{Reprinted from the Special Number of THE PHILADELPHIA MEDICAL
JOURNAL on Tuberculosis, December 1, 1900. |

ON THE STUDY OF TUBERCULOSIS.*

By WILLIAM OSLER, M.D.,
of Baltimore, Md,

Tue history of the acceptance of any great truth in
medicine is an interesting study. A slow, gradual
recognition seems essential to permanency and stability.
As Locke well said, “ Truth scarce ever yet carried it by
vote anywhere at its first appearance.” Even in this
electric age the practical application of new knowledge
is singularly tardy. Antiseptic surgery took twenty
years to win its victory, and for about the same period
we physicians have been participants in another long
warfare, the successful outcome of which may be said to
be now in sight. The twentieth anniversary of the dis-
covery of the germ of tuberculosis by Robert Koch is
near at hand—a discovery which, in far-reaching results,
will prove to have had few equals in human history.
Since 1881 the laboratory phase of the question, with its
experiments and researches, has so far been the most
complete; the clinical side has been enriched with two
facts of supreme importance; first, the earlier and more
positive diagnosis of the disease; and, second, a fuller
knowledge of the means for its cure; and we have now
entered upon an economic stage, and the tuberculosis
leagues and congresses, laws and enactments, show how
alive we have become to the importance of the disease
in national and eivic life.

I. General Relations of Tuberculosis.—If we compare
the mortality bills of any large city today with those of
fifty years ago, the most striking change is in a reduc-
tion of the deaths from fever, and in the absence of the
names of certain diseases which were formerly amongst
the most fatal of their kind. Public hygiene has done
a great work in ridding us of several of the great scourges,

 

* Introductory Remarks at the organization of a Society for the Study of
Tuberculvsis, Johns Hopkins Hospital, Octuber 30, 1900.
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and in lessening the danger from such epidemics as
cholera and yellow fever. Of the 10,152 persons who died
last year in this city, 3,765 were victims of the infectious
diseases. Measles, scarlet fever, diphtheria, whooping-
cough, influenza and dysentery together accounted tor
801. Three diseases head the list, each one as fatal as
all the others combined; tuberculosis of the lungs
974, pneumonia 778, and cholera infantum 703.
If we add the deaths due to tuberculosis of other
organs, we are well within the mark in saying that one-
tenth of the deaths in this city are due to this disease.
It is estimated that above a million of persons are suf-
fering with consumption alone in this country, of whom
at least 150,000 die annually. The white plague, as
Holmes called it, is the great scourge of the race, kill-
ing more than 5,000,000 yearly. Let me read you an
abstract from De Quincy, which, while expressing an
old, erroneous idea, gives in his strong and character-
istic language the terrible, the appalling nature of
this annual slaughter. “ Are you aware, reader, what
it is that constitutes the scourge (physically speaking)
of Great Britain and Ireland? All readers, who direct
any part of their attention to medical subjects, must
know that it is pulmonary consumption. If you walk
through a forest at certain seasons, you will see what is
called a blaze of white paint upon a certain élite of the
trees marked out by the forester as ripe for the axe.
Such a blaze, if the shadowy world could reveal its
futurities, would be seen everywhere distributing its
secret badges of cognizance amongst our youthful men
and women. Of those that, in the expression of Peric-
les, constitute the vernal section of our population,
what a multitudinous crowd would be seen to wear
upon their foreheads the same sad ghastly blaze, or
some equivalent symbol of dedication to an early grave.
How appalling in its amount is this annual slaughter
amongst those that should by birthright be specially
the children of hope, and levied impartially from every
rank of society! Is the income-tax or the poor-rate,
faithful as each is to its regulating tide-tables, paid by any
class with as much punctuality as this premature florile-
gium, this gathering and rendering up of blighted blos-
soms by all classes? Then comes the startling question
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—that pierces the breaking hearts of so many thousand
afflicted relatives—Is there no remedy? Is there no
palliation of the evil?” Let us be thankful that we
can answer today—There is !

II. Some Special Features of Tuberculosis as a Subject of
Study—In a comprehensive view of the diseases which
we are called upon to study, three only are of wide and
universal interest—tuberculosis, cancer, and syphilis.
In almost every particular tuberculosis out-tops the
others. It isa disease of extensive distribution among
animals, in which the veterinarian is interested equally
with us. The general surgeon must know it thoroughly,
and it occupies his thoughts almost as much as cancer,
and his hands more than syphilis. The specialist must
be familiar with its manifestations. Though not a dis-
ease upon which the specialist thrives, the laryngologist,
the neurologist, the gynecologist, and the dermatologist
see cases almost daily. Syphilis has a more enduring
grasp, and, not content to follow man from the
cradle to the grave, nips the fruit in the bud, and
more often brands and maims than kills. Tubercu-
losis and cancer respect the embryo, and are not fac-
tors in intrauterine pathology. In many ways syphilis
is the most benign of the three. There is a silver lining
on the luetic cloud, which we never see in cancer, and
not often enough in tuberculosis. And yet tuberculosis,
which is a more serious disease than the others combined,
offers a greater hope of a reduction in its ravages. _We
know the cause, the conditions under which the germs
thrive and the modes of infection. and the public is at
last awake to the importance of the subject, as shown
by the remarkable manifestation of national and civic
interest during the past few years. We have reached
agreement on two points; first, the right of the State to
insist that a tuberculous patient shall not be a source of
danger to others, (and to this end there must be some
supervision, to the extent at least of notification of the
cases); and, secondly, the duty of the State, of civic
authorities, or of private benefaction to provide suitable
accommodation for the poor consumptives. The danger
is not from the few well-to-do patients, in whose en-
vironments there may be less risk of infection than else-
where. A person would probably run less risk of
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“catching” consumption in the Adirondacks’ sana-
torium than living in the tenement districts of New
York, or in the Jewish quarter of this city.

Til. The Physician as a Student of Tuberculosis —The
brunt of the battle in the warfare against. tuberculosis
falls on the medical profession. We must not only be
alive to our duties, but thoroughly prepared to carry
them out. If aman looks back on the best work of
his life he will find it to be that for which perhaps
he has had the least acknowledgment from the pub-
lic or his colleagues in either cash or credit; and so
it must ever be with the work of the units of our army, °
and particularly in their crusade against tuberculosis.
Within the past ten years there has been an extraordi-
nary change in the attitude of the average doctor to the
question of consumption ; he is more expert in the early
recognition of the disease; he appreciates the conditions
under which cure may be expected, and he is more
ready to take every advantage of the opportunities
offered by the health boards and their laboratories; but
I must confess he still very often lacks the enthusiasm
which is necessary to make a strong fighter. I know
how hard it is in general practice, particularly among
the poor, to carry out instructions which we rattle off so
glibly or write down with so much self-satisfaction, but
physicians cannot escape from their responsibility in
this matter. To them the public must turn for help,
since they alone can insist that the tuberculous patients
shall live a hygienic life, and when all fully realize their
duties we may look for a marked reduction in the inci-
dence of the disease. The really serious peril is the
prevalence of the disease among the poorer classes, who
live in the smaller houses and tenements, who for the
most part have no physicians to advise and instruct
them, and who seek aid at the hospitals and dispensa-
ries. Two years ago I was much impressed with the
number of such cases applying at our out-patient de-
partment of the Johns Hopkins Hospital, and some
kind friends placed at my disposal a sum of money
which was to be used to promote the study of tubercu-
losis, and to diffuse among the poor a proper knowledge
of how to guard against the dangers of the disease. A
plan of systematic visiting of each applicant was organ-
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ized, and Miss Dutcher will speak of her experience
during the past year. It was felt that if a well-informed
and sympathetic person paid a visit to the house, saw
the conditions under which the patient lived, directions
could be given with much more likelihood’ that they
would be carried out. Valuable information could also
be obtained as to the mode of life and surroundings of
these people.

This Society hag been organized to promote the study
of tuberculosis among the physicians and surgeons of
the Hospital, the senior students of the Medical School,
and any physicians who may wish to attend our meet-
ings. Believing in the inspiration of great names, we
have called it after the name of the greatest student of
the disease. An historical review of the great epochs,
a minor item relating to the symptomatology of the dis-
ease, a critical summary of the conditions relating to
tuberculosis in the country at large and in this city,
together with a presentation from each of the depart-
ments of the work upon tuberculosis in the Hospital
during the first decade, will constitute our program for
the session.