allowed to mix
with the rest of the herd. It is now a common requirement among
intelligent breeders of pedigreed cattle to demand, as a formal
condition of sale, their submission to the tuberculin test, or the
certificate of a competent veterinarian that the animal has been so
tested without reacting. Protected herds have now been in existence
under these conditions, notably in Denmark, where the method was first
reduced to a system under the able leadership of Professor Bang, of
Copenhagen, for ten years with scarcely a single case of tuberculosis
developing. Only a fraction of one per cent of calves from the most
diseased mothers are born diseased.
Not only is the method spreading rapidly among the more intelligent
class of breeders, but many progressive countries of Europe and states
of our Union require the passing of the tuberculin test as a requisite
to the admission within their borders of cattle intended for breeding
purposes. So that, while the problem is still an enormous one, it is now
confidently believed that complete eradication of bovine tuberculosis is
only a question of time.
The other instance furnishes a much more crucial test, as it is carried
out upon wild animals under the unfavorable conditions of captivity in a
strange climate, like our slum-dwellers from sunny Italy, and comes home
to us more closely in many respects, inasmuch as it is concerned with
our nearest animal relatives on the biological side--monkeys and apes,
in zoölogical gardens.
Tuberculosis is a perfectly frightful scourge to these unfortunate
captives, causing not infrequently thirty, fifty, and even sixty per
cent of the deaths. This, however, is only in keeping with their
frightful general mortality. The collection of monkeys in the London
Zoo, for instance, some fifteen years ago, was absolutely exterminated
by disease and started over afresh _every three years_, a death-rate of
thirty-five per cent per annum as compared with our human rate of about
two per cent per annum. Here, it would seem, was an instance where there
was little need to call in the bacillus. Brought from a tropical climate
to one of raw, damp fog and smoke, from the freedom of the air-roads
through the tree-tops to the confinement of dismal and often dirty cages
in a stuffy, overheated house, condemned to a diet which at best could
be but a feeble and far-distant imitation of their natural food, it
seemed little wonder that they "jes' natcherly pined away an' died."
But let the results speak. A thorough system of quarantine was enforced,
beginning with one of the Vienna gardens, and finally reaching one of
its most brilliant and successful exemplifications in our own New York
Zoölogical Gardens in the Bronx. All animals purchased or donated were
tested with tuberculin, and those that reacted were either painlessly
destroyed or disposed of. Those which appeared to be immune were kept in
a thoroughly healthy, sanitary quarantine station for six months or a
year, and again tested by tuberculin before being introduced into the
cages. The original stock of monkeys was treated in the same manner or
else destroyed completely, and the houses and cages thoroughly cleaned
and sterilized or new ones constructed. Keepers employed in the
monkey-house were carefully tested for signs of tuberculosis, and
rejected or excluded if any appeared. Signs were posted forbidding any
expectoration or feeding of the animals (which latter is often done
with nuts or fruit which had been cracked or bitten before being handed
to the monkeys) by the general public, and these rules were strictly
enforced.
At the same time the houses were thoroughly ventilated and exposed to
sunlight as much as possible, and the animals were turned out into open
air cages whenever the weather would possibly permit. As a result the
mortality from tuberculosis promptly sank from thirty per cent to five
or six per cent. In our Bronx Zoo, for instance, it has become decidedly
rare as a cause of death in monkeys, no case having occurred in the
monkey-house for eighteen months past. What is even more gratifying, the
general mortality declined also, though in less proportion, so that,
instead of losing twenty-five to thirty per cent of the animals in the
house every year, a mortality of ten to fifteen per cent is now
considered large.
And to think that we might achieve the same results in our own species
if we would only treat ourselves as well as we do our monkey captives!
To "make a monkey of one's self" might have its advantages from a
sanitary point of view.
"But this method," some one will remind us, "would silence only a part
of the enemy's infection batteries." Even supposing that we could
prevent the spread of the disease from human sources, what of the animal
consumptives and their deadly bacilli? If the milk that we drink, and
the beef, pork, and poultry that we eat, are liable to convey the
infection, what hope have we of ever stopping the invasion?
The question is a serious one. But here again a thorough and careful
study of the enemy's position has shown the danger to be far less than
it appeared at first sight. Even bacilli have what the French call "the
defects of their virtues." Their astonishing and most disquieting powers
of adjustment, of accommodation to the surroundings in which they find
themselves, namely, the tissues and body-fluids of some particular host
whom they attack, bring certain limitations with them. Just in so far as
they have adjusted themselves to live in and overcome the opposition of
the body-tissues of a certain species of animals, _just to that degree
they have incapacitated themselves to live in the tissues of any other
species_.
Some of the most interesting and far-reachingly important work that has
been done in the bacteriology of tuberculosis of late years has
concerned itself with the changes that have taken place in different
varieties and strains of tubercle bacilli as the result of adjusting
themselves to particular environments. The subject is so enormous that
only the crudest outlines can be given here, and so new that it is
impossible to announce any positive conclusions. But these appear to be
the dominant tendencies of thought in the field so far.
Though nearly all domestic animals and birds, and a majority of wild
animals under captivity, are subject to the attack of tuberculosis,
practically all the infections hitherto studied are caused by one of
three great varieties or species of the tubercle bacillus: the _human_,
infesting our own species; the _bovine_, attacking cattle; and the
_avian_, inhabiting the tissues of birds, especially the domestic fowl.
These three varieties or species so closely resemble one another that
they were at one time regarded as identical, and we can well remember
the wave of dismay which swept over the medical world when Robert Koch
announced that the "_perlsucht_" of cattle was a genuine and
unquestioned tuberculosis due to an unmistakable tubercle bacillus. But
as these varieties were thoroughly and carefully studied, it was soon
found that they presented definite marks of differentiation, until now
they are universally admitted to be distinct varieties, each with its
own life peculiarities, and, according to some authorities, even
distinct species.
"But," we fancy we hear some one inquire impatiently, "what do those
academic, technical distinctions matter to us? Whether the avian
tuberculosis germ is a variety or a true species may be left to the
taxonomists, but it is of no earthly importance to us."
On the contrary, it is of the greatest importance. For the distinctive
feature about a particular species of parasite is that it will live and
flourish where another species will die, and, vice versa, _will die in
surroundings where its sister species might live and thrive_.
One of the first differences found to exist among these three types of
bacteria was the extraordinary variation in their power of attacking
different animals. For instance, while the guinea-pig and the rabbit
could be readily inoculated with _human_ bacilli, they could only be
infected with difficulty by cultures of the _bovine_ bacillus; while the
only animal that could be inoculated at all with the _avian_ or bird
bacillus was the rabbit, and he only occasionally. In fact,
bacteriologists soon came to the consoling conclusion that the _avian_
bacillus might be practically disregarded as a source of danger to human
beings, so widely different were the conditions in their moist and
moderately warm tissues to those of the dry and superheated tissues of
the bird to which it had adjusted itself for so many generations.
And next came the bold pronunciamento of no less an authority than Koch
himself, that the bovine bacillus also was so feebly infective to human
beings that it might be practically disregarded as a source of danger.
This promptly split the bacteriologists of the world into two opposing
camps, and started a warfare which is still being waged with great
vigor. As the question is still under hot dispute by even the highest
authorities, it is, of course, impossible to pronounce any definite
conclusions. But the net result to date appears to be that while Koch
made a serious error of judgment in declaring that meat and milk as a
source of danger to human beings of tuberculosis might be disregarded,
yet, for practical purposes, his position is, in the main, correct: the
actual danger from the bovine bacillus to human beings is relatively
small.
There was nothing whatever improbable, in the first place, in the
correctness of Koch's position.
It is one of the few consoling facts, well known to all students of
comparative pathology or the diseases of the different species of
animals, how peculiarly specialized they are in the choice of their
diseases, or, perhaps, to put it more accurately, how particular and
restricted disease-germs are in their choice of a host. For instance,
out of twenty-eight actually infectious diseases which are most common
among the domestic animals and man, other than tuberculosis, only
one--_rabies_--is readily communicable to more than three species; only
three--_anthrax_, _tetanus_, and _foot-and-mouth disease_--are
communicable to two species; while the remainder are almost absolutely
confined to one species, even though this be thrown into closest contact
with half a dozen others.
Again, we have half a dozen similar instances in the case of
tuberculosis itself. The horse and the sheep, for instance, are both
most intimately associated with cattle, pastured in the same fields, fed
upon the same food, and yet tuberculosis is almost unknown in sheep and
decidedly uncommon in horses, and when it does occur in them is from a
human source. The goat is almost equally immune from both human and
_bovine_ forms, while the cat and the dog, although developing the
infection with a low degree of frequency, almost invariably trace that
infection to a human source.
There is, therefore, no _a priori_ reason whatever why we should be any
more susceptible to bovine tuberculosis than the remainder of the
domestic animals. It is only fair to say, however, that the animal whose
diet--and appetite--most closely resembles ours, the hog, is quite
fairly susceptible to bovine tuberculosis if fed upon the milk or meat
of tuberculous cattle.
Next came the particularly consoling fact that although nothing has been
more striking than the great increase in the amounts of meat and milk
consumed by the mass of the community during our last twenty years'
progress in civilization, this has been accompanied not by any increase
of tuberculosis, but by a _diminution of from thirty-five to forty-five
per cent_. The allegation so frequently made that there has been an
increase in the amount of infantile tuberculosis has been shown, upon
careful investigation by Shennan of Edinburgh, Guthrie of London, Kossel
in Germany, Comby in France, Bovaird in New York, and others, to be
practically without foundation.
Then, while repetitions of Koch's experiment, upon which his
announcement was based, of inoculating calves and young cattle with
_human_ bacilli have proved that a certain number of them can be, under
appropriate circumstances, made to develop tuberculosis, that number has
never been a large percentage of the animals tested, and in many cases
the infection has been a local one, or of a mild type, which has
resulted in recovery. Lastly, while a number of bacilli, with _bovine_
culture and other characteristics, have been recovered from the bodies
of children dying of tuberculosis, and these bacilli have proved
virulent to calves when injected into them, yet, as a matter of
historical fact, the actual number of instances in which children or
other human beings have been definitely proved to have contracted the
disease from the milk of a tuberculous cow is still exceedingly and
encouragingly small. A careful study of the entire literature of the
past twenty years, some three years ago, revealed _only thirty-seven
cases_; and of these thirty-seven Koch's careful investigations have
since disproved the validity of nine.
On the other hand, it is anything but safe to accept Koch's practical
dictum and neglect the meat and milk of cattle as a source of danger in
tuberculosis. First, because the degree of our immunity against the
bovine bacilli is still far from settled; and, second, because, while
bacteriologists are fairly agreed that the _avian_, the _bovine_, and
the _human_ represent three distinct and different variations, if not
species, of the bacillus, they are almost equally agreed that they are
probably the descendants of one common species, which may possibly be a
bacillus commonly found upon meadow grasses, particularly the well-known
timothy, and hence very frequently in the excreta of cattle, and known
as the _grass bacillus_ or _dung bacillus_ of M[oe]ller. This bacillus
has all the staining, morphological, and even growth characteristics of
the tubercle bacillus except that it produces only local irritation and
little nodular masses, if injected into animals. Our knowledge of its
existence is, however, of great practical importance, inasmuch as it
warned us that in our earlier studies of the bacilli contained in milk
and butter we have been mistaking this organism for a genuine tubercle
bacillus. As a consequence, of late years our tests for the presence of
tubercle bacilli in milk are made not only by searching for the organism
with the microscope, but also by injecting the centrifugated sediment of
the infected milk into guinea pigs, to see if it proves infectious. Many
of our earlier statements as to the presence of tubercle bacilli in milk
and butter are now invalidated on this account.
Not only are the three varieties of tubercle bacilli probably of common
origin, but they may, under certain peculiar conditions, be transformed
into one another, or, at least, enabled to live under the conditions
favorable to one another. This was shown nearly fifteen years ago by the
ingenious experiments of Nocard, the great veterinary pathologist. He
took a culture of bovine bacilli, which were entirely harmless to fowls,
and, inclosing them in a collodion capsule, inserted them into the
peritoneal cavity of a hen. The collodion capsule permitted the fluids
of the body to enter and provide food for the bacilli, but prevented the
admission of the leucocytes to attack and destroy them. After several
weeks the capsule was removed, the bacilli found still alive, and
transferred to another capsule in another fowl. When this process had
been repeated some five or six times, the last generation of bacilli was
injected into another fowl, which promptly developed tuberculosis,
showing that by gradually exposing the bacilli for successive
generations to the high temperature of the bird's body (from five to
fifteen degrees above that of the mammal), they had become acclimated,
as it were, and capable of developing. So that it is certainly quite
conceivable that bovine bacilli introduced in milk or meat might manage
to find a haven of refuge or lodgment in some out-of-the-way gland or
tissue of the human body, and there avoid destruction for a sufficiently
long time to become acclimated and later infect the entire system.
This is the method which several leaders in bacteriology, including
Behring (of antitoxin fame), believe to be the principal source and
method of infection of the human species. The large majority, however,
of bacteriologists and clinicians are of the opinion that ninety per
cent of all cases of human tuberculosis are contracted from some human
source. So that, while we should on no account slacken our fight against
tuberculosis in either cattle or birds, and should encourage in every
way veterinarians and breeders to aim for its total destruction,--a
consummation which would be well worth all it would cost them, purely
upon economic grounds, just as the extermination of human tuberculosis
would be to the human race,--yet we need not bear the burden of feeling
that the odds against us in the fight for the salvation of our own
species are so enormous as they would be, had we no natural protection
against infection from animals and birds.
The more carefully we study all causes of tuberculosis in children, the
larger and larger percentage of them do we find to be clearly traceable
to infection from some member of the family or household. In Berlin, for
instance, Kayserling reports that seventy per cent of all cases
discovered can be traced to direct infection from some previous human
case.
Lastly, what of the left wing of our army of extermination, composed of
those light-horse auxiliaries--the general progress and new developments
of civilization, and the net results upon the individual of the
experiences of his ancestors, which we designate by the term "heredity"?
For many years we were in serious doubt how far we could depend upon the
loyalty of this group of auxiliaries, and many of the faint-hearted
among us were inclined to regard their sympathies as really against us
rather than with us, and prepared to see them desert to the enemy at any
time. It was pointed out, as of great apparent weight, that consumption
was decidedly and emphatically a disease of civilization; that it was
born of the tendency of men to gather themselves into clans and nations
and crowd themselves into villages and those hives of industry called
cities; that the percentage of deaths from tuberculosis in any community
of a nation or any ward of a city was high in direct proportion to the
density of its population; and that the whole tendency of civilization
was to increase this concentration, this congestion of ground space,
this piling of room upon room, of story upon story. How could we
possibly, in reason, expect that the influences which had caused the
disease could help us to cure it?
But the improbable has already happened. Never has there been a more
rapid and extraordinary growth of our great cities as contrasted with
our rural districts, never has there been a greater concentration of
population in restricted areas than during the past thirty-five years.
And yet, the prevalence of tuberculosis in that time, in all civilized
countries of the earth, has shown not only no increase, _but a decrease
of from thirty-five to fifty per cent_. To-day the world power which has
the largest percentage of its inhabitants gathered within the limits of
its great cities, England, has the lowest death-rate in the civilized
world from tuberculosis, although closely pressed within the last few
years by the United States, whose percentage of urban population is
almost equally large, while England's sister island, Ireland, with one
of the highest percentages of rural and the lowest of urban population,
has one of the highest death-rates from tuberculosis, and one which is,
unfortunately, increasing.
The real cure for the evils of civilization would appear to be _more
civilization_, or, better, perhaps, _higher_ civilization. Nor are these
exceptional instances. Take practically any city, state, or province in
the civilized world, which has had an adequate system of recording all
births and deaths for more than thirty years, and you will find a
decrease in the percentage of deaths from tuberculosis in that time of
from twenty to forty per cent. The city of New York's death-roll, for
instance, from tuberculosis, per one thousand living, is some
thirty-five per cent less than it was thirty years ago. So that our
fight against the disease is beginning to bear fruit already. As Osler
puts it, we run barely half the risk of dying of tuberculosis that our
parents did and barely one-fourth of that of our grandparents.
But this gratifying improvement goes deeper, and is even more
significant than this. It is, of course, only natural to expect that our
vigorous fight against the spread of the infection of the disease would
give us definite results. But the interesting feature of the situation
is that this diminution in England and in Germany, for instance, began
not merely twenty, but thirty, forty, even fifty years ago--two decades
before we even knew that tuberculosis was an infectious disease with a
contagion that could be fought.
In the case of England, for instance, we have the, at first sight,
anomalous and even improbable fact that the rate of decline in the
death-rate from tuberculosis for the twenty years preceding the
discovery of Koch's bacillus was almost as great as it has been in the
twenty years since. In other words, the general tendency, born of
civilization, toward sanitary reform, better housing, better drainage,
higher wages and consequently more abundant food, rigid inspection of
food materials, factory laws, etc., is of itself fighting against and
diminishing the prevalence of the "great white plague" by improving the
resisting power and building up the health of the individual.
Civilization is curing its own ills.
It must be remembered that vital statistics, showing the decrease of a
given disease within the past forty or fifty years, probably represent
not merely a real decrease of the amount indicated by the figures but an
even greater one in fact; because each succeeding decade, as our
knowledge of disease and the perfection of our statistical machinery
improves and increases, is sure to show a prompter recognition and a
more thorough and complete reporting of all cases of the disease
occurring. Statistics, for instance, showing a moderate apparent rate of
_increase_ of a disease within the last thirty years are looked upon by
statisticians as really indicating that it is at a standstill. It is
almost certain that at least from ten to twenty per cent more of the
cases actually occurring will be recognized during life and reported
after death than was possible with our more limited knowledge and less
effective methods of registration thirty years ago. So we need not
hesitate to encourage ourselves to renewed effort by the reflection that
we are enlisted in a winning campaign, one in which the battle-line is
already making steady and even rapid progress, and which can have only
one termination so long as we retain our courage and our common-sense.
This decline of the tuberculosis death-rate is, of course, only a part
of the general improvement of physique which is taking place under
civilization. If we could only get out from under the influence of the
"good old times" obsession and open our eyes to see what is going on
about us! There is nothing mysterious about it. The soundest of physical
grounds for improving health can be seen on every hand. We point with
horror, and rightly, to the slum tenement house, but forget that it is a
more sanitary human habitation than even the houses of the nobility in
the Elizabethan age. We become almost hysterical over the prospect that
the very fibre of the race is to be rotted by the adulteration of our
food-supply, by oleomargarine in the butter, by boric acid in our canned
meats, by glucose in our sugar, and aniline dyes in our candies, but
forget that all these things represent extravagant luxuries unheard of
upon the tables of any but the nobility until within the past two
hundred, and in some cases, one hundred, years. Up to three hundred
years ago even the most highly civilized countries of Europe were
subject to periodic attacks of famine; our armies and navies were swept
and decimated with scurvy, from bad and rotten food-supplies; almost
every winter saw epidemics breaking out from the use of half-putrid
salted and cured foods; only forty years ago, a careful investigation of
one of our most conservative sociologists led him to the conclusion
that in Great Britain _thirty per cent of the population never in all
their lives had quite as much as they could eat_, and for five months
out of the year were never comfortably warm. The invention of steam,
with its swift and cheap transportation of food-supplies, putting every
part of the earth under tribute for our tables, meat every day instead
of once a week for the workingman, and the introduction of sugar in
cheap and abundant form, with the development of the dietary in fruits
and cereals which this has made possible, have done more to improve the
resisting power and build up the physique of the mass of the population
in our civilized communities, than ten centuries of congestion and
nerve-worry could do to break it down.
We shake our heads, and prate fatuously that "there were giants in those
days," ignorant of the thoroughly attested fact, that the average
stature of the European races has increased some four inches since the
days of the Crusaders, as shown by the fact that the common British
soldier of to-day--Mr. Kipling's renowned "Tommy Atkins," who is looked
upon by the classes above him in the social scale as a short, undersized
sort of person--can neither fit his chest and shoulders into their
armor, get his hands comfortably on the hilts of their famous two-handed
swords, nor even lie down in their coffins.
We are at last coming to acknowledge with our lips, although we scarcely
dare yet to believe it in our heart of hearts, that not merely the
death-rate from tuberculosis, but the general death-rate from all causes
in civilized communities, is steadily and constantly declining; that
the average longevity has increased nearly ten years within the memory
of most of us, chiefly by the enormous reduction in the mortality from
infant diseases; and that, though the number of individuals in the
community who attain a great or notable age is possibly not increasing,
the percentage of those who live out their full, active life, play their
man's or woman's part in the world, and leave a group of properly fed,
vigorous, well-trained, and educated children behind them to carry on
the work of the race, is far greater than ever before. Even in our
much-denounced industrial conditions, made possible by the discovery of
steam with its machinery and transportation, the gain has far exceeded
the loss. While machinery has made the laborer's task more monotonous
and more confining, the net result has been that it has shortened his
hours and increased his efficiency.
Even more important, it has increased his intelligence by demanding and
furnishing a premium for higher degrees of it. Naturally, one of the
first uses which he has made of his increased intelligence has been to
demand better wages and to combine for the enforcement of his demands.
The premium placed upon intelligence has led both the broader-minded,
more progressive, and more humane among employers, and the more
intelligent among employees, to recognize the commercial value of
health, and of sanitary surroundings, comfort, and healthy recreations,
as a means of promoting this. The combined results of these forces are
seen in the incontestable, living fact that the death-rate from
tuberculosis among intelligent artisans and in well-regulated factory
suburbs is already below that of many classes of outdoor and even farm
laborers, whose day is from twelve to fourteen hours, and whose children
are worked, and often overworked, from the time that they can fairly
walk alone, with as disastrous and stunting results as can be found in
any mine or factory. Child-labor is one of the oldest of our racial
evils, instead of, as we often imagine, the newest.
All over the civilized world to-day the average general death-rate of
each city, slums included, is now below that of many rural districts in
the same country. If I were to be asked to name the one factor which had
done more than any other to check the spread and diminish the death-rate
from tuberculosis I should unhesitatingly say, the _marked increase of
wages among the great producing masses of the country_, with the
consequent increased abundance of food, better houses, better sanitary
surroundings, and last, but not least, shorter hours of labor.
_Underfeeding and overwork are responsible for more deaths from
tuberculosis than any other ten factors._ Rest and abundant feeding are
the only known means for its cure.
This is one of the reasons why the medical profession has abandoned all
thought of endeavoring to fight the disease single-handed, and is
striving and straining every nerve to enlist the whole community in the
fight. Its burden rests, not upon the unfortunate individual who has
become tuberculous, but _upon the community_ which, by its ignorance,
its selfishness, and its greed, has done much to make him so. What
civilization has _caused_ it is under the most solemn obligation to
_cure_.
* * * * *
One more brigade of irregular troops on the extreme left remains to be
briefly reviewed, and that is those forces resulting from the successive
exposure of generations to the physical influences of civilization,
including the infectious diseases. For years we never dreamed of even
attempting to raise any levies among these border tribes of more than
doubtful loyalty. Indeed, they were supposed to be our open enemies.
When we first attempted to take a world-view of tuberculosis, the first
great fact that stood out plainly was that it was emphatically a disease
of the walled town and the city; that the savage and the nomad barbarian
were practically free from it; that range cattle and barnyard fowls
seldom fell victims to it, while their housed and confined cousins in
the dairy barn and the breeding-pens suffered frightfully. It was one of
our commonplace sayings that we must "get back to nature," get away from
the walled city into the open country, revert from the conditions of
civilization in a considerable degree to those of barbarism, in order to
escape. While, as for heredity, its influence was almost dead against
us. How could a race be exposed to a disease like tuberculosis,
generation after generation, without having its vital resistance
impaired?
But a marked and cheering change has come over our attitude to this wing
of the battle of life. So far from regarding it as in any sense
necessary to revert to barbarism, still less to savagery, for either
the prevention or the cure of disease, we have discovered by the most
convincing, practical experience, that we can, in the first place, with
the assistance of the locomotive and trolley, combined with modern
building skill and sanitary knowledge, put even our city-dwellers under
conditions, in both home and workshop, which will render them far less
likely to contract tuberculosis than if they were in a peasant's cottage
or _the average farmhouse or merchant's house_ of a hundred years ago,
to say nothing of the cave, the dugout, or the hut of the savage.
In the second place, instead of simply "going back to nature" and living
in brush-shelters on what we can catch or shoot, it takes _all the
resources of civilization_ to place our open-air patients in the ideal
conditions for their recovery. Let any consumptive be reckless enough to
"go back to nature," unencircled by the strong arm of civilized
intelligence and power, and unprotected by her sanitary shield, and
nature will kill him three times out of five. There could not be a more
dangerous delusion than the all-too-common one--that all that is
necessary for the cure of consumption is to turn the victim loose among
the elements, even in the mildest and most favorable of climates.
He must be fed upon the most abundant and nutritious of foods, even the
simplest being milk of a richness which is given by no kind of wild
cattle, and which, indeed, only the most carefully bred and highly
civilized strains of domestic cattle are capable of producing; eggs such
as are laid by no wild bird or by any but the most highly specialized
of domestic poultry at the season of the year when they are most
required; steaks and chops, hams and sides of bacon, sugar and fruits
and nuts, which simply _are not produced anywhere outside of
civilization_, and often only in the most intelligent and progressive
sections of civilized communities.
Put him upon even the average diet of many people in this progressive
and highly civilized United States the year round,--with its thin milk,
its pulpy, half-sour butter, its tough meat, its half-rancid pickled
pork, its short three months of really fresh vegetables and good fruit,
and six months of eternal cabbage, potatoes, dried apples, and
prunes,--and he will fail to build up the vigor necessary to fight the
disease, even in the purest and best of air.
The saddest and most pitiful tragedies which the consumptive
health-resort physician can relate are those of wretched
sufferers,--even in a comparatively early stage of the disease,--whose
misguided but well-meaning friends have raised money enough to pay their
fare out to Colorado, California, Arizona, or New Mexico, and expect
them to get work on a ranch, so as to earn their living and take the
open-air treatment at the same time.
Three things are absolutely necessary for a reasonable prospect of cure
of consumption. One is, abundance of fresh air, day and night. Another,
abundance of the best quality of food. And the third, absolute--indeed,
enforced--rest during the period of fever. Let any one of these be
lacking, and your patient will die just as certainly as if all three
were. _Not one in five_ of those who go out to climates with even a high
reputation as health-resorts--expecting to earn their own living or to
"rough it" in shacks or tents on three or four dollars a week, doing
their own cooking and taking care of themselves--recovers. They have a
four-to-one chance of recovery in _any_ climate in which they can obtain
these three simple requisites, and a four-to-one chance of dying in any
climate in which any one of these is lacking.
Instead of nature being able to cure the consumptive unaided, as a
matter of fact she has neither the ability nor the inclination to do
anything of the sort. There is no class of patients whose recovery
depends more absolutely upon a most careful and intelligent study and
regulation of their diet, of every detail of their life throughout the
entire twenty-four hours, and of the most careful adjustment of air,
food, heat, cold, clothing, exercise, recreation, by the combined forces
of sanitarian, nurse, and physician. So that, instead of feeling that
only by reverting to savagery can consumption be prevented, we have no
hesitation in saying that it is _only under civilization, and
civilization of the highest type, that we have any reasonable prospect
of cure_.
Finally, we are getting over our misgivings as to the intentions of the
hereditary brigade. It is certainly not our enemy, and may probably turn
out to be one of our best friends.
Our first sidelight on this question came in rather a surprising manner.
It was taken for granted, almost as axiomatic, that if the conditions of
savage life were such as to discourage, if not prevent, tuberculosis,
certainly, then, the race which had been exposed to these conditions for
countless generations would have a high degree of resisting power to the
disease. But what an awakening was in store for us! No sooner did the
army surgeon and medical missionary settle down in the wake of that
extraordinary world-movement of Teutonic unrest, which has resulted in
the colonization of half the globe within the past two or three hundred
years, than it was discovered that, although the hunting or nomad savage
had not developed tuberculosis, and the disease was emphatically born of
civilization, yet the moment that these healthy and vigorous children of
nature were exposed to its infection, instead of showing the high degree
of resisting power that might be expected, they died before it like
sheep.
From all over the world--from the Indians of our Western plains, the
negroes of our Southern States, the islanders of Polynesia, New Zealand,
Hawaii, Samoa--came reports of tribes practically wiped out of existence
by the "White Plague" of civilization. To-day the death-rate from
tuberculosis among our Indian wards is from _three to six times_ that of
the surrounding white populations. The negro population of the Southern
States has nearly three times the death-rate of the white populations of
the same states. Instead of centuries of civilization having made us
more susceptible to the disease than those savages who probably most
nearly parallel our ancestral conditions of a thousand to fifteen
hundred years ago, we seem to have acquired from three to five times
their resisting power against it. Not only this, but those races among
us which have been continuous city-dwellers for a score of generations
past have acquired a still higher degree of immunity.
In every civilized land the percentage of deaths from tuberculosis among
the Jews, who, from racial and religious prejudices, have been prisoners
of the Ghetto for centuries, is about half to one-third that of their
Gentile neighbors. In certain blocks of the congested districts of New
York and Chicago, for instance, the Jewish population shows a death-rate
of only one hundred and sixty-three per hundred thousand living, while
the Gentile inhabitants of similar blocks show the appalling rate of
five hundred and sixty-five. Similarly, by a strange apparent paradox,
the highest mortality from tuberculosis in the United States is not in
those states having the greatest urban population, but, on the contrary,
in those having the largest rural population.
The ten highest state tuberculosis death-rates contain the names of
Tennessee, Kentucky, West Virginia, Virginia, and South Carolina, while
New York, Pennsylvania, and Massachusetts are among the lowest.
The subject is far too wide and complicated to admit of any detailed
discussion here. But, explain it as we may, the consoling fact remains
that civilized races, including slum-dwellers, have a distinctly lower
death-rate from tuberculosis than have savage tribes which are exposed
to it even under most favorable climatic and hygienic conditions; that
those races which have survived longest in city and even slum
surroundings have a lower death-rate than the rest of the community
under those conditions; and that certain of our urban populations have
lower death-rates than many of our rural ones.
As for the immediate effect of heredity in the production of the
disease, the general consensus of opinion among thoughtful physicians
and sanitarians now is that direct infection is at least five times as
frequent a factor as is heredity; that at least eight-tenths of the
cases occurring in the children of tuberculous parents are probably due
to the direct communication of the disease, and that if the spread of
the infection could be prevented, the element of heredity could be
practically disregarded.
We are inclined to regard even the well-marked tendency of tuberculosis
to attack a considerable number of the members of a given family to be
due largely, in the first place, to direct infection; secondly, to the
fact that that family were all submitted to the same unfavorable
environment in the matter of food, of housing, of overwork, or of the
New England conscience, with its deadly belief that "Satan finds some
mischief still for idle hands to do."
Upon direct pathological grounds nothing is more definitely proven than
that the actual inheritance of tuberculosis, in the sense of its
transmission from a consumptive mother to the unborn child, is one of
the rarest of occurrences. On the other hand, the feeling is general
that, inasmuch as probably four-fifths of us are repeatedly exposed to
the infection of tuberculosis and throw it off without developing a
systemic attack of the disease, the development of a generalized
infection, such as we term consumption, is in itself a sign of a
resisting power below the average. Should such an individual as this
become a parent, the strong probability is that his children--unless, as
fortunately often happens, their other parent should be as far above the
average of vigor and resisting power--would not be likely to inherit
more vigor than that possessed by their ancestry. So that upon _a
priori_ grounds we should expect to find that the children born of
tuberculous parents would be more susceptible to the infection to which
they are so sure to be exposed than the average of the race. So that the
marriage of consumptives should, unquestionably, upon racial grounds, be
discouraged except after they have made a complete recovery and remained
well at least five years.
To sum up: while the earlier steps of civilization unquestionably
provide that environment which is necessary for the development of
tuberculosis, the later stages, with their greatly increased power over
the forces of nature, their higher intelligence and their broader
humanity, not merely have it in their power to destroy it, but are
already well on the way to do so.