THE NECESSITY OF SPECIAL INSTITUTIONS FOR THE CONSUMPTIVE POOR. THE FIRST STEP TOWARD THE COMPLETE ERADICATION OF TUBERCULOSIS. H. LONGSTREET TAYLOR, A. M., M. 0. Member of the American Climatological Society; American Medical Asso- ciation; Ramsey County Medical Society, etc. ST. PAUL. REPRINT FROM NORTHWESTERN LANCET. DECEMBER 15, lb93. THE NECESSITY OF SPECIA/, INSTITU- TIONS FOR THE CONSUMPTIVE POOR. THE FIRST STEP TOWARD THE COM- PLETE ERADICATION OF TUBERCU- LOSIS. Member of the American Climatological Society; American Medical Association; Ramsey County Medical Society; etc. By H. Longstreet Taylor, A. M., M. D. St. Paul. This is an age when a great deal is being done on all sides to help the unfortunate members of so- ciety. Almost no class of sufferers has been over- looked. The missionary spirit, not content with good works to its neighbors, stretches its helping hands across oceans and continents,and in the most remote quarters of the globe extends the consola- tion of religious teaching, and also more material comforts to the most benighted tribes of men. Homes for orphans, for widows and for the aged; refuges for the fr.iendless and outcasts; in- stitutions where foundlings are reared and cared for; reformatories for men, women and children; asylums for those bereft of their reason; colonies for the care of epileptics; hospitals special and general; churches and schools, convents and mon- asteries innumerable; all of these and many more attest the truth of the declaration in the opening paragraph, many of them enduring monuments of hardest stone and classic architecture which will 2 stand for all time as silent witnesses to the spirit of charity that gave them birth. Too much praise cannot be given to those who, having wealth, have turned it in part or as an entirety into channels that would bring happiness to other hearthstones, even if in all this flood of liberality and generous help one large class of sufferers has been almost entirely overlooked. While many are the recip- ients of so much charity and attention for ills which they have brought on themselves by their own follies and vices, these unfortunates are suffering from a condition transferred to them from others by the neglect of the state in not putting an end to it, and are themselves spreading it unwit- tingly right and left, among rich and poor, the high and the low, at such a rate that one individ- ual in seven falls a victim. This acquired condi- tion is one, too, which would yield to scientific care and treatment if applied early, but which once past this borderland of safety destroys nearly every victim it fastens upon. It is indeed difficult to explain, with all the boasted advantages of the nineteenth century, why such preventable misery should be allowed to grow and flourish. This is all the more surprising in a commercial age, an age that counts the cost and reckons the interest, and finding a profitable balance plunges into the most enormous undertakings and carries them through successfully. Such an estimate shows that the state is an annual loser of many millions over and above what it would cost to eradicate this form of suffering and effectually put an end to its future ravages. Self-preservation is the first law of nature. The inhabitants of a village on Long 3 Island armed themselves last fall and attempted by violence to prevent the landing of the quarantined passengers from the cholera ships, while they had in their midst a plague more destructive and as readily subject to sanitary prevention as cholera. This plague, which knows no geographical limits and respects no race or condition of man, is tuber- culosis, and the unfortunates on whose behalf this plea is issued are the consumptive poor, than whom none appeal to us more strongly for sym- pathy and help, and although the world has, with a few exceptions, remained deaf to their supplica- cations, yet every motive of charity and selfishness urges us on to do our utmost for them. Truly it has been said that the wrongs of Lazarus are avenged on the children of Dives, for the conta- gion reared in the hovel finds its way into the palace and does its deadly work on the child of luxury, who is oftentimes less able to resist its at- tack than the offspring of poverty. No steps are being taken by national, state or municipal governments to prevent the propaga- tion, and very little to rescue the victims of this disease, although science has been proclaiming with increasing emphasis each year of the past decade that the possibility of prevention is beyond question, and that many can be rescued whom the fell destroyer has marked as his prey. In short, if the state did its duty, consumption would be one of the rarest diseases instead of the common- est. Such statements must be sustained by facts, and facts can be produced to prove every one of them. 4 Careful and shrewd observers long ago an- nounced the doctrine that tuberculosis was a con- tagious disease, although in what the contagion resided, or of what it consisted, was a mere matter of conjecture. So strong was this belief that in the year 1782, in the kingdom of Naples, where tuber- culosis was more prevalent and more fatal than it has ever been known elsewhere, enacted rigid and oppressive laws for the protection of the well from the dangers that hung about those suffering with the disease. These laws were enacted to protect the people from a real but unknown dan- ger. The methods were crude, and in the absence of exact knowledge were made very sweeping in their application, and, although they missed the mark, yet the target was well peppered in its vicin- ity. The sputum of the consumptive, the pus or matter discharged from tubercular joints and abscesses, and the food supply of the masses, were overlooked. The first and second mistakes were in a large measure equalized by the strict isolation of those attacked and the attempted purification of the apartments that had been oc- cupied by them. The beneficial results of these laws are now apparent and are related by Dr. L. F. Flick, of Philadelphia, to whose masterly analy- sis and painstaking research acknowledgement is made for many of the facts recorded in this article. He writes in The Sanitarian for Feb- ruary, 1891: " Italy has at present the lowest mortality rate from consumption of any country in Europe, with possibly the exception of Spain, and that part of it which formerly constituted the kingdom of 5 Naples is, in the country districts and small towns, practically free from the disease. Forty- five towns in this part of Italy, with an aggregate population of 742,068, had a mortality of 0.58 per thousand from consumption and general tuber- culosis during the year 1887. Ten selected towns, with an aggregate population of 146,924, had a mortality rate of 0.28 per thousand from the same diseases during the same year. Four selected towns, with an aggregate population of 36,460, had a mortality rate of 0.19 per thousand. It is- fair to suppose that the country districts in this part of Italy have a still lower death rate from these diseases. "Expressed in figures the reduction in the mor- tality from tuberculosis in Italy since 1782 ranges from fifty per cent, to ninety per cent. The much greater reduction in that part which formerly con- stituted the kingdom of Naples is no doubt due to. the immediate influence of the Neapolitan law. When side by side with the reduction in the mor- tality from tuberculosis in the kingdom of Naples under the operation of the Neapolitan law is placed the reduction which has taken place in England during the last forty years from the same disease, as the result of isolation in special hospitals, it can certainly no longer be said that the prevention of this disease is a mere theory. In England there has been a reduction of fifty per cent, in the mor- tality from tubeculosis in forty years as the result of the isolation of from three per cent, to eighteen per cent of all cases yearly." In 1798 the immortal Jenner propounded to a sneering and skeptical world the results of twenty 6 years' investigation of the relations of cow pox and small pox and his method of protective vac- cination. In a comparatively short time small pox, which for two centuries had headed the mor- tality lists of acute infectious diseases, and had disfigured for life countless numbers, and had filled the asylums and poor houses with its blinded victims, sank into the comparatively insignificant position it has since occupied on these lists. To- day pockmarked faces are seldom seen, and the question of how to support those left blind and rendered impecunious by this pest no longer oc- cupies a place on the calendars of legislative bodies. In the face of all this there are still op- ponents to vaccination to be found, some of them even disgracing the ranks of medicine, and just such doubting Thomases are today either passively or actively engaged in retarding the introduction of sanitary laws, and refuse to educate the people in those things that are necessary and able to wipe out this plague of tuberculosis from among civil- ized communities. As before stated we are ready to resort to the shotgun to keep cholera from our shores, and have millions of treasure to spend in the same object, and yet we are daily exposed and allow our loved ones to be exposed, without a murmur, to this most deadly poison, which sweeps off one in seven of those born into the world, which lives are all unnecessarily sacrificed on the altar of a preventable disease, as taught by science and demonstrated by history.[> Consumption is a very fatal disease as at pres- ent managed by the profession, and many who might be saved by a timely warning and rigorous 7 treatment are allowed to slip along beyond the line of safety before they are even warned of their danger. This is due partly to the pessimistic view entertained by too many of the profession as to the possibilities of treatment, strengthened by a charitable desire not to give pain to others by candidly making known the true nature of the malady. That this is a sad mistake is shown by the number of persons who have been rescued by timely treatment, and also by the large per- centage of individuals who, dying of some other disease, show evidences of healed tubercular ulcer- ations in their lungs. Leading authorities upon the treatment of phthisis are almost a unit in their opinion of the advantages of treating this disease in special in- stitutions, where incomparably better results can be obtained, on account of the constant profes- sional supervision rendered possible, than in any other way. The results of forty years' experience of special consumptive hospitals in England, dur- ing which time the growth of these institutions has been very gradual, reaching a maximum of 7,000 free beds in 1890, has already been referred to, and the reduction in the mortality from consump- tion, which has kept pace with the increase of ac- commodations for the consumptive poor, is due to the actual saving of lives in these institutions, as well as to the protection they afford to commun- ities by the isolation of those afflicted with a com- municable disease. In Germany there are quite a number of these special institutions. Foremost among them is the one founded by the late Dr. Brehmer,at Goerbers- 8 dorf in 1857, and that of Dr. Deitweiler at Falk- enstein. In a report from the latter institution of 731 cases, of which 131 were of the acute type, and really but 600 could be regarded as amenable to treatment, of which number but 105 were in the early ' stages, of the entire 600 eighty-one per cent, showed decided and lasting gain as a re- sult of treatment. Dr. Karl von Ruck, director of the Winyah Sanitarium for diseases of the lungs and throat, at Asheville, N. C., reports that of over six hundred cases treated by him there are forty-five per cent, of cured and arrested cases of all stages, forty per cent, have improved and fifteen per cent, have grown worse and died. Besides this institution at Asheville, which affords accommodations to 100 patients, but has no free beds, we have the Adirondack Cottage Sanitarium, a noble charity which opened its doors, in the Adirondack mountains, in 1885, with accommodations for nine patients, which have since grown until it now shelters sixty. It is sup- ported by voluntary contributions and is under the professional supervision of Dr. A. L. Loomis, of New York, and Dr. E. L. Trudeau, of Saranac Lake. Near Boston is the Sharon Sanitarium, directed by Dr. V. Y. Bowditch, and in Philadel- phia the Rush Hospital for consumption and allied diseases, upon whose staff the name of Dr. L. F. Flick appears, with those of several other dis- tinguished gentlemen. Both of these latter insti- tutions are in their infancy and are of. small capacity. At Colorado Springs is the Glockner Sanitarium, an institution erected by Mrs. Albert Glockner in 9 memory of her husband, which provides a home for patients with limited means, such as are un- able to procure the necessary comforts and nursing demanded by their condition. All of these institutions collectively offer some 250 or 300 beds, a part of them free, as con- trasted with England's 7,000 free beds. Those interested in practical charities and phil- anthropic works should seriously consider these facts. If organized societies opened special hospitals in every large city in the United States for the treatment of incipient cases of consumption, and if these hospitals could have the capacity neces- sary to accortimodate all who applied, the next census of the United States would show such a decrease in the mortality from this cause that the national and state governments would be forced to assist these institutions by the irresistible logic of figures. "Public health is public wealth." In no way can this motto be more convincingly proven than by rescuing those who would other- wise fall in this contest, in which they are enticed into an ambush, where the very flower of the army is picked off by the enemy's sharpshooters, and the lists of dead, if we omit those in the first few years of life, are in over sixty per cent, of the entire number made up of those between the ages of twenty and forty years. The graphic curve representing the mortality of any community will be found to mount up suddenly at the beginning of the second decade of life, to fall again at the end of the third. If now the deaths from phthisis are subtracted this upward curve will be seen to 10 be almost obliterated, showing what may be ex- pected when the necessary sanitary measures are enforced, as they are bound to be sooner or later, which will stamp out this scourge. To the state the successful operation of such hospitals would mean a decreased death rate, a decreased number of days lost by sickness, and consequently an in- creased number of wealth producers. To the fam- ily of a consumptive it would mean less loss of the valuable time of the bread-winner of the family, less loss of time in nursing the sick and a decrease in expenses for sickness, while to very many families it would mean a chair still occupied, which would otherwise be one of those vacant chairs at the family fireside, the cause of so many heartaches, chairs that have usually been occupied by the favorites of the flock. To the sufferer it would oftentimes be a convincing Christian argument, for it is not necessary to cross the ocean to find a darkest Africa in which to do missionary labors. It would mean an opportunity to rest from the un- ceasing round of toil, which is the lot of many who are harassed by the constant cough, the burning hectic and weakening sweat, which latter, as though directed by the hand of an evil genius, comes at dead of night to rob the sufferer even of the comfort of temporary oblivion. It would gladden hearts into which no ray of hope had penetrated for many a day, whose heavy burden is hidden under the cheerful mask which so many consumptives present to the world, but which, in the privacy of the consulting room, is frequently discarded. It is unnecessary to attempt to de- scribe the feelings of the head of a dependent 11 family when he finds this fell destroyer has fas- tened itself upon him, and he realizes that very soon he will cease to be the helper and bread- winner and become a burden to his loved ones. As the disease progresses and he looks around for help he finds that the doors of the general hos- pital, while not closed to him, are but grudgingly opened, and he learns that, while his case is des- perate at home, if he enters the wards of a city hospital it will be rapidly fatal. His is not a unique case, but among the hundred thousand an- nual deaths finds its prototype time and again in every large city in the United States. Added to this is the knowledge, for the people learn rapidly, that he may communicate the disease to those he would shield before all others, and his ignorance of the exact extent of this danger and how to avoid it greatly increases his sufferings. Just here another function of these special hos- pitals appears, which will appeal to those who will not admit that treatment and management can be in any sense curative, and that is as centres of ed- ucation, from which the scientific methods of ren- dering consumptives harmless to their surround- ings will be spread among the people. There is no city in the United States, no matter what splendid hospitals it may possess, but would be richer and happier if a large institution for the care of consumptives were erected in its immedi- ate vicinity, and there is no city or town where a little search will not reveal the hiding places of the misery produced by this disease. The nineteenth century is drawing rapidly to its close. It has the honor of having discovered the 12 cause and also of having defined Ihe methods which are capable of exterminating this form of human suffering, and it should not be left to the next century to see them put into execution. From numerous small beginnings this reform will rapidly gain in volume and momentum, and is destined to sweep with irresistible force over all obstacles, until in every civilized portion of the globe tuberculosis has bowed down to the majesty of preventive medicine. Note. - Because tuberculosis has. been so often termed a communicable disease in this paper, it is by no means intended to create a sentiment of fear in the bosom of any reader if there happens to be a tubercular member of his or her family, but rather, by pointing out wherein the danger lies, to give to such an one the knowledge neces- sary to protect themselves and others from what otherwise would be a very positive danger. There is no danger in the breath of a consumptive. The cause of the disease, the tubercle bacillus, is found only in the expectoration, or in any matter dis- charged from a tubercular abscess, whether of the lungs or other parts, and if this is thoroughly de- stroyed by fire, steam or chemicals, and the patient is scrupulously clean and always deposits this sputum or matter in spittoons or other prepared receptacles, he is a safe inmate for any dwelling. The tracts distributed by the Pennsylvania Society for the Prevention of Tuberculosis are very val- uable, and they, or something like them, should be in every household whose happiness is clouded, by the presence of this disease. 13 Since writing the above the state of Michigan has, through its efficient Board of Health, put tuberculosis upon the list of contagious diseases that must be reported by the physician to the health board. This will soon collect a mass of data of the greatest value to the student of the disease in that state, and will, by the limitation of the ravages of the disease in Michigan, soon force the matter to the attention of the other states, and eventually the national government must take it up.