Popular Science Monthly/Volume 65/August 1904/The Great White Plague

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IT is with a very real sense of melancholy that one contemplates the long death-roll of those of the world's great men and women who have succumbed untimely to the tubercle bacillus, which is and has been through countless generations by far the most potent of all death dealing agencies. Had it not been for this detestable parasite, Bastien Le Page might have given us another Joan-of-Arc to feast our eyes upon; Rachel might for many years have continued to permeate the spirits of her audiences with the divine fire that was in her. Our navy did well enough in the 1812 war, as all the world knows; but what a rip-roaring time there would have been if John Paul Jones had lived to take a hand in it. We might be reading some more of Stephen Crane's splendid war stories; we might have had some more of Robert Louis Stevenson's delicious lace-work; Schiller might have given us another 'Song of the Bells'; we might have taken another 'Sentimental Journey' with Laurence Sterne; Henry Cuyler Bunner might have continued to delight us, and to touch our hearts; John Keats might have given us another Endymion. Had the tubercle bacillus permitted, Nevin might have vouchsafed us another 'Rosary'; von Weber another 'Euryanthe Overture'; Chopin might have dreamed another 'First Polonaise'; and the tender flute notes of Sidney Lanier might even now be heard. Maria Constantinova Bashkirtseff, Zavier Bichat, John Godman, Rene Theophile Hyacinth Laennac, Henry Purcell, John Sterling, Henry Timrod, Artemas Ward, Henry Kirk White, Henry David Thoreau, Baruch Spinoza—such names as these are but a moiety among those of the world's nobility, whose precious lives were cut off in their prime by the 'Great White Plague.'

And our sense of resentment is by no means mitigated when we reflect that this bacillus is so minute that it was reserved for Koch, in our own time, with the aid of an exquisitely high-powered microscope, to discover it, and to reveal its life history and its habits and properties. It were indeed worthy the pen of a Heine to set forth how, although our mastodons are extinct, although we easily destroy all other visible brute creation, although we hold ourselves to be world masters and universe compellers, the race has nevertheless until our generation been impotent in the presence of an organism, measuring in length one ten-thousandth of an inch and in breadth one fifty-thousandth of an inch—an organism which multiplies so rapidly and so invisibly and insidiously that the consumptive, in coughing, emits several billions of it during twenty-four hours.

There would be no excuse truly for putting such sinister details as these before the laity were it not that the condition of things, which we term consumption or tuberculosis, is a tremendous, much-pervading human factor. I have intimated that of all death-dealing agencies, Koch's bacillus claims the greatest number of victims; the cholera, typhus, the plague of the middle ages, small-pox—are not in the running with consumption. The last, although its ravages have not been so picturesquely gruesome, has claimed many more victims than any of the others; it has probably been coeval with human existence, and very likely has afflicted our primordial ancestors.

To-day every third or fourth adult dies of consumption. In the periods between birth and senescence every seventh death is caused by it. The point about these two propositions is this: Very few of us die only of old age; almost every one dies of one disease or another, so that it would not seem to matter much what the particular disease might be that would carry us off. But, although all periods of life are precious—infancy and childhood and old age, as well as any other—it is during adult life that consumption gets in its fell work, in the periods when young people should entertain wholesome anticipations of matrimony, when husbands should be strong to work for and maintain their families, when wives should have strength to rear their children, and when men and women generally should have physical and mental capacity so that they may accomplish the world's work.

No one knows better than the physician how truly touching may be the condition of things we are considering at the first of these periods—the period of early manhood and womanhood, when poetry, music, flowers, sunshine, and the new-born instinct to love and power to inspire love, are gloriously dominant, when sentiments ring true, when thoughts of compromise with unworthy factors, of subordinating ideals to considerations of interest, have not yet been conceived; when the love exists which welcomes sacrifices and feels that if it is ever to manifest itself, it should do so most gladly and most abundantly when the beloved is sorely stricken; the love that feels bound to triumph over all obstacles, and which snaps its fingers contemptuously in the face of fate. One is proud for human nature when such spirit is exhibited. Nevertheless it is then that this dreadful disease demands with deplorable frequency to be reckoned with. And it is then that the mature physician discerns the practical certainty that marriage, in cases where consumption exists or is suspected, will be followed by intensified illness, and perhaps death (which might not otherwise have occurred), on the part of the sick one; the possibility of infection of the healthy mate; the likelihood of unhealthy offspring, or of its early and perhaps—under the circumstances—fortunate death; and other indications suggesting disaster at the very beginning of married life, when all the circumstances, if any time in life ever required it, should be favorable and founded upon virility of mind and body.

The tubercle bacillus gets into the body either with the air we breathe, or with tuberculous food-stuffs, or rarely through wounds. Wherever it implants itself an inflammation may occur about it, with the result that a tubercle is formed (tuber is Latin for root or bulb). This tubercle is in size from that of a millet seed to a hickory nut or larger. Its development is called tuberculosis. Under favorable circumstances it becomes surrounded by fibrous tissue, somewhat like the scar which would follow a wound of the skin; and then the tubercle will be comparatively harmless to the organism. However, 'cheesy degeneration' may result, two or several adjacent tubercles may break down together, a cavity may form, containing purulent material in which, on being coughed up, the bacilli are discerned by the microscope. These bacilli and these tubercles may exist in any part of the body—the skin, the bones, the joints, the lymph glands. And they, or the products of their disintegration, may be carried by the lymph and blood channels to other parts; and it is probable that in many cases the pulmonary type of tuberculosis is not originally a lesion of the lung tissue, but a product transferred from a point of implantation elsewhere.

If tuberculosis does not undergo fibrosis it is likely to be developed, through the agency of some acute 'predisposing cause,' into the complex of symptoms which we term consumption. Those thus afflicted become progressively very weak and very much emaciated. Their hearts beat rapidly and they are apt to have a pink flush on their cheeks, which is quite unlike the blush of. a healthy person, but which is in reality an indication of the fever that is consuming them. The rest of their faces is very pale and thin and is suffused with a clammy sweat. Their cheek bones are prominent. And their eyes have a quite unnatural brilliancy, seeming large and beautiful. But their luster is not of health—rather of disease and too often of death. It is such eyes that the poet Bryant has portrayed in a touching and melancholy sonnet. And the consumptive spits blood sometimes, and is short of breath, and has a persistent, hacking cough, that harasses him dreadfully, and does not let him rest.

The reader is now likely to wonder how, with all these teeming billions of bacilli about, any one ever escapes the disease. The fact is, the bacillus allows very few of us to die without leaving some trace of its activity in our system. Jeder Mensch hat am Ende ein bischen Tuberculose, as Naegali demonstrated in 98 per cent, of the bodies which he examined on autopsy, of people who had died of all sorts of disease, besides those dying of old age.

There are two conditions essential to the development of consumption. In the first place, there must be the presence of the bacilli of Koch as its specific or essential cause. In the second place, the body must be predisposed to the disease by various unhealthful factors, such as vicious heredity, alcoholism, poverty and the like. Most of us are able to resist the bacillus because our bodies are sufficiently strong to resist the organism, and because there are in our tissues certain germicidal properties, which are ordinarily sufficient to cope with and destroy the bacillus. The layman will easily get the idea from the following experiment: Some rabbits were inoculated with tubercle bacilli and placed in relations generally deleterious to health; these became consumptive. Another group, selected from these same rabbits, were likewise confined, but were not subjected to infection, and these did not develop the disease. Whilst among a third group, which were inoculated like the first, but which were, on the contrary, favorably located as to hygiene, most of the rabbits escaped the disease.

The tubercle bacillus is indeed originally a saprophyte, feeding upon dead or decomposing material. Its next congenial habitat is such tissue of living animals as has been previously devitalized by unwholesome factors; that is to say, these factors have rendered the tissues of the body vulnerable to the onset of the bacillus and certain other microorganisms which later join it in its work of devastation. These predisposing factors render the tissues a fruitful soil in which the bacillus and its allies may germinate and thrive. I should like to touch briefly upon certain of these predispositions.

It was formerly held that consumption is a hereditary disease. But we know now it is practically impossible for such to be the case, for parents can not transmit the bacillus to their offspring. What parents may transmit is a tendency to the disease, resulting from unhealthful conditions in their own organisms. Such hereditary transmission may be manifested by the offspring in the scrofulous temperament. The child may have a pallid skin and flabby flesh; and inflammation of the mucous membranes, as would be indicated by reddened and suffused eyelids, coryza and congested and unhealthy throats. There would be adenoid growths in the back of the nose and enlarged tonsils, so that such children would be mouth breathers, starved for oxygen. The glands of the neck and in other parts of the body would become enlarged. Besides these things, there might be malformations of the thorax and a capacity for breathing evidently below the average, congenital affection of the heart and the rest of the circulatory system, slow teething and deficient and tardy ossification. There would, in short, be evidence of defective development and of a generally torpid condition of the system.

It is easily to be comprehended how tuberculosis can become engrafted upon such an organism. The French government has grappled most nobly with the problem indicated in this state of affairs. It has established in various parts of France hospitals for tuberculous children, many of whom are no doubt only scrofulous. Several of these institutions are on the sea coast, at Berck-sur-Mer and at Hendaye; and the children are assured the benefit of the sea air, and of ozone, lots of sunshine, plenty of pure food-stuffs—bread, meats, milk and eggs; careful nursing; and excellent medical care of their 'white swellings' of the joints, tuberculous affections of bones, and of the many other conditions requiring the physician's attention. Thus, instead of early deaths, or of the prospect of growing up weaklings, many of these children are vouchsafed happy lives and strong constitutions, thereafter resistant to infection, and have inculcated in them habits of cleanliness and hygiene which they are sure to disseminate after their graduation. In this manner there are secured to the state many worthy and splendid citizens who would otherwise be lost to it. It is really a movement worth the consideration of the political economist.

Excessive alcholism stands in a causative relation to tuberculosis because of the resulting tissue impoverishment. The pulmonary type is almost invariably found in persons dying in the course of chronic alcholism. 'L'alcoolisme fait le lit de la tuberculose' states the physician, Landouzy.

It is difficult to explain the effects of alcohol. Like most of the simplest things in life, no definite agreement has ever been reached concerning its mode of working. It is evident, for instance, that there is no hardier stock than the wine-drinking countries; and it would seem that alcoholic fluids that are of good quality and purity, and are taken temperately, are conducive generally to health.

In all likelihood the bad effects fairly attributable to alcohol lie largely in the vicious quality of what is consumed, and in the state of affairs which it connotes: unsanitary habits, poverty, lack of nutrition or bad food, ill-ventilated living rooms; and, most of all, a condition of the organism exhausted by overwork, in which the reserve force is all that is left to carry on the struggle for existence. We may imagine a man in whom the tidal strength, such as we use in dealing with the ordinary affairs of life, is gone, and who has to depend upon his reserve strength to cope with an extraordinary difficulty which would overwhelm him, but for which, if we had to deal with it, our reserve strength would be altogether adequate. Such a man is in the condition of the camel to whom the last straw is fatal. So alcohol is oftentimes taken first with a view to keeping a defective organism up to the working point, perhaps in a tuberculous subject, or in one in whom all the conditions are receptive to tuberculosis; alcohol is then taken in increasing amounts to stimulate the flagging energies, thus making a bad matter worse. Some who contract the disease in this way have occupations directly conducive to alcoholism, such as workers in the liquor trade, barmen, waiters and hotel servants, people who are thus employed because they are, from their physical and moral make-up, 'unfit' (as the evolutionist might say) for another and a better sort of work.

Poverty, with all that the word implies—underfeeding, deficiency of sunlight, defective ventilation, overcrowding, uncleanliness, bad drainage, rank-smelling and damp-walled houses—stands enormously in a causative relation. There are plenty of data to demonstrate that tuberculosis is preeminently a disease of humanity's submerged strata.

It was estimated in Hamburg, for instance, among the several income tax classes (inclusive of the dependents of the tax-payers) that for incomes of from nine to twelve hundred Marks the death rate from consumption is 55.4; for incomes of from twenty-five to fifty thousand Marks the death rate is 7.5—a proportion against the poorer classes of nearly eight to one.

One may grasp the idea in a glance upon the maps of New York City districts which its Health Board has prepared under the medical directorship of Dr. Herman M. Biggs. By far the greatest number of our consumptives are in the poorer districts; eleven of them, for instance, dying in one year in a house in the 'lung block.' Instructive, too, are the thousand odd photographs which the New York City Tenement House Department has taken during the two years just passed, showing air shafts twelve inches wide and six stories deep; more than 360,000 'dark rooms' whose only means of ventilation, if they have any ventilation at all, is through such air shafts. Enlightening, too, is Mr. Ernest Poole's brochure on 'The Plague in its Stronghold.' Such grim humor as the following may also have illuminative value: Three families occupied an apartment of three rooms, one living in the front room, another in the rear room, the third in the middle room; and they all got along very well together until the family in the middle room wanted to take in boarders.

Besides these predispositions to tuberculosis there are many others. There are the family relations. If one member is consumptive, his sputum may in various ways be infective. It may be spat upon the floor, and if there is an infant, it will, in playing about, pick up bacillus-laden objects and, after the habit of infants, put them in its mouth. Then after weeks or months the child becomes tuberculous. So that on such accounts as these it was formerly considered that the disease itself was of hereditary origin. Then 'neglected colds,' fevers and exhausting diseases, such as typhoid or malaria, enervate the body and make it a fruitful soil for microbic germination. Direct injury, or open wounds, or the shock occasioned by injury, or depressing emotions generalty, may predispose. There are many trades which may stand in a causative relation to tuberculosis. In the excellent book entitled 'Dangerous Trades' there are nearly sixty such occupations specifically considered.

It were impossible even to mention all conditions which might predispose to consumption. For we are told that living itself is but the body's response to environmental stimuli, either physical or chemical in character; and such are about as numerous as there are external phenomena. For my part, I would reserve the opinion that the whole of life is by no means comprehended in this tenet; still it is valid as denoting the innumerable agencies, which may make the organism receptive to tubercular infection.

May we then hope to fight tuberculosis with any measure of success? Yes, indeed. To do so, two objects must be kept in view: We must destroy the bacillus; and we must render the organism of the individual resistant to infection. The disposition of the tubercle bacillus is theoretically extremely simple. Tuberculosis as an infectious disease is totally unlike certain others, as, for instance, diphtheria or scarlet fever. One can not be sure, after having been half an hour in the same room with a diphtheria patient, that he will not contract the disease. If, however, certain very elementary precautions are taken, one may live with a consumptive for months or years without jeopardizing his health. It has been truly said that there is no place where one is less likely to contract consumption than in a scientifically conducted sanitarium for consumptives. For instance, all the dust in one of Dr. Trudeau's cottages at Saranac Lake was gathered together, and a culture made from it; and this culture, when injected into a guinea pig, was not sufficient to give this little creature tuberculosis. And we may observe, in passing, that consumptives, who have been cured in such institutions, go out as well-trained medical missionaries, teaching others the habits of sanitation and cleanliness they have accustomed themselves to. Nor is any other community likely to be as healthy as one in which such a sanitarium is situated.

The sputum of the consumptive must be destroyed; and our government inspectors must see to it that no tuberculous meat and milk gets into our markets. These are practically the only sources of tubercular infection we need fear, and if these things were thoroughly attended to, there would be no danger of infection.

There are many, indeed, who have in this direction an unnecessary and not altogether dignified dread. For instance, some time ago a young woman left New York City for the west. She was of splendid intellectual capacity, amiable, gentlewomanly and withal of an exquisitely sensitive nature. She had little means; and, in order to travel as cheaply as possible, she look a slow train, Lei us say, on a Monday evening. She reached her destination late on Wednesday afternoon, very much exhausted and very ill. Although almost six feet tall, she weighed, before going, just ninety-seven pounds. She had the lustrous eyes and the pink Hush associated with consumption; her pale face was suffused with a cold, clammy sweat; and she had the cruel cough, which wracked her chest and would not let her rest. The first thing she did was to go to a home for young women, where she asked to stay over night, so that in the morning she could go to the sanitarium where her stay had been arranged for. They would not take her in. It was their rule to refuse consumptives, even for a night; and with the name of the 'Poor Nazarene' over their door, they turned her away.

The reader, if he have read only this paper, will now see that there was no occasion for this. We might dilate upon the spirit of Christliness, to which this institution would ostensibly lay claim, and through which spirit this very sick traveler might surely have been given shelter until the morning at least. But upon a purely practical basis, there is no reason why, with elementary knowledge and common sense, such as those controlling such an institution should have, this sick one could not have been provided for without in the least jeopardizing the health of any other person. The progress of civilization is never furthered, indeed it is most horribly retarded, whenever the stigma of inhumanity is fixed upon the fair countenance of religion.