Preventable Diseases Part 7

"But how do you know that these ma.s.ses of chalky-material, these enlarged glands, are the result of tuberculosis? They may be due to some half-dozen other infections."

Almost before the question was asked a test was made by the troublesome but convincing method of cutting open these scars, dividing these enlarged glands, sc.r.a.ping materials out of their centre, and injecting them into guinea pigs. Result: from thirty to seventy per cent of the guinea pigs died of tuberculosis. In other cases it was not necessary to inoculate, as sc.r.a.pings or sections from these scar-ma.s.ses showed tubercle bacilli, clearly recognizable by their staining reaction.

Here, then, we have indisputable evidence of the fact that the tubercle bacillus may not only enter some of the openings of the body,--the nostrils, the mouth, the lungs,--but may actually form a lodgment and a growth-colony in the lungs themselves, and yet be completely defeated by the ant.i.toxic powers of the blood and other tissues of the body, prevented from spreading throughout the rest of the lung, most of the invaders destroyed, and the crippled remnants imprisoned for life in the interior of a fibroid or chalky ma.s.s.

It gave one a distinct shock at the meeting of the British Medical a.s.sociation devoted to tuberculosis, some ten years ago, to hear Sir Clifford Allb.u.t.t, one of the most brilliant and eminent physicians of the English-speaking world, remark, on opening his address, "Probably most of us here have had tuberculosis and recovered from it."

Here is evidently an a.s.set of greatest and most practical value, which changes half the face of the field. Instead of saving, as best we may, from half to two-thirds of those who have allowed the disease to get the upper hand and begin to overrun their entire systems, it places before us the far more cheering task of building up and increasing this natural resisting power of the human body, until not merely seventy per cent of all who are attacked by it will throw it off, but eighty, eighty-five, ninety! We can plan to stop _consumption by preventing the consumptive_.

A very small additional percentage of vigor or of resisting power--such as could be produced by but a slight improvement in the abundance of the food-supply, the lighting and ventilating of the houses, the length and "fatiguingness" of the daily toil--might be the straw which would be sufficient to turn the scale and prevent the tuberculous individual from becoming consumptive.

Here comes in one of the most important and valuable features of our splendid sanatorium campaign for the cure of tuberculosis, and that is the nature of the methods employed. If we relied for the cure of the disease upon some drug, or ant.i.toxin, even though we might save as many lives, the general reflex or secondary effect upon the community might not be in any way beneficial; at best it would probably be only negative. But when the only "drugs" that we use are fresh air, sunshine, and abundant food, and the only ant.i.toxins those which are bred in the patient's own body; when, in fact, we are using for the cure of consumption _precisely those agencies and influences which will prevent the well from ever contracting it_, then the whole curative side of the movement becomes of enormous racial value. The very same measures that we rely upon for the cure of the sick are those which we would recommend to the well, in order to make them stronger, happier, and more vigorous.

If the whole civilized community could be placed upon a moderate form of the open-air treatment, it would be so vastly improved in health, vigor, and efficiency, and saved the expenditure of such enormous sums upon hospitals, poor relief, and sick benefits, that it would be well worth all that it would cost, even if there were no such disease as tuberculosis on earth.

This is coming to be the real goal, the ultimate hope of the far-sighted leaders in our tuberculosis campaign,--to use the cure of consumption as a lever to raise to a higher plane the health, vigor, and happiness of the entire community.

Enormously valuable as is the open-air sanatorium as a means of saving thousands of valuable and beloved lives, its richest promise lies in its function as a school of education for the living demonstration of methods by which the health and happiness of the ninety-five per cent of the community who never will come within its walls may be built up.

Every consumptive cured in it goes home to be a living example and an enthusiastic missionary in the fresh-air campaign. The ultimate aim of the sanatorium will be to turn every farmhouse, every village, every city, into an open-air resort. When it shall have done this it will have fulfilled its mission.

Our plan of campaign is growing broader and more ambitious, but more hopeful, every day. All we have to do is to keep on fighting and use our brains, and victory is certain. Our Teutonic fellow soldiers have already nailed their flag to the mast with the inscription:--

"No more tuberculosis after 1930!"

So much for the serried ma.s.ses of the centre of our anti-tuberculosis army, upon which we depend for the heavy, ma.s.s fighting and the great frontal attacks. But what of the right and the left wings, and the cloud of skirmishers and cavalry which is continually feeling the enemy's position and cutting off his outposts? Upon the right stretch the intrenchments of the bacteriologic brigade, with the complicated but marvelously effective weapons of precision given us by the discovery of the definite and living cause of the disease, the _Bacillus tuberculosis_. Upon the left wing lie camp after camp of native regiments, whose loyalty until of very recent years was more than doubtful,--heredity, acquired immunity, and the so-called improvements of modern civilization, steam, electricity, and their kinsmen.

To the artillerymen of the bacteriologic batteries appears to have been intrusted the most hopeless task, the forlorn hope,--the total extermination of a foe so tiny that he had to be magnified five hundred times before he was even visible, and of such countless myriads that he was at least a billion times as numerous as the human race. But here again, as in the centre of the battle-line, when we once made up our minds to fight, we were not long in discovering points of attack and weapons to a.s.sault him with.

First, and most fundamental of all, came the consoling discovery that though there could be no consumption without the bacillus, not more than one individual in seven, of fair or average health, who was exposed to its attack in the form of a definite infection, succ.u.mbed to it; and that, as strongly suggested by the post-mortem findings already described, even those who developed a serious or fatal form of the disease had thrown off from five to fifteen previous milder or slighter infections. So that, to put it roughly, all that would be necessary practically to neutralize the injuriousness of the bacillus would be to prevent about one-twentieth of the exposures to its invasion which actually occurred. The other nineteen-twentieths would take care of themselves. The bacilli are not the only ones who can be numbered in their billions. If there are billions of them there are billions of us.

We are not mere units--scarcely even individuals--except in a broad and figurative sense. We are confederacies of billions upon billions of little, living animalcules which we call cells. These cells of ours are no Sunday-school cla.s.s. They are old and tough and cunning to a degree.

They are war-worn veterans, carrying the scars of a score of victories written all over them. _They_ are animals; bacteria, bacilli, micrococci, and all _their_ tribe are _vegetables_. The daily business, the regular means of livelihood of the animal cell for fifteen millions of years past has been eating and digesting the vegetable. And all that our body-cells need is a little intelligent encouragement to continue this performance, even upon disease germs; so that we needn't be afraid of being stampeded by sudden attack.

The next cheering find was that the worst enemies of the bacillus were our best friends. Sunlight will kill them just as certainly as it will give us new life. The germs of tuberculosis will live for weeks and even months in dark, damp, unventilated quarters, just precisely such surroundings as are provided for them in the inside bedrooms of our tenements, and the dark, cellar-like rooms of many a peasant's cottage or farmhouse. In bright sunlight they will perish in from three to six hours; in bright daylight in less than half a day. This is one of the factors that helps to explain the apparent paradox, that the dust collected from the floors and walls of tents and cottages in which consumptives were treated was almost entirely free from tuberculous bacilli, while dust taken from the walls of tenement houses, the floors of street-cars, the walls of churches and theatres in New York City, was found to be simply alive with them. One of the most important elements in the value of sunlight in the treatment of consumption is its powerful germicidal effect.

CHAPTER VII

TUBERCULOSIS, A SCOTCHED SNAKE

II

Closely allied to the discovery that sunlight and fresh air are fatal to the microorganisms 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 a.s.sociated 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 ill.u.s.trated 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 inst.i.tution 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 a.s.sume 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 munic.i.p.ality 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 inst.i.tution; and, also, some inst.i.tution 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 cla.s.s 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 sp.a.w.ning 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 ill.u.s.trations 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 ma.s.ses 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 ma.s.s 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 cla.s.s of breeders, but many progressive countries of Europe and states of our Union require the pa.s.sing 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 zoological 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 Zoological 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. .h.i.therto 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_.