COMMONWEALTH OF PENNSYLVANIA. 
STATE BOARD OF HEALTH AND VITAL STATISTICS. 
THE CONTROL OF TOBERGULOSIS 
A PAPER READ BEFORE THE 
it State Sanitary Convention of Pennsylvania 
AT WILLIAMSPORT, MAY, 1896, 
BY 
Lawrence F. Flick, M. D., 
OF PHILADELPHIA. 
EXTRACTED PROM THE TWELFTH ANNUAL REPORT OF THE JjTATE JBQAbY) 
op heU'l'h. ' 
CLARENCE M. BUSCH, 
STATE PRINTER OF PENNSYLVANIA, 
1897. THE CONTROL OF TUBERCULOSIS. 
Lawrence F. Flick, M. D., Philadelphia. 
Government exists for the protection of the individual in those 
matters in which for the general good he cannot be permitted to 
protect himself. When immediate danger threatens, the individual 
may act, but for all remote dangers the government must intervene. 
The reason for this is self evident. If the individual were allowed 
to protect himself, there would be continuous warfare, and the weak 
would ever succumb to the strong. 
So jealous has the law always been of human life, that for every 
danger that has arisen along new avenues of human activity, a new 
safe-guard has been built up. Our statute books are filled with 
laws protecting life and limb against accident in every walk of life 
and under every possible circumstance. The railroad company, the 
manufacturer, the merchant—in short, every employer, and indeed, 
the government itself, is bound to give every possible protection, 
and if they do not, they are mulcted in damages for loss of life or 
injury to limb. Even in providing for the pleasures and for the 
sustenance of others, we are bound by the law to protect them 
against injury to life, limb or health. In fact, no injury can come 
to a man through the application of physical force or through the 
taking in of deleterious substances into the system in the form of 
food, drink, gases or medicines against which the law has not at 
least attempted to set up some barrier; and yet, strange to say, 
almost nothing has been done to protect man against disease. 
The reason for this is that governments are not yet adjusted to 
the newly discovered knowledge about disease. Our statute books 
still tacitly ascribe disease to the direct interference of an angry 
Providence, instead of looking upon it as a physical phenomenon 
subject to the control of man. We have, as yet, no adequate 
machinery by which legal protection can be given to man against 
the microscopic foes in the organic world which have been brought 
within range of our vision and knowledge by the modern science of 
microscopy and bacteriology. It takes time to create such ma- 
chinery, and before it can be done in our country, where govern- 2 
ment is by the people, the whole people will have to be educated to 
the new way of thinking. Not only will the public mind have to be 
enlightened about the cause of disease, but a public sentiment will 
have to be created in favor of subjecting private rights to public 
interest, where the suppression of disease requires it, and of expend- 
ing public money with sufficient liberality to accomplish the end 
aimed at. When the subject of prevention of diseases has once 
properly taken hold of the public mind, and the people have thor- 
oughly grasped the full meaning of its theme, in the avoidance of 
suffering and expense, by the stamping out of such diseases as con- 
sumption, diphtheria, scarlet fever, measles, typhoid fever, whoop- 
ing cough and pneumonia, there will be no difficulty in establishing 
a department of health, with the necessary powers and resources to 
accomplish the end for which it is created and free from the shackles 
of political slavery. It is, therefore, highly proper that an active 
spirited campaign of enlightenment be carried on, and that from the 
greatest to the humblest among us every one be made familiar with 
modern views about disease and how it can be controlled. 
Of all diseases, the one about which we know most at the present 
day, from an etiological point of view, at least, is tuberculosis. 
From being the disease hidden in the deepest darkness, it has been 
brought out into the brightest light. In fact, we have now so defi- 
nite a knowledge about it that it is as completely within our power 
as the wild beasts of the forest and the vermin of our household. 
Wild animals, dangerous to man, have been exterminated from the 
abodes of civilization, and when rats, mice, bugs or vermin of any 
kind infest our houses, we know how to rid ourselves of them. 
Science has given us the same power over the great white plague of 
consumption. 
Consumption is produced by a little bit of organic life, which, 
although only visible under the higher power of the microscope, has, 
nevertheless, an individuality as perfect and unalterable as has the 
largest animal. This little member of the invisible plant world— 
for it is a vegetable and not an animal parasite—has existed since 
the earliest records of medical knowledge, and during all that time, 
as is evident from the recorded descriptions of the disease which it 
produces, has maintained its identity through myriads of genera- 
tions. It has existed during all that time, and continues to exist 
nndor definite environments, requiring a certain soil for its develop- 
ment, a certain temperature for its prosperity, and certain cycles of 
organic change for its propagation. These have all been unwit- 
tingly furnished it by the human family since the days of Hippo- 
crates, at least, and probably since the dawn of man’s day upon 
earth, although at any time they could have been withdrawn, as 3 
they have been by certain races and peoples, had man possessed the 
knowledge necessary to enable him to do it. 
The microscope and the modern laboratory have enabled man to 
look into the hitherto unknown microscopic world and to carefully 
study the habits of life of this vexatious little organism, to see what 
it needs for its maintenance, how it gets it, why man has served so 
well as its host, how it can be staved out, how it can be destroyed, 
in short, how it can be stamped out of the world. This scientific 
detective work has been simpler than one would suppose. The clue 
to how to do it came with Koch’s discovery of how to stain a micro- 
scopic organism. The scientific world was practically unanimous 
in its opinion that an organism existed which was the primary cause 
of tuberculosis. But in vain the scientist peered through his micro- 
scope; he could see nothing to wrhich he could ascribe life or pow- 
ers such as must be possessed by an organic substance capable of 
producing the symptoms of tuberculosis. The trouble was that he 
was looking right through the organism, for it was transparent. 
Finally, however, the genius arose who could master this difficulty, 
and Koch made his celebrated discovery by which he could stain 
these little bits of organism and make them visible. With this dis- 
covery all became easy. Being able to see the germ which pro- 
duced tubersulosis it was easy to identify it, study its habits, in 
short, learn all about it. This has been done, and we now have 
even a more complete knowledge of the habits of life and the neces- 
sary environments of the tubercle bacillus than we have of many of 
the much larger representatives of the organic world. 
The knowledge that has been gained about tuberculosis in the 
laboratory has been supplemented by a careful study of the disease 
at the bedside and in history with so striking a parallel in the log- 
ical conclusions that the truth is made to stand out all the more 
prominently thereby. Close observation and patient research made 
it possible to trace nearly every case of the disease to its source of 
infection, and historical study has shown its spread from country to 
country, and the practicability of stamping it out by appropriate 
preventive efforts. Family, individual and race predisposition to 
the disease as revealed to the clinician, the enhancing and restrain- 
ing influence of different climates upon the development of the dis- 
ease, the predisposition to the disease growing out of want, depres- 
sion, grief, etc., and the tendency of the spread of the disease along 
the lines of civilization, all fit in exactly with the knowledge that 
has been gained in the laboratory about the life-history of the tuber- 
cle bacillus. Indeed, every scintilla of knowledge, from whatever 
source derived, has helped to blazen forth the great truth that con- 
sumption is a preventable disease, and only aAvaits intelligent effort 
to be stamped out of civilization. 4 
What is this intelligent effort? First: The civilized world must 
be educated to the new doctrine. Every man, woman and child 
must be made familiar with the fact that consumption is always con- 
tracted by contagion, and cannot be contracted in any other way. 
The old idea that consumption comes through a cold must be done 
away with, because it stands in the way of truth and leads to mis- 
chief. As long as people stick to this old error, they cannot grasp 
the truth, and they, to a certain degree, are led to predispose them- 
selves to consumption by dreading and avoiding fresh air and the 
hardening influences of out-door life. The idea that cold leads to 
consumption has done more in civilized life than any other cause to 
prepare people for the germs of the disear.' 
Secondly: It must be made known to every one that the conta- 
gion of consumption resides in and is confined to the matter given off 
by a person suffering from some form of tuberculosis, this matter 
being given off either as spit or discharges from a running sore or 
from the bowels or kidneys. It is through this matter that in every 
day practical life nearly all new cases of tuberculosis are produced. 
The bacilli, given off in this matter, from the old host, find their 
way into a new host either by getting into the blood through the 
alimentary canal with the food, or by finding their way into the 
lympathic system through the lungs, being inhaled with dust and 
absorbed by the bronchial lymphatics. Nine-tenths, and possibly 
ninety-nine-hundredths of all cases of consumption are contracted 
in this way. The only other way in which the disease can be con- 
tracted is by the use as food of the meat or milk products of animals 
suffering from the disease. In practical life, however, this is not a 
frequent method of getting it, for the reason that cooking destroys 
the germs in meat and milk of tuberculous animals, and it is not 
likely to be contaminated. Although I have, for years, been look- 
ing for such cases, I have not found half-a-dozen well-authenticated 
cases in either my own experience or in literature, which I had rea- 
son to believe were contracted by drinking tuberculous milk. And 
these clinical observations are entirely harmony with laboratory 
experiments, for although a few bacteriologists claim to have found 
tubercle bacilli in milk, the majority, and, by all odds, the most re- 
liable, have not found them except in such cases as had the udder 
involved with tuberculosis disease. 
Besides education, there must, however, be interference on the 
part of the Government, And in what should this interference con- 
sist? Studying the question from all points of view, and under the 
soft light of Christian charity, the most far-reaching and, at the 
same time, the most humane step that can be taken is the establish- 
ment of well-equipped hospitals for the treatment of those suffering 
from the disease—hospitals in the mountains for those in the incip- 5 
ient stage of the disease, and hospitals in or near large cities for 
those far advanced in the disease. This one step, if taken on a 
large enough scale, would promptly stamp out. tuberculosis. In 
England, where private charity has for half a century prompted 
the establishment of large hospitals for consumption, the disease is 
rapidly disappearing. The method by which removal of the patient 
to a hospital prevents the spread of the disease is easily understood. 
A case of consumption may last from six weeks to ten years, during 
all of which time the home and environment of the consumptive, un- 
less certain precautions are taken, become centres of infection, and 
all who are continuously exposed to those centres, such as members 
of his family, business or occupation associates and friends, are liable 
to contract the disease. But if the case is removed to a hospital 
before the breaking down which is the beginning of the infectious 
period, all of this danger of infecting others is avoided. The in- 
fluence of such a single preventative effort is much more far-reaching 
than appears at first sight; for not only is the immediate infection 
prevented, but also those that would be propagated by subsequent 
cases. 
As to any hardship involved in sending consumptives to hospitals, 
a bugbear which is being conjured up by certain well-meaning in- 
dividuals who have very little practical knowledge of the subject, 
there can be none in practice. A well-equipped hospital in the 
mountains would hold out sufficient inducement in possible cure to 
attract all cases of incipient tuberculosis. It would not be so much 
a question how to force people to go to it as how to supply accommo- 
dations for those who would apply for admission. For the ad- 
vanced cases, hospital treatment is so imperative for the very poor 
that they beg for admission into hospitals. lam constant!}' in con- 
tact with the consumptive poor, and I know that the majority of 
them will cheerfully go to a hospital if the opportunity is given 
them. At the present time they are denied admission to nearly all 
hospitals. 
As yet, very little has been done by the Government in this coun- 
try in the way fsupplyinghospital accommodations for the consump- 
tive poor. Private charity has led the way, and various move- 
ments are on foot to give practical aid to> this sadly afflicted class of 
sufferers, and some of them promise well for the future. Every 
effort should, however, be made to induce the State and City Gov- 
ernments to at once establish well-equipped hospitals for the con- 
sumptive poor. A fair division of the work would be for cities to 
establish hospitals for advanced cases, and the State hospitals for 
incipient cases. The Pennsylvania Society for the Prevention of 
Tuberculosis has had a bill with this end in view before the State 
Legislature for years, and is now urging Philadelphia City Conn- 6 
oils to establish and equip a municipal hosjjital for advanced cases. 
In this effort it seeks, and should obtain, the co-operation of all in- 
dividuals and organizations that have the public welfare at heart. 
Next to the establishment of hospitals for the treatment of the 
consumptive poor the most important step for the Government to 
take is the registration of all cases of tuberculosis, and the proper 
supervision and disinfection of vhe environments of the consump- 
tive. Could every case of tuberculosis be removed to a hospital, 
nothing more would be necessary, as the centres of infection would 
be removed from the community. Close confinement would not be 
necessary, as the education in methods of prevention which could be 
given in a hospital would make the patients innocuous to the pub- 
lic. It will, however, for a long time to come, be practically impos- 
sible to provide hospital accommodations for all cases of consump- 
tion. Until this can be done, it is the duty of the Government to give 
such other protection to the public as lies within its power. By 
registration and proper supervision and disinfection a good deal of 
protection could be given with the existing machinery of the law at 
a trifling expense. Physicians should be required to report every 
case of tuberculosis which has progressed to the stage of breaking 
down. When this stage of the disease has been reached, a diagnosis 
can be made with absolute certainty by a microscopic examination 
of the broken down tissue, so that there can be no objection to regis- 
tration on the score of difficulty of diagnosis or unnecessary hard- 
ship to the patient. Prior to the stage of breaking down, there is 
no danger of communicating the disease to others. 
When a case has been registered, if it is a person unable by rea- 
son of ignorance or poverty to protect the public, it should be visited 
by the health inspector, and supplied by him with the necessary 
germicides and paraphernalia for thorough and immediate steriliza- 
tion of all tubercular matter given off, and instructed in their use. 
It has been said that the physician can do all this, and that a visit 
from the health inspector would be espionage and invasion of pri- 
vate rights. But the physician does not do it, sometimes because 
he does not know enough about the technique, sometimes because he 
has not the time, and very often because there is no physician in 
regular attendance. Among the very poor, consumption is looked 
upon as necessarily a fatal disease, and when it has once passed a 
certain stage in its progress, the family calmly awaits death, and the 
physician, usually a dispensary doctor, is called in at the end to 
avoid a coroner’s inquest. Moreover, it is not proper to place upon 
(be physician’s shoulders duties which belong to the Government. 
As to espionage the word cannot properly be applied to such super- 
vision of (he consumptive as is necessary for the protection of the 
public. The health officer need not go where, in Christian charity, 7 
lie is not needed. The wealthy are abundantly able to take care of 
themselves. The poor are not, and it will be no hardship to them 
or interference with their private rights to help them to protect 
those near and dear to them against so fatal a disease. 
In addition to education of the public, establishing hospitals for 
the treatment of the consumptive poor, registration of tuberculosis 
and supervision and disinfection of the environments of consump- 
tives, much else could be done for the control of tuberculosis, 
but until these measures have all been successfully inaugurated, it 
is vain to speculate about others. For the present, every effort 
should be made to influence State and city government to take 
action along these lines. 
As regards government control of tuberculosis among cattle, as a 
measure for stamping out the disease in the human family, I fear 
that it is much over-rated. The government of Pennsylvania has 
already spent much money in this direction, and from the point of 
view of an economical agricultural measure I think quite properly 
but we must not permit ourselves to be lulled into inactivity by 
great expectations of its accomplishing much in the way of stamp- 
ing out the disease among men'. It moreover looks like a hopeless 
task to me to try to stamp out tuberculosis among domestic animals 
so long as nothing is being done to prevent the spread of the disease 
among human beings. From my own observations and from my 
readings I am convinced that domestic animals are rarely a source of 
infection to human beings, but that man is frequently the means of 
conveying the disease to animals. Too much has been said in pub- 
lic print during recent years about the danger of contracting tuber- 
culosis by drinking milk, and unnecessary alarm has been created 
and injury done by setting up a prejudice against the use of one of 
the most, valuable articles of food. Until it can be shown that 
tuberculosis is contracted in this way in practical every day life, the 
mere theoretical possibility of its being so contracted must weigh 
very little. As yet, no one has been able to point to a respectable 
number of cases that have been taken in this way. On the other 
hand, there are very few cases in human beings which cannot be 
traced directly to their source of infection.