Popular Science Monthly/Volume 48/November 1895/Consumption Considered as a Contagious Disease
|CONSUMPTION CONSIDERED AS A CONTAGIOUS DISEASE.|
By A. L. BENEDICT, M. D.
A FEW years ago the newspapers were discussing rumors of the advent of leprosy in this country. Many were apprehensive of an epidemic of this disease, whose very name suggests all that is unclean, horrible, and loathsome. Although official reports made it certain that the lepers who had reached our shores were few, and that comparatively simple precautions could prevent the spread of the disease, public sentiment demanded the most rigorous quarantine and the sending back of those lepers who had already landed.
But there is in our midst another leprosy whose victims we meet, not outside the city wall warning us of their presence with the cry "Unclean! unclean!" but who walk the public streets, whom we meet in our places of business and amusement, in social gatherings, and, too frequently, in our very homes. It is doubtless a surprise that consumption should be mentioned in terms applicable to leprosy, but investigation shows that a close analogy may be drawn between the two diseases. Consumption or phthisis, as either word implies, is a consuming or wasting disease, characterized by a progressive failure of strength and an almost certain tendency toward death. Although the exact lesions differ in different cases, the essential nature of consumption is in inflammation, excited by a small germ which, magnified five hundred times, is just visible as a minute hyphen, usually tilted up at one end.
The same germ the—Bacillus tuberculosis—may lodge in bones, joints, the intestines, the membranes of the brain, and, in fact, in almost any part of the body. Thus, consumption is only a special manifestation of the general disease—tuberculosis. The germs are not merely thorns in the fleshy producing a local inflammation, but they are plants which multiply rapidly, and form in their growth poisons as dangerous to life as if they were elaborated in one large plant instead of millions of small ones.
The germ of leprosy is very like that of tuberculosis. In both diseases, little masses of inflammatory tissue form around the bacilli, and then, not having the vitality of normal structures, these break down, involving other parts in their own destruction. Leprosy attacks chiefly those parts of the body which are exposed, like the hands, feet, arms, and legs, though it occasionally invades the mucous membranes, and it is seen in the nose, mouth, and throat. Tuberculosis, on the other hand, seeks the deeply seated organs by preference, though it, too, may affect the throat; and many of the so-called scrofulous sores are tubercular. Leprosy thrusts out its hideous deformities and disgusting ulcers to the gaze of the passer-by; tuberculosis hides its devastations beneath an exterior which may be even beautiful. The greater sufferer from fever, lassitude, and pain is the consumptive. So, too, is his mental suffering greater, since the leper is usually a person who has lived in filth and squalor, while the tubercular patient is more likely than not to be one who has worked hard to gratify some ambition and who feels more keenly than bodily pain the necessity of abandoning active life. Leprosy is not a rapidly fatal disease, usually lasting from nine to twenty years after its recognition. Consumption fortunately does not allow its victims to linger so long, but kills in from one to four years in the great majority of cases.
In order to see how formidable an enemy we have in tuberculosis, let us contrast it with some other diseases which are even more dreaded. Leprosy is rare in most civilized countries; even in Asia Minor it causes less than one per cent of the total death rate. Typhoid and scarlet fevers are each held responsible for three per cent; diphtheria and pneumonia, for five per cent each. The deaths from consumption alone, omitting such tubercular troubles as hip-joint disease. Pott's disease of the spine, some forms of meningitis, intestinal marasmus, caries of bone, and many abscesses, make up, according to one authority, about twenty per cent of the total death rate of this country. It is estimated that one third of all deaths occurring in the medical wards of hospitals are due to tuberculosis, and that a fifth of all surgical cases treated—many of which are cured—are tubercular. We may bring these statistics home by saying that you and I were born with one chance in five of dying of some form of tuberculosis. If our chance of being instantaneously and decently killed by an electric shock were one in five hundred, we would turn the wheels of progress back twenty years rather than allow an electric light or a trolley car to threaten our safety. No pains and no expense are thought too great in maintaining a quarantine against cholera, smallpox—which the sensible part of the community is already vaccinated against—diphtheria, and the like. Large appropriations are made that there may be tried a yet unproved defense against diphtheria, but to the insidious enemy that numbers its dead by hundreds where these other open foes count theirs by scores we are blind. It is time that the veil should be drawn from the loathsomeness of "the great white scourge," that the false sentiment which poetry and prose have thrown over infection, blood poisoning, suppuration, and decay should be dissipated.
In the case of a disease so fatal and so general as tuberculosis, the considerations of cause and prevention become all-important, especially since few cases are curable. The most sanguine authority on the subject—a New York physician whose patients can command every means of relief, and who usually seek medical advice at the first suspicion of illness—claims to cure only one consumptive out of six. Most physicians would consider this an extremely high proportion, while with regard to well-established cases there is no question that all or nearly all end in death.
It has been demonstrated by the experimental inoculation of guinea-pigs and other animals that the tubercle bacillus needs no dormant period outside the body—such as is requisite for certain other germs—but that the disease is directly transmissible. There are two factors in the establishment of any disease the presence of the germ and a certain predisposition. It is not a metaphor but a plain statement of fact to compare the former to the planting of a vegetable, the latter to the adaptability of the soil. Some germs will thrive only under the most favorable conditions, others will grow in almost any person. In other words, some diseases are liable to occur only under definite circumstances of predisposition, and these may be readily prevented, while others are virulent, attacking whole communities at once. Fortunately, the latter usually "exhaust the soil," so that if the patient recovers from one attack he is not liable to a second, though there are exceptions to all such rules. Measles, scarlet fever, smallpox in fact, nearly all the eruptive fevers—find the proper soil in almost every body, but the something on which they thrive is exhausted, so that thereafter an immunity exists. Tuberculosis never "exhausts the soil." Even if the patient recovers as not infrequently happens in surgical cases, hip-joint disease, inflammation of bones, etc. he is always liable to a subsequent attack of tubercular disease, not necessarily in the same organ. On the face of the matter it would seem that a germ that kills a fifth or, to give the lowest estimate, a tenth—of the civilized human race is not very exacting as to the soil afforded. Yet until recently consumption has not been recognized as a contagious disease, and the factor of predisposition, as determined by heredity, lack of proper air and exercise, failure of vital strength, impoverished blood, "weak lungs," etc., has been considered paramount. It is certainly true that a robust person may be placed in the most intimate contact with the germs of tuberculosis and throw them off or inclose them as inert foreign bodies in his tissues; on the other hand, nearly every one is at one time or another susceptible to tuberculosis and escapes or becomes a victim according as he is free from or is exposed to contagious influences. A mother and her baby, for instance, both die of consumption and heredity is blamed. But does the child inherit the bacilli, or does it imbibe them in the milk—where they have been repeatedly found—or are they inhaled as the mother bends over the child and smothers it with kisses? Again, brothers and sisters drop off' one after another, and it is said that "consumption runs in the family"; but we would seek another explanation if the same succession of deaths were due to scarlet fever. Tubercle bacilli have been found in the dust on the top of the door and window casings, in carpets, bedding, and wall paper. Is it not rational to suppose that these foci of infection have more to do with the death of successive members of the family than a hereditary taint? When we note that members of the family who leave home escape the disease and that other persons occupying the same house later contract it, is not the evidence tolerably clear? Are not husbands and wives, roommates, and other persons intimately associated almost as likely to follow one another with consumption as if there were a blood relationship? Such questions can only be fully answered by a careful collection of statistics, taking advantage of the experiments of chance; enough evidence has been already gathered to warrant the adoption of the contagiousness of tuberculosis as a practical basis for preventive measures.
The predisposing tendencies to tuberculosis may be modified, often absolutely removed, by hygienic and tonic treatment. If, however, any systematic attempt is to be made to stamp out the disease, such an attempt as has been eminently successful in the case of cholera and smallpox, it must depend upon isolation and disinfection. We may logically hope to be able to vaccinate against any disease which occurs but once in a lifetime—that is to say, we may dwarf the germs so that their growth will occasion no dangerous symptoms while they will still "exhaust the soil" so as to prevent a subsequent development of the corresponding unmitigated germs. This hope has been realized only in the case of smallpox, but it is quite likely that the bacteriological horticulturist may learn to dwarf the germs of scarlet fever, typhoid, and similar diseases. Diseases, on the other hand, which are essentially chronic, which remain or recur without a tendency to self-limitation, must be attacked in another manner. The failure of Koch's tuberculin was simply an illustration of this general principle.
At present the main obstacle to the carrying out of measures of quarantine against tuberculosis is public sentiment. Public sentiment requires all smallpox patients to be sent to a pest house, though, with rare exceptions, such patients can be of danger only to the ignorant who have refused vaccination. Public sentiment kept a poor Chinese leper confined in a bare stone cell with almost the same neglect of humanity as characterized the treatment of prisoners in the dark ages. Public sentiment checked immigration and commerce in the effort to quarantine against cholera. Yet this same public sentiment would characterize as barbarous the isolation of consumptives, with every provision for their comfort, in hospitals so arranged as not only to prevent the spread of the disease, but to afford every possible chance for the relief or cure of their inmates.
While yielding to the inevitable, something may still be done to limit the spread of tubercular disease without removing the consumptive from his customary associations. Barring surgical tuberculosis, in which the ordinary antiseptic dressings and the destruction of old bandages by fire will suffice, we have to contend against the dissemination of germs by the various excretions of the body. Fortunately, in the vast majority of instances we can restrict our attention to the expectorated matter. Few germs are exhaled in the breath, yet it is unwise for any one with a severe cold or bronchitis to be in the same room with a consumptive, and no one should sleep night after night in the same bed. If it is absolutely necessary for an attendant to sleep in the same room, the freest ventilation should be insisted on.
Our sleeping cars are, I believe, a positive source of infection. A considerable proportion of travelers are consumptives seeking warmer or drier climates. An almost equal number are persons predisposed to the disease, but not yet infected, going to the same resorts to escape our northern winters. Imagine such a person passing three or four days in the confined air of a palace car, with several consumptives sleeping in a berth whose hangings have been infected from the exhalations of consumptives on previous trips, and, on reaching his destination, spending a number of months at a hotel which is practically a hospital for consumptives! In many instances public hospitals are breeding places for tuberculosis, patients with various depressing ailments, including those that render the lungs particularly vulnerable, being assigned to wards occupied also by consumptives. Such instances are more often due to lack of funds than to a failure to appreciate the danger.
The idea is apparently widely entertained that sidewalks and the floors of public conveyances and buildings are a sort of ever-ready cuspidor. The habit of ubiquitous expectoration—always disgusting and unnecessary in health—becomes dangerous when practiced by consumptives. Sweeping trains catch a surprising amount of filth, and tubercle bacilli as well as other germs have been found in the skirts of ladies' dresses, whence they may be introduced into houses. How often do we see a consumptive shivering over a register and dropping the scourings of the cavities in his lungs down the hot-air pipe, to be dried and disseminated throughout the building 1 An apparatus, differing only in detail from the ordinary register, is used in laboratories for the experimental inoculation of guinea-pigs with tuberculosis.
On the other hand, the consumptive must not swallow the infectious material raised from the lungs, for, by so doing, he might set up tubercular inflammation of the stomach and intestine. The expectoration should take place into a cup that can be readily disinfected, or into a waterproof-paper receptacle that can be burned. For disinfection, strong carbolic acid or a solution of zinc chloride may be used, and the disinfectant must remain in contact with the sputum for a long time; preferably the cup should always contain some of the solution. For use away from home, pocket cuspidors, or those fitted into canes, may be used. The sputum should never be allowed to dry. Handkerchiefs, sheets, etc., should be boiled for at least half an hour so resistant are the tiny plants that cause the trouble—apart from other clothing.
The communication of tuberculosis through cow's milk is at length obtaining the attention that it deserves. Milk once infected can not be made safe except by such treatment as will seriously interfere with its nutritious qualities. Ordinary germs of putrefaction may be killed by boiling, or even by letting the milk stand in water previously brought to the boiling point, but the only satisfactory dealing with tuberculous milk is destruction at the hands of Government inspectors.
So long as tubercular patients are allowed the freedom of social intercourse they must be held to the moral obligation of certain restrictions. Kissing has been called an elegant method of transmitting disease. Consumptives must hold their affection in check; above all, they must not kiss little children, whose resistance to disease is slight. They must recognize the necessity, if they are not to be isolated from their surroundings, of isolating from themselves children and those at all inclined to tubercular trouble. Cleanliness of habit and thorough disinfection of sputum must largely depend upon the conscientiousness of consumptives themselves. All these precautions involve a great amount of self-sacrifice on the part of those affected with this terrible disease; they necessitate the realization of certain facts which we would gladly keep from the sufferer; they demand a sacrifice of sentiment on the part of those near and dear to the patient. To this extent the attempt to exterminate the greatest plague of civilization is cold-blooded. But a worse alternative confronts us. So long as we neglect to consider tuberculosis as a contagious disease, though not so conspicuously so as the eruptive fevers; so long as we occupy homes in which the germs of this disease linger, neglecting to disinfect, repaint, and repaper; so long as sick and well mingle without an effort to destroy the virus, so long will the great white scourge shorten valuable lives and bring mourning on millions. Because its foulness is concealed, because it strikes painlessly and its wound is not felt for weeks or months, because it does not mark its victims in letters of red or choke them in a week with a visible mass of poison, shall we ignore the fact that this insidious, relentless foe is the chief lieutenant of Death?