SOME THOUGHTS ON PHTHISIS PULMONALIS. T5y WHITFIELD WINSEY, M. D., Of Baltimore. llKPRIKT FROM TRANSACTIONS OF .Iftcbical anti Cbiniroicat i'aruttia, OF THE STATE OF MARYLAND. 1S8G. STEAM PRESS OF GUGGENHEIMER, WEIL & CO. BALTIMORE. [Reprint from “ Transactions of the Medical and Ghirurgical Faculty of Maryland'’ for 1886.] SOME THOUGHTS ON PHTHISIS PULMONALIS. By Whitfield Winsey, M. D., Of Baltimore. Phthisis pulmonalis is a disease that has been known, studied and treated from the earliest times. That it was frequent among the Greeks is evident from the writings of Hippocrates (Syd. ed. Vol. 1). That it prevailed among the Romans, is also evident from the writings of Celsus, Aretaeus and Galen. All sorts of theories have been entertained with regard to its etiology, pathology and treatment, and yet, to-day it is justly one of the most dreaded diseases, claiming as it does about one-ninth of those who die from all causes. So well recognized in its fatality, that to tell a man that he has consumption is like reading his death-warrant. I do not pretend to offer anything new in this paper, but rather to inquire into the evidence as to whether or not the African mixed races, in whose blood there is a tinge of the African, are peculiarly susceptible to this disease. How far the same is inherent on the one hand, how far on the other ; extrinsic causes contribute to the large mortality from this disease among all classes, but particularly among those of African descent. That different races possess greater susceptibility or immunity with regard to certain diseases is as well recognized as almost any fact in medicine; and the greater immunity of the negro from zymotic diseases, while possessing greater susceptibility to pulmo- nary diseases, seems to be established almost beyond controversy. No doubt the chief cause of this susceptibility is the change from his native climate to another, whether cold or temperate. Dr. Ancell, in his great work on tuberculosis, says: “There is no case in which the injurious effects of a change of climate appears to be more conclusive than in the negro race.” Every writer on the subject has noted the same fact. Ilis great suscep- tibility is most marked when placed under similar circumstances 2 WHITFIELD WINSEY, M. D. with whites. For example : the negro troops serving with white ones in the West Indies, where the former fell in large numbers from the disease from which the latter were comparatively exempt. Mr. Parsons, who has brought over so many African hoys to London to be educated, deplores the fact that “they all die of consumption.'’ The change of the African to the West Indies, where the range of the thermometer is quite as high as at home, could not account for this high mortality without the presence of another factor, which is supplied by the humidity of the climate. Heat and mois- ture go hand-in-hand in this wholesale slaughter. An interesting fact with regard to the power of climate is shown in the fact that the Europeans have persistently tried to live in the Valley of the Nile, but the emigrants have all died and left the country to its ancient inhabitants. Romans and Visigoths lived in Africa for centuries by continu- ally recruiting their ranks from Europe, and yet, except in the mountains, all traces of them have disappeared. We think, however, that in the case of the negro, the superior knowledge of the present century will come to the rescue. In support of the statement that heat and moisture are favoring conditions, Dr. Guilbert states that the large mortality on the coast of Peru and of the West Indies is directly due to this con- dition. In an elaborate report, prepared by Mr. Carter, our courteous and efficient Secretary to the Health Department, and to whom I am indebted for valuable assistance, he furnishes me facts, from which I perceive the following : Mean Mean Colored Mortality, White Mortality, Thermometer. Moisture. from P. from P. 98° 67.8 23.17 16.07 99° 67.1 21.37 16.17 while in a period of diminished humidity, though of high tem- perature, we find— Moisture. Col. Deaths from P. White Deaths from P 101° 66. 18.09 11.05 Prof. Quantrofangs, in Pop. Sci. Mo., No. 2,551, says: “That the negro is not affected by emanations from swamps and marshes, but is more liable to tuberculosis. Yet,” he continues, “ all immunities and predispositions disappear with time. He noticed VOLUNTEER PAPERS. 3 that in Barbadoes elephantiasis attacked only negroes till 1704, but since that time many white natives have become its victims, showing it to be a question of acclimation. Under the heading, “Geography,” Dr. Ancell says that nearly the whole of Africa is free from this disease; and as long ago as the time of Pliny, Egypt was exempt. He seldom saw it among the people of Abyssinia or Nubia, or along the West Coast, and in 124 deaths in this last locality, among British soldiers, not one was from tuberculosis. In St. Helena he found 3.2 in 1,000. In British Guinea, where nearly all the inhabitants are negroes, phthisis is unknown. In Mauritius, where there is a great varia- bility of climate, many more men took the disease than in the Brit- ish Isles, or on the Mediterranean. It is most fatal to negroes in Ceylon, where the climate is equable, but moist. Here the natives are but little affected, while the troops, all black, fall in large numbers. In Van Diemen*s Land there is only one death from this disease in one hundred from all causes. In Lapland there is neither phthisis nor scrofula, but the Laplanders acquire both when they go to Denmark. In the Madras army, sent into China, the deaths from phthisis became, in five years, five times as great as it had been in India. Finland youth, apprenticed in St. Petersburg, die in large num- bers from this disease, though in this case other important ele- ments no doubt contributed to the large mortality, prominent among which may be homesickness. An interesting fact bearing upon this point of my subject is the exodus of negroes from the South to the West within the past few years. Animated by an idea of bettering their condi- tion, their tone and vitality have been so preserved that, so far as I have observed, there has not been that great mortality among them that statistics show to exist in the large northern cities, although the climate in some of the new settlements has been found very severe. Louis, the Great Master, says : “All calcu- lation in which the occupation, food, habits, etc., of the inhabi- tants are not duly considered may be regarded as negative.** All the statistics bearing on the subject are interesting and instructive. Dr. Mossell, of Philadelphia, has published in The Alumni, a quarterly issued in that city, an article entitled, “Excessive Mor- tality of Negroes living in Northern Cities.** He shows an ext emely high mortality among negroes from all causes, but 4 WHITFIELD VVINSEY, M. D. particularly from phthisis. The four cities, Boston, New York, Philadelphia and Baltimore, all give larger death-rates from this disease among the colored than the other portion of the popula- tion, being in the case of the negro £ greater. lie shows, by the following table, that in 1884 Boston, with a colored population of G,000, gave a death-rate of 42.10 to the 1,000 colored deaths, while that among the whites was 24.12. The per cent, from con- sumption alone among the— Colored population was 22.22 And from pneumonia and bronchitis 13.79 While among the whites the per cent, from— Consumption was 1G.12 Pneumonia and bronchitis 12.89 A table for Philadelphia, covering a period of 23 years, from 18G2-84, inclusive, shows an average— Mortality among whites 22.41 per cent. “ “ colored 37.29 “ “ Another table, covering a period of 10 years, from 1875-84, inclusive, shows an average mortality from— Consumption among whites 14. “ “ colored 18. A table for New York, from 18G7-84, shows average— Total mortality among whites 2G.78 “ “ “ colored 30.72 This shows also that the average mortality among the colored peo- ple of New York from all causes is smaller than in Philadelphia. In another table for New York, from 1880-84, he found that the per cent, of deaths from zymotic diseases and consumption was as follows : Zymotic disease, white 31 “ “ colored 18.8 Consumption, white 14.G “ colored 21.5 Thus sustaining an average of about one-third greater mortality among the colored than the white population—as in Boston and in Philadelphia. Coming nearer home, I again quote our own Secretary of Board of Health. In his report for 1885 he presents a table, which covers a period of 10 years, from 1875-84, which I append in full. VOLUNTEER PAPERS. 5 He shows the total mortality from all causes among the two races and the sexes separately : Among the whites it was 13.3 “ colored “ , 18.2 Another for 1885 alone shows—white 14.07 “ “ “ “ colored 20.78 Mortality in Baltimore during Ten Years—1875-84. Tot. h-» 1—ihmmmhhH OOGOGOGOGOGOGOOOGOOO GO CO GO tO GO 1 * 9,005 1-* H M COOOO GO GO GO CD —I QGOMXGOHaOC4**0 Colored males. > d ■ ft at 9,677 MHM h-* cc co oo "o go GCMCOGOGOXOIM^IO C M GO O Cl 4* GO W oi O Colored females. QO to 4- to J»JO 00 00 00J—1 h-1 1—1 ‘—i I—1 CHODCit-OuiOWit* Colored males. d H o 525 1,912 ®MCOQ0OOffl00>t- Colored females. h-1 O CO to hhhhhhmmhh h-» to to to tOMHOMO 4- Cit0^05Ht0vl4*MO Totals. Mortality in Baltimore eor 1885. White males. White females. Col. males. Col. females. Total ueaths 3,211 3,113 878 951 Consumption 430 458 192 190 Ratio of consumption to total mortality 13.38 14.71 21.87 19.87 Col. females. White. Colored. Total mortality 1,830 Consumption 382 Per centage 20.78 Total mortality, wliite and colored 8,154 “ consumption, “ “ 1,280 Per centage 14.47 6 WHITFIELD WINSEY, M. D. Year. White males. White females. Colored males. Colored females. Totals. TEMPERATURE. Humidity, per cent. Mean. Max. Min. Mean. f Total mortality from all causes 2,878 2,872 739 769 7,258 J “ “ “ consumption 364 403 124 149 1,040 53° 1 June 27. Jan. 10. 66 9 ] Ratio of mortality from consumption to total 97° 1° 5 12.65 13.99 16.78 19.37 14.33 f Total mortality from all causes 2,879 2,720 974 875 7,268 1 Q7A ] “ “ “ consumption 398 439 143 187 1,167 54° 9 July 9. Dec. 10. 67 1 1 Ratio of mortality from consumption to total 99° 1° [ mortality ,. 13.82 16.17 18.13 21.37 16.05 f Total mortality from all causes 2,969 3,090 838 1,013 7,910 ] “ “ “ consumption 358 413 126 197 1,094 56° 3 June 26. Jan. 5. 68 4 | Ratio of mortality from consumption to total 95° 1° mortality 12.05 13.36 15.06 19.44 13.83 f Total mortality from all causes 2,556 2,603 716 858 6,733 j “ “ “ consumption 386 417 125 199 1,127 56° 9 July 19. Jan. 8. 67 8 I Ratio of mortality from consumption to total 98° 6° l mortality 15.10 16.02 16.06 23.17 16.73 f Total mortality from all causes 2,790 2,913 851 884 7,618 A “ “ “ consumption 406 416 150 190 1,162 July 16. Jan. 3. 65 8 "1 Ratio of mortality from consumption to total 99° 0 [ mortality ' 13,67 17.02 17.63 21.49 15.20 Mortality in Baltimore from All Causes, and per cent, of Consumption to Total Mortality. 7 VOLUNTEER PAPERS. f Total mortality from all causes 3,180 2,990 888 985 8,043 Dec. 30. “ “ “ consumption 416 462 154 189 1,221 56° 7 July 13. 3° below 64.6 ] Ratio of mortality from consumption to total 99° zero. [ mortality 13,06 15.45 17.34 19.18 15.48 f Total mortality from all causes 3,420 3,317 1,008 1,089 8,816 Jan. 1. 1 ftftl J “ “ “ consumption 376 463 170 197 1,206 57° 1 Sept. 7. 6° below 66.0 j Ratio of mortality from consumption to total 101° zero. mortality 11.05 13.95 16.86 18.09 13.68 f Total mortality from all causes 3,606 3,272 1,007 1,038 8,923 i sa9 J “ “ “ consumption 406 443 168 200 1,217 55° 7 June 25. Jan. 24. 67.9 | Ratio of mortality from consumption to total 97° i mortality 11.25 13.53 16 68 19.27 13.64 f Total mortality from all causes 3,659 3,466 1,078 1,177 9,380 1 cca J “ “ “ consumption 411 470 171 220 1,272 55° 1 July 23. Jan. 23. 66.4 1 Ratio of mortality from consumption to total 96° 11° 1. mortality 11.26 13.56 16.02 18.69 13.35 * f Total mortality from all causes 3,340 3,058 906 989 8,293 j “ “ “ consumption 402 390 150 184 1,126 56° 2 July 24. Jan. 6. 64.7 | Ratio of mortality from consumption to total 94° 8 8 mortality 12.04 12.75 15.78 18.75 13.0 { Total mortality for 10 years from all causes 31259 30301 9,005 9,677 80242 “ “ “ “ “ consumption. 3,923 4,316 1,481 1,912 11632 Ratio of mortality from consumption to total mortality 12.55 14.24 16.37 19.77 14.48 A. R. CARTER, Secretary Health Department. 8 WHITFIELD WINSEY, M. D. A little higher in 1885 than in the preceding 10 years, bnt making the ratio between the two races about the same—one-tliird greater in the colored than in the white. How much of this is due to inherent weakness, to climate, to occupation and hygienic influences must be considered sub judice. The U. S. Census Mortality Report for 1884, says: “An impor- tant question is how far the excessive mortality among the colored population is due directly to race characteristics—that is to less vital force ? or to the fact that the great mass of these people are poor and ignorant, live in the midst of unhealthy surroundings, in the dampest and dirtiest parts of the city, have poor food and are in other respfects unusually exposed to well-organized causes of death ? If we could separate the vital statistics of the poor and ignorant whites, the tenement-house population of our northern cities from those of the whole white returns, we should undoubt- edly find a high rate of death in this class, especially in infancy and childhood/’ The authorities that we have quoted show the negro to have come from a climate that made but little demand upon his respi- ratory organs, and his simple pastoral life under the old regime was not such as to fit him even under more favorable circumstances for the high-pressure mode of living peculiar to all large American cities. Had the large numbers who flocked to the cities, particu- larly those of the North, continued life upon the farm, we might not have been confronted with this large mortality, which unde- niably exists among them. Another unfavorable element has been the cramming system practiced in the schools. The evil elfect of this upon all classes, in retarding physical development and well-being, is happily receiving the attention that it loudly calls for. The bad elfect upon the negro could hardly have been expected to be less in view of other conditions. In thus expressing myself, I do not desire to be understood as depreciating the value of true education, but that the eternal fitness of things should be considered here, as in the other rela- tions of life, and that the methods of teaching, as well as the amount attempted, should be suited to the individual in his con- dition in life and his opportunities for usefulness. Wendell Phillips, in speaking upon the modes practiced in New England, says: “Most of the graduates from the schools can do VOLUNTEER PAPERS. 9 nothing to earn a dollar. They cannot write a decent letter, nor read aloud a newspaper; but over-educated they find themselves unable to earn a living according to their taste. Thus they are led into temptation and vice/’ Perhaps in the case of the negro we can give the same cause with this effect—despondency and disease. In Poston the climate is particularly trying to all who have any predisposition to lung disease, irrespective of race. Baltimore is next to Boston in the number of cases among colored people, but right here we can largely explain the fact, for so many of the peo- ple work in the oyster and packing houses, continually surrounded by dampness and filth, and are required to go to work between three and four in the morning, during the most trying a*nd unhealthful season of the year. The crowded and unsanitary condition of small and badly arranged houses in the lanes and alleys where large numbers of these people live, their ignorance of the most elementary laws of health, often their enforced idleness, owing to the few avenues in which they can find steady employment and living wages, all combine to make the lot of the negro in our large cities like that of the policeman in the Pirates of Penzance, .“not a happy one/’ Having demonstrated by facts and figures that consumption is a formidable enemy to mankind in general, and to those of Afri- can descent in particular, the question naturally arises, how may we best combat it ? To name and describe one-half of the drugs and methods proposed and vaunted for its cure would require volumes, but in the present state of our knowledge we have much more to hope for in prophylaxis than in cure. If the bacillus theory of Koch, as a specific agent, is to stand, our efforts should be directed to prevent the propagation and spread of this mor- bific agent. The late lamented Dr. Flint, in The American System of Medi- cine, says : “ The doctrine that phthisis depends on the presence of a special micro-organism is to be considered as probably estab- lished. Assuming it to be demonstrated that the disease involves a specific agent, and that this agent is proven to be a contagion by its capabilities of producing the disease when introduced into a healthy body, the conclusion as to the communicability is not to 10 WHITFIELD WINSEY, M. D. be shaken b)r the lack of corroborative clinical evidence, or by inability to explain certain facts which seem to be inconsistent with that conclusion. Having accepted a demonstrated truth, the endeavor should be to reconcile therewith facts which do not sustain it, and which appear to be opposed to it.” And again : “The development and continuance of phthisis involve two factors : the presence of the parasite and the existence of those unknown conditions constituting the tuberculous predisposition or cachexia, usually developed independent of any antecedent affection of the lung. That a congenital predisposition exists in certain cases is to be inferred from the number of cases that often occur in one family.” All of this suggests the importance of separating as far as possible those affected with phthisis from others immediately around them in the closer relations of families. As physicians in contact with our patients, especially the poor and ignorant, it should be our constant endeavor to disseminate some slight knowledge of hygiene. We should constantly remind them that living in damp and overcrowded houses, in the midst of filth, is a most fruitful cause of the large mortality among them, particu- larly in infancy and childhood ; that it is oftener man’s improvi- dence than God’s providence by which whole families are swept out of existence. To cope with any formidable evil, we must go to the root of the matter. So here we may hope to do much by physically strengthening the young and avoiding the tendency to over- educating the masses, or perhaps I might more properly say, avoid cramming the head with useless knowledge at the expense of the balance of the body. Dr. Renebaugh read an essay before the Social Science Associa- tion of Philadelphia, February, 1879, in which he said : “Let hand culture go side by side with head culture, as I am confident that without it we are deteriorating morally, physically, intellec- tually.” In Hampton Institute they are carrying on this work of indus- trial education among negroes and Indians. The literary train- ing is of a very moderate degree, but every boy and girl is taught a trade, as well as all sorts of useful employment. VOLUNTEER PAPERS. 11 Our own manual training-school is carrying out this idea, with the difference that it is open to white boys only. This is also true of the McDonough school. As great as have been the achievements of preventive medicine within the past, it no doubt has greater triumphs awaiting it; and should it place phthisis pulmonalis in the category of preventable diseases, such as small-pox, yellow-fever, cholera, etc., the boon to living and unborn millions will be great indeed.