TUBERCULOSIS, A SCOTCHED SNAKE

I

One of the darling habits of humanity is to discover that we are facing a crisis. One could safely offer a large prize for a group of ten commencement orations, or political platforms, at least a third of which did not announce this momentous fact. Either we are facing it or it confronts us, and unutterable things will happen unless we “gird up our loins,” and vote the right ticket. An interesting feature about these loudly heralded crises is that they hardly ever “crise.” The real crisis either strikes us so hard that we never know what hit us, or is over before we recognize that anything was going to happen. And most of our reflections about it are after ones-trying to explain what caused it. In fact, in public affairs, as in medicine, a crisis is a sign of recovery. Its occurrence is an indication that nature is preparing to throw off the disease. Nowhere is this truth more vividly illustrated than in the tuberculosis situation. When, about thirty years ago, the world began to awake from its stupor of centuries, and to realize that this one great disease alone was killing one-seventh of all people born under civilization, and crippling as many more; that its killed and wounded every year cast in the shade the bloodiest wars ever waged, and that it was apparently caused by the civilization which it ravaged,-no wonder that we were appalled at the outlook.

Here was a disease of civilization, caused by the conditions of that civilization. Could it be cured without destroying its cause and reverting to barbarism? Yet this very apprehension was a sign of hope, a promise of improvement. That we were able to feel it was a sign that we were shaking off the old fatalistic attitude toward disease,-as inevitable or an act of Providence. It was brought about by the more accurate and systematic study of disease. We had long been sadly familiar with the fact that death by consumption, by “slow decline,” by “wasting” or “slow fever,” was frightfully common. “To fall into a decline” and die was one of the standard commonplaces of romantic literature. But that was quite different from knowing in cold, hard figures and inescapable percentages exactly how many of the race were killed by it. It is one of the striking illustrations of the advantages of good bookkeeping. Boards and departments of health had just fairly got on their feet and started an accurate system of state accounts in matters of deaths and births. We were beginning to recognize national health as an asset, and to scrutinize its fluctuations with keen interest accordingly.

We may decry statistics as much as we like, but when we see the effects of a disease set down in cold columns of black and white we have no longer any idea of submitting to it as inevitable. We are going to get right up and do some fighting. “One-seventh of all the deaths” has literally become the war cry of our new Holy War against tuberculosis. Still another stirring phrase of inestimable value in rousing us from our torpor was that coined by the brilliant and lovable physician-philosopher, Oliver Wendell Holmes: “The Great White Plague of the North.” This vivid epithet, abused as it may have been in later years, was of enormous service in fixing the public mind on consumption as a definite, individual disease, something to be fought and guarded against. Before that, we had been inclined to look upon it as just a natural failing of the vital forces, a thing that came from within, and was in no sense caused from without. The fair young girl, or the delicate boy whose vitality was hardly sufficient to carry him through the stern battle of life, under some slight shock, or even mental disappointment, would sink into a decline, gradually waste away, and die. What could be done in such a case, except to bow in submission to the inscrutable ways of Providence?

It seems incredible now, but such was the light in which smallpox was regarded by physicians of the Arabian and mediaeval schools: a natural oozing forth of “peccant humors” in the blood of the young, a disagreeable, but perfectly natural, and even necessary, process. For if the patient did not get rid of these humors either he would die or his growth would be seriously impaired. Now smallpox has become little more than a memory in civilization, and consumption is due to follow its example.

Sanitary pioneers had already begun casting about eagerly for light upon the influence of housing, of drainage, of food, in the causation of tuberculosis, when a new and powerful weapon was suddenly placed in their hands by the infant science of bacteriology. This was the now world-famous discovery by Robert Koch that consumption and other forms of tuberculosis were due to the attack of a definite bacillus. No tubercle bacillus-no consumption.

At first sight this discovery appeared to be anything but encouraging. In fact, it seemed to make the situation and the outlook even more hopeless. And when within a few years it was further demonstrated in rapid succession that most of the diseases of the spine in children, of the group of symptoms associated with enlarged glands or kernels in the neck and known as “scrofula” or struma, most cases of hip-joint disease, of white swelling of the knee, a large percentage of chronic ulcerations of the skin known as lupus, a common form of fatal bowel disease in children, and many instances of peritonitis in adults, together with fully half of the fatal cases of convulsions in children, were due to the activity of this same ubiquitous bacillus, it looked as if the enemy were hopelessly entrenched against attack. And when it was further found that a similar bacillus was almost as common a cause of death and disease in cattle, particularly dairy cattle, and another in domestic fowls, it looked as if the heavens above and the earth beneath were so thickly strewn and so hopelessly infested with the germs that to war against them, or hope to escape from them, was like fighting back the Atlantic tides with a broom.

But this chill of discouragement quickly passed. Our foe had come down out of the clouds, and was spread out in battle array before us, in plain sight on the level earth. We were ready for the conflict, and proposed to “fight it out on this line if it takes all summer.” It was not long before we began to see joints in the enemy’s armor and weaknesses in his positions. Then, when we lowered our field-glasses and turned to count our forces and prepare for the defense, we discovered with a shock of delighted relief that whole regiments of unexpected reinforcements had come up while we were studying the enemy’s position. These new allies of ours were three of the great, silent forces of nature, which had fallen into line on either side and behind us, without hurry and without excitement, without even a bugle-blast to announce their coming.

The first was the great resisting power and vigor of the human organism, which we had gravely underestimated. The second, that power of adaptation to new circumstances, including even the attack of infectious diseases, which we call “survival of the fittest.” The third, that great, sustaining, conservative power of nature-heredity. More cheering yet, these forces came, not merely fully armed, but bearing new weapons fitted for our hands. The vigor and unconquerable toughness of the human animal presented us with three glittering weapons, sunshine, food, and fresh air.

“If the deadly bacillus breaks through the lines, put me in the gap! With these weapons, with this triad, I will engage to hurl him back, shattered and broken.” “Equip your vanguard with them, and the enemy will never break the line.”

The survival of the fittest held out to us two weapons of strange and curious make, one of them labeled “immunity,” the other “quarantine.” “Give me a little time,” she said, “and with the first of these I will make seven-tenths of the soldiers in your army proof against the spears of the enemy, as Achilles was when dipped in the Styx. With the other, surround and isolate every roving band of the enemy that you can find; drive him out of the holes and caves in which he lives, into the sunlight. Hold him in the open for forty-eight hours, and he will die of light-stroke and starvation. Divide and conquer!”

These reinforcements of ours have proved no mere figure of speech. They have won many a battle for us already upon the tented field. They have not merely made good their promises, but gone beyond them, and we are only just beginning to appreciate their true worth, and how absolutely we can rely upon them.

The first outpost of the enemy was captured with the sunshine-food-air weapons, and a glorious victory it was,-great in itself, and even more important for its moral effect and its encouragement for the future. To pronounce an illness “consumption” had been from time immemorial equivalent to signing a death-warrant. Even the doctors could hardly believe it, when the first open-air enthusiasts began to claim that they had actually cured cases of genuine consumption. For long there was a tendency to mutter in the beard, “Well, it wasn’t genuine consumption, or it wouldn’t have got better.”

But after a period of incredulity this gave way to delighted confidence. The open-air method would cure, and did cure, and the patients remained cured for years afterward. Our first claims were barely for twenty-five or thirty per cent of the threatened victims. Then we were able to increase it to fifty per cent; sixty, seventy, and finally eighty were successively reached. But with the increase of our power over the cure of this disease came a realization of our knowledge of its limitations. It quickly proved itself to be no sovereign and universal panacea, which would cure all cases, however desperate, or however indiscriminately it was applied. And emphatically it had to be mixed with brains, on the part both of the physician and of the patient.

In the first place, the likelihood of a cure depended, with almost mathematical certainty, upon the earliness of the stage at which it was begun. Eight or ten years ago the outlook crystallized itself into the form which it has practically retained since: of cases put under treatment in the very early stage, from seventy to ninety per cent were practical cures; of ordinary so-called “first-stage” cases, sixty to seventy per cent; second-stage cases, or those in whom the disease was well developed, thirty to sixty per cent; and well-advanced cases, fifteen to thirty per cent of apparent cures. The crux of the whole proposition lies in the early recognition of the disease by the physician, and the prompt acceptance of the diagnosis by the patient, and his willingness to drop everything and fight intelligently and vigorously for his life. Physicians are now thoroughly awake on this point, and are concentrating their most careful attention and study upon methods of recognition at the earliest possible stages. At the same time those magnificent associations for the study and prevention of tuberculosis, international, national, state, and local,-the greatest of which, the International Tuberculosis Congress, has just honored America, by meeting in Washington,-are straining every nerve to educate the public to understand the importance of recognizing the earliest possible symptoms of this disease, no matter how trivial they may appear, and making every other consideration bend to the fight.

This new Word of Power, the open-air treatment, alone has transformed one of the most hopeless, most pathetic, and painful fields of disease into one of the most cheerful and hopeful. The vantage-ground won is something enormous. No longer need the family physician hang back, in dread and horror, from allowing himself even to recognize that the slow loss of weight, the increasing weakness, the flushed evening cheek, and the restless sleep, are signs of this dread malady. Instead of shrinking from pronouncing the patient’s doom, he knows now that he has everything to gain and nothing to lose by promptly warning him of his danger, even while it is still problematical. On the other hand, the patient need no longer recoil in horror when told that he has consumption, and either go home to set his house in order and make his will, or hunt up another medical adviser who will take a more cheerful view of his case. All that he has to do is to turn and fight the disease vigorously, intelligently, persistently, with the certain knowledge that the chances are five to one in his favor; and that’s a good fighting chance for any one.

Even should there be reasonable ground for doubt as to the positive nature of the disease, he has nothing to lose and everything to gain by taking the steps required to cure it. There is nothing magical or irrational, least of all injurious, in any way about them. Simply rest, abundant feeding, and plenty of fresh air. Even if the bacillus has not yet lodged in his tissues, this treatment will relieve the conditions of depression from which he is suffering, and which would sooner or later render him a favorable lodging-place for this omnipresent, tiny enemy.

If he has the disease the treatment will cure it. If he hasn’t got it, it will prevent it; and the gain in vigor, weight, and general efficiency will more than pay him for the time lost from his business or his study. It always pays to take time to put yourself back into a condition of good health and highest efficiency.

It was early recognized that the campaign could not be won with this weapon alone. Inexpressibly valuable and cheering as it was, it had obvious limitations. The first of these was the obvious reflection that it was idle to cure even eighty per cent of all who actually developed tuberculosis, unless something were done to stop the disease from developing at all. “Eighty per cent of cures,” of course, sounds very encouraging, especially by contrast with the almost unbroken succession of deaths before. But even a twenty per cent mortality from such a common disease, if it were to proceed unchecked, would make enormous inroads every year upon our national vigor.

Secondly, it was quickly seen that those who recovered from the disease still bore the scars; that while they might recover a fair degree of health and vigor, yet they were always handicapped by the time lost and the damage inflicted by this slow and obstinate malady; that many of them, while able to preserve good health under ideal conditions, were markedly and often distressingly limited in the range of their business activities for years after, and even for life. Finally, that as these cases were followed further and further, it was found that even after becoming cured they were sadly liable to relapse under some unexpected strain, or to slacken their vigilance and drop back into their former bad physical habits; while the conviction began to grow steadily upon men who had devoted one, two, or more decades to the study of this disease in the localities most resorted to for its cure, that the general vigor and vitality of these cured consumptives were apt to be not of the best; that their duration of life was not equal to the average; and that, even if they escaped a return of the disease, they were apt to go down before their normal time under the attack of some other malady. In short, cure was a poor weapon against the disease as compared with prevention.

But before this, a careful study of the enemy’s position and investigation of our own resources had brought another most important and reassuring fact to light, and that is, that while a distressingly large number of persons died of tuberculosis, these represented only a comparatively small percentage of all who had actually been attacked by the disease. One of the reasons why consumption had come to be regarded as such a deadly disease was that the milder cases of it were never recognized. It was, and is yet, a common phrase in the mouths of both the laity and of the medical profession: “He was seriously threatened with consumption”; “She came very near falling into a decline,”-but they recovered. If they didn’t die of it, it wasn’t “real” tuberculosis. Now we have changed all that, and have even begun to go to the opposite extreme, of declaring with the German experts, “Jeder Mann ist am ende ein bischen tuberkuloese.” (Every one is some time or another a little bit tuberculous.) This sounds appalling at first hearing, but as a matter of fact it is immensely encouraging. Our first suspicion of it came from the records of that gruesome, but pricelessly valuable, treasure-house of solid facts in pathology-the post-mortem room, the dead-house. Systematic examinations of all the bodies brought to autopsy in our great hospitals and elsewhere revealed at first thirty, then, as the investigation became more minute and skillful, forty, sixty, seventy-five per cent of scars in the apices of the lungs, remains of healed cavities, infected glands, or other signs of an invasion by the tubercle bacillus. Of course, the skeptic challenged very properly at once:-

“But how do you know that these masses 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, scraping 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 scrapings or sections from these scar-masses 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 antitoxic 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 mass.

It gave one a distinct shock at the meeting of the British Medical Association devoted to tuberculosis, some ten years ago, to hear Sir Clifford Allbutt, 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 asset 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 antitoxin, 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 antitoxins 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 masses of the centre of our anti-tuberculosis army, upon which we depend for the heavy, mass 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 assault 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, succumbed 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 class. 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.