Reprinted from THE CANADIAN PRACTITIONER. THE PREVENTION OF TUBERCULOSIS IN ONTARIO* By E. Herbert Adams, M.D., Toronto, Physician to St. John's Dispensary, The Nursing-at-Home Mission, The Yorkville Dispensary, etc. DURING the last few years no disease has received so much attention nor been productive of so much discussion as tuberculosis. When Robert Koch in 1890 announced to the world the marvellous effects pro- duced by tuberculin, many physicians and consumptives made veritable fools of themselves in their eagerness to obtain an early supply of the remedy. The bubble has burst. Many of the patients who were among the first to receive injections are dead; others are living in spite of the lymph ; while a third and smaller class have perhaps received some bene- fit from a judicious use of tuberculin along with climatic and other treatment, and are apparently cured. It was indeed a wonderful remedy in its selective and specific action on tubercular affections, and, despite the ban it is under at present, may yet in an improved form fill a more or less important place in the materia medica of the future. Be that as it may, it is certain that tjjis much-vaunted and much-libelled remedy did much to awaken original study and investigation into the nature, cause, and cure of this dread disease, which cannot but be pro- ductive of great good in the near future. The medical magazines and the secular press have been teeming with literature on this subject. For some time past, almost every fresh medi- cal journal has had a description of some new and seductive remedy for tuberculosis. Many of these are more or less useful, while others are utterly useless, and often positively harmful. After a careful and practical study of the results and possibilities of the better class of these remedies, my conclusions are that pulmonary tuberculosis is curable in a large percentage of cases in the earlier stages of the disease, and not infrequently even in the more advanced stages; but that as the disease is undoubtedly contagious, and as the source of the contagion is capable of being isolated and destroyed with comparatively * Read before the Ontario Medical Association. 2 little inconvenience to the individual or expense to the state, that prevent- ive measures are of primary and not secondary importance to medicinal treatment. And it is with a view of advocating a systematic and feasible method of prevention that this paper is written. PREVALENCE OF THE DISEASE. It is safe to say that no other disease, no form of accident, no civil or other war, has produced so much suffering or caused so many deaths as tuberculosis. During the twenty five years ending 1886, the average annual total deaths from consumption in England were 50,000. Other tuberculous affections caused 17,700 deaths, making in all a total yearly death rate of 67,700. In the United States in 1880 the deaths from this disease, estimated from the census returns, were 150,000. Baer states that the tubercular death rate of the whole world is 15 per cent., and that in prisons it ranges from 40 to 50 per cent. Between the ages of 20 to 40, it is estimated that from one-half to one-third of all deaths are due to tuberculosis. From the end of 1880 to the end of 1890, there were in Ontario 24,437 deaths from consumption. This does not include deaths from other than the pulmonary form of the disease, and shows that there wrere as many deaths from consumption alone in Ontario in ten years as from scarlet fever, measles, smallpox, whooping cough, diphtheria, croup, and typhoid fever combined. And yet the death rate is not the only point to consider ; for the duration of illness, and consequently suffering, is greater in this disease than in most other diseases. Senn,1 of Chicago, says that most of the large hospitals contain 25 to 50 per cent, of patients afflicted with this disease, and that a very large percentage of surgical operations are due to tuberculosis. Konig states that in surgical clinics the surgeon will have one hundred cases of tuberculosis of the joints to deal with to one of other classes of inflammation, such as rheumatic, gonorrheal, syphilitic, or suppurative. From a study of the hospital reports of the Sick Children's Hospital, Toronto, for the ten years ending 1890, I found that over 34 per cent, of all the diseases for which patients were admitted into the hospital during that time were of a tubercular nature. As a test to prove that this percentage was approximately correct, Dr. George Clingen, the house surgeon, made a careful and thorough examina- tion of all the cases admitted during the year he was house surgeon, and found that percent, of all the patients admitted into the hospital that year were suffering from some form of tubercular disease. And so i Principles of Surgery. N. Senn, 1890. 3 we may consider that from one-quarter to one-third of all the patients that have ever been admitted into the hospital are suffering from some form of tuberculosis. From the foregoing statements a fair idea can be obtained of the immense ravages of the disease, and the consequent suffering and loss of life and of wealth to the nation. Nor is the disease confined alone to humanity. The cow, and the pig, and other animals are also victims of the scourge. Toussaint, in 1888, gave the percentage of tuberculous cattle as 6 per cent. Bitter states that he believes that at least 10 per cent, of dairy cattle are tuberculous in cities and their environs. Of all the cattle slaughtered in Berlin in 1890, 4.5 per cent, were tubercular. In Saxony, in 1889, of 34,975 cattle inspected, 3,986, or 11.4 per cent., were tubercular. The percentage varied in localities from 1.1 to 15.8 per cent. Veterinary surgeons tell me that they know several different dairies around Toronto in which there are tubercular cattle, and in one herd most of the animals are affected. (This herd has since been isolated by the Provincial Board of Health.) It is a startling statement, but, nevertheless, a highly probable one, that about one-sixth of the cattle supplying milk to Toronto are tubercular. This is a source of danger, especially to young children, for the bacillus tuberculosis is present in such milk, and is undoubtedly, in some cases, at least, a cause of intestinal and other forms of tuberculosis. Sufficient has been said to show the prevalence of this dread disease. Not that it is more common in Ontario than elsewhere. In fact, the death rate is much less here than in many countries and states ; but the loss of life and suffering here are sufficiently alarming-for there are few families but have had some relative or near friend die of the disease-to make us all united in the desire to spare neither money nor labor to eradicate the disease, if such be possible. THE CONTAGIOUS NATURE OF TUBERCULOSIS. The overwhelming evidences which, during the last decade, have been adduced in favor of the bacillus tuberculosis being the direct exciting cause of tuberculosis have silenced the objections of almost all conscientious scientific doubters. Among old school physicians and others unversed in modern pathological methods of investigation, there are still many strong opponents to this doctrine. These Prof. Tyndall ("On the Origin, Propagation, and Prevention of Phthisis," Fortnightly Review, Sept., 1891) defines as "a number of loud- tongued sentimentalists who, in view of the researches they oppose and the fatal effects of their opposition, might be fairly described as a crew of well-meaning homicides." Before such a scientific gathering of medical men as this, and in a 4 country where the standard of medical education is so excellent, it will hardly be necessary to do more than briefly review the data upon which we base our knowledge of the contagious nature of tuberculosis. Our knowledge on this subject is comparatively modern, though more than a century ago there were many believers in the contagion theory. For sixty-six years, from 1782 to 1848, in Naples, rigorous though some- what crude laws were enacted for the prevention of consumption on the theory of its contagious nature, and Dr. Lawrence F. Flick, who has care- fully studied the condition of Italy before and after the enactment of these laws, states : " It will not be overstepping the mark to place the mortality rate from tuberculosis for the Kingdom of Naples and Italy for 1782 at 10 per 1,000 living. In 1887 the mortality rate from all tubercular affec- tions for all Italy was 1.29 per living 1,000. Expressed in figures, the reduction in mortality from tuberculosis in Italy since 1782 ranges from 60 to 90 per cent. Villemin, in 1865, was about the first to produce tuberculosis in rab- bits by inoculating them with tuberculous material; but it remained for Robert Koch, in 1882, to demonstrate that the true cause of tuberculosis of all kinds was the tubercle bacillus (" Die der Tuberculose," Berlin Klin. Wochenschrift, 1882, No. 15). He showed the bacillus to be present in all forms of tuberculosis, and obtaining pure cultures of the bacillus proved that artificial tuberculosis could be produced in animals by inoculation. His observations have since been abundantly verified by numerous other observers, and at the present time all reputable medical colleges teach their students how to stain, mount, and examine under the micro- scope sputa or diseased tissues suspected of containing the bacillus tuber- culosis. And there is no hesitation on my part in saying that the medical student who is not able to make such examinations successfully should not be allowed to graduate from any Canadian medical college; and also that the general practitioner who does not use this means of diagnosis in consumption is omitting one of the most important elements for the cor- rect and early diagnosis of the disease, and without which he cannot do full justice to his patient. We know, then, that this peculiar bacillus, which is definite in form and in its susceptibility to certain staining materials, is present in every form of tuberculosis, no matter what organ of the body is affected, and there are few tissues of the body but have been implicated in this disease. We know that this disease is identical in man, the monkey, the cow, the horse, the pig, the rabbit, etc., and that without the presence of this bacillus there is no true tuberculosis. We know also that by inhalation and inoculation of pure cultures of these germs, the same disease can be produced in animals. 5 Senn ("Surgical Bacteriology," 1889) gives an excellent resume of results achieved by experimental inoculation in animals, and mentions many cases of inoculation in surgical cases in man after contact with tuber- culous material. Abundant clinical evidence shows that where these germs most abound there other cases of tuberculosis, both of man and animals, most frequently occur. Many instances are recorded in medical literature of several or all the members of a previously healthy family being carried off with the disease after moving into a house formerly occupied by a victim of tuberculosis. You have all doubtless come across many such cases in your practice; though, on account of the slow and insidious course of the disease and the varying length of time it may take to mani- fest itself, it is very difficult usually to ascribe the exact source of the con- tagion. A case is recorded in Paris where, in the course of eleven years, fifteen out of twenty-three clerks employed in an office died of tubercu- losis. Cornet showed that 62.8 per cent, of the deaths among the reli- gious orders for the care of the sick in Germany were due to tuberculosis. Flick's study of the death rate for twenty-five years from tuberculosis in the fifth ward of Philadelphia showed that many of the houses had six to eight deaths, and that over 33 per cent, of the houses where deaths occurred from consumption had more than one case. Cornet has published some statistics on the mortality from phthisis in Prussian prisons. During fifteen years, the mortality among males was 45.82 per cent, of all deaths; and among females, 49.33 per cent, of all deaths. Confinement, bad ven- tilation and lighting, together with the presence of the bacillus tubercu- losis in the cells, due to improper cleansing of the compartments after the removal of former consumptive occupants, were the probable causes of the great mortality from consumption. I have stated that the bacillus tuberculosis is the exciting cause of the disease, but there are certain other contributory and predisposing condi- tions which are also necessary before these germs can manifest their pathological effects. Among these are hereditary and acquired predisposi- tion, bad drainage, bad ventilation and heating, bad sanitation of all kinds, overwork, and any debilitating influence whatsoever, and I do not wish to belittle in the slightest manner the great influence such conditions have in the production of tuberculosis, but merely to emphasize the fact that without the presence of the bacillus tuberculosis these debilitating influences zvill not produce consumption or any other form of tuberculosis. Heredity has hitherto been considered the chief of these predisposing causes, and we cannot deny that it has considerable influence in the production of the disease, though, undoubtedly, many cases ascribed to 6 heredity are due to direct personal contagion and the infection of pre- viously healthy members of the family long after birth, and not due to any hereditary influence whatsoever. The great source of infection is, then, the inhalation of the dried ex- pectorations of tubercular patients, the ingestion of tuberculous meat and milk from animals affected with the disease, and by the direct inoculation of tuberculous material into the blood through a wounded or abraded surface. The first is by all means the greater source of danger, as hitherto little has been done towards destroying the bacilli which are so numerous in the expectoration of tubercular patients. The danger of infection, though at present almost universal, is much greater in the localities where the consumptives reside. The bacilli and their spores have considerable tenacity for life in the dried state, and exist for considerable periods of time after expulsion from their former host. Cornet and others have repeatedly shown the presence of these bacilli in the dust taken from the rooms and surroundings of tubercular patients, and by inoculation of ani- mals with cultures taken from such dust have produced tuberculosis in these animals, which resulted in their death. METHODS OF PREVENTION. And now we will consider what measures of prevention are necessary and practicable for lessening this great scourge. In the first place, the reporting of all cases of tuberculosis to the health department should be made compulsory for physicians, householders, and employers. By this means the responsibility would be with the health officer to see that proper methods for the isolation and destruction of the sputa were attended to, and that the surroundings of the patient were in a sanitary condition, and the patient not a source of contagion to others. These matters, in the better class of consumptives, are, as a rule, fairly well attended to on the recommendation of the family physician, but among the poorer classes these conditions are often much neglected. Free microscopical examination of the sputa of the supposed phthisical patients should be made by the health department at the request of any physician, as many physicians are unable to make such examination themselves. By means of suitable pamphlets, distributed by the health department, the public should be educated to the fact that the expectoration of every patient in the advanced stages of the disease is a source of contagion to others unless such expectoration is destroyed, and that such patients should never expectorate on the floor or in a handkerchief, but always in a sputum cup or some other special receptacle. Other useful hygienic information in reference to the disease should be inculcated in the same manner. 7 Tubercular mothers and wet nurses should cease to nurse infants, as their milk is a source of contagion. The public should be secured from danger from tubercular milk or meat by means of a rigid and systematic inspection of cattle, and specially qualified inspectors should be detailed for this work. The notification of the health authorities by owners of infected animals should be made com- pulsory. All tuberculous animals should be condemned and killed after having been valued and paid for by the government. Railroad and street car companies should furnish receptacles for sputa containing water, or a germicide, in their cars and stations. There should be a careful cleansing and disinfection of the floors and walls or rooms after removal, by death or otherwise, of a consumptive patient. In prisons and asylums, pulmonary tuberculosis in any of the inmates should be recognized as soon as possible by examination upon entering, and at frequent intervals. Such tubercular inmates should be separated from others, and their compartments cleansed and disinfected after their removal. In such cases the use of sputum cups and cuspidores should be enforced, and their employment in outdoor work, as far as possible, should be urged. The prevention of consumption would be greatly aided by the erection of special hospitals or sanitaria for the consumptive poor. Municipal and government aid should be given to these institutions. For the poor, the ignorant, the careless, and the friendless, and for all consumptives in whose homes or boarding houses proper sanitary measures could not be used, such places would be a great boon, not only to themselves, but to others to whom they would otherwise be a constant source of worry as well as of contagion. My own personal experience as a resident physician in a sanitarium for consumptives justifies me in saying that better results can be obtained there in many cases than elsewhere, and, under proper conditions, the depressing influence of segregation is not to be felt.