Arthur Latham.

The conquest of consumption; an economic study online

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I. The Cost in Life .


. 7


Our Knowledge op the Disease . 17


Our Present Defences .

. 49


Working Class Organisation

. 79


The Cost in Money

. 101

i. To Friendly Societies

. 104

ii. To Poor Law Institutions .

. 108

iii. To Charitable Institutions .

. Ill

iv. In " Life-Capital " .

. 114

V. In Wages .

. 118

Summary ....

. 120


State Intervention

. 123




VII. An Efficient Campaign . . . 149

I. Some Results Achieved by Working

Class Societies .... 177

II. Cheap Sanatoriums. By A. Wm. West,

Architect ..... 184






TUBERCULOSIS exists in many forms.
In all its forms — consumption, bone
disease, glandular disease, peritonitis, &c. —
it is a direct product of civilisation. The
disease does not exist in uncivilised countries,
until it is introduced, as it always is, in the
train of civilising influences. The South
African natives until recently were free from
the curse of tuberculosis ; but now with the
spread of civilisation the disease has settled
in their midst and bids fair to decimate them.
The Blood Indians of Canada were free of the
disease, but now Professor Osier states that


The Conquest of Consumption

in the Blood Indian Reserve of the Canadian
North- West Territories the deaths from one
form of tuberculosis alone, viz., consumption,
approach 25 per cent, of the total death-rate,
and that in one of the finest climates in the
world — at the foothills of the Rocky JNIoun-
tains. What civihsation produces civilisation
should be able to stamp out. It surely is a
serious reflection upon our method of living
that we allow tuberculosis to continue to sap
our manhood and to cause the huge sum of
misery it does. It is impossible for those who
realise the magnitude of the evil and the curse
it brings to humanity to understand why a
nation, so much in the forefront of sanitary
endeavour as the British, does so Uttle to cope
with this scourge. We cannot do more than
guess at the number of persons in England
and Wales who, at the present moment, have
their lives darkened by this aflliction. Com-
pulsory notification of the disease is im-
perative if we are to make real progress.
Recently notification of the disease, when it
occurs amongst those under the Poor Law, has
been adopted ; and, although this step savours
of a different law for the rich and the poor, it is


The Cost in Life

of hopeful import. We know that there are
about 40,000 deaths from pulmonary consump-
tion alone in England and Wales each year.
If we put the average duration of life
after the commencement of the disease in any
individual at five years, we see that there
must be at least 200,000 persons now in
England and Wales suffering from consump-
tion. If the average duration of Ufe is longer
than five years, the total number of afflicted
persons automatically rises. If notification
were enforced we could supply these most
necessary data. In any event it is clear that
the number of persons who contract consump-
tion in a given year in this country assumes
colossal proportions. When we remember
that the greatest mortality is between 35
and 45 years of age — that is, at an age when a
man is at his prime and when he has others
dependent upon him for their livelihood — we
begin to realise what a drain even this one form
of tuberculosis is upon the national resources.

When we try to estimate the amount of
damage to life and earning capacity caused by
other forms of tuberculosis — hip disease or
other joint disease, peritonitis, glandular


The Conquest of Consumption

disease, meningitis — we are face to face with
even more meagre information. It has been
estimated that there are 100,000 cripples in
this country. The large proportion of these
owe their suffering and their poverty to tuber-
culosis. We have no definite records of the
havoc produced by glandular and other forms of
disease caused by the tubercle bacillus, beyond
the fact that over 18,000 deaths from forms
of tuberculosis other than consumption are
annually recorded in England and Wales.
An accurate estimate of the amount of damage
to life and earning capacity from all forms
of tuberculosis is obviously impossible. A
number of estimates have been made, and it
may be said that one man's guess is as good
as another's. We are, however, probably
making an underestimate when we say that
in England and Wales there are at least
40,000 deaths from consumption and 20,000
deaths from other forms of tuberculosis each
year, and that there are at least 250,000 to
300,000 persons now in this country who are
sufferhig from consumption, and some 150,000
to 200,000 who are suffering in an active way
from other forms of tuberculosis.


The Cost in Life

Whatever the exact figures are, enough has
been said to show that the loss in life and
wages to our country from this disease is more
than sufficient to cause statesmen to turn
their attention to the question of its preven-
tion. That statesmen have paid so little
attention in this country to the disease so far
can only be explained on the ground that they
do not reahse its magnitude nor the fact that
it can be prevented, absolutely, by intelligent
effort and co-operation in the course of a
comparatively short period of time. States-
men do not appear to have realised either the
magnitude of the evil or the amazing advance
in our medical knowledge of the subject.
They do not realise that the medical profession
has acquired such a grasp of the essential
facts connected with the disease that the bulk
of the scientific work which was necessary to
make the eradication of tuberculosis possible,
within no distant date, has been accomplished.
We know how to prevent and how to cure
tuberculosis, and statesmen must now be made
to realise that the eradication of the disease
lies in their hands. The working man upon
whom the evil presses so hardly and in such


The Conquest of Consumption

undue proportion has begun to realise these
things. He has begun to reaHse that con-
sumption and other forms of tuberculosis are
products of civilisation and that they can be
prevented. Shortly he will demand with no
uncertain voice that he has a citizen's right to
be protected from this product of civilisation,
and that he shall be assisted when he falls a
victim, not only in his own interests, but in
the interests of the community at large.

The time is therefore ripe for a short non-
technical statement of our knowledge of the
cause, detection, cure and prevention of the
disease. To this we add a few facts of
the more or less half-hearted efforts which
are being made to cope with the disease at the
present time. And in addition we state, as
far as we can ascertain it, the cost to the
country of these efforts together with the cost
of the disease in loss of life and wages. It will
be clear from what follows that comparatively
little result, great though it is when compared
with fifty years ago, is achieved, and that at
an extravagant cost. Finally we sketch out
how a State scheme for the provision of
efficient sanatorium treatment would, when


The Cost in Life

combined with better housing of the work-
ing classes and an efficient control of the
milk supply, do much to prevent the spread
of infection from a consumptive to a healthy-
person, and would go far to restore those who
are infected to a wage-earning capacity and
so rescue them from what is their portion at
present— long drawn-out suffering and early



B 17





IT was until recently generally but erro-
neously held both by the public and
the medical profession that consumption
was an hereditary disease. This was largely
due to the persistence of ideas which were
accepted before the fact that the disease is
caused by the tubercle bacillus was proved.
The slightly greater incidence of the disease
amongst the descendants of tuberculous
parents as against that amongst the descend-
ants of non-tuberculous parents is amply
accounted for by the greater exposure to
infection. Bang of Copenhagen demonstrated
that if the calves of tuberculous cows were
removed at birth from their mothers, it was
possible to form a herd which was absolutely
free from tuberculosis. It is now generally


The Conquest of Consumption

accepted that the same thing is possible in
human beings, and that the disease is not
hereditary. An infinitesimal number of cases
are on record in which tubercle bacilli are
present in children at birth, and this holds
good for other infective diseases also. In
no infective disease has any satisfactory evi-
dence been brought forward to show that,
apart from these few examples, it is hereditary
either by the direct transmission of the disease
or by the transmission of a peculiarly vulner-
able "soil." In 1908 a discussion on the
subject was held at the Royal Society of
Medicine, and not one medical man spoke in
favour of the old theory of heredity in

Consumption is caused by the tubercle
bacillus. The type of the bacillus is not of
great importance. It is now ascertained
beyond any doubt that all forms of this
bacillus — whether derived from man, cattle,
or other animals — are capable of setting up
the disease in human beings. Tubercle bacilli,
whether derived from a case of consumption
or from milk, are capable of causing havoc
in human beings. No matter what degree


Our Knowledge of the Disease

of health and strength a man may enjoy he
will contract consumption or some other form
of tuberculosis, if a sufficient quantity of
tubercle bacilli are introduced into his system.
If his defensive forces are run down, if his
resistance to disease is undermined by pre-
vious illness, by insufficient nourishment, or
by an insanitary environment and lack of air,
he falls an easier prey, and a smaller dose
of bacilli will establish the necessary hold in
his tissues and so produce the disease. Im-
pure air, dirty, insanitary houses, want of
nourishment, the effects of drink or disease
act by rendering the soil more vulnerable to
the tubercle bacillus, inasmuch as they
diminish the power of the defensive forces
of the body which in ordinary conditions are
sufficient and more than sufficient to resist
and overcome the invasion of this micro-
organism. It is often said that poverty
produces consumption. It is equally true
that consumption produces poverty. Again,
drink is regarded by many as a potent factor
in the incidence of this disease ; but it is also
true that many take to drink because they
have contracted consumption.


The Conquest of Consumption

The part played by the "soil" — that is, the
condition of the body tissues — is most im-
portant. Although the invasion of the
tubercle bacillus is the dominant factor, yet
this bacillus must be present in enormous
numbers to set up the disease unless the
person attacked has had his defensive and
resisting forces weakened or permanently
undermined by illness, want of food, or in-
sanitary conditions of Hfe or occupation.
Thus Trudeau inoculated rabbits with
tubercle bacilli. Some were kept in a dark,
damp place without sunlight or fresh air.
These rapidly succumbed. Others were
allowed to run wild. These either recovered
or showed very slight traces of the disease.

If consumption is to be acquired the seed —
the tubercle bacillus — must fall on suitable soil
— that is, must obtain an entrance to tissues the
defensive capacity of which has been lowered.
The parable of the sower affords an exact
parallel. If the soil is unprepared the seed
fructifies in very few instances. If the soil
is suitably prepared the seed fructifies a
thousandfold. Two examples may be given.
Cornet, investigating the death-rate among


Our Knowledge of the Disease

certain religious orders, found that nearly
63 per cent, of the death-rate was due to
tuberculosis. This author came to the con-
clusion that in such sisterhoods, where con-
finement and bad ventilation are marked
features and where opportunities for infection
are great, a healthy girl who enters the sister-
hood at 17, dies twenty-one years earlier
than her sister who remains outside the con-
vent, that such an inmate in her 25th year
has the same expectation of life as a woman
outside the convent has at the age of 45, and
that a nun of 33 must be classed with a
woman outside whose age is 62.

Another instructive example is more or less
tjrpical of what goes on in this country owing
to the lack of simple means of disinfection
being employed and the absence of com-
pulsory notification. Engelmann cites the
case of a newly built flat which was badly
lighted and ventilated. This was occupied
for eight years by three families in succession ;
all of them had presented a clean bill of
health until the family X took up their
residence in the same quarters. In this family
the mother was a consumptive when she


The Conquest of Consumption

came. She died in the flat. Shortly after
her death — that is, after a year's tenancy — the
family left. The flat was now occupied by
the family Y, of seven healthy persons.
After a year's stay this family left, and some
years later the father, mother, and one son
died of consumption, and another son of
tuberculous peritonitis. A third family, Z,
now took the rooms. All were healthy. Of
this family one child died of tuberculous
meningitis, one of wasting disease, and
another suffered from tuberculous hip disease.
Subsequently the father died from consump-
tion, and another child of tuberculous menin-
gitis. The mother acquired consumption,
and a child developed tuberculous disease of
the glands. A fourth healthy family, W,
came into the flat. The mother became
consumptive, and two children died of tuber-
culous meningitis. In this case the flat was
free of the disease for eight years. Then
came a tuberculous tenant. In a period of
twelve years at least thirteen cases of tuber-
culous disease were traced to this source.
The dwelling was never vacant, and during
the whole period was never painted, cleaned,



Our Knowledge of the Disease

or disinfected. A striking fact is that in the
other flats of precisely the same character
in the building, where cleaning was not
neglected, no single case of consumption or
other form of tuberculosis could be traced.

From what has been said it is clear that any
national movement which improves the general
health of the community, makes for a dimi-
nished death-rate from consumption, in that
it makes the soil more resistant to and less
suitable for the seed. Any improvement in
the housing and the conditions of life amongst
the poor must be rewarded in the near future
by improvement in the national health. It
follows that a continuous supply of fresh air
should receive more attention than it does
from architects in their designs at the present
time. It is also clear that compulsory notifi-
cation, followed by efficient disinfection, would
do much to diminish the number of persons
who fall victims to consumption.

It is not always possible to keep the soil in
such condition that under the stress of modern
Ijife it can offer a successful resistance to the
invasion of the tubercle bacillus. Fortunately
we now have accurate knowledge of the sources


The Conquest of Consumption

of tubercle bacilli, and we know that if states-
men can be prevailed upon to deal with the
matter these sources of supply can be con-
trolled to a very large extent, if not completely
eradicated. There has been much controversy
on the question whether tubercle bacilli derived
from bovine sources are capable of infecting
human beings. This controversy is now at
rest. It is agreed by nearly all authorities in
every country that tubercle bacilli can infect
human beings, no matter what their original
source may be. It is a matter of indifference
whether the bacilli are derived from the expec-
toration of a consumptive or from milk, butter,
or other sources. They are one and all capable
of setting up the disease in human beings.
There is still controversy as to whether
tubercle bacilh derived from human sources
or tubercle bacilh derived from animal sources
are responsible for the greatest amount of
disease in human beings. This is an academic
question, for it is certain that bacilli from both
sources take an enormous toll of life. So far
as recent scientific investigation goes there is
proof that bacilli derived from animal sources
take a much bigger toll of human hfe than


Our Knowledge of the Disease

was formerly allowed, and there is a consider-
able body of evidence to suggest that these
bacilli are a more potent factor in the causation
of human tuberculosis even than bacilli derived
from the expectoration or other discharges of
tuberculous persons.

It has recently been shown that once the
tubercle bacillus has gained an entrance into
a human being it is largely a matter of chance
whether the lungs or other organs are affected.
The old idea that consumption of the lungs
was caused by the direct inhalation into the
lungs of germs which were then able to settle
down in the apices of the lungs, owing to the
relative stagnation of air in these situations,
rests on an insecure foundation. Further, we
know that if a man has a healthy nose and
breathes through it the mechanism of this
organ is such that no micro-organism passes
into the lungs, as many as 10,000 germs being
caught in an hour by its defensive mechanism.
On the other hand, it has been shown that
tubercle bacilli can pass through the intestinal
coverings without causing any local lesion,
and thus get into the lymph stream, and in
this way to any portion of the body. It has


The Conquest of Consumption

been shown, in fact, that tubercle baciUi intro-
duced under experimental conditions into the
stomach of a young pig can be demonstrated
twenty-four hours later in the animal's lungs.
It would appear, then, that bacilli, from what-
ever source derived, enter the human body
largely by the mouth and that they are not
inhaled direct into the lungs. Some have
their course impeded by the tonsils, some by
other lymphatic structures of the pharynx
and other portions of the intestinal tract. In
all these situations the bacilli may escape the
first line of defence and so get into the general
lymphatic stream, and eventually into the
blood. Indeed, it has quite recently been
asserted that tubercle bacilli can be recovered
from the blood of all those who suffer from
any form of tuberculosis. Whether this is
true or not, there can be no question that
bacilli are carried to different organs, widely
apart, by the lymph stream. In their passage
many are killed. In other cases bacilli are
brought to anchor where the lymph stream is
slow, as, for example, in glands and at the
apices of the lungs, or they reach a tissue
which is deficient in resistance owing to


Our Knowledge of the Disease

previous injury. When the resistance of the
body is lowered by disease or injury, the
" poHcemen of the body," the white cells of
the blood, are not able to attack and destroy
the invading germs which have come to
anchor. Consequently, the germs multiply,
their poison is absorbed, local changes follow,
and tuberculosis is set up. Tubercle bacilli
contained in milk probably gain entrance
through the intestinal canal. The bacilli
contained in a consumptive's expectoration
mingle with the dust, and in this way obtain
entrance to a new host, probably by the
mouth and the upper air passages.

The two main sources of bacilli which
destroy the human race are milk and butter,
and the expectoration or discharges of
consumptives. These facts are established
beyond all possibility of criticism. They call
for comprehensive action, for the simple
reason that these sources of supply can be
effectively controlled. Many samples of milk
contain tubercle bacilli in considerable
numbers. Dr. Newsholme, Principal Medical
Officer to the Local Government Board,
estimates that 20 per cent, of the mixed milk


The Conquest of Consumption

supplied to towns contain living tubercle bacilli.
In other words, every fifth glass of milk sold
at present is capable of producing tuberculosis
in its consumer. The American Government
Analyst finds tubercle bacilli in 11 per cent,
of samples of butter. The sale of tuber-
culous milk should be made a criminal
offence, and every effort should be made to
provide a pure milk supply. The ideal
measure would be to establish herds of cattle
free from tuberculosis, and to prohibit the
sale of milk derived from tuberculous cows;
but it is probably a hopeless task to endeavour
to rid the country of tuberculous cows within
a reasonable time and at a reasonable cost.
Fortunately the attempt is not essential. Mr.
Nathan Strauss, the American philanthropist,
has shown that it is possible to deal with milk
by efficient pasteurisation and to supply milk
which is free from tubercle bacilli and other
germs on a commercial scale without increase
of cost to the consumer. It is necessary that
the milk should be pasteurised for twenty
minutes at 140oF.

The purity of the milk supply is known by
medical men to be vital to the health of the


Our Knowledge of the Disease

nation. The remedy is so simple and so
inexpensive, neglect of the remedy leads to
such suffering and such a drain on the national
resources, that it is incredible that statesmen
can realise the position of affairs. There
cannot, however, be any doubt that before
long the necessary steps will be taken by the
Government to ensure a supply of pure milk
and to prohibit the sale of germ-laden supplies.
Once no milk can be sold unless it comes from
tuberculin-tested cows or has been pasteurised,
one of the main battles of the anti-tuberculous
campaign will have been won, and the steady
loss of life from this disease will have received
a definite check.

The other great source of tubercle bacilli
— that is, the supply derived from the ex-
pectoration of consumptives and the dis-
charges from other tuberculous lesions — can
only be satisfactorily dealt with by means of a
comprehensive and expensive campaign. For-
tunately we may say that the risks of infection
from forms of tuberculosis other than pul-
monary consumption are adequately dealt
with and do not call for any State mterference.
In the case of consumption the matter is


The Conquest of Consumption

different, and each consumptive is a menace to
his neighbours unless he is adequately in-
structed in the simple precautions necessary to
prevent the infection of others and is given an
opportunity to regain his health. Any scheme
which is to combat this source of infection
successfully must be thorough and comprehen-
sive. It must embrace machinery for the de-
tection of the disease in its earliest stages, for
the provision of efficient sanatorium treatment
for those who are likely to receive lasting
benefit, for the instruction, in the simple
precautions necessary to prevent infection of
others, of those in whom the disease has made
such an advance, as to render sanatorium treat-
ment nugatory, and for the supervision and
disinfection of their homes.

The most important thing in the cure of
a consumptive is the early detection of
the disease. A pin prick is more easily
healed and less dangerous than a sword cut.
An early localised lesion in the lungs may,
in probably 80 per cent, or more cases, be
permanently healed by prompt and adequate
treatment. An advanced lesion of the lungs
is necessarily harder to heal, and in any case it


Our Knowledge of the Disease

takes a much longer period of sustained and
continuous effort. The detection of pulmonary
consumption in its early stages is a difficult
and expert matter. It is probable that a tuber-
culous lesion of the lung may exist for as long
as two years without giving rise to very obvious
physical signs, as detected by the stethosc^ '^.

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Online LibraryArthur LathamThe conquest of consumption; an economic study → online text (page 1 of 8)