THE 
CONTAGIOUSNESS OF PHTHISIS 
(TUBERCULAR PULMONITIS). 
BY 
LAWRENCE F. FLICK, M.D., 
OF PHILADELPHIA. THE 
CONTAGIOUSNESS OF PHTHISIS 
(TUBERCDLAR PULMONITIS). 
BY 
LAWRENCE F. FLICK, M.D., 
OF PHILADELPHIA. 
REPRINTED FROM THE 
TRANSACTIONS OF THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA, 
junb, 1888. 
PHILADELPHIA: 
WM, J. DORNAN, PRINTER. 
1888. THE CONTAGIOUSNESS OF PHTHISIS 
(TUBERCULAR PULMONITIS). 
By LAWRENCE F. FLICK, M.D., 
OF PHILADELPHIA. 
Ever since medicine became a science, the contagiousness1 of 
phthisis has been one of the mooted questions. In different epochs 
of medical history the opinions of medical men and the beliefs and 
superstitious of the laity have tipped the scale on one side or the 
other, bat never has the question been settled practically and perma- 
nently the world over. And yet, until it is so disposed of, no 
progress can be looked for in either the prevention or cure of the 
disease. 
Isocrates, who lived about the fifth century before Christ, and who 
shortly preceded or was contemporary with Hippocrates, taught that 
consumption was contagious,2 but apparently had few disciples. 
Hippocrates himself, in his book, discoursed upon phthisis as an 
epidemic. He, however, apparently believed the disease to be due 
to a certain condition of the air, and evidently did not consider it 
communicable from person to person by contact and association. It 
was rather a quality of the atmosphere or of the breezes that affected 
people than germs of disease. His was the usually accepted theory, 
and one which prevailed for many years. Many of the greatest 
minds, however, who gave thought to medical subjects, from his day 
until toward the end of the eighteenth century, believed consumption 
to be contagious. Such men as Aristotle, Galen, Lorn mins, Ballonius, 
Riverius, Morton, Hoffman, Morgagni, Lieutaud, Van Swieten, 
Cullen, Reid, Raulin, Withering, Emale, Selle, Darwin, and 
Baume taught the doctrine.3 Valsalva, who believed himself predis- 
posed to the disease, avoided being present at dissections of the 
1 I use the word contagious in its broadest sense. 
2 Francis Adams’s translation of Hippocrates. 
8 Young, on Consumption. 4 
FLICK, 
lungs of persons who had died of consumption, and Morgagni is 
said to have done the same thing.1 The doctrine must have been 
pretty generally believed and taught throughout Continental Europe 
at one time; but the only traces of it left at the present day are 
among the peasantry of Italy and Spain, by whom consumption is 
dreaded as much as smallpox. England seems never to have been 
willing to accept the doctrine. English colleges declared against it 
in a body,2 and most English writers controverted it. Toward 
the end of the eighteenth century, Dr. Heberden wrote: “In 
England we have very little apprehension of the contagious 
nature of consumption, of which, in other countries, they are fully 
persuaded.” In the early part of the present century, Dr. James E. 
Smith wrote “that in Italy consumptions are found contagious, 
though less evidently so in England.”3 In some parts of Spain 
and Portugal, writes Dr. Rush, when on the subject of consumption, 
“its contagious nature is so generally believed that cases of it are 
reported to the magistrates of those countries, and the clothes of 
persons who have died of it are ordered to be burned.”4 
During the last century the far-reaching influence of English 
civilization has so obliterated the doctrine that to revive it will, to 
many, appear an invention. The only countries in which it at 
present appears to be bearing any practical fruit are Greece and 
Turkey, where governmental disinfection is said to be carried out 
with marked benefit. The discovery of the bacillus tuberculosis 
during recent years has created new interest in the subject, which, 
it is to be hoped, will lead to a practical solution. In England and 
America, however, traditional prejudices are so strong against the 
doctrine that they will have to be removed before it can receive an 
impartial hearing and gain a lasting foothold. Medical science, 
however, is bringing us to that stage at which it is important for 
every country which desires to be abreast of the times to take up a 
position on the subject other than one based upon handed-down 
belief. 
Either consumption is contagious, or it is not. Whether it is or 
is not ought to be easily ascertained at the present day. Such dis- 
eases as smallpox, measles, scarlet fever, diphtheria, and typhoid 
fever are universally accepted as being contagious; and the same 
process of reasoning which led the profession and the public to 
1 An Inquiry into the Cause and Cure of Pulmonary Consumption, by Rush, page 57. 
2 Young, on Consumption. * Gregory’s Dissertations, page 157. 4 Supra, page 57. THE CONTAGIOUSNESS OF PHTHISIS. 
5 
that conclusion, if the facts are the same, ought to bring them to 
the same conclusion in phthisis. 
The difficulty in the way of making a comparison lies in the 
great difference in the duration of the diseases—the former always 
being acute and the latter usually chronic, and, even when acute, of 
comparatively long duration. This especially holds good in that 
portion of the disease known as the incubation period. In acute 
diseases it is comparatively easy to note the length of time which 
elapses between exposure and determining symptoms of the disease; 
bnt in chronic diseases, and especially in phthisis, this is no easy 
matter. With these facts before us, I will endeavor to show that 
phthisis is contagious for as many reasons as any of the admittedly 
contagious diseases, and that it is governed by the same laws of 
contagion as are the others. 
But before proceeding to advance arguments upon the point at 
issue, it may be well to remove some of the cobwebs of prejudice 
which have been accumulating for centuries. The most closely 
woven of these is the theory of heredity. So integral a part of the 
medical belief of the average man and woman is this theory that 
to call it into question would to many be prima facie evidence of 
genteel insanity. The world is governed more by belief than by 
knowledge. Born to the doctrine, most people have accepted it 
without investigation, and cling to it with fanatical pertinacity. 
Hereditary consumption, as a theory embodying a scientific truth, 
will, however, not bear the light of reason. Webster defines hered- 
itary as “ transmitted, or capable of being transmitted from a 
parent to a child.” The word is derived from the Latin u hered- 
itas,” an heirship, an inheritance, a patrimony. In a physiological 
sense anything transmitted from a parent to an offspring must be 
an intrinsic part of the parent. A quality, for example, can be 
transmitted, such as color of hair, complexion, etc.; or traits of 
character, such as temper, affection, and such like. Disease, how- 
ever, is an entity in itself, and, therefore, extrinsic to the parent. 
It is temporarily engrafted upon a person, and unless it can be 
cast off will put an end to physical existence. As long as even a 
vestige remains in the body there is constant warfare between it 
and the economy. It is quite reasonable that a child conceived, 
matured, and born whilst this conflict is going on will or, at least, 
may be affected by the same disease which afflicted the parent, for 
the child is part of the parent; but it is contrary to all reason that 6 
FLICK, 
a child bom of diseased parents, or of healthy parents whose 
parents or grandparents were diseased, can be healthy at birth, and 
ten or fifteen or twenty, or any number of years thereafter develop 
that same identical disease which the parents or grandparents had, 
from a something which it got from those parents or grandparents. 
To accept such a doctrine would be to make disease a physiological 
condition, or a quality of the body. 
But many will say, Why fly in the face of truth and contradict 
that which is self-evident? Do not we all daily see the best evidence 
of hereditary consumption in whole families becoming extinct from 
it? A careful study of such families and their mode of exit from 
mortal clay will give the most striking proof of the contagiousness 
of phthisis. A few examples will illustrate my point: 
Family S. has been sadly afflicted by the disease. About five 
years ago E., a daughter, who was a factory girl and who had 
worked hard and had been suffering from dyspepsia for a year or 
more, took the disease. She lived in a neighborhood where the 
disease was prevalent and she had been making frequent visits to 
and had helped nurse a cousin on the father’s side, who was dying 
of the disease. She lingered about two years and died. Her 
mother, who had undergone many hardships during life, and who 
was quite delicate and suffered much from dyspepsia, nursed her 
during her illness. During the latter part of the daughter’s illness 
the mother began to develop the disease, and two years after her 
daughter’s death followed her to the grave. During the mother’s 
illness, the eldest sou, who had been lately working indoors, began 
to develop unmistakable symptoms of the disease. He resumed 
outdoor employment, to which he had been accustomed, and after 
several mouths recovered and is well at the present day. The 
father and husband, who had been a very robust man, but who had 
lived a life of dissipation for many years until within six months of 
his wife’s death, now also developed the disease, and is at present 
within view of the land of the majority. Family Sh., who lived 
very close neighbors to the above family, has been almost entirely 
exterminated by the disease. P., the eldest sou, died first, after an 
illness of six months. In one year he was followed by the father. 
The mother died next, one year after the father; and she was in turn 
followed in two years by the eldest daughter. Within less than a 
year of the latter’s death the youngest child died of tubercular 
meningitis. The only remaining members of the family are two THE CONTAGIOUSNESS OF PHTHISIS. 
7 
boys and one girl, and, of these, the youngest had every indication 
of tubercular deposit in the lungs about the time at which his sister 
died of tubercular meningitis, but recovered, and the other brother 
is at present apparently struggling with tubercular deposit. 
These families are looked upon by their neighbors and by every 
one who knows them, or anything about them, as practical demon- 
strations of hereditary consumption. And yet, if those same fami- 
lies had died, in the same order of succession, of a disease which 
runs a shorter course, no one would have doubted its contagiousness. 
If recurrence of a disease in the same family disproves con- 
tagiousness, every acceptedly contagious disease can be proven to 
be non-contagious by the same process of reasoning. In family P., 
for example, consisting of twelve members, six have had typhoid 
fever at different times, and in different parts of the country. Is 
it, therefore, hereditary ? Some families will not contract scarlet 
fever under the worst exposure. Does this disprove the conta- 
giousness of scarlet fever? These facts, individually, lead to false 
conclusions, but, collectively, argue a most important truth ; namely, 
that there is a family as well as an individual predisposition to 
certain diseases. Every fort does.not yield to the same weapons of 
assault. 
Unfortunately, predisposition is constantly confounded with 
heredity, even by the profession. A little thought, however, 
will clear up the subject to any oue who is willing to give it. 
Predisposition being a quality of the body, can be transmitted 
consistently with the laws of physiology; or, iu other words, it 
it is hereditary; but disease, which is foreign to the body, cannot 
be so transmitted. Parents can give to their offspring a peculiar 
shape, a peculiar nervous system, a peculiar digestive apparatus, or 
even condition of the blood which will make them more or less 
liable to this or that disease; but they cannot instil into them germs 
of disease which will, in after life, unexpectedly develop and crush 
them to the earth. 
But to come to direct argument, probably the most logical and 
most convincing proof of the contagiousness of a disease that can 
be offered, is to show that it did not exist among people and in 
countries until it was introduced from without. Unfortunately, 
consumption is such an old disease, and oue which claims its victims 
so generally throughout the world, that it would be very difficult 8 
FLICK, 
to find a country in which it does not exist. History, however, 
helps us out. 
Prior to the advent of the white man, and, especially, the 
Englishman, among the American Indians, consumption did not 
exist in America. Dr. Benjamin Rush, a man whose word can 
scarcely be doubted, said over a hundred years ago, “that it is 
unknown among the Indians of North America.”1 Even after the 
arrival of the Europeans the country remained comparatively free 
from the disease for many years. 
In the same paper above quoted, Dr. Rush said : “It is scarcely 
known by those citizens of the United States who live in the first 
stage of civilized life, and who have lately obtained the title of first 
settlers.” 
In the early part of the eighteenth century, Lieutenant-Governor 
Golden wrote about New York: “The air of the country being 
almost always clear, and its spring invigorating, we have very few 
consumptions or diseases of the lungs.” “ People inclined 
to be consumptive in England, are often perfectly cured by our fine 
air; but if there be ulcers formed they die.”2 
When we consider that these statements were made from fifty 
to a hundred years after the first settlement of America by Euro- 
peans, it will[be clear that the disease was slow in getting a foot- 
hold here. 
In addition to this direct testimony, there is strong inferential 
evidence that the disease was introduced into America from Europe. 
The two countries which were most active in the early population 
of what is now the United States were England and Spain. Eng- 
land never accepted the contagious theory of phthisis and never 
practised any preventative measures. During the seventeenth and 
eighteenth centuries, consumption was what might be called endemic 
in the British kingdom, as during at least part of that time, from 
33 per cent, to 50 per cent, of the deaths were due to that disease.3 
As this was the most active epoch of English emigration, and as 
many consumptives were no doubt attracted to America by the 
reputation it had of being free from the disease, infected spots were 
soon scattered all over the northern and eastern portions of the 
1 Treatise upon the cause and cure of pulmonary consumption, vol. ii. page 37. 
2 Gregory’s Dissertations, page 151; also American Med. and Philos. Register, vol. i. 
3 Historical Survey of the Diseases of London, page 22, by Thomas Bateman. Also 
Dr. Willards Statistics. THE CONTAGIOUSNESS OF PHTHISIS. 
9 
country. This fact led Dr. Rush to say: “ Its rapid progress 
among us has been attributed unjustly to the growing resemblance 
of our climate to that of Great Britain.” 
And Mr. de Witt Clinton, of New York: “If the climate of 
Yew York was formerly thus mild and healthy, and a constant 
amelioration in its temperature is consequent upon our numerous 
settlements and improvements, as has been maintained by distin- 
guished writers, to what shall we ascribe the extraordinary mortality 
occasioned by consumption at the present day?”1 
Another writer, Dr. Lettson, in a letter from London, near about 
that same period, says : “Whilst the phthisis pulmoualis is rapidly 
increasing in America and in the European continent, it is dimin- 
ishing here.” 2 
The indisputable fact is that England was, during the seventeenth 
and eighteenth centuries, a propagator of consumption throughout 
the world; and that wherever an English colony settled, phthisis 
pulmonalis became epidemic in the course of time. So noticeable 
was this fact at one time that consumption received the title of the 
English disease. 
But the most striking fact is that, wherever England colonized, 
the Indians took the disease, and it in course of time became more 
prevalent among them than it was even among the English. A 
study of the literature on this subject will show that the disease 
increased among them from east to west, and that, with some modi- 
fication, the more recent the report the greater the mortality. John 
D. Hunter, Esq., who was a captive among the western Indians 
for fifteen years, wrote to Dr, Henry W. Durachet, after his return 
in 1822 ; “I have known pulmonary consumption to occur among 
the Indians. It is rarely seen, however, except in those who are 
addicted to intemperance, and even in those cases it is by no means 
as common as among the whites. It is worthy of notice that their 
females are not as much subject to the disease as the males are.”3 
George B. Buckley reported to Governor Stevens, in 1854, that 
“ Indians east of the Rocky Mountains suffer from inflammation of 
the eyes and consumption.”4 
Dr. Thomas Williams writes of the Dacota Indians of Minnesota, 
L Gregory’s Dissertations, page 153. 
2 Ibid, page 150, or Amer. Med. and Phil. Reg., vol. ii. 
3 Amer. Med. Record, Philada., 1822. 
4 Report to Gov. Stevens, of the East. Div. ot Expl. for the Pacific Railroad, p. 178. 10 
FLICK, 
in 1870 : “ Of those over ten years who die of disease, I think half 
die of consumption.”1 
Now if, with this picture of the growth of phthisis pulmonalis in 
that portion of the United States which was colonized by England 
well fixed in our minds, we turn to study the development of the 
disease in the Spanish colonies of our country, we will arrive at 
results which cannot be explained except upon the theory of con- 
tagion. 
At the time when Spanish immigration into the present territory 
of the United States was active, governmental disinfection was in 
all probability practised in Spain. It was certainly practised in 
the latter part of the eighteenth century.2 Those portions of our 
country which were settled by the Spaniards, namely, California, 
Arizona, New Mexico, Texas, Florida, and Colorado, were almost 
absolutely free from consumption until they became the Sanataria 
of consumptives from the north and northeast. Intelligent natives 
of those countries will tell you that, prior to the mingling of the 
English-speaking people amongst them, the disease did not occur in 
their country. In fact, it was the generally acknowledged freedom 
of those places from the disease that gave them their reputation as 
resorts for the phthisical. But, while everybody is ready to admit 
these facts, climatologists claim that the comparative absence of the 
disease from those countries is due to the climate. They, however, 
fail to explain why consumption becomes prevalent in those regions 
as soon as they have been resorts for consumptives for some time. 
In this way some of the finest phthisical climates have lost their 
reputation, and have gotten to be shunned as places to be avoided, 
Santa Rosa, in California, is such a place. Indeed, the whole 
Pacific Coast, as well as Florida and Colorado, is acquiring a 
doubtful reputation for consumption. A look at the map of the 
U. S. Census Report for 1880, in which the topography of phthisis 
throughout the United States is indicated, will be apt to shake the 
confidence of the searcher after a climate for the cure of consumption, 
so far as those countries are concerned at least. That the change is 
due to the introduction of the disease by people from the older 
States will appear evident from the fact that in proportion as the 
sections of our country which were settled by the Spaniards have 
been less frequented by English-speaking people, and for a shorter 
1 Northwestern Med. and Surg. Journ., 1873, vol. xiv. page 412. 
2 Treatise upon the Cause and Cure of Pulmonary Consumption, by Dr. Rush. THE CONTAGIOUSNESS OF PHTHISIS. 
11 
period, they are freer from consumption. The Indians, moreover, 
who were in contact with the Spaniards for centuries, remained free 
from the disease, and some tribes remain free from it to this day.1 
America is, however, not the only country which was free from 
consumption until the disease was introduced from without. The 
islands of Bermuda and Madeira probably underwent the same 
experience. Both, at one time, enjoyed the reputation of being ideal 
climates for consumptives. They have both lost that reputation 
because the disease became too prevalent there. The history of 
Madeira is especially interesting. The natives of that island so 
feared consumption that “no pecuniary consideration whatever 
would induce them to accommodate phthisical patients,”2 wrote Dr. 
John Gordon, in 1784. And well they might fear it, for, after 
years of introduction by the English, the disease became endemic in 
the island. Dr. William Gourlay wrote, in 1811, “that the disease 
of phthisis pulmonalis was an endemic in the island, and that its 
fatality was prodigious among the inhabitants.”3 
There is reason to believe that also the Jewish people were free 
from the disease whilst they dwelt in the Promised Land.4 The 
disease is referred to in the Old Testament as a disease of Egypt, 
and is spoken of as a visitation or plague. 
Africa was also free from consumption until its inhabitants began 
to associate with other races. By Africa, I, of course, mean that 
portion of the continent occupied by the colored race. Dr. Millard 
writes : “ I have excellent authority for saying that the disease is 
rare among the negroes in Africa, and in the interior is almost 
never known.”5 
The disease exists along the different coasts, and prevails in ratio 
as the natives associate with the outside world. When the negro 
is taken from his native country into a country where the disease is 
prevalent, he is almost certain to contract it. 
But the theory of the contagiousness of phthisis does not depend 
upon historical argument for its establishment. I have already 
said that it can be proven by as many reasons as can be adduced 
in favor of any of the acceptedly contagious diseases; and I, of 
course, had in view scientific reasons. 
1 Does Pulmonary Consumption tend to Exterminate the Indians ? By Thomas 
J. Mays, M.D. 
2 Gregory’s Dissertations, page 74. 
3 Ibid., page 72. 4 Deuteronomy, xxviii. 22, Cruden’s Concordance. 
5 The Clim. and Statis. of Consumption, page 67. 12 
FLICK, 
The most prominent scientific ear-mark of the recognized con- 
tagious diseases is the fact that the persons who come in contact 
with the affected persons, or who live in close proximity to them, 
may fall victims to the same disease. In proportion as a larger or 
smaller number of the exposed contract the disease, the contagion 
is termed mild or strong. In some diseases, almost every one who 
comes in contact, and who is not protected, will contract the dis- 
ease; whilst in others comparatively few take it. Yet, inasmuch as 
only those who come in contact, or are in close proximity, fall 
victims, the latter is as truly contagious as the former, differing 
only in degree. In other words, contagious diseases are dependent 
upon a disease germ, and cannot be contracted, except through the 
medium of that disease germ. Every case is dependent upon some 
other case, and no case can spring up of itself. 
By a topographical study of phthisis in the Fifth Ward of the city 
of Philadelphia,1 for a period of twrenty-five years, I am able to 
show, as well as this can be shown of any disease, that consumption 
observes this law. To illustrate the matter, I present a series of 
three maps, the first and second of which contain diagrams repre- 
senting the approximate locality of all cases of phthisis and haemop- 
tysis which could be located in the ward for each year; together 
with diagrams of all cases of scarlet fever and diphtheria for two 
years each, the deaths from typhoid fever for one year, and the 
deaths from smallpox for one year. The third map gives the 
exact location of all deaths from phthisis and every form of tuber- 
culosis, which were properly returned to the Board of Health, for 
the entire period of twenty-five years. I only claim for these maps 
as great a measure of correctness as conscientious labor could give 
them. Mistakes in the returns of physicians and undertakers to the 
Board of Health, and such mistakes as are inseparable from copying 
long records, as well as the practice of returning deaths from the 
offices of undertakers, and the change of street numbers, have, of 
course, somewhat interfered with both their fulness and correctness; 
but they contain at least 90 per cent, of the cases which occurred 
in the ward during the twenty-five years, and of these, at a low 
estimate, 85 per cent, are located at the place at which they occurred. 
Only the deaths are represented in consumption, and some allow- 
1 I desire here to express my appreciation of and return thanks for the many 
kindnesses shown and assistance given me by Messrs. Turner and Murray, of the 
Registry Department of our City Board of Health. Diagrams of the Fifth Ward of Philadelphia, on which are approximately located all deaths from phthisis for each year from 1863 to 1887. 
and from smallpox and typhoid fever for one year, and all cases of diphtheria and scarlet fever for two years. 
MAP I. 
MAP 11. MAP 111. 
EXPLANATION OF SIGNS. 
Tuberculosis D 
Tubercular Meningitis + 
Tuberculosis of Inver S 
Tubercular Enteritis 
Laryngeal Phthisis A 
Abscess of Lung □ 
Phthisis • 
Hemorrhage of Lungs O 
x c:e 
\?\\ / / , / 
—V/ * ' s' " 
W A S^xl IST 
\ \ I i 'V '\\ 
I> JE /. A \v A. R E Jl I y £ Jl 
. _ \ \ i s'v \ - 
Map <3xact location of all deaths from phthisis, haemoptysis, and tuberculosis of every hind, which occurred in the Fifth Ward of Philadelphia for twenty-five years (1863-1887), THE CONTAGIOUSNESS OF PHTHISIS. 
13 
ance must be made for recoveries, and for change of residence 
shortly before death. As regards the latter, Ido not think that the 
general result is ranch affected by it. With the exception of a small 
boarding-house population, the people of the Fifth Ward are prob- 
ably more fixed in their residences than in any other part of Phila- 
delphia. They are mostly poor people, but few belonging to the 
middle class, and probably none to the wealthy. Of all classes of 
people, the poor are least likely to change their places of abode, and 
when they do have to change them, they go as short a distance as 
possible ; for around that spot, be it ever so low and miserable, is 
centred for them all that is embodied in the word home. By 
careful inquiry, I have found that in even those portions of the 
ward which are usually looked upon as the homes of no one, but 
the moral pitfalls of many, the deaths returned from phthisis were 
those of permanent residents. That the broken-down men and 
women who frequent such neighborhoods mostly die of phthisis, 
I am aware of; but an investigation of the subject has convinced 
me that such cases are never reported from those localities, and that 
the number of deaths reported represents but a small percentage of 
the cases contracted in them. During the twenty-five years niuety- 
nine cases were returned to the Board of Health as having been 
buried from the residences of undertakers, the majority of whom 
had died in hospitals (mainly Blockley), and had probably been 
residents of such localities and had contracted the disease there. 
From my own practice, I know, moreover, that persons who have 
drained the dregs of vice in those dens of iniquity return into the 
bosoms of their families when stricken down by phthisis, there to 
make their peace with God in the glow of parental love; and that, 
when this is impossible, their memories are at least screened by 
burial from some other place than the one which witnessed their 
degraded lives. Even those who have been severed entirely from 
friends and relatives find a charitable obscurity in the Potter’s 
field or on the dissecting table. Could a true picture be drawn 
of all the cases of phthisis contracted in such centres of infection 
what a sad spectacle it would present. 
A study of the diagrams on Maps Nos. 1 and 2 will show that 
consumption is centralized ; that it gradually changes its centre; 
that it completely changes its centre every three or four years ; that 
it reappears in the same locality in from one to two years; that it 
has a preference for filthy neighborhoods; and that its grouping is 14 
FLICK, 
identically the same as that of typhoid fever, smallpox, scarlet fever, 
and diphtheria. Of scarlet fever and diphtheria, although I give 
all the cases which occurred in the ward during two years, there 
are not enough to show a good grouping, which, when compared 
with the deaths from consumption for a single year, will bring in 
strong contrast the fatality of a disease which no one fears and 
against which there is no protection, except such as every individual 
can secure for himself; and diseases which every one dreads and for 
the prevention of which the Government, most properly, spends a 
large sum of money every year. Even as between smallpox and 
consumption and typhoid fever and consumption, during years 
when the former were raging as epidemics, the mortality from the 
former was no greater than it is from consumption every year. 
In order that the density of population may be studied in con- 
nection with the localization of the disease, I have divided the ward 
into election districts, and have given the population of each dis- 
trict, computed upon the election returns for 1887. This places 
the population of the ward a little below the census returns for 
1880, but makes it near enough correct for practical purposes. I 
may also say that I have selected the Fifth Ward for my demon- 
stration because it is one of the oldest, and has a fixed population, 
and its people are of an even class. 
Map No. 3, which is a careful drawing of all the building lots 
in the ward, taken from actual surveys, and therefore absolutely 
correct, and which has located upon each lot the number of cases 
of consumption which occurred upon it during the twenty-five 
years, as correctly placed as care could place them, will show that 
a house which has had a case of consumption will probably have 
another within a few years, and may have a very large number of 
cases in close succession; that when a case of consumption occurs 
in a house, approximate houses are considerably exposed to the 
contagion; that houses in localities where endemic after endemic 
has existed have, nevertheless, escaped the disease; that tuber- 
culoses of various kinds occur in the same localities, and often on 
the same lots as consumption; that whilst density of population 
and filth attract the disease, thinness of population and cleanliness 
afford no protection when the disease germ is introduced into a 
locality; that the disease has a decided predilection for the colored 
race; and that during the twenty-five years scarcely twenty per cent, 
of the houses of the ward were infected. THE CONTAGIOUSNESS OF PHTHISIS. 
15 
A comparison of the three maps will show that cases are grouped, 
not only in locality, but also in time of occurrence. This, however, 
does not show as well in the map as the facts warrant; but it could 
not be shown better, except by giving the date of death of each 
case, which is practically impossible. Frequently several deaths 
occur in the same neighborhood within a few weeks, and sometimes 
even a few days of each other. 
Of the infected houses scarcely ten per cent, are isolated—that is, 
standing by themselves—or, rather, not having an infected house 
next to them. About thirty-three per cent, of the infected houses, 
moreover, have had more than one case. These two facts alone 
seem to me to warrant the conclusion that consumption is never 
contracted except either by contact, by association, or by living in 
close proximity. 
How closely consumption follows this first law of contagious 
diseases is best demonstrated by a comparison of the diagrams of 
smallpox, typhoid fever, diphtheria, and scarlet fever with those of 
phthisis. It will be found that the grouping is identically the same, 
as well as the localization, except in scarlet fever' in which disease 
the localization is influenced by the age of those predisposed to the 
disease. 
Another distinguishing mark of contagious diseases, and one well 
demonstrated in the diagrams, is the fact that, after it has used up 
all the available material in a district, it dies out, to reappear when 
new matter fit for its operation presents itself. Although I have 
already referred to this point, I will expatiate upon it somewhat, as 
it is in itself almost positive evidence of the contagiousness of a dis- 
ease. It is this law of self-limitation which produces what are 
called cycles of disease, which in days of bad hygiene constituted 
scourges. The duration of a disease regulates the time required for 
its self-extinction. Most of the contagious diseases run a rapid 
course, and, therefore, produce short epidemics. Phthisis being of 
long duration, each individual case can infect all the susceptible 
persons who come in contact with it for a number of years, and in 
this way the epidemic becomes prolonged. The duration of 
endemics, as they are properly called, appears to be about three 
years, some being longer and some shorter. A series of endemics, 
dovetailing into each other, give a city and the country at large the 
appearance of a perpetual epidemic which yearly claims nearly the 
same number of victims. An analysis, however, of the facts shows 16 
FLICK, 
that the large epidemic consists of a very large number of small 
endemics. 
Another landmark of contagious diseases, and one which I have 
likewise already touched upon, is that they develop preeminently in 
filthy neighborhoods, in which the outside and inside hygienic con- 
ditions of dwellings are bad. The compliance of consumption with 
this law is well demonstrated by the diagrams. It will be seen 
that it occupies the very same localities as typhoid fever and small- 
pox ; and my notes show that it often occurs in identically the same 
houses. 
Another characteristic of contagious diseases is that persons 
become acclimated to them. From a scientific point of view, this is 
possibly one of the most interesting features of a contagious disease. 
It is a physiological principle that the human economy will in time 
accommodate itself in a measure to the presence of foreign and even 
detrimental substances. In this way we in time become proof against 
the most deadly poisons. It is for this reason that the first part of 
an epidemic is always the most fatal; and that in the early part of 
an epidemic a disease proves fatal in a shorter period of time than 
in the latter part of it. 
The history of consumption in all new countries into which it 
has been introduced, shows that it has had a rise, a climax, and a 
decline in prevalency. The islands of Madeira and Bermuda illus- 
trate this fact, and the progress of the disease from east to west in 
the United States points to it with great emphasis. In New York 
City, from 1804 to 1820, the deaths by consumption were 1 in 4.2 ; 
from 1820 to 1835, 1 in 5.4; from 1835 to 1850, 1 in 6.5; and 
from 1848 to 1859, 1 in 8.46.' In Rhode Island the percentage of 
deaths from consumption was, in 1867, 20.74; in 1883, 15.03.2 
In this way I might quote the mortality statistics of all the older 
States and cities, showing a decrease; and those of the newer ones 
and the Territories, showing either a stand-still or an increase 
The avidity, however, with which the disease takes hold of new 
material illustrates its subservience to the law of acclimatization 
better even than its history in different countries. It has almost 
exterminated some of the tribes of American Indians; it has deci- 
mated the natives of probably every island which has been colonized 
by England during the last few hundred years ; and wherever it 
1 The dim. and Stat. of Consumption, by H. B. Millard, page 18. 
2 Health Reports of Rhode Island. THE CONTAGIOUSNESS OF PHTHISIS. 
17 
comes in contact with the native-born colored people of Africa its 
fatality among them is marvellous.1 In Egypt the Negroes and 
Abyssiniaus are decimated by it.2 In Gibraltar, the comparative 
deaths per 1000, for twenty years, between whites and blacks has 
been: whites, 6.1 per 1000, and blacks, 33.5 per 1000.3 During 
the early history of America, while the slave-trade was going on, 
the proneness of the colored race to contract consumption was 
frequently noted. Dr. Rush records an instance where several 
colored servants were brought into a New England family in which 
the disease existed, and all contracted the disease. The marked 
decrease in mortality among the American Indians, after it has 
existed among them for a number of years,4 and the present mor- 
tality among the colored people of the United States, in connection 
with the severity with which it at first attacks both these races, are 
ample evidence that the law of acclimatization is in operation among 
them in regard to consumption. I have, moreover, myself observed 
that country people who move into infected districts will more 
readily contract the disease, and will have it in a more acute form 
than persons who have always lived in those districts. 
Another mark of contagious diseases is that, while in active 
progress, they will not tolerate the active presence of any other con- 
tagious disease. To this law there are said to be some exceptions, 
but they so seldom occur that they may be said to prove the rule. 
As regards consumption, I have been unable to find a single authen- 
ticated case in which any other contagious disease was concomitant. 
Dr. Welch, of the Municipal Hospital, in this city, writes me: 
“Although I have seen upward of 5000 cases of smallpox, I do not 
recollect that I ever came across one in which there was also well- 
marked and advanced phthisis. Possibly some of these patients 
may have been suffering from phthisis in its incipient stage; on this 
point, however, I cannot speak positively, since I have no recorded 
observations in that direction.” 
Dr. Taylor, of the Board of Health of this city, tells me that, in 
his experience with contagious diseases of every kind, he does not 
recollect having ever seen any other contagious disease in a person 
suffering from consumption. Dr. Longstreth, Pathologist to the 
1 The Glim, and Stat. of Consumption, by 11. B. Millard. 
2 Ibid., page 70. 
3 Ibid., page 64. 
1 Does Pulmonary Consumption tend to Exterminate the American Indians ? N. Y. 
Med. Journ., 1887, vol. i.page 508. 18 
FLICK, 
Pennsylvania Hospital, informs me that in twenty years, during 
whieh he has been connected with that institution, he has never 
found consumption in an autopsy for typhoid fever. The only cases 
of even alleged coexistence of consumption and other contagious 
diseases which I have been able to discover, occurred in Riverside 
Hospital, New York, but I have been unable to get such notes 
in regard to them as are necessary for scientific use. It is to Hr. 
L. L. Seaman, of New York, that I owe my knowledge of their 
existence. He writes me : “In reply to your question, ‘ Have you 
ever seen a case of smallpox, measles, diphtheria, or scarlet fever in 
a person suffering from phthisis?’ I can give an affirmative 
answer. I have seen fatal termination in each of the above cases; 
but for more definite information, notes, etc., I must refer you to 
the officers of the Riverside Hospital, Board of Health, New York 
City.” 
Unfortunately that Board did not deem it worth while to reply 
to my note of inquiry for further information. In order to throw 
some further light upon the subject, my friend, Hr. William 
M. Angney, physician to the Consumptives’ Home, of this city, 
kindly offered to vaccinate a number of consumptives for me. Two 
of the cases which he vaccinated at the Home took mildly. Both 
cases, I believe, had cavities, and the doctor informs me that in both 
cases the disease was active at the time of vaccination. In neither 
case was the vaccination typical, but inasmuch as the cases were 
secondary, this could not be expected. At the same time, however, 
the doctor vaccinated a woman at the Pennsylvania Hospital, who 
was believed to be suffering from phthisis, but of whose case there 
was some doubt, and she developed true vaccinia. Thus, as far as 
I have been able to gather facts upon the subject, the preponderance 
of evidence seems to point to the non-concurrence of consumption 
with other contagious diseases. An astonishing fact in connection 
with this matter is, that during the reign of the severe epidemics of 
typhoid fever and smallpox, in 1864-65 and 1871-72, deaths from 
consumption decreased, to become augmented as soon as the 
epidemics ceased. This might argue that some consumptives died 
of typhoid fever and smallpox during those years, were it not that 
the mortality from consumption throughout the whole city, for 
those same years, was much above the average. 
Another mark of contagious diseases is that they have media of 
contagion peculiar to themselves. Hiphtheria has the membrane THE CONTAGIOUSNESS OF PHTHISIS. 
19 
in the throat, scarlet fever has the decayed epidermis, small- 
pox has the pus from the pustules, typhoid fever has the dis- 
charges from the bowels, and phthisis has the sputa. Whether 
or not the contagion is confined to these various peculiar excretions 
and discharges, I do not know; but I believe that they are the 
most important media. As regards consumption, I am inclined 
to think that tubercular pus, formed in any part of the body, 
will produce the disease if the disease germ from that pus gains 
entrance into and secures a lodging in the lung. Whether or not 
the bacillus tuberculosis is the “ fell destroyer” I do not know; 
but that he dwells in the pus, whether it has formed in the lung or 
anywhere else, Ido believe. It is possible that, like so many other 
parasitic beings, he parades under different forms in different media, 
and that some of his aliases are yet to be discovered. At any rate, 
I am under the impression that his principal avenue into the human 
economy is through the stomach, and that only when that organ is 
off its guard can he secure an entrance. As a perfectly healthy 
stomach will digest and destroy the cholera bacillus, so I believe 
will it destroy the bacillus tuberculosis. It is only upon such a 
supposition that the method of grouping and centralization of 
phthisis can be explained. The fact, for example, that houses 
surrounded by consumption will escape for years, would indicate 
that social relations, such as neighborly acts of kindness, constitute 
a prominent factor in the spread of the disease, and that without 
such relations the disease is not ordinarily conveyed. A careful 
study, moreover, of the early stages of phthisis will satisfy every 
one that the disease is invariably preceded by some form of indiges- 
tion. So absolute is this rule that I doubt whether consumption 
can occur without a preliminary malnutrition of some kind. I 
question whether the disease can gain entrance into the body 
through the lungs, unless possibly by the inhalation of particles 
of dried pus, and then I think a denuded or inflamed bronchial 
surface would be required to afford admission to the disease germ. 
I recently expressed the belief that the bacillus tuberculosis floated 
about in the air everywhere, and in great numbers. A topographical 
study of phthisis has shaken that belief. Were that the case, the 
disease would not be confined to centres, as it is, nor travel so slowly 
over a given district. I am now of the opinion that the air is 
inimical to the disease germ, and that the latter only retains its 
vitality so long as it is protected by the purulent matter in which FLICK, 
it is imbedded, or by congenial extraneous matter. I have no 
doubt that it will propagate in decaying matter of any kind, and 
that it can thus perpetuate itself indefinitely. Tubercular pus, 
however, is the chief source of contagion, and by finding its way 
into the system with food and drink, spreads the disease slowly, 
but with the certainty of nature’s most infallible law. 
It may be well, in conclusion, to answer some of the objections 
which are raised against the theory of the contagiousness of phthisis. 
The oldest, and possibly the one that has done more than any other, 
to obscure the vision of thinkers on the subject, is the fact that 
nurses in hospitals for consumptives, and physicians treating cases 
of consumption, do not, as a rule, contract the disease. It was this 
argument, advanced by the professors of one of the great medical 
schools of Great Britain,1 which gave the death-blow to the theory 
in its infancy in England. It has been the standing argument ever 
since; and whilst it may have been a strong and proper one at one 
time, at the present stage of medical science it is so frivolous that, 
were it not so consonant with general belief and public prejudice, 
no scientific man would dare advance it. Nurses in typhoid fever 
and cholera hospitals, and physicians attending upon typhoid fever 
and cholera patients, do not usually contract those diseases; and yet, 
who would use that fact as an argument against the contagious 
nature of those diseases ? It must, moreover, be borne in mind that 
a deranged stomach and some form of malnutrition are essential 
precursors of phthisis; and that nurses and physicians are usually 
well-nourished, healthy people. 
Another and a very odd objection to the theory is, that consump- 
tion does not carry off enough victims for a contagious disease. 
The persons who raise this objection admit that a great many die 
of consumption, but they claim that inasmuch as the disease is so 
Avidespread, if it were really contagious, it ought to exterminate 
the human family. Such persons lose sight of the two great laws 
Avhich keep in check all contagious diseases, and but for Avhich the 
human family probably Avould become extinct, namely, acclimatiza- 
tion and exhaustion of proper materials. In some parts of Asia 
cholera is always endemic and yet the country remains densely 
populated. 
Finally, many are willing to admit that consumption is conta- 
1 The Medical School of Edinburgh, 1793-94. THE CONTAGIOUSNESS OF PHTHISIS. 
21 
gious, but they do not think that it is sufficiently so to be taken 
much notice of, or to warrant governmental interference. They, 
themselves, have frequently been exposed and have not contracted 
the disease, and they, therefore, cannot see how it can be very con- 
tagious. It is true, that the rich and those in comfortable circum- 
stances have it in their power to escape the disease if they have the 
wit to do so. But how about the poor? They who, like dumb 
cattle, are driven by their necessities into the very face of death ? 
Consumption claims most of its victims from that class, and they 
have neither the power nor the knowledge to escape its clutches. 
Does not the Government owe them a duty ? If consumption is 
contagious, it can be exterminated, or, at least, its ravages much 
curtailed ; it consequently behooves every government to take up 
some other position in the matter than one of passive neutrality.