Tuberculosis: A Social Question.

New Zealand Graphic, Volume XXXIX, Issue 4, 27 July 1907, Page 28

Tuberculosis: A Social Question.

By

S. SOLIS COHEN, M.D.

ST the battle of Austerlitz a division of Russian troops, being hemmed in by the French, attempted to cross the frozen ponds Satschan and Melnitz. Napoleon trained his guns upon the ice beyond the fugitives, breaking it, and precipitating them into the water. The French artillery then eeased fire, and the Emperor ordered boats and rafts to be sent out in the attempt to save as many as possible of the survivors. Thousands jwere forced upon the frozen surface of the ponds; barely hundreds were rescued. Austerlitz Well typifies the conduct of society toward the victims of tuberculosis. A complex social organisation that drives hundreds of thousands of illfed men, women and children into factories and sweatshops, where, shut in from air and sunshine, they work at monotonous tasks with increasing weariness throughout fatiguing hours—then go home, in many cases, to cheerless rooms in crowded tenements or squalid Jiovels in narrow, noisome alleys—differs from the destructive genius of Bonaparte only in the greater effectiveness of its weapons. “Never battlefield was more horrible,"’ says the official bulletin .dispatched by the Emperor to Paris. “From the middle of the immense ponds one yet hears the cries of thousands of men whom one cannot save. One’s heart bleeds.” How compassionate that victor’s heart! Yet, withal, it iiad deliberately repeated at Austerlitz the tactics of Aboukir, where the Sultan’s great army was forced into the sea. And society is full of compassion towards the hosts of the tuberculous. Have We not established for them hospitals and dispensaries in the cities, sanatoriums in the mountains, camps in the Joiest, children’s homes by the sea? Boats of Napoleon, these —pitiably inadequate! At most saving hundreds out of the hundreds of thousands! But the limited capacity of our rafts, compared with the enormous mass of our ■victims, does not entirely represent the extent of our failure to eope with tuberculosis as a social problem. The victors at Austerlitz after they had pulled a remnant of the Russians out of the water. resuscitating the partially drowned, drying their clothing, feeding them, did not throw the rescued again into the ponds. THE DILEMMA OF THE DOCTORS. The physician attending a hospital for consumptives is confronted constantly with a most distressing problem—what to do with the patients who have recovered. Rational work under proper conditions is one of the best preventives of tuberculosis, as it is one of the most important factors—though perhaps the most frequently neglected—in bringing about the recovery of those • affected. But to send the patient back to the Same kind of work, to the same kind of food, to the same unwholesome surroundings under which he became consumptive, is like throwing the man rescued from drowning back into the water. The situation is more difficult with women than with men. Occasionally outdoor work, if only running errands, can be found for a man, but what can the average woman do in the fresh air? She goes back to the shop, the factory, the sewing inaclrine, the I rhool^rooiii —and death. Thus it is that the statistics of recoveries published by various institutions arc so misleading; the relapses are not reported. The patients get into other hospitals or disappear altogether from the domain of medical records. Tuberculosis differs from such infectious discasees as smallpox and scarlet fever in the fact that recovery does not render the patient immune against further attacks.

In fact, the prevention and cure of tuberculosis is not, strictly speaking, a medical question at all; it is a social, and especially an economic, question. This was observed many years ago

by Graves, of Dublin. With the same keen insight that led Him to oppose the starvation and bloodletting wherewith the routi fists of his day mistreated those sick of infectious fev< rs, he remarked concerning tuberculosis: “ft is important to know i>jw to make a man phthisical, so that by pursuing an opposite course of eonduit we may prevent it.” And he graphically described how lack of air and sunshine, grinding toil, wretchedness, starvation — in a word, poverty—will “make men phthisical,” and. in consequence, the relief of poverty and its attendant privations “prevent it.” When Graves thought and taught the bacillus ol tuberculosis was not yet known. That great discovery was, indeed, reserved for Robert Koch in 1882, b it not the knowledge that tuber miosis is an infection. Edward Jenner had recognised a mutual adaptation between vegetable excrescences and larvae, permitting a modified “symbiosis” between the plant host and the insect guest. His comparison of this to the structure of tubercle and the needs of the hypothetical parasite which he saw with his mind’s eye, though as yet unable to place it under the microscope, was far in advance of the majority of even more modern pathologists. Then, with the co-opera-tion of John Baron Jenner conclusively demonstrated the conditions under which this parasite could become active and manifest its effects. More important still, they showed the conditions under which recovery from the disease could take place. They confined a number of rabbits in a damp place under ground to which little air and no light was admitted. After a certain length of time they set half of the animals free in the air and sunlight, keeping the others in captivity. The prisoners died from tuberculosis; their more fortunate companions regained, and apparently retained, the full enjoyment of life and health. THE LESSON OF THE IMPRISONED RABBITS. Again repeated by Trudeau, in 1888, upon rabbits deliberately infected with a culture of Koch’s bacillus, its significance began to be generally realised. For under the impetus which Koli’s discovery had given to the germ theory of infectious disease, there bad become dominant in medicine a school that threw aside all the lessons of experience in regard to heredity and habits as factors in the causation of tuberculosis and regarded the infective germ as the only element demanding care. The importance of the germ is not to be underestimated, and too much stress cannot be laid upon the necessity of guarding in every possible way against its spead. Especially must the uncleanly habit of promiscuous spitting be prevented. All such precautions are wise, are necessary, and ought to be enforced strictly. What is unwise is the belief that with their enforcement the duty of the physician and of the State in the prevention of tuberculosis is al an end. MAN’S ALLY IN THE DAILY BATTLE. Everybody is exposed—but not everybody succumbs. The invasion of one's tissues by the tubercle bacillus will not of itself set up tuberculosis. There must be, in addition, an abnormal lack of resistance to the disease-producing action germ. Guinea pigs and rabbits are extremely susceptible and become infected fatally upon inoculation of small quantities of comparatively mild cultures. Cows and swine are somewhat more resistant but can readily be infected, and, tuberculosis acquired through accidental infection is not* rare among these animals. Dogs, goats, horses, donkeys are extremely resistant. Accidental infection Is practically unknown among them, and deliberate infection can be brought about only by the repeated use of large quantities of virulent cultures, after tneir tissues have been enfeebled by confinement and starvation.

Human beings may be divided into three classes in their relation to tuberculosis; the guinea-pig class; the cow and pig class; the horse and donkey class. Men of the guinea-pig class succumb readily and it is difficult to save them. Those of the cow and pig class succumb only under unfavourable conditions, and may readily be saved. The horse and donkey class succumbs only under the most highly unfavourable conditions and recovers quickly when brought into a good environment. That more than sixsevenths of mankind are highly resistant is shown by the records of post-mor-tem examinations of persons dying from all sorts of diseases other than tuberculosis, and who, so far as known, have never shown recognisable symptoms of that affection. A proportion of such bodies, estimated by no observer as less than one-half, and by some as high as ninety per cent, show healed tuberculous lesions, usually of very slight extent; while in some few cases the presence of tubercle bacilli can be demonstrated in the glands. In other words, all these persons have been exposed to infection, but have resisted it. The imprisonment of the bacilli in giants is a significant fact which we shall recur to later. Meanwhile, another lesson from zoology. Wild animals are, under their natural conditions, immune from tuberculosis, but many of them succumb to it after years of captivity. Monkeys—who are much like men—if long confined in the monkey-houses of zoologic gardens and menageries, usually die of consumption; but we have no evidence that theyare specially susceptible when living in a wholesome environment. Here, then, is cumulative proof that the bacillus of tuberculosis is but one factor in the production of the disease. From our present viewpoint it is the least important factor. Environmental conditions being what they should be, the germ may come and go harmlessly. Only when the natural resistance of man’s tissues has been overcome by other factors can it effect lodgment and development therein. But, it may be asked, how does this accord with what has‘been said concerning the existence among men of a guineapig class, highly susceptible to the disease, whom it is often difficult to save? The answer is, that these individuals are not of normal physical constitution. Thus, in the normal human being, the tubercle bacillus is either prevented from entrance into the body by the guards at the gates —the healthy cells of the skin and mucous membranes; or, should it by some chance evade their watchfulness and slip through at some weak or unguarded point, it is attacked by certain juices of the blood, which so weaken it that it ean be destroyed by the white corpuscles. This, however, dbes not exhaust the resources of the normal body against the bacilli of tuberculosis. Should they perchance penetrate in such large numbers as to exhaust the ability of the opsonins and phagocytes to deal promptly with them all, still another barrier stands in their way. They are taken up and imprisoned by the lymph glands: sometimes dying in captivity, sometimes remaining, like Monte Cristo, alert to escape and swim through the blood stream to safety and revenge. ATTACKED WHILE THE DEFENDERS SLEEP. Let now a man’s vitality become reduced, and quickly the imprisoned germ escapes and multiplies and works its will upon his enfeebled tissues. So, too, if he be already in this condition of low vitality when the invader first appear, the outer defences are quickly passed and tuberculosis established. We have shown how a man may acquire this condition through his own fault, folly or misfortune. Often it is inherited. But hereditary liability does not necessarily mean defenseleaspess. Prevention is to be achieved in part only by the attempt at exclusion of the germ. Far more certainly can it be attained bv the abolition of those eouditious whwh make men suoceptibla.

And, once more, what are these conditions? Dampness and darkness and' dirt, the herding together of large numbers of people, stagnant air, fouled many breaths, narrow streets and alleys, and on the wider streets where stand the factories and shops, buildings so high that even the avenue becomes relatively an alley. Long hours of work! and weariness. Anxiety cutting short the hours of rest, Poverty so grinding that the laughter of children and the smiles of men are banished from the dwelling, that the theatre and dance and country vacation or seashore excursion are impossible. To preserve normal vitality, men need not only the fresh air and the sunshine, not only the comfort and purification of frequent baths, not only good food eaten leisurely and in pleasant company, net only suitable slothing and sufficient changes, not only rest and a reasonable degree of freedom from anxieties —but also proper food for the mind, innocent relaxation, wholesome merriment. And rest, recreation, freedom from sordid cares, are the very things of which our present industrial and social organisation inexorably deprives so many, not alone among the “submerged tenth,” but even, at times among the “upper ten.” Yet, after all, it is upon the submerged tenth, and the four-tenths with: their heads just above water, that the disease-producing pressure’ of society bears most heavily. The poor are the victims of forces beyond their control. Misery is theirs, and with it helplessness. Responsibility is not theirs, but is that of society at large; and only from society, through a general recognition of the social responsibility, can re-al help come. Among the lower and lowest strata of our economic classes, especially in the cities, the bacillus tuberculosis finds its depressed and enfeebled victims in thousands and tens of thousands, and no measure of proyhplaxis can be considered scientific or efficient that is not directed toward remedying the conditions under which they live and move and have their being. Factory inspections, tenement laws, school breakfast, abolition of chill labour regulation of buildings, provision of publie squares and playgrounds—these are desirable and. playgrounds—these are desirable and helpful, but they are still inadequate palliatives. We must go to the fundamental cause. The poverty and the misery, the privations and the squalor, that make men food for the bacillus tuberculosis to devour, can all be reduced in final analysis to two causes—high rents and low wages. Bacillus may be the father, but the mother is Poverty. Divorce the bacillus from Poverty and his monstrous child will not be conceived to prey upon man. The parents of Poverty, also, the physician names. High Rent is the father, Low Wages the mother; but these cannot be divorced. Wise, broad, farsighted measures, founded upon the preservation of individual rights; upon the protection of every man in his equality, of opportunity, in his possession of the fruits of his toil, are needed to cope with the evil. WHERE THE BLAME RESTS. Nor is it for the sake of the very poor only that we must learn to prevent the conditions in which the infection of tuberculosis flourishes. They suffer the most, but others in all economic ranks are overworked ami harassed and depressed by the same impersonal and merciless envelopment that produces the misery and squalor of the tenement dwellers and the fatigue and ill-nourishment of the factory hand and the shop girl. Tie small merchant, the banker, the manufacturer, the teacher, the writer, the minister, the lawyer and the doctor—ths butcher, the baker, the candlestickmaker — all ere driven physically or me*tally at a pressure that must often cause breakdown. Or take the reverse- side ef the shield —the unearned wealth whieli represents the lack suffered by the victims of society, piling up in the cofferl

of Its pampered pete, tempts to sloth, «O over-indulgence, to dissipation, which Oan also break down the normal resistance. Thus, in diminishing degree, the disease penetrates upward and upward from the sunken base of society to the towering apex. Did Napoleon at St. Helena hear reechoing cries of distress from the waters of Aboukir and Austerlitz? Did he realise that Waterloo was the inevitable goal of such progress, St. Helena its inescapable penance ? Toward what Waterloo is our boasted industrial progress hastening our social organisation? What bleak rock, in what waste of waters, awaits our expiation? This vast, inexorable machine that is grinding our fellows is no impersonal abstraction. It is the sum of its living units, by whose knowledge, consent and participation it acts. We are society—we, the well-fed and comfortable; we, who have intelligence to observe and time to reflect. What society does, we do. We are not indifferent to suffering; we are no longer apathetic concerning tuberculosis. We relieve individuals when we can; we are tolerant of all “practical” suggestions for the extension of charity and benevolence to the masses —especially “organised” charity and “scientific” benevolence. We are intolerant only when the futility of our palliatives is exposed; when we are told that our charity is misdirected and oV philanthropy selfish; when it is shown that even while we restore one consumptive to health, we are making fifty healthy men consumptive; when science, asked for the real cause of tuberculosis, holds before our eyes the mirror of trutn —and we see therein —Ourselves!