Popular Science Monthly/Volume 50/January 1897/Consumption and Consumptives
By WILLIAM L. RUSSELL, M. D.
TEN or twelve years ago even the most advanced physicians were not agreed that consumption belonged to the communicable diseases, and practically none took any steps to prevent its spread from the sick to the well. In fact, there were not a few who denied that it was ever contracted in this way. Heredity, physical conformation, atmospheric and soil conditions were regarded as the important factors, and all efforts were directed to the study and control of these. To-day there is an entire change of position. Communicability stands first in importance, and there are few who deny that it is the essential factor in the perpetuation of the disease. The most strenuous efforts now being made against its ravages are based on the belief that the greatest menace to the well is the presence of the sick.
Tuberculosis—of which, as will be explained more fully below, consumption is a variety—now appears at the head of the list of contagious diseases published weekly by the New York Board of Health, and means have been taken to have all cases in the city reported and instructed. Circulars containing directions for preventing contagion by disinfection of sputa have been placed in the hands of physicians for distribution, and many, if not all. reported cases are visited and instructed by the health officers. When an apartment has been vacated by a consumptive the following notice is posted:
Consumption is a communicable disease. This apartment has been occupied by a consumptive, and may have thus become infected. It must not be occupied by persons other than those residing here until an order from the Board of Health, directing that it be cleaned and renovated, has been complied with.
Name of occupant
This notice must not be removed until the order of the Board of Health has been complied with.
The reason for this new departure is to be found in the rounding out of the evidence of the contagious nature of consumption, by the discovery of the living agent whose presence and growth constitute the very essence of the disease, and the transfer of which from the sick to the well causes its spread. This is the microscopic, rod-shaped, vegetable organism named the tubercle bacillus. It was discovered by Dr. Koch, of Berlin, in 1882, and much of the mystery which had previously shrouded the disease was thereupon cleared up; for, although consumption is a disease which has been recognized during the whole period covered by history, no adequate explanation of its nature was offered until recent times. Previous to this century, it was thought that the destruction of the lungs was due to simple inflammation and ulceration. Then Laennec, a French physician, who invented the stethoscope, set forth the view that the small, pearl-like bodies with which the lungs were found studded constituted the sole cause. He called these bodies tubercles, and thus the disease came to be spoken of as tuberculosis.
Laennec's view was not accepted without opposition, and, until Koch's discovery set the matter at rest, many claimed that there were two or more kinds of consumption. In 1867, Villemin, also a Frenchman, demonstrated the possibility of producing the disease in certain animals by inoculating them with tuberculous material. It was found by others, however, that the same animals became tubercular if inoculated with apparently innocent material, or simply if an open sore were kept on them. The matter was thus still unsettled. The pathologists now came to the support of the contagionists by the discovery that the development and extension of the disease in contiguous cells and tissues and along the small vessels could only be explained by the presence of a contagious element. When, therefore, Koch demonstrated that the tubercles themselves were but the work of living organisms which had been introduced from without, a flood of light was thrown on the subject which cleared up all disputed points. He showed that not only was the diseased tissue crowded with these organisms, but that they were being constantly discharged in the sputum; that they could be cultivated in colonies free from all other germs outside the body; and that the pure cultures introduced into healthy animals caused them to become diseased, the bacilli being again found in their dead bodies. It may then be accepted as a settled fact that consumption is invariably produced by the introduction into the lungs from without the body of vegetable organisms, which, finding lodgment, multiply and eventually cause the destructive changes by which the death of the individual is accomplished. When it is remembered that consumptives have been expectorating countless millions of these organisms for ages, and that the cattle whose milk and flesh are used for food are not exempt from tuberculosis, no mystery need surround the source of any particular case. The mystery is rather that any of us escape. Nor could we, were it not that certain conditions, happily not always fulfilled, are necessary before the germs gain a foothold in the body.
It may strike some as extraordinary that while the contagiousness of the fevers, of cholera, and syphilis was established beyond question before disease germs were discovered, sufficiently convincing evidence was not also at hand in the case of such a prevalent disease as consumption. The popular conception of contagion and contagious disease has been derived from the behavior of such a disease as smallpox. It prevails often as an epidemic. Its onset is sudden and accompanied by pronounced symptoms. It runs a short and sharp course, and results in speedy death or recovery. A large proportion of those exposed are attacked, and the exposure may have been very brief. The case is entirely different with tuberculosis. Epidemics are almost unknown. The beginning of the disease is usually obscure and insidious; the course may extend over months and even many years, the individual being perhaps not seemingly very ill during much of the time. The majority of those exposed seem to have escaped, and of those attacked comparatively few are known to have been in especially close relations with the sick. It will thus he seen that in the one case the evidence is nearly always clear, cumulative, and convincing, in the other it is usually confusing and sometimes contradictory. In former times, when controversies on the subject were frequent in the medical profession, equally good observers often came to diametrically opposite conclusions. It must not be supposed, however, that knowledge of the bacillus as a causative agent is the only ground for belief in the contagiousness of consumption. If this were the case, the matter could hardly be regarded as settled, for malarial fevers are known to be produced by a micro-organism, but are not contagious. There has seldom or never been a time when a conviction that consumption was contagious did not prevail to some extent, and few physicians of much experience have failed to see one or more cases which could only be satisfactorily accounted for on this ground. It has even occasionally happened that in certain localities this theory of its nature has gained such widespread credence as to lead to definite action. This was the case in Italy during the period from 1787 to 1848, when vigorous measures were taken to stamp out the disease, and a special hospital for consumptives was established at Olivuzza. At Naples the bedding of consumptives was burned, and their vacated apartments were completely renovated before being used again. In fact, the unfortunate sufferers were often shunned, and whole families were driven to want. It is said, however, that this method of dealing with the disease made no impression on the death-rate, and it was therefore abandoned.
Some of the recorded instances of the communicability of tuberculosis are, especially with our added knowledge of the bacillus, quite striking. Among these may be mentioned the inoculation experiments of Villemin, already referred to. Before this, however, Laennec, who became eventually a victim to the disease, believed that he had inoculated his own finger by means of a saw while he was making a within four months of the introduction of the first case, and four of them died. No new cases occurred after the remaining sick had been removed. In 1787 an inmate of a convent in Bilbao, Spain, died of consumption, and, as was customary then, the bedding and furniture were destroyed and the room thoroughly cleaned before it was again occupied. Two months later the new occupant of the room was attacked by the disease and afterward died. The same cleaning and destruction of furniture followed, but the next occupant succumbed within a year. It was then discovered that certain cords which might have been the means of conveying the disease had been allowed to remain in the room. These were now removed, the same precautions taken as before, and no other case had appeared at the end of five years. A few years ago the British Medical Association made an attempt to investigate the subject, and a circular letter of inquiry concerning cases of contraction by contagion was sent to each member. Reports of three hundred and twenty-one instances were received, two hundred and twenty-three of which related to husbands or wives who were thought to have contracted the disease the one from the other. It is worthy of note that many observers of long experience had seen but one or two instances, and some had not seen any.examination of the dead body of a consumptive. A tuberculous nodule developed at the seat of the wound. Morgagni, too, at a still earlier period, showed by his writings that he realized the danger of inoculation in this way. Calves which have sucked cows suffering from pearl disease or tuberculosis are frequently found to be affected with the same disease. Dr. Jacobi has recorded an instance of a dog contracting tuberculosis by licking the sputa of his diseased master as he followed him about the garden. Acute or hasty consumption has prevailed in almost epidemic form among young recruits in crowded barracks in England, and the inmates of certain convents have been almost exterminated by the same disease. In a convent in Louisville nine of the nuns developed consumption
The following observations relate to instances in which there have been more than one husband or wife, and embrace all such that have been recorded:
1. Thirteen instances in which a consumptive man had married more than one healthy wife. There were in all thirty-one wives, of whom twenty-seven contracted the disease, four remaining perfectly well.
2. Three instances of a wife becoming infected from her husband, and a second husband from her.
3. Two instances of women dying of consumption, after each had lost two husbands by the same disease.
4. Ten instances of husbands contracting the disease from their first wives, and their second wives in turn from them.
5. One instance in which a man had become infected from a diseased wife, his second wife from him, and a second husband from her.
The marriage relation furnishes conditions exceptionally favorable to contagion, and it is not surprising that so many of the recorded instances relate to contraction of the disease from husband or wife. And yet it can hardly be claimed that most of those who lose husband or wife by consumption contract the disease. Of 6,167 patients who had been treated at the Brompton Hospital in 1863, but 239 were widowed. Of these, however, 106 had lost husband or wife by consumption. Dr. Cotton, of England, found that only eleven of one thousand cases which he investigated had lost husband or wife by the disease, and our own Dr. Flint states that there were but five such instances in 670 cases observed by him.
Previous to the discovery of the bacillus, such observations as those last mentioned led many to doubt that consumption was communicable at all. It may be well, then, to consider a few other facts pointing to the same conclusion, as they are important in arriving at correct views on the whole matter. Chief among them may be mentioned the experience of the Brompton and Victoria Park Hospitals of London, where consumptives have been treated for many years. It is well to recall at the same time that special precautions against contagion have not been taken until recently. It was stated in 1882 that of sixty or seventy physicians employed at these hospitals during twenty years, but five had been attacked by consumption, of whom two died. The record of the large number of nurses employed during the same period, and whose relations with the sick were more intimate than those of the doctors, was still better; there were but two cases, and one of these was doubtful. One of the physicians to these hospitals. Dr. Williams, says that though he has been watching for twenty years he has not yet met with a case in which alleged contagion could be sustained, after close investigation. He adds that while the disease may be contracted in this way, the circumstances must be extremely favorable. At the Vienna General Hospital, where 2,736 deaths from consumption occurred in three years, not a physician or nurse was known to have contracted the disease. Nearly every one has known of relatives or friends who have lived in the most intimate relations with consumptives for long periods and have suffered no injury whatever.
Now, it does not follow from these observations that we are mistaken in assuming that consumption is communicable. We shall see in a moment that there is a good reason for exceptional instances. It is quite possible, though, that in our enthusiastic zeal to deal with it and stamp it out on this basis other important considerations are being neglected. Destruction of clothing and renovation of rooms seem to have been pretty thoroughly practiced in Naples and other places a hundred years ago without making any impression on the death-rate. Improvements in general sanitary conditions at Naples, however, have in these later times had a marked effect. It is, to be sure, highly important to destroy or disinfect sputa, and to discourage in general the pernicious practice of expectorating. The sputum is the very fountain-head from which the army of bacilli is re-enforced. This does not necessarily imply, however, that the concentration of our efforts on the destruction of the bacilli is the only, or even the best, way of exterminating the disease. Few diseases prevail so generally throughout the world as tuberculosis. No zone is exempt from its ravages, and it has prevailed from the earliest times. Its victims constitute seventeen per cent of all deaths, and nearly five thousand succumbed to it in New York city in 1894. It affects also the lower animals, especially the cow, which is so important a source of food supply. Many persons are fatally affected by it long before they are obliged to leave their occupations, or even to consult a physician. The methods which have proved so successful with the acute infectious diseases can hardly be applied effectually with such a disease as this, and the attempt to deal with it solely on this line may even prove mischievous sometimes by fostering a belief that exemption can be secured simply by shunning the sick. Should such a view prevail generally, unnecessarily severe and even cruel measures would sometimes be adopted by the timid and ignorant. Not long ago a writer proposed that all cases be segregated and quarantined in a valley in New Mexico, where climatic conditions were favorable to recovery. Government aid being given the impecunious, and a leading New York daily commented favorably on the proposition.
The importance, then, of correct views on this subject can scarcely be overestimated. We have seen that, though the disease is undoubtedly communicable, it does not prove so under all circumstances. It is a question if any one of sound heredity and good health has ever developed it simply from living with a consumptive in ordinarily good hygienic surroundings. It is generally admitted that predisposing conditions can always be found. The germs of this disease can not obtain a foothold until the resistive powers of the tissues have been reduced. There must be not only the seed but the soil. This impaired power of resistance may be the result of heredity, and this influence in the causation of disease is seldom shown to better advantage than in the history of consumption. There have been instances in which a single case introduced into a long and sound ancestry has vitiated the stock forever. How unfortunate that such matters are so little considered in marrying and giving in marriage! It is not that the disease is inherited, but the vulnerable tissues, the feeble resistive powers, render the offspring an easy prey to the ubiquitous bacillus. This weakness often shows itself by a tendency to become ill from slight causes, a sickliness, not by any means to be confounded with merely a lack of robustness or strength. One organ or part of the body, frequently the mucous membrane, is usually more prone to become affected, and the beginning of the disease can often be traced to an attack of some slight ailment. Not only the children of consumptive parents may show these characteristics, but also those of parents generally enfeebled, or whose ages are widely separated, or who are closely related by blood, or of a mother who has previously borne a number in quick succession. Even when heredity is sound, the same condition is sometimes induced by coddling, by improper feeding, by attacks of acute disease, or by want and distress. In growing children, a bad carriage of body may act injuriously by contracting and deforming the chest. The stooped position which boys sometimes assume in bicycle-riding should be discouraged for this reason.
Before the period of bacteriological research conditions thought to bear a causative relation to consumption were eagerly studied. Some of these thought to be important, it can now be seen, were principally operative by affording favorable circumstances for contagion, or were themselves symptoms of disease already present. They still teach useful lessons, however, and deserve more attention than is at present given them. We all know now the reason why bad air was for so long regarded as a cause of the disease, but it still remains the fact, nevertheless. Imperfect food supply was also assigned a place among the causes, but second to an imperfect supply of pure air. Well-fed factory operatives who work in close rooms are much more prone to the disease than poorly fed laborers who work outdoors. A French laborer moved to Paris with his wife and three sons from the country, where they had worked outdoors. The father and two of the sons soon died of tuberculosis; the mother and remaining son returned to the country and survived. This illustrates the well-known fact that the mortality increases with the density of population, being greatest in large cities and in barracks, prisons, and factories. Sixty-seven per cent of the deaths among the Guards in the English army are due to it. The death-rate in prisons increases steadily with the years of confinement, and diminishes as ventilation is improved. Inadequate nutrition because of insufficient food supply or of indigestion, which in turn may be the result of improper or poorly prepared food, undoubtedly predisposes to the disease. The same may be said of exhausting discharges or hæmorrhages, of childbearing, of enervating habits or practices, and of depressing emotions, all of which tend to reduce the resistive power of the body. Considerable importance has been attached to damp soil, and it would seem justly so. Dr. Buchanan, of England, found that the drainage of such soil always reduced the death-rate among the inhabitants of the region. Dr. Bowditch, of Boston, says that three fourths of 201 cases investigated by him lived in houses built on damp soil. He observed also that the death-rate was lowered by draining. He mentions several specific instances, among them the following: A and B married sisters. No tuberculosis had ever been known in any of the families, except perhaps in the case of one grandmother, who had marks of former abscesses in her neck. A and his wife lived on dry soil. They had nine children, all of whom remained healthy. The house of B, on the other hand, was on damp soil. His wife and six of his eleven children died of consumption, and one of the survivors was ill with the disease when the observations were made.
The importance of these predisposing conditions can only be realized by knowing that the large majority of consumptives have never lived with others similarly affected. The disease is in these cases a result of a combination of circumstances into which direct known exposure has not entered. Nor can immunity be secured by shunning the sick. In fact, nothing further is required to protect those of sound health and heredity, who are obliged to associate with consumptives, than scrupulous cleanliness and an abundant supply of fresh air and sunshine. If, in addition, the sputum and everything soiled by it are destroyed and disinfected, the sick become harmless to all. The human body has within it the capacity of preventing the lodgment and growth of the tubercle bacillus. This capacity is only overcome as a result of hereditary or acquired influences. It is against these that the efforts of every one can and ought to be directed.