Mortality and Morbidity Statistics. Up to about 1880 tuberculosis caused from one-fourth to one-fifth of all deaths. With the discovery of the tubercle bacillus and with the application of the knowledge that the disease is communicable, the mortality from tuberculosis has slowly decreased. This decrease has only been noted, however, in those communities in which precautions have been taken to prevent the spread of the contagion. The reasonable isolation of the consumptive has everywhere been associated with a reduced mortality. Thus statistics of tuberculosis mortality vary widely for different localities. In the United States in 1915 tuberculosis caused slightly more than ten per cent of all the deaths, a total of 98,194 in the registration area which covers two-thirds of the population. Presumably 150,000 die annually of tuberculosis in the United States. As a basis for comparison, it may be remarked that in the Civil War there were killed or died from wounds 205,000, averaging about 50,000 each year. The reduction from twenty to twenty-five per cent of all deaths as before 1880 to ten per cent in 1915 is to be attributed to the various preventive and curative measures directly depending on Koch’s discovery of the causative agent.
There are no means of determining how many people actually suffer from tuberculosis. From various studies it seems probable that for each death there are at least ten sufferers from the disease in any given year. Hence there are probably at least 1,500,000 sufferers from tuberculosis in the United States at the present moment, or one out of every seventy persons. Out of every ten births, one out of ten will die of tuberculosis sooner or later.
Age Incidence. The average age at death from tuberculosis is between thirty and thirty-five. Every third death during the working period of life is caused by tuberculosis. The average period of total disability before death is over one year, and this is preceded by a period of partial disability likewise averaging over a year. Thus tuberculosis not only causes death during the most active period of life, but the long disability before death is frequently a greater financial burden and loss than the actual death. Even recovery from tuberculosis entails a large financial burden.
Cost of Tuberculosis. Statisticians have attempted to determine the monetary loss caused by tuberculosis. But it is obviously impossible to translate into figures the human suffering, the misery of poverty, and many other ills which tuberculosis causes. If we accept $8,000 as the value of the adult life, including the average earning capacity for the future, we find a yearly loss of $1,200,000,000 in the United States alone. Such computations do not include the recovered cases and are of interest only as indicating in a small measure the tremendous wastage of tuberculosis even when translated into dollars and cents.
Transmission of Tuberculosis. Tuberculosis is not hereditary. A few cases have been recorded where the mother transmitted tuberculosis to the child in the uterus, but this is excessively rare. Formerly we heard much of an inherited predisposition to tuberculosis, but it is easily possible to explain the well-known frequency of the occurrence of tuberculosis in families on the basis of increased exposure. It may be stated definitely that there is no positive evidence of an inherited predisposition to tuberculosis.
The tubercle bacillus may gain entrance into the body in the following ways:
- Through the air passages by means of droplets directly from a coughing consumptive, or indirectly from air-borne particles of sputum or the use of common utensils.
- Ingestion, especially in milk from tuberculous cows, or food which has been contaminated with tuberculous material in handling or by flies.
- Through the skin. This method is rare and usually gives rise to a local tuberculosis of the skin.
By far the most common method of transmission is the first. The tubercle bacillus is rather hardy outside the human body, and such bacilli have been found alive in dried sputum after six months. They may live in water for several months. Living virulent tubercle bacilli apparently live almost indefinitely in butter. Moisture and darkness favor the prolongation of the life of the tubercle bacillus, while drying to desiccation of the contaminated material and sunlight favor its destruction. This bacillus is killed by ordinary disinfectants, but penetration of the material, as sputum, is necessary.
Any material which contains tubercle bacilli may spread the disease. It may be spread by all the discharges of a tuberculous patient and by the discharges and the use as food of tuberculous animals. But the general sources of infection are two: the consumptive and his sputum, and the tuberculous cow and her milk. The sputum of the consumptive is generally agreed to be the most important factor in the spread of the tubercle bacillus.
Prevention of Tuberculosis. The first consideration in the prevention of tuberculosis is the prevention of infection. It is obviously desirable that all material containing tubercle bacilli be destroyed before it can infect others, but this is only theoretically possible. Presumably there are a million and a half persons with active tuberculosis in the United States, and institutional segregation of such a multitude is not feasible. Furthermore, many consumptives go for months or years spreading the disease in complete ignorance of the fact that they have tuberculosis or that they are a possible menace to all with whom they come in contact. Long experience, especially in tuberculosis hospitals, shows that the diagnosed consumptive who is intelligent and obedient can be cared for under suitable conditions without menacing the health of others. Under such conditions it is possible to control tuberculosis not only in hospitals but in the home. But in general we are far from meeting the requirements. Frequently tuberculosis is not diagnosed, and this fault may be divided between the medical profession and the laity. The consumptive may not seek a physician or he may refuse a thorough examination. The physician may be at fault in not performing a thorough examination as well as in failing to detect the disease. In this connection there are several rather complicated considerations. The diagnosis of tuberculosis may be difficult and demand training and equipment not possessed by many physicians. The board of health laboratories which examine sputum for tubercle bacilli free of charge help to ameliorate this difficulty, but these laboratories are used far too little and too often a single negative sputum examination is accepted as final.
Again the patient may be unable or unwilling to pay for a thorough examination, particularly when he feels convinced that the alleviation by drugs of a troublesome cough will make him well. The physician, perhaps, cannot afford for a small fee to spend the time on the thorough examination of all his patients, particularly when he knows that most of his patients will prove to be sound. The increased number of tuberculosis dispensaries and the various schemes for encouraging the periodic complete physical examinations in health have not solved this aspect of the problem. Such schemes reach only special classes and not the average man or woman.
A further complication is seen in the reluctance on the part of the physician and the patient’s family to acquaint the patient with the disagreeable truth. In ignorance the patient does not benefit either himself or the community by the mere fact that the diagnosis has been made. The solution of the difficulty attending the early diagnosis of tuberculosis lies exclusively in the education of both the medical profession and the laity. To the individual early diagnosis means the only possibility of cure; to the community early diagnosis means the prevention of the spread of the disease.
Only the patient who understands the possibilities of the transmission of tuberculosis can be trusted to take care of sputum and other discharges which contain tubercle bacilli. Since many other diseases are spread in the same way as tuberculosis, it is imperative that as far as possible all persons, whether manifestly diseased or not, should exercise reasonable precautions. Habits firmly fixed in health can be trusted in disease. Hence education concerning coughing, promiscuous spitting, and the use of common utensils should be universal and not restricted to the known consumptives or other disease carriers. Many persons are unrecognized disease carriers and every individual is a possible disease carrier in the future. The community has an obvious duty in regard to the ignorant, refractory, or incorrigible consumptive,—the compulsory segregation of such persons under such conditions that they cannot menace their fellow beings.
In many instances the conditions of the consumptive are such that adequate precautions are impossible. The consumptive himself may be willing, but too sick. The conditions of work or living may be such that infection of others is a certainty. Here we find the pressing problem of the homecare of the consumptive in all conditions of society except the well-to-do. A family of seven in a three-room tenement furnishes conditions which preclude the exercise of satisfactory precautions. The presence of young children with the careless habits of childhood furnishes an important factor of difficulty. We have already noted the frequency of tuberculous infection in childhood, which may be largely attributed to the impossibility of eliminating the unhygienic habits of children. Tuberculosis cannot be controlled in the conditions of poverty, overcrowding, and ignorance. Ample statistics are available, which show that the institutional segregation of the advanced consumptive is followed in all countries by a fall in the death rate. The advanced consumptive daily expectorates millions of tubercle bacilli, and he can be controlled and the spread of the disease prevented only under the conditions which have been described. An important part of the tuberculosis prevention work consists in the increased accommodations for the advanced consumptive in hospitals where adequate precautions against the spread of the disease are possible.
Man is by no means the only carrier and source of tubercle bacilli and tuberculosis. The disease occurs in cattle and other mammals, in birds, and in some of the cold-blooded beasts. It is only in cattle, however, that tuberculosis of other animals is of real importance to man. Bovine tuberculosis is caused by a tubercle bacillus which is typically somewhat different from the human tubercle bacillus. The bovine tubercle bacillus in its typical form probably does not cause consumption, but it is a frequent cause of tuberculosis of the intestines and the peritoneum, of glands (scrofula), of tuberculosis of the spine (Pott’s disease and humpback), of tuberculosis of the joints (hip disease, white swelling), and of fatal generalized tuberculosis with tuberculous meningitis. Over one per cent of beef cattle, over two per cent of hogs, and five to twenty-five per cent of dairy cattle show tuberculosis. The disease rarely affects the muscles of animals, and, in any event, thorough cooking will destroy the bacilli and render the carcass entirely safe for human consumption. The main source from which bovine tubercle bacilli enter the human body is milk, and in order that such bacilli be present in milk, it is usually necessary that the cow have tuberculosis of the udder. Collected statistics from all parts of the world show the frequency of tubercle bacilli in milk, the percentage varying from five to twenty per cent. Butter is slightly more frequently infected with tubercle bacilli.
The bovine infections in man are essentially alimentary in origin and are largely restricted to childhood when the diet is to so large an extent made up of milk. This explains the frequency of scrofula (tuberculosis of the glands of the neck) and bone and joint tuberculosis in children. Such tuberculosis is not necessarily bovine in origin, but it probably is in from twenty-five to fifty per cent of the cases. About five per cent of all cases of tuberculosis come from tuberculous cows, but on account of its usual localization only one to two per cent of the mortality is due to bovine tuberculosis. However, this is a form of the disease which can readily be prevented. The tuberculin test, while not infallible, is a reasonably accurate and very useful method of determining the existence of tuberculosis in cattle. Under proper restrictions such cattle may be used for food, but the milk should not be used unless pasteurized. If cows are not tuberculin tested, it is probable that about ten per cent will have tubercle bacilli in the milk. Periodic, careful, and thorough inspection of dairies and cows by trained veterinarians and the removal of all cows with clinical tuberculosis and with any suspicious abnormalities of the udder will eliminate all danger of tuberculosis from milk. Such a procedure is naturally violently opposed by many milk producers, but progress is being made. It is necessary to convince the farmer that milk which pleases the palate may, nevertheless, cause disease. But the facts are incontrovertible and despite the hardships of strict regulations, which are often not uniform in different communities, it is intolerable that we continue to drink tubercle bacilli with our milk and eat them with our butter, when the means of eliminating this source of infection is readily at hand. This source of danger has been underestimated for too long a time, and it can be overlooked no longer.
The second important consideration in the prevention of tuberculosis is the prevention of the development of tuberculous disease from tuberculous infection. While over half of the population is infected with tuberculosis, only one-tenth die from it. The large majority of those infected never develop tuberculous disease. Even our most modern and searching methods of examination, including the X-ray and the tuberculin test, are quite inadequate to reveal to us, as a general rule, the person who is infected with tuberculosis but who has not the disease. We do not know positively the factors which determine the latency or the activity of the infection. We know, of course, that the three fundamental principles which govern all infections also apply to tuberculosis, namely, the amount of the infection, the virulence of the organism, and the resistance of the individual. But long experience with this dread disease has given us valuable additional data. We know how frequently tuberculosis is the cause of death of drunkards, of prostitutes, and of prize-fighters who no longer train but indulge in various excesses. We know that while tuberculosis does not spare the rich, it is more common among the poor. Recent statistics show that the percentage of tuberculosis is over ten times more frequent among the heads of families who earn less than $500 a year than among those who earn $700 or over a year. In other words, poor habits of hygiene and unhealthy conditions of life, whether created voluntarily or by force of circumstances or by ignorance, carry a strong probability that a quiescent tuberculous infection may develop into tuberculous disease.
Tuberculosis is frequently the penalty of dissipation. The tubercle bacillus is practically ever-present, so that the lowering of bodily resistance tends to favor the development of the disease. Hence tuberculosis may be rightly called more a social than a medical problem. To eliminate tuberculosis means to eliminate poverty, overcrowding, undernutrition, over-fatigue, and lack of recreation. All this, of course, involves a complete readjustment of our social and industrial world. In any event the problem of tuberculosis cannot be separated from the poverty which causes tuberculosis and the poverty created by it. Better housing, adequate food, better hours for labor under better conditions, more parks, and open air schools are steps in the right direction. But it is even more essential to provide adequate machinery by which whatever knowledge and whatever facilities for the preservation of health that we now have may be better utilized.
The Treatment and Cure of Tuberculosis. It must be repeated that most of us have been infected with tuberculosis at some time or other, although we overcome the infection and keep it under control. We know that poor health habits and faulty conditions of life encourage the development of the disease. Sound health habits and faultless conditions of life restrict the development of the disease and create a cure. Even so long ago as Hippocrates it was recognized that consumption was curable if taken in time. Bodington, in 1840, was the first in modern times to possess sufficient courage to oppose the teachings of the day and treat consumption with fresh air and sunlight. In 1854, Brehmer, himself a cured consumptive, built a sanatorium for consumptives in the Black Forest of Germany. In 1883 Dr. Trudeau, of New York, who had found health in the open air of the Adirondacks, established a sanatorium at Saranac Lake. By this time, through the work of Koch, tuberculosis was being understood and consumptives were being cured. Sanatoria were established all over the world. But even now there is much misunderstanding concerning the functions of sanatoria. Such institutions do not cure in the ordinary sense; sanatorium life provides the essential requirements which make a cure possible. These requirements, in simplest terms, are the best possible health habits and surroundings under competent supervision. The aim is to put the body in the highest state of efficiency and thus combat disease. This procedure is not solely applicable to tuberculosis, but it is also applicable to any other abnormal condition, whether due to infection or other causes, such as excessive fatigue, neurasthenia, and the like. Fresh air and sunlight, rest, which means the conservation of energy and the avoidance of fatigue, and good food in abundance are only the means to the end of physical efficiency. It is possible to secure these requirements at home, but it is usually easier to carry out, these instructions in a sanatorium under constant supervision in company with others, away from the usual distractions of the home life. Milk and eggs, so often glorified in the treatment of consumption, merely mean so many easily assimilated calories. The benefits of a change of climate often mean increased opportunity for the out-of-door life and, sometimes, freedom from family cares.
Statistics show that there is no great difference in the percentage of recoveries in sanatoria whether at sea level or in high altitudes. The evidence indicates a slight difference, not yet explainable, in favor of the higher altitudes. Yet the indigent consumptive, who can get rest, fresh air, and good food at home at sea level, will do far better than to endure loneliness on insufficient food in poor quarters at a high altitude.
Eighty per cent of the consumptives in the early stages, under proper treatment, will recover, but this treatment may require months and the exercise of much fortitude and patience. Furthermore, after the disease is arrested, much care is frequently necessary to prevent the redevelopment of the disease. The arrested case is like the infected case without the disease, only much more liable to redevelop the disease. Bitter experience has taught us to be chary in the use of the word “cure” in connection with tuberculosis. It is difficult or impossible to be positive that the infection has been permanently destroyed. The cure of a consumptive means more than the saving of an individual life; it means the prevention of a focus which may spread the infection.
In order that a consumptive may have four chances out of five to recover, his disease must be discovered in the early stages. Therefore, the public at large, all liable to this disease, must understand the necessity of seeking medical advice concerning a persistent cough, chest pains, fevers, unexplained loss of weight, and other possible symptoms of tuberculosis. In addition the medical profession must possess the training and equipment for early diagnosis. Only by systematic and widespread education can this be brought about.
Since consumption is such a universal disease, it inevitably follows that cures of all sorts are everywhere recommended. Many things may contribute to recovery. Tuberculin in skilled hands, in selected cases, lung compression under the same conditions, the wise use of drugs, may all be of value. But none of these means is essential. There is no specific cure. There are those who chase such cures. Those that move from climate to climate, from sanatorium to sanatorium, from doctor to doctor make up a small army and they are well described as “tuberculous tramps.” Instead of finding the sure and quick cure, they have lost the opportunity which too often comes but once and is soon gone.
Tuberculosis and Housing. Prolonged proximity with consumptives is obviously of great danger, and such proximity usually obtains in houses. Of course, as a rule, the factor which compels crowding is poverty. Investigation in all large cities shows tenement blocks in which there is an average of over two persons per room. Under such circumstances, granted a consumptive, the spread of the disease is almost inevitable. Berlin statistics in 1907 showed that in only sixteen per cent of over 6,000 persons dying of tuberculosis did the family occupy a home of three rooms or more.
In Edinburgh Philip found that in sixty-six per cent of the cases, the affected persons slept in the same room with one or more members of the family, and in eleven per cent more than one more occupied the same room. Such conditions also explain the fact that the infection in tuberculosis is, as a rule, received in childhood.
Miss La Motte, in Baltimore, found that seventy-three per cent of a group of consumptive children came from homes in which there was already tuberculosis. Mac Corrison and Burns, in Massachusetts, found 134 instances of family clusters of three or more in a study of 1,300 cases. Three houses in New York have records of 37, 25, and 19 cases respectively within nine years. Another example of this condition is that of a well-known man who moved away from home early in life. His parents, and all his brothers and sisters remained in the little old homestead and one by one died of consumption. The homestead at last reverted to the only member of the family who moved away and who alone escaped tuberculosis. He had the house burned. In such a house consumption was mainly spread by the constant presence of a consumptive, but the rather hardy tubercle bacilli might well infest every dark nook and corner, and, due to the long-continued extensive infection of every article in the house, the certain destruction of all the infecting organisms would be difficult. Probably ninety per cent of tuberculous infection of human origin takes place in the living rooms of the house. The incapacitated consumptive often remains at home. He may do light work at home or to him may fall the task of caring for the children. It is certain that in the past we have not appreciated the importance of home infection and the danger to children. Under proper conditions adequate precautions can be taken at home, but the control of the consumptive at home is made more difficult by the presence of children.
Tuberculosis and Occupation. Volumes could be written on the relation of tuberculosis and poverty. For poverty furnishes all the surroundings favorable not only to infection with tuberculosis but also for its development after the individual is infected. It is difficult to disassociate many occupations from the accompanying poverty so common in them. Statistics show that certain trades have a high mortality from tuberculosis. The so-called dusty trades, including the out-of-door quarryman, show mortality from tuberculosis that is far above the average from all occupations. The factor here seems to be the irritation of the lungs which favors not only infection but also development. Out-of-door occupations in general show a relatively low tuberculosis mortality.
As might be expected tuberculosis is rife among the poorly paid indoor trades. On the other hand, one may be surprised to learn that tuberculosis is the cause of more than half the deaths among stenographers and school teachers. The high incidence of tuberculosis here cannot be attributed to any peculiarity of the work, but to the general habits of living. It is not only the indoor work but the general faulty hygiene of life and surroundings which determine this high mortality. A dusty occupation undoubtedly favors tuberculous infection and the development of consumption. In all other occupations the ordinary factors of health and hygiene, that is, overcrowding, fatigue, bad air, and the like, merely play their proportionate part in the daily total of the individual’s health habits and conditions of life.
Conclusions. It is becoming increasingly evident that the problem of tuberculosis in its entirety is too great for private enterprise. The problem is medical, social, and economic. Even in the aspects which are mainly medical, uniform public action and new legislation are necessary. Only by the concerted thorough covering of the entire field of human activity can tuberculosis be controlled. No tuberculosis program is adequate which does not include the following items.
- Sanatorium provision for the treatment and cure of early cases. Sanatoria are entirely inadequate in this country. Germany has solved, to some extent at least, the financial problem of the erection and maintenance of sanatoria by obligatory health insurance. This problem of health insurance is slowly coming to the fore in the United States, but the decision, unfortunately, lies in the field of politics.
- Hospital accommodation for the advanced consumptive. This is largely for the protection of the community, but, happily, some advanced consumptives will always recover.
- Facilities for the early diagnosis of tuberculosis. This will include tuberculosis dispensaries and all methods of the periodic routine physical examination of all persons, in order to detect all cases of tuberculosis. Readily available laboratories are also important.
- The collection and use of vital statistics. This includes not only the reporting of all cases of illness and death from tuberculosis, but the investigation of these cases. For example, in Berlin the systematic examination of the 4,500 new cases of consumption revealed 4,500 unrecognized cases of tuberculosis, most of which were in an early and favorable stage for treatment. Furthermore, the source of the infection must be discovered and stopped forever, if possible.
- Care of the health of children. The infection usually takes place in childhood.
- Improvement in the general hygienic habits and the sanitary conditions, especially in the homes.
- The education of the public and of the medical profession. Regulations and legislation will be useless unless there is an intelligent application of the known facts.
Only a few visionaries foresee, in any immediate future, the stamping out of tuberculosis. The infections which are transmitted by droplets and in the air are difficult of eradication, as we know from experience with measles and scarlet fever. The difficulty of making an early diagnosis often presents an obstacle. Furthermore, the incidence of tuberculosis is closely interwoven with our present social and economic status. Nevertheless, despite these difficulties, it is possible to accomplish much in the prevention of this disease, the greatest scourge of civilization, and in this belief we get encouragement from the considerable diminution of the disease already achieved by the application of the discoveries of science.
Epidemic cerebrospinal meningitis is caused by a bacterium of the coccus group—the meningococcus. There are still other forms of meningitis which are due to other organisms, and the diagnosis is only made with certainty by the examination of the spinal fluid after “lumbar puncture.”
Cerebro-spinal meningitis has been known in epidemics for centuries. The disease is an inflammation of the lining membranes of the brain and spinal cord, a condition which not so long ago was extremely fatal. The mortality, while varying in different epidemics, was always from sixty to eighty per cent. Now we have a most effective antitoxic serum which is produced by the immunization of a horse. This serum is of little value when injected subcutaneously, so that to be effective it must be applied directly to the inflamed meninges, i.e. by injection into the spinal canal. Through the use of the anti-meningococcus serum the mortality of the disease has been reduced to under twenty per cent and there are fewer complications than before the serum was discovered.
The exact method of spread of cerebrospinal meningitis is not known, although we have learned the following facts. The meningococcus has slight vitality outside of the body, and the disease is most prevalent at the time that the other air-borne diseases are prevalent. While the disease seems to be largely localized in the lining of the brain and spinal cord, virulent meningococci are found in the mucous membranes of the nose and throat and in their secretions, not only in the human but in the experimental disease. Furthermore, a proportion of persons harbor these organisms without ever having the disease. It seems probable, therefore, that the transfer is effected by the droplet method of infection, presumably through the sick and through carriers. Isolation and quarantine of such persons is, of course, necessary, and thorough disinfection of the nasal secretions of the sick should be carried out. Since exposure is only very irregularly followed by the disease and since the administration of anti-meningococcus serum must be by lumbar puncture, the serum is rarely used as a preventive measure.
Smallpox is a highly infectious disease in which the mortality varies from one to fifty per cent, but the average in the unvaccinated is about thirty per cent. The cause is undoubtedly some sort of a micro-organism, which still remains undiscovered. The infection is probably carried largely in droplets from the nose and throat of the sick to other persons. Infection through the skin is possible. Smallpox is a self-limited disease and there is no specific cure.
History of Smallpox. Smallpox seems to have been known in India and China from time immemorial. Ebers believes that he has found, in the papyrus which bears his name, a reference to the existence of smallpox in ancient Egypt (about 3700 B.C.). Throughout classical and medieval times references to the occurrence of smallpox are comparatively numerous. In the sixth century of the Christian Era, Bishop Marius, of Lusanne, and Gregory, of Tours, wrote of epidemics of smallpox sweeping over Italy and France, thus giving the first positive references to the disease. The oldest known medical account of this scourge seems to be that of the Arabian writer Rhazes in the tenth century. In more modern times there are records of epidemics of smallpox in almost all parts of the civilized world. The disease is said to have been introduced into America (1520) by a negro who accompanied Cortez on his expedition into Mexico. It appeared among the New England Indians in 1633 and since that time America has never been free from smallpox. It is estimated that from 1700 to 1800 an average of 760,000 persons died from smallpox each year throughout Europe. It was a proverbial saying “that few escaped smallpox and love.”
No historical fact is better established than that before the discovery of vaccination smallpox was one of the most fatal and dreaded scourges of mankind. So widespread was the disease that, as Macaulay informs us, it was a rare thing at one time to find a person in London not disfigured by smallpox. To have had smallpox was a valuable recommendation in seeking employment. An advertisement of the eighteenth century reads: “A parcel of likely negro women and girls, 13 to 21 years of age, who have all had smallpox, were lately imported.” The experience of the city of Boston is illuminating of the conditions. The population at the time of the epidemic was 15,684. Of these 5,998 had had the disease. During the epidemic 5,545 contracted the disease, while 2,124 were inoculated with it; 1,843 left town, so that there were in the city only 174 persons who had never had smallpox.
Before the introduction of vaccination smallpox was more common than measles, and, on account of its infectivity, people usually contracted it in childhood. One-tenth of all deaths were due to smallpox, and in years of epidemics it was the cause of half the deaths. More than half of the living carried the scars of smallpox and blindness was a frequent result.
Now, little more than a hundred years later, comparatively few people in this country ever see smallpox and the story of this scourge has come to be almost legendary. In our present-day security many people have come to doubt the dangers from this disease and even maintain that it is extinct. Yet in the United States there are approximately 70,000 cases yearly. Over 30,000 cases were reported in the registration area during 1914. In many of the Western states smallpox is present continuously. From 1893 to 1898 the number of deaths from smallpox in Russia, including Asiatic Russia, was 275,502. In Spain, during the same period, there were nearly 25,000 deaths, and Hungary, Italy, and Austria each had about 10,000 deaths. Smallpox is still rampant in the Far East and the severity of the disease and its highly infectious nature is similar to that of a hundred years ago in Europe. Epidemics have been recorded in Illinois as recently as 1901-02; in St. Paul, 1899-1900; in Michigan, 1912; in Topeka, Kansas, 1911; in London, 1901-02, and in Montreal, 1902.
Vaccination. While it is true that general sanitation and hygiene have improved greatly, this improvement has not materially affected the mortality curve of measles, whooping cough, and scarlet fever, which can be fairly compared to smallpox both in their method of transmission and their infectiousness. One factor, and one factor alone, has brought about this prodigious change in the so-called civilized countries. That factor is vaccination. Everywhere the prevalence of smallpox is in direct proportion to the frequency of vaccination. In well-vaccinated Germany smallpox is practically unknown. In the United States about one-tenth of the population is unvaccinated, hence the 70,000 cases yearly. This failure to be vaccinated is not peculiar to any one class of the population, since five per cent of the students in the first year at Harvard College are unvaccinated. Furthermore, there is no record of a single instance where thorough vaccination did not completely stop an epidemic.
The story of vaccination is an interesting one. Although discovered in the last years of the eighteenth century, it was not understood at all until the work of Pasteur over fifty years later. Even today, in spite of the extensive use of vaccination, we do not know the actual infective agent of either the vaccine or smallpox. But the statistics of over a century have demonstrated its efficiency, although we are denied full knowledge of its action. The efficiency of vaccination against smallpox has been so striking that the discovery of other vaccines equally effective against other scourges has been the dream of many medical scientists and the goal of their labors. Pasteur believed that, since each infectious disease is caused by its own peculiar organism, there could be a vaccine for each disease. Pasteur himself developed an effective vaccine against anthrax and another against hydrophobia (rabies), which protected even after the disease had gained entrance. Since his time we have obtained a vaccine against typhoid fever. Nevertheless the most applicable and most effective vaccination which we have today is that against smallpox.
The principle of vaccination is simple in the extreme. A single attack of certain diseases confers on the victim an immunity for life against that disease. This principle has been recognized since the earliest times. Frequently in the past, and occasionally even today, parents deliberately expose their children to mild cases of certain diseases. Since, to their mind, the child must almost inevitably contract the disease, it is better to contract a mild attack and secure immunity than to run the risk of a later and more severe attack. Unfortunately, while there are frequently mild epidemics of any disease, it does not follow that the disease deliberately contracted from a mild case will be mild. In addition such a practice spreads the disease. Smallpox has been contracted deliberately in this way for this purpose from the earliest times. Centuries before Christ this was a common practice in China and India. The procedure usually consisted in taking a pustule of a patient with a mild form of smallpox and transferring that pustule to a scratch on the arm of a second person. This practice was known as inoculation. Inoculation was passed from one inoculated person to another. Obviously, in such a procedure, other diseases besides smallpox could also be transferred. But the practice of inoculation had much to commend it for the resulting mortality was less than one per cent, while the mortality from virulent smallpox was many times higher.
But inoculation, though effective, actually spread smallpox in a mild form and some of the cases became virulent and started severe epidemics. In 1770 Edward Jenner heard a farmer’s daughter say, on being told that smallpox had broken out in the neighborhood, “I cannot take that disease for I have had the cowpox.” Dairymen had noted that persons infected from sores on the udders of cows, known as “cowpox”, escaped smallpox. Jenner substantiated this belief by careful statistics, and on May 14, 1796, he did his first vaccination on a lad with virus taken from a sore on the hand of a milkmaid accidentally infected while milking a cow. The boy did not take smallpox, although he was repeatedly exposed to the disease. In 1798 Jenner published his work.
Vaccination was introduced into America in 1800 by Dr. Benjamin Waterhouse. He vaccinated his children and sent them into a smallpox hospital, thus establishing the fact that they resisted the disease.
Since 1800 vaccination has been carried to all parts of the world and always with the same result,—the eradication of smallpox. The collected statistics and the attendant researches have told us much about smallpox and vaccination, and the following facts are now well established. Vaccination to be effective must “take”, i.e. must leave a typical scar. After a successful vaccination the person is usually completely immune for a period of years, averaging seven to ten. If the disease is contracted, it will be mild and with a low mortality. Vaccination and revaccination after about ten years will give immunity for life. Laboratory investigations have shown that cowpox is really identical with smallpox, being only a mild modification of smallpox. Vaccination from animals like calves is much preferable to transfer from human being to human being. Calf vaccine cannot transfer most of the human diseases, since the calves are not susceptible to them, this being particularly true of syphilis. If the calves are properly cared for and are subjected to the tuberculin test, the danger of the transmission of bovine diseases is eliminated.
Since in the United States the Public Health Service inspects all vaccines, there is great security in their use. In Massachusetts a wise State Board of Health has for years furnished free a pure vaccine virus of its own make. The vaccination scratch is, of course, subject to the same infections as any other scratch, but the use of the usual surgical precautions will remove any danger of infection. Statistics of vaccinations under every and all circumstances show one fatal infection to 65,000 vaccinations. In the Philippine Islands, however, 3,500,000 persons were vaccinated without a death.
Strange to say, in the face of this evidence the anti-vaccinationists and anti-vaccination societies exist. The opponents of vaccination generally dwell on the following points. In the first place they point to the large use of animals and object, further, to the administration of disease material from animals to human beings. It may be granted that the use of animals for such purposes may be repugnant and can only be justified by public necessity. Confessedly it would be much better if the vaccine virus could be prepared in a test tube, but that is impossible at present. Likewise, no one is vaccinated by choice, but it is necessary for the community, and most people, therefore, submit with good grace, particularly in view of the negligible danger and the enormous protection afforded.
The second point brought up by those opposed to vaccination deals with the dangers of the procedure. Cases of syphilis, tuberculosis, tetanus, and other infections are recounted. The answer is simply that the careful use of a proper vaccine virus is attended with no dangers. Gross carelessness will infect the scratch wound, but, at the worst, the danger is less than that from scratches from pins and splinters.
The third point questions the accuracy of the statistics and the efficacy of vaccination. Emphasis is laid on the improvements in hygiene and sanitation. It is true, due partly to the activity of those opposed to vaccination, that vaccination is imperfectly carried out in most countries. But we have in Germany not only vaccination properly carried out but also an illustration of the uselessness of other methods in combating smallpox. At first smallpox was combated in Germany by rigid quarantine, isolation, and disinfection with the best German thoroughness. Nevertheless smallpox raged as before. In 1874 Germany passed the vaccination and revaccination law which required vaccination at birth and then again in the early teens. The result has been no epidemics and very few fatalities, and these almost exclusively among immigrants who had never been vaccinated. In the German army up to the time of the European War there had been only two deaths from smallpox since 1874, and one of these had never been vaccinated successfully. It is instructive to contrast the conditions where vaccination is enforced and where anti-vaccinationists are influential. From 1901 to 1910 there were in all Germany only 380 deaths from smallpox and most of these cases came from outside, but during the same period in England and Wales with half the population of Germany there were 4,286 deaths from smallpox. Statistics fail to show any great reduction in measles or scarlet fever which are transmitted like smallpox and which are, on the whole, less infectious.
The vaccination history of the victims of any epidemic of smallpox always makes interesting reading although it is always monotonously the same. In an epidemic in Chicago, 1899-1901, there were 310 cases of the disease. Of these, 271 had never been vaccinated successfully; only five had typical scars; the other scars were doubtful. The most recent vaccination of the thirty-nine who had been vaccinated was sixteen years before. We have, further, the evidence of the doctors and nurses who care for smallpox patients and never contract the disease, since they, are always well vaccinated. Doctors and nurses, who care for measles and scarlet fever and who are not immune through previous attacks, not infrequently contract the disease in the course of their duty.
In most civilized countries the story of smallpox is something as follows. There are vaccination laws which a proportion of the population obey,—in the United States about nine-tenths. The vaccinated nine-tenths generally protect the unvaccinated one-tenth. Revaccination and, in some cases, vaccination, is only done at times of epidemics. The result is that smallpox is constantly with us. If vaccination and revaccination were carried out among our population and all immigrants were vaccinated, smallpox would disappear from this country. But man’s nature is such that he is forgetful of anything beyond his present troubles. Even incomplete vaccination has protected him from a widespread scourge. Hence the tendency is to relax our already somewhat inadequate vaccination laws rather than to stiffen them.
This lamentable tendency gained such headway in England that not only were the vaccination laws rather overlooked, but the supporters of vaccination were subjected to violent personal abuse. Finally, in exasperation, Sir William Osler, long a foremost physician in the United States and now Regius Professor of Medicine at Oxford University, made the following statement in the course of an account of the benefits to man of science:
“I would like to say a word or two on one of the most terrible of all acute infections, the one of which we first learned the control through the work of Jenner.
“I do not see how any one who has gone through epidemics as I have, or who is familiar with the history of the subject, and who has any capacity left for clear judgment, can doubt its value. Some months ago I was twitted by the editor of the Journal of the Anti-vaccination League for ‘a curious silence’ on this subject. I would like to issue a Mount Carmel-like challenge to any ten unvaccinated priests of Baal. I will go into the next severe epidemic with ten selected vaccinated persons and ten selected unvaccinated persons. I would prefer to choose the latter,—three members of Parliament, three anti-vaccination doctors, if they can be found, and four anti-vaccination propagandists. And I will make this promise—neither to jeer nor to jibe when they catch the disease, but to look after them as brothers, and for the four or five who are certain to die I will try to arrange the funerals with all the pomp and ceremony of an anti-vaccination demonstration.”
Needless to say that this challenge which sums up so excellently the case for vaccination has never been answered.