Various Sanitary
Sanitary Topics.

BY A. G. YOUNG, M. D., Secretary of the Board.

TUBERCULOSIS AND CONSUMPTION.

In the Fourth Annual Report of this Board and in the preceding reports, the results were given of the more important late investigations into the nature and causes of tuberculosis, and especially that form of human tuberculosis which we call consumption. The evidence presented since 1882, when Koch first announced his discovery of the bacillus tuberculosis, has been so plentiful and so convincing, that he who now declares his incredulity as to the infectious nature of this disease puts himself in an unenviable position. But along with the establishment of the fact of infectiousness, we have made some substantial advances in our knowledge of the conditions and influences under which infection or immunity is the most likely to occur. We have learned

That tuberculosis or consumption does not occur except through the agency of the tubercle bacillus.

That the bacillus, though widely distributed over the earth, is not generally present in the atmosphere, as some other micro-organisms

are.

That the multiplication and development of the bacillus can take place only in a human or animal body.

That the infection of a human being or an animal may occur as the result of breathing in the bacillus, swallowing it in food, or by inoculation through the skin, mucous membranes or otherwise.

That in man, at least, infection occurs, in the great majority of cases, by means of inhaling the virus.

That practically the only source of the inhaled virus is the sputa of consumptives.

That the sputa is harmless so long as it is prevented from drying.

That when dried it is readily pulverized and floated in the air as an invisible, but infectious dust.

That, though the infectiousness of the bacillus is positive and unquestionable, on account of its slow growth it implants itself in the animal organism with some difficulty and only after a considerable lapse of time.

That the power of the bacillus to invade the animal organism, and the power of the animal body to resist the attacks of the parasite are very nearly equally balanced.

That this balance of power may be destroyed, in a way unfavorable to the person or animal attacked, by the repeated re-infection of the system, or by inborn or acquired conditions of debility.

That this balance of power may, on the other hand, be destroyed, in a way unfavorable to the parasite, by conditions or influences which strengthen the general powers of the individual, and probably by conditions or treatment inimical to the bacillus.

That heredity as a factor in the causation of tuberculosis is much less operative than was formerly supposed.

It will be seen therefore that though tuberculosis is an infectious disease, the sources of the bacillus are so few and so well defined, the channels of infection are now so well known, and the growth of the bacillus is surrounded by such limitations, that we can very gladly exchange our former belief in hereditary influence and inevitable fate for the recent one of infectiousness and the preventability of infection.

The importance of this new direction for public health endeavor is of the greatest-is worthy to engage the earnest attention of statesmen as well as sanitarians. The field is broad and the modern tendency to press toward urban and manufacturing centres makes the need of work imperative. Consumption has aptly been called by somebody the "great white plague." One of the leading English physicians lately in speaking of the ravages of this disease in his own country has said:

Tubercle at the present day carries off annually nearly 70,000 persons in the form of phthisis, at the ages between fifteen and forty-five, the most useful stages of human existence; it kills more than one-third of the people who die, and nearly half between fifteen and thirty-five. Moreover, in its prolonged and painful course it either prevents its victims from earning their livelihood, or at least interferes greatly with their daily work. Its habit of seizing upon the flower of the population, its slow but almost certain progress towards death, the utter misery of the last few months or weeks of

existence-all these are features in the fell disorder that render its study all-important not only to medical men but also to the statesman and to all who are concerned with the welfare of the nation *

In the German Empire from 170,000 to 180,000 die yearly from tuberculosis. In our own country Dr. D. E. Salmon, Chief of the Bureau of Animal Industry, estimates the annual number of human deaths from consumption at over 130,000; and the deaths from all forms of tuberculosis at 150,000.

CONSUMPTION AS AN INFECTIOUS DISEASE.

Since the publication of the last report, a large number of histories have come to my notice, mostly within the literature of the year in which the communicability of pulmonary tuberculosis is pretty well shown. The presentation of a few of them may serve a good purpose in helping to impress the fact, that the danger of infection is a real one.

Numerous experiments upon animals have shown that tuberculosis may readily be communicated to them by causing them to breathe air into which the tubercle bacillus has been diffused by the atomization of tuberculous matter, or of the pure artificial cultures of the bacillus. That tuberculosis may be communicated to human beings in the same way, the fool-hardiness of one person, at least, has shown. While Tappeiner was engaged in his inhalation experiments upon animals, he was assisted by a servant in his fortieth year, who had always been very strong and healthy, and was absolutely free from suspicion of hereditary taint. In spite of energetic and repeated warnings to keep out of the inhalation room this man, to show the freedom from danger in doing so, persisted in entering the room. In this way he acquired the same form of inhalation tuberculosis which he had so often seen given to dogs, and he died fourteen weeks afterwards. The post-mortem showed the same changes which had been previously found in the dogs that had been subjected to the experiments. §

Recently Vallin, in the French Academy of Medicine, told about a family, whose home the arrival of a consumptive brother transformed into a "house of the doomed," where five persons died of

*Lancet I, 1890, 531.

Centralblatt für al. Gesundheitspflege, VIII, 255. 1889.

Trans. Amer. Pub. Health Assoc., XIV., 92.

§Zeit. für Hygiene, V, 299.

consumption within three years. The family, living in the country in easy circumstances, consisted of father and mother, both of more than sixty years of age, but very healthy, and five children at ages from twenty-five to thirty-two years. The eldest son living in Paris, became consumptive, and, returning to the home of his parents, died in about six months. Within the two years that followed, there died in rapid succession, a sister of thirty, another of thirty-two, a third of twenty-seven, and finally a son-in-law, husband of one of these young women, who had continued to live with the rest of the family after his wife died. It may be added that the sisters who became infected occupied successively the same chamber in which their dead brother had passed the last month of his sickness. years later the lather died of apoplexy, and the mother was then living without a trace of tubercle.*

Ten

Dr. A. Ollivier,† physician to l'Hôpital des Enfants Malades, Paris, states that a family previously in robust health occupied two small rooms opening into a narrow court. The parents, a young son, and the baby, slept in one of the rooms. An older son, who had been living elsewhere contracted phthisis, returned home, and slept in the same apartment. He died January 16, 1883. His mother, who was constantly at his bedside, began to cough, emaciated and died of the same disease in the following May. Seven days after the death of the mother, her infant had tubercular meningitis, of which it perished, and a little later the older child who occupied the same apartment, sickened and died like the mother. The father only remained of those who occupied the small room, and his immunity was probably due to the fact that he was most of the time in the open air.

Dr. E. I. Kempf relates the following striking instance of infection (Louisville Medical News, March 22, 1884). In the fall of 1880, a girl of eighteen years, whose brother had died of consumption, was found to have tubercles at the apices of both lungs. She belonged to a sisterhood, and slept in the general dormitory with the other sisters. In four months nine of her companions began to cough, and were found to have tubercles. No one of the sisterhood had previously had disease of this kind.‡

Dr. Marfans gives an account of a local epidemic of pulmonary consumption which appears to have been due to infection. In the centre of Paris an office gave employment to twenty-two clerks. The wooden floor was old and uneven, and the building otherwise was far from being in a sanitary condition; but there appears to have been no cases of consumption among the employes before the one of which we are to speak. In 1878, a man who had been in the office twenty-four years, died of consumption after a sickness

*Revue D' Hygiene, XII, 56, 1890.

†Medical News, LV, 651, 1889.

Ibid.

§Semaine Med. quoted in Revue D'Hygiene, XII, 66, 1890.

of three years, during all of which time, excepting the last six months, he had been at his desk in the office, coughing and spitting upon the floor. Since this time, of the twenty-two employees, fifteen have died, one of cancer, and all of the others of consumption. Before the death of the first case, two other men who had been in the office six years, began to cough and spit upon the floor. They died in 1885. For a while the deaths succeeded each other at frequent intervals, the decedents having been in the office for periods of from two to twenty years. It appears to have been the custom to have the office swept every morning, and the sweeping was not usually completed before the arrival of some of the employees. When Dr. Marfan, head of the medical clinique of Paris, advised the office that the probable cause of the heavy mortality had been the inhalation of the infectious dust from the floor, the floor was promptly removed and burned and a new one laid. In future, the sweeping is to be done evenings after the departure of the clerks, and other precautions against the continuance of the trouble were taken.

INFECTION FROM THE ALIMENTARY CANAL.

In the preceding cases it is presumable that the infection was due to the inhalation of the virus, -the breathing in of the dried and pulverized sputa. In the following cases the infection was from the alimentary tract.

Dr. W. J. Wilson* observed the following case : B W., aged four months; family history good, and no trace of phthisis or syphilis discoverable in either family. Had had no previous illness, was plump, fat, and well-nourished. The mother was forced to wean the child when about a month old, and it was fed on cow's milk from a bottle, and thrived well for a time, having no digestive troubles. It was attended by a nurse, who was well advanced in consumption, and had free expectoration. The child slept with the nurse, and, consequently, was much exposed to her breath. Nothing unusual was noticed in the child's condition for the first three or four weeks after the nurse's arrival, when it began to loose flesh and cough slightly. This cough and wasting gradually increased, and finally Dr. Wilson was called in. On examination he found well marked and far advance phthisis, with frequent cough and great emaciation. The child died in its eighth month, three months after the first symptons were noticed. The same nurse who, later on died of consumption, attended five other children, and four out of the five died of some wasting disease, but as Dr. Wilson did not see any of them he was unable to state its nature.

*Canadian Practitioner, quoted by Health Journal, XI., 116.