TUBERCULOSIS.

ITS PREVENTION.

At the May meeting, 1897, of the Board, Dr. J. M. Emmert presented the following paper, which was ordered printed:

Can tuberculosis be prevented? is one of the most important questions of the day. Sanitarians, physicians and other scientists are not alone interested in this question, but it is of vital interest to every father and mother, brother and sister.

When we remember that the "Great White Plague" is the cause of every seventh death; that in the State of Iowa nine persons die of tuberculosis every day, three thousand every year; that the United States contributes every year one hundred and fifty thousand and the world five million, I say, when these facts confront us it is no wonder that the people are asking what can be done to prevent this disease All infectious and contagious diseases are preventable to a certain extent, and among the list there is none that has received so much patient, scientific study and investigation as that of tuberculosis, and to-day there is no disease in the infectious and contagious list that we so thoroughly understand the natural history of, the germ causing the disease, its modes of growth, products of growth, its climatic distribution and modes of infection.

Notwithstanding the accumulated knowledge upon this subject, and our thorough understanding of the disease, we have made but little advancement toward preventing or stamping out the disease.

Our boasted knowledge of the cause of the disease is of little use to humanity if we do not use it in applying preventive measures.

The disease can be prevented to such an extent that many valuable lives may be saved by obeying certain hygienic and sanitary laws, thereby rendering persons less susceptible to the disease and removing the cause, which consists in destroying the pathogenic germs.

Hereditary transmission is now looked upon as very doubtful, if not impossible, but there is inherited a condition that predisposes the person to the disease, a condition that makes of the system a suitable culture by inviting the disease and making it dangerous for the person to breathe air but slightly contaminated with poison, and for even a few minutes

This class of persons can do much in avoiding the disease and live long and healthy lives by giving special attention to personal hygiene.

The most important factor in preventing the disease in predisposed persons is that of fresh air and sunlight. God has given man no better disinfectant or disease destroyer than these two universal elements. The person should live in the fresh air and sunshine as much as possible. Dr. Trudeau,

of Baltimore, in a paper before the American Climatic Association, very truthfully says: "All means which tend to increase the vitality of the body cells have been found to be precisely those which are most effectual in combating tuberculosis; one by one, specific methods of treatment which for a season enjoyed popularity have fallen into disuse, and hygienic, climatic, and feeding--in other words, a favorable environment, have alone given results which have stood the test of time." The home should be high and dry; no damp cellars, no leaky sewer pipes, or cesspools, or filth piles should be tolerated; the sleeping room should be well ventilated and living rooms the same; all indulgence in alcoholic liquors, tobacco, over-eating, worry, anxiety and mental strain should be avoided. All these lower the vitality, and consequently the personal resistance.

The methods of infection are almost entirely confined to two sources: from tuberculous animals to man, and from one human being to another. There are two principal channels by which the germs get into the system, the lungs and stomach. Although direct inoculation by way of denuded surfaces may, and often does take place, as in operation and post mortem wounds, it has been abundantly proven that eating uncooked or partially cooked tuberculous meat, and drinking milk containing the tuberculous bacilli, will produce tuberculosis in the human being.

To avoid the danger of infection from meat and milk there should be a most rigid system of inspection of all cattle for food and milk supply in each county. This should apply not only to the larger towns and cities, but to the villages as well, with supervision over all farm stock. Literature should be distributed among the dairymen and farmers, instructing them how to house, feed and care for their cattle to prevent tuberculosis; they should also be instructed how to use the tuberculin test, and how to treat all suspected animals. In by far the largest number of cases, tuberculosis has been caused by the disease in some other human being. If we ever succeed in preventing tuberculosis, it will have to be along the line of personal and legal control of those already infected. This may not necessarily mean strict quarantine, but it does mean an abridgement of personal liberties, a medical or legal supervision of action, with entire control of all excretions from lungs and bowels.

Every case of pulmonary tuberculosis is a walking culture bed, sowing seed broadcast. He is a wholesale dealer in his particular line of living germs; he is a living example of the parable of the sower: "A sower went forth to sow his seed, and as he sowed, some fell by the wayside, and others fell on good ground, and it sprang forth and bore fruit an hundred fold." Unfortunately for the human family many fall on good ground and keep up the fearful mortality stated in the beginning of this paper. There is no longer any doubt as to the correctness of Koch's theory; the germ has been isolated and injected into animals, producing this disease, demonstrating that the bacillus is the cause of the disease.

But of as much, if not more interest to us, is the fact that the sputa of a pulmonary tuberculous patient is loaded with these germs, and that this sputa fed to animals or injected into them will produce the disease. It has also been proven by scientific investigation and demonstrated that these germs will maintain their vitality for months in a dry state, floating in the air, to be carried into the lungs of the unsuspecting victim.

Some authors go so far as to say that ninety per cent of cases are produced by inhaled germs thrown off in the sputa of an infected person. If these statements are true, and I believe they are, how necessary it is to prevent the spitting by tuberculous persons, upon the streets, in stores, hotels, depots, railway cars, in fact, anywhere and everywhere, except a receiving vessel, containing a strong antiseptic solution, or in cloths or other materials that can be burned at once.

The promiscuous spitting of tuberculous matter is not only spreading the disease throughout the inhabited globe, but is making a pest-house out of some of the most healthful parts of the country, but unfortunately used for health resorts for these patients.

The Denver Medical Times says: "It was some time ago intimated in an Eastern paper that the streets and walks of Denver were covered with the sputa of consumptives. The statement was not far from the truth. Unless very rigid measures for the prevention of the spread of consumption in Colorado are adopted and put into force, Colorado will become a pesthole." The Pacific Medical Journal, recognizing the danger, insists upon stringent measures being adopted to stop expectoration upon and about public places. The inhabitants of Los Angeles have become aroused to the danger of indiscriminate mingling of consumptives with healthy persons, and the board of health of this city has passed an ordinance against expectorating upon the streets and in public places. San Francisco has passed the same kind of an ordinance which, so far, has been impracticable. While the people are not ready to endorse and give their moral support to the enforcement of a street quarantine law, a law can be so drawn as to have the endorsement of the best people of every community; such a law should require the placarding the premises to warn the predisposed from entering, to require the sputa to be received in cloths and upon paper, and immediately burned. The first law of nature, self-preservation, would demand at least this much. The patient should not be allowed to attend large gatherings, especially in closed rooms containing children. They should be allowed to travel the streets, walks and roadways only when they carry receiving vessels for the sputa, and a fine should be attached for expectorating, except in this vessel, while absent from the house. The eminent sanitarian, Henry B. Baker, secretary of the Michigan State Board of Health, advises small pieces of cloths, each large enough to receive one sputum, and parafined paper envelopes or wrappers in which the cloth as soon as once used may be put and securely enclosed, and with its envelope, burned on the first opportunity

Dr. George Casnet, of the Berlin Hygienic Institute, with the dust gathered from the walls of rooms inhabited by tuberculous persons, and not contaminated directly with the sputum, has, upon being mixed with sterilized bouillon, and then injected into the peritoneal cavity of guinea pigs, produced tuberculosis. Twenty-one hospital wards were examined in the same way and the dust from fifteen of them produced tuberculosis. This admonishes us that thorough disinfection of all buildings, rooms and wards where persons have died of tuberculosis should be had, and that all sick rooms should be ventilated as thoroughly and as often as possible, as well as occasionally washing down the walls with a disinfectant and then whitewashed, which also should contain some disinfectant not injurious when inhaled. There is another sower that has attracted some attention lately

and will more in the future; that is the railway coach, and especially the elegant Pullman cars; they are veritable" whited sepulchers, which indeed appear beautiful outwardly, but within are full of dead men's bones, and of all uncleanliness." With all its magnificent settings, rich tapestries and beautiful velvet curtains, it is a modern death-trap of the worst kind Think of being closed up a room forty feet long and ten feet wide, containing probably forty persons, among them two or three consumptives, without any ventilation, except when the doors are open, and then for a moment, filled with hangings and velvet-covered seats that had accommodated probably hundreds of tuberculous and other diseased persons, with only an occasional dusting which only brought out the germs that had hidden in the dead recesses of the velvet folds, ashamed to look a poor mortal in the eye because he had no chance for his life. But this will all be corrected in the future.

The votaries of sanitary science, and those who love their fellow men, like Abou Ben Adhem, will rise up and demand that a sanitary car be built that will reduce the dangers of disease to a minimum. The law should demand that every trunk line, running through trains, should carry a hospital car, not only for the protection of the well but for the comfort of the sick. The closets upon cars should be so arranged that the dejecta could be received into a strong disinfectant befo e being thrown to the ground. It has been proven that the dejecta, both urine and fecal matter, contains millions of germs, and these germs are now being dropped all over this country to be dried and scattered to the four winds of heaven.

I have, in a very brief and disconnected manner pointed out a few of the important measures for arresting tuberculosis, and firmly believe that if they, as well as others, could be enacted into laws, the mortality from tuberculosis in the future would decline in a direct ratio to the enforcement of said laws.

In presenting this paper for your consideration I shall assume that you are all in sympathy with the germ theory as to the cause of tuberculosis — that with Koch you assent to the apparently well demonstrated proposition that tuberculosis in all its forms, whether occurring in the human or animal subject, is the result of morbific conditions arising from the presence and multiplication of the bacillus tuberculosis. If you are not a believer in that proposition I shall not at this time undertake to prove it.

Assuming therefore that this theory is correct, with the knowledge we have of the vitality and life processes of this bacillus, we are led to believe from analogy and from demonstration, that the disease produced by it is easily communicable; that it is contagious; and that the only successful way of combating it is by disinfection, or those measures that will most readily destroy the vitality of these micro-organisms.

In order best to treat the subject of this paper-The Prevention of Tuberculosis - your attention should be called to the generally admitted, and most common means of infection. There are two general sources: From tuberculous animals, by their flesh and milk to man; and from one human being to another.

*Read by Dr. J. F. Kennedy before the Polk County Medical Society, at Des Moines, July 6, 1897.

It is generally supposed that tubercular affections of the brain and bowels in children are caused by the ingestion of tuberculous milk and that these manifestations of the disease may be produced in the adult in the same way.

The methods of transmission from the human are fortunately comparatively few. As to heredity it is pretty generally believed that the disease is not transmitted, and yet there can be no doubt that children born of tubercular parents are more susceptible to the disease than others- that the bacillus, if introduced into the system, finds less resistance from a lowered vitality, and hence conditions are more favorable for its growth and multiplication.

Catarrhal affections, successive "colds" and pneumonia — especially when it assumes a chronic form all favor the growth and development of the bacillus.

Among the indirect causes of tuberculosis, aside from heredity, are confinement in prisons and barracks; employment in crowded and ill-ventilated rooms; and occupations that require the breathing of dust and other foreign substances.

The most common direct cause, however, is the inhalation of the dried sputum of consumptives. It has been quite satisfactorily demonstrated that the breath of the consumptive is not infectious, and that the sputum itself is not, so long as it remains moist.

As a final proposition, it may be safe to say tuberculous infection is produced in the great majority of cases by the inhalation of dust laden with dried and pulverized tuberculous sputum.

The greatest and most rational preventive measures, therefore, are the destruction by burning, or the thorough disinfection of all tuberculous sputum; and care that the milk, butter and meat that are used are from non-tuberculous animals.

I have not the time, nor is it necessary to detail the methods of the prevention of tubercular infection by tuberculous sputum, and by food. Our text-books, medical journals, and lectures upon hygiene and preventive medicine, and all well-regulated colleges, happily abound in such information. I design rather, this evening, to enter a field not so well explored; to emphasize some conditions that very largely, though somewhat indirectly, contribute to this disease, and to recommend some preventive measures that are practical, and I believe if more generally and faithfully carried out would greatly reduce the number of cases, and as greatly increase the number of recoveries.

As before hinted, whatever undermines the general health increases the susceptibility to the infection, and diminishes the power of recovery from incipient or advanced tuberculosis. The highest condition of health and resistful vitality is best promoted by the habitual breathing of pure air. I believe the greatest enemy to the bacillus tuberculosis is an abundance of oxygen, as found in pure, fresh air.

The open air treatment of consumptives and of those threatened with tuberculous disease, has, when systematically carried out, given better results than any other. In Germany, and to some extent in this country, the systematic treatment of those believed to be predisposed, and of those afflicted with tuberculosis in various stages, is resorted to in "sanitaria," with the most encouraging results. In these resorts the inmates have the