Is consumption contagious? and can it be transmitted by means of food?

Front matter

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Consumption Contagious ?

Preface To The Second Edition

During the twenty months which have passed since the appearance of the first edition of this book, many communications from readers in different parts of the country, laymen as well as physicians, have been received, in which cases of consumption, probably originating from contagion, were reported, or strong beliefs in the possibility of such origin expressed. Further experiments, not necessary to be here mentioned, but mostly confirming the inoculability of tubercle, have during this time been undertaken. The most important addition to our knowledge on the subject, however, has come from the recent very remarkable researches of Dr. Koch of Berlin, an abstract of which by the celebrated Prof. Tyndall, who appreciates their scientific importance, is quoted in the Appendix on page 179. Most of the prominent medical journals of the world have already described them and admitted their great value.

Although Schiiller, Toussaint, Klebs, and Aufrecht had, previously to Koch, announced the discovery with the microscope of peculiar spherical, or actively moving, or rod-shaped micrococci, which they thought were the specific germs of tubercle, and had even tried to cultivate them in albuminous fluid, yet it is now probable that, owing to faulty methods of experimentation, together with the real tubercle bacilli several other minute organisms were also cultivated by them in the same fluid, and were mistaken for these microscopically. Of course the injection into ii PREFACE TO THE SECOND EDITION.

animals of this fluid, as it contained among other things the true tubercle bacilli, occasioned tuberculosis, as had the injection of crude tubercle by manyprevious experimenters. It has remained for Koch to prove that his recently described organisms of rods, which are invisible under the microscope by previous methods of observation, are really the specific parasites of tubercle, (i) by skilfully isolating them by ingenious methods from other minute organisms as well as from their gross surroundings ; (2) by cultivating them, generation after generation, for months on a specially prepared solidified gelatinous substance ; and then (3) by invariably producing the disease in animals by the inoculation of the cultivated parasites, and those only; the simultaneous inoculation in other animals of the same culture substance without the parasites always resulting negatively.

Koch's experiments have also settled a question over which there has been much controversy. The infectious cattle disease Perlsncht (see page 120) is now proved by him to be identical with human tuberculosis. Since our first edition, Dr. Charles Creighton, whose views on this subject are briefly presented on page 138, has given a very detailed and interesting account of them in a book entitled "Bovine Tuberculosis in Man."

Last year Toussaint vaccinated a cow, suffering from advanced tuberculosis, with absolutely pure vaccine lymph. The vesicles progressed normally, and with lymph from them he vaccinated successfully a number of animals. All of these latter animals, however, became tuberculous. {Medical Times and Gazette, Sept. 3, 1881.) Does not this suggest the necessity of caution in the selection of heifers on the part of propagators of animal vaccine virus ?

PREFACE TO THE SECOND EDITION. Ill

One of the chief arguments of these propagators against humanized virus has been the possibility of conveying from one person to another, not only the vaccination, but also some disease. It has been asserted that with virus direct from the cow this is impossible !

As to Koch's discovery of the presence of tubercle bacilli in large numbers in the expectoration of phthisical patients, and of such only, and of their activity retained even for weeks in the dried sputum, much of which in a pulverized form floats in the air, one must be blind indeed not to see the very practical connection of this demonstration with the contagiousness of consumption. Some of the possible reasons why phthisical sputum is not oftener the cause of the disease are given in the quotation from the Lancet on page 184. The latter suggestion there made, as to the aptitude of the soil, had been previously brought forward by the world-renowned Prof. Rindfleisch (Virchow's Archiv., 1881, B. 85, p. 71), who believes tuberculosis to be undoubtedly an infectious disease, but one for which mankind has to some extent established a tolerance, and which in consequence appears in its original character only in a person where this tolerance does not exist. Good food and a free blood formation, he thinks, give immunity from the outward manifestation of this latently almost universal disease. If these fail, tuberculosis becomes evident.

While contemplating the importance of Koch's great discovery, it is impossible for us not to speculate on the future probability of preventing, by its inoculation in a modified form, that disease which is the greatest scourge of mankind ; nor is it merely an idle invasion of the province of dreamland thus to speculate. Pasteur was lionized more than any other iv PREFACE TO THE SECOND EDITION.

man at the International Medical Congress at London last summer because of his brilliant achievements in preventing anthrax, the fatal splenic fever in cattle, by inoculating its bacillus modified by cultivation, and thus producing the disease in a mild and harmless form. Vaccination itself many now regard as simply inoculation with the bacillus of smallpox, modified by its transmission through the bovine race. The opinion seems to be rapidly gaining ground that the other eruptive fevers, which are most likely due to the growth within the body of minute parasites, generically called bacilli, may perhaps be forestalled at some future time by the designed production of very mild forms of them by the inoculation of their bacilli altered by cultivation. Dr. Koch, in his experiments hitherto, has only cultivated the tubercle bacillus in its original virulence ; but of course now many other investigators, who think they can forecast the signs of the times, will attempt with eagerness to cultivate these parasites in diminished intensity, and grapple, full of hope, with one of the greatest problems ever offered to the physician, — the prevention of consumption. Whether consumption can ever be prevented in this way is somewhat doubtful, we grieve to say. The analogy with small-pox is not a perfect one, because one attack of consumption, however mild, surely does not confer immunity from future attacks, but on the contrary rather predisposes the victim to them. However, even if Koch's researches do not facilitate the prevention of the disease by inoculation, they surely will do a great deal towards accomplishing the same object by enforcing on public attention the contagions nature of the disease, and by warning people not to breathe in nor eat its germs.

ii Columbus Square, Boston, July, 1882.

Introduction

It is not from any desire to create a few hours' " sensation," or to gratify a gaping curiosity, or even to attempt to settle any purely abstract and theoretical discussion, that I have prepared the following pages, but because I have become thoroughly imbued with the great importance of the subject, and feel impelled by an irresistible urging to point out and emphasize, by word and implication, its exceedingly practical bearings. Consumption is such a fearfully common and fatal disease all over the world, that few questions can be more practical than those on our title-page, which involve very important methods of its propagation. To .be sure, our knowledge is not sufficiently accurate to enable us to give just now, with mathematical exactness, a positive answer to these questions, but it is very doubtful if any thoughtful person can read through these seven chapters without being persuaded that there is " something in it," and that to a certain extent at least, and under certain conditions, consumption is contagious.

Some of the more important practical results to be obtained by a judicious agitation of this subject are

8 INTRODUCTION.

the following: (i.) That no person, particularly if young, should be allowed to sleep in the same bed, or even (if it can possibly be prevented) in the same room with a consumptive. (2.) That no person should be allowed to remain for too long a time in too close or too constant attendance on a consumptive. (3.) That ventilation as perfect as possible should be secured. (4.) That the most rigid inspection of all the meat that comes into our markets, particularly at the slaughter-houses, and of all the cows which furnish us milk, by competent government officials beyond the temptation of bribes, should be insisted on for the public safety.

Of course, it is not to be supposed that these points would be entirely neglected without the agitation of this subject, but it certainly supplies an incentive in their behalf of wonderful power. Those physicians who do not believe in the contagiousness of consumption may, on general principles, advocate the necessity for good air, good food, and good hygienic surroundings, because it seems, on the whole, the proper thing to do ; but such general advice as this often comes with very little force, and they frequently fail to insist energetically on these points when disregarded. The friends of the sick person, too, if they are not aware of the danger to which they are exposed, frequently think they cannot, and certainly often will not, carry out these necessary precautions, as almost any physician will testify. But give them a stimulus to vigorous action, convince them of the possible contagiousness of the disease, and the physician's advice will be

INTRODUCTION. g

prompt and earnest, and the patient's friends will faithfully carry out his instructions to the letter, with a firm purpose and resolution born of an intelligent conviction. It must necessarily be that those who are lulled to sleep in a false security through disbelief in an enemy's presence, are thereby rendered less able to ward off the unforeseen attack.

Some physicians, like the well-known Frenchman Dr. Pidoux, have been known to say : " Well, even if consumption is contagious, we ought not to terrify people by telling them of it, for, if they find it out, they will turn with loathing from their best friends when taken sick, as if they had the leprosy, and consumptives will thus be left to perish miserably in great neglect." Shame on the man who could for a moment entertain such villanous opinions ! Does a mother neglect her child because it has such a contagious disease as scarlet fever or diphtheria ? Does a wife refuse to provide suitable care for her husband, even if he has such a loathsome affection as the small-pox ? Again, is it any kindness to people to lie to them and tell them there is no danger from contagious diseases, when we know there is or may be danger ? No ; let us be honest with them, and tell them our convictions, our opinions, or even our suspicions, if they rise no higher in the scale, that they may be able intelligently to take due precautions. Even if we run the risk of frightening them unnecessarily, we should not withhold the truth at any hazard. However, as far as our knowledge extends at present, they need not be frightened at all, if they will only take the proper precautions.

IO INTRODUCTION.

In order to arrive at the truth as nearly as possible, and to avoid every appearance of distortion, I have tried to present both sides of the argument, derived from all accessible sources, in an impartial manner, often quoting the very words of the authorities drawn upon. If my only object had been to prove contagion, it would have been comparatively easy to work up a one-sided argument in favor of the doctrine, carefully concealing everything that has been or might be said in opposition.

During the last ten years I have noticed quite a number of apparent cases of contagion from husband to wife, or from wife to husband, or from friend to friend. This has been more particularly since I began to look for them, for at first, being rather skeptical, I regarded those cases about which a suspicion might have arisen as merely curious coincidences, and undoubtedly neglected to inquire carefully into others, about which I am now persuaded something might have been learned in reference to the matter now under consideration. I have not included, in Chapter IV., reports of any of my own cases, because I deemed those which I had collected from others (all of them undoubtedly trustworthy sources of information) amply sufficient to illustrate the subject, and also because those which have occurred in my own experience have not, as a rule, seemed to present anything especially interesting to detail beyond the simple fact of con- 1 tagion. I have not met with any example's of those remarkable series of cases linked together, which characterize several of the reports which I have borrowed from different authorities.

INTRODUCTION. 1 1

I hope that nothing which may be found in this book will be construed into an argument against the use of two of the most important, healthful, and nutritious foods which we possess, — milk and beef. While, on the one hand, people would be very foolish to allow their timidity to induce them to give up two of the great necessaries of life, on the other hand they would be very culpable, if, in view of the facts already demonstrated by scientific experiments, incomplete though they may as yet be, they did not energetically insist on the most rigid governmental inspection possible.

To those who are convinced of the possible contagion of consumption by statements herein contained, it is of course unnecessary to say anything as to the advisability of marrying a consumptive.

I desire to call attention to the practical instructions given by Dr. Bowditch on page 33. With the exception of his recommendation of the wine, I can heartily indorse them.

Reports of cases or facts bearing on this subject, or opinions from any source, will be thankfully received by the undersigned.

H. C. C.

16 Concord Square, Boston, Nov. i, 1880.

Is Consumption Contagious ?

Chapter I. What We Mean By The Words " Consumption " And- " Contagious."

In entering on the discussion of such a subject as that now under consideration, it will be exceedingly important for us, at the very outset, to state what signification we attach to these words. Time and time again have long and excited wordy wars been waged, utterly profitless in their results, simply because of misunderstandings of the exact meaning of each other's phrases - by combatants, whose opinions possibly might not have been very widely different, after all.

Both words have been chosen, because on the whole they seemed to be more expressive and less open to the charge of ambiguity than any others which presented themselves. More particularly was this the case with the word consumption, which, not only among physicians, but also among the public at large, is the commonest expression for that dread disease, whose most prominent symptoms are emaciation,

14 WHAT WE MEAN BY THE WORDS

cough, spitting of blood, night-sweats, chills and flushes, etc., and which carries off in most countries from one eighth to one fifth of all those who die. Plithisis and tuberculosis in the present work are used synonymously with consumption. No one will question this use of the word phthisis, simply because it means precisely the same thing ; and even those who follow Niemeyer's pathology, and refuse to acknowledge the primary dependence of cheesy pneumonia or pneumonic phthisis on tubercles, will yet admit the frequency of their occurrence in this disease in its last stages, only during which, as a rule, as will be seen in the following pages, contagion is claimed.

Much harder is it to reconcile the various and often conflicting interpretations of the word contagious. To show some of the difficulties here to be encountered, a few out of many definitions given by good authorities are quoted.

In Webster's Unabridged Dictionary we read under Contagion : —

"Contagious, Infectious. — These words have been used in very diverse senses ; but, in general, a contagious disease has been considered as one which is caught from another by contact, by the breath, by bodily effluvia, etc. ; while an infectious disease supposes some entirely different cause acting by a hidden influence, like the miasma of prison ships, or of marshes, and iiifccting the system with disease."

Also, under Infection : —

" Medical writers in Europe do not, most of them, recognize any difference between contagion and infec-

"consumption" and "contagious." 15

Hon. In America the distinction referred to under contagion [just quoted] is, to a considerable extentj admitted."

In Bennett's Practice of Medicine : —

" By infection is understood the power of being propagated through the inhalation of air tainted by the breath or perspiration of the affected person. By contagion is understood communication of disease by actual contact."

In Chambers s EncycLpcedia, we read : —

"Infection is distinguished from contagion by some medical writers, who would restrict the latter word to the cases in which there must be contact of the healthy person with a patient, while they imply the term infectious to diseases which can be conveyed by the atmosphere. The distinction is unimportant." Also :

" Contagion, the communication of a disease from the sick to the healthy, either by direct contact of a part affected by the disease, or through the medium of the excretions and exhalations of the body. Some authorities have employed the term infection to designate this latter method of communication, and have correspondingly limited the meaning of the word contagion ; but no practical end is served by this refinement, and it has, indeed, led to great confusion by obscuring the fact of the communication, which is, when clearly proved by instances, the most important element in the inquiry."

The last edition of Dunglison's Medical Dictionary says : —

" Contagious diseases are produced either by a virus

1 6 WHAT WE MEAN BY THE WORDS

contagium, capable of causing them by inoculation, .as in small-pox, cow-pox, hydrophobia, syphilis, etc., or by miasmata proceeding from a sick individual, as in plague, typhus gravior, and in measles and scarlatina. Physicians are, indeed, by no means unanimous in deciding what diseases are contagious and what not. It seems probable that a disease may be contagious under certain circumstances and not under others. . . . Contagion and infection are generally esteemed synonymous. Frequently, however, the former is applied to diseases not produced by contact, as measles, scarlet fever, etc., while infection is used for those that require positive contact, as itch, syphilis, etc., and conversely. Diseases which cannot be produced in any other way than by contagion, are said to have their origin in specific contagion, as small-pox, cow-pox, measles, hydrophobia, syphilis, etc. Those which are produced by contagion, and yet are supposed to be sometimes owing to other causes, are said to aiise from common contagion?

In Ziemssen's Cyclopcedia of the Practice of Medicine, in the introduction to the volumes on the " Infectious Diseases," by Professor Liebermeister, of Tubingen, occurs the following definition : —

" Under the name Infectious Diseases we group together those affections which we know (or at least believe) must originate through the infection of the system with certain peculiar poisonous matters, and which are mainly distinguished by the fact that they can reproduce themselves, under favoring conditions, to an endless degree."

"consumption" and "contagious." 17

He subdivides infectious diseases into three classes : Miasmatic, contagions, and miasmatic-contagious. The malarial diseases are purely miasmatic ; the purely contagious diseases are measles, scarlet fever, smallpox, cow-pox, typhus fever, diphtheria, glanders, malignant pustule, hydrophobia, virulent ulcers and blenorrhoeas, syphilis, pyaemia, and puerperal fever ; and the miasmatic-contagious diseases are cholera, typhoid fever, dysentery, and probably also yellow fever and the plague.

In explanation, he says: —

" Miasm, in the original and broadest sense, is the name for any material contained in the air that can produce disease. The old writers frequently used the term in this broader sense, when they spoke of the miasm of measles and small-pox, but they also included with it the non-specific noxious matters mingled in the air, as, for example, the products of putrefaction and decomposition, and sometimes even all kinds of injurious gases. Later, the term miasm, being brought into contradistinction with the term contagium, was used in a far narrower sense, and in this narower sense it is now solely used.

"It is usual, now, to speak of contagium as a specific excitant of disease, which originates in the organism suffering from the specific disease ; while miasm, on the other hand, is used of a specific excitant of disease, which propagates itself outside of, and disconnected from, a previously diseased organism. Contagion can be conveyed, by contact, from a diseased person to a sound one, produce the disease in him, and then again

1 8 WHAT WE MEAN BY THE WORDS

reproduce itself . . . but it is true that direct contact is not a necessary condition for the transmission; it can also follow mediately from the vaccinator's lancet, from other instruments, from clothing, through third persons, and in many of these diseases by the air, . . . Miasm originates from without ; taken up into the body, it can call a specific disease into action ; but it cannot spread the disease any further by conveying it from a diseased to a sound person."

Neither of these definitions will cover his third class of infectious diseases — the miasmatic-contagious — which, as its name indicates, partakes of each, but belongs strictly to neither of the two preceding classes. Here the germs of disease are originally furnished by the affected body, but before they can reproduce their disease in another person, they have to pass through a distinct stage of development outside of the human body, under favorable surroundings, as, for instance, when the discharges which contain them remain some time standing, particularly when in contact with great quantities of organic substances that readily decompose, as in water-closets, sewers, etc.

It may not be out of place here to add that the distinguished author just quoted from, gives it as his opinion that, in the future, phthisis will also be included among the chronic infectious diseases. (Vol. I., page 24.)

From the various and often contradictory definitions just quoted, some of which we feel obliged to characterize as very impractical, to say the least, it will readily be seen that confusion worse confounded almost

" CONSUMPTION AND " CONTAGIOUS." 19

necessarily arises from any ex parte attempt at scientific refinement through the multiplication of terms and the corresponding limitation of their meaning concerning subjects on which our knowledge is at present no more thorough. The main point which we desire to keep in view in this investigation is, not the proper theoretical exact classification of consumption among diseases, but whether consumption can in any way, under certain conditions (we do not now speak of heredity), be communicated from one person to another. This is the question in which the profession and the people at large are, or ought to be, interested, and no amount of hair-splitting as to the exact meaning of technical terms should be allowed to obscure this really vital question. Therefore we shall use the word contagious in its broadest sense ; that, indeed, in which it is now popularly used almost everywhere, as synonymous with communicable, transmissible, " catching! 1 This definition surely is simplicity itself, and we do not thereby commit ourselves to any particular theory as to the exact mode of its transmission ; a procedure which, until we know more about it, is undoubtedly safe.

Chapter II. Historical And Descriptive

If the question which forms the subject of this book had been asked of any intelligent physician one hundred years ago, the answer would have come promptly, " Why, yes, from the earliest times medical men and the people generally have believed, almost without exception, that consumption is, to a certain degree at least, contagious." The question was tolerably well settled at that time, and did not admit of much controversy. Any one who is interested in investigating the subject historically to-day, by consulting the medical department of our Boston Public Library, of which we may well be proud, the Boston Athenaeum, and such other libraries, public and private, as he may be able to gain access to, and poring over the many musty old volumes which treat of a disease which is so fearfully common and distressing that its literature is necessarily extensive, will find that almost all the celebrated medical writers in the world, down to 1780, have shared this belief. Aristotle (330 B. C.) says that " it makes the breath corrupt and offensive, and those who breathe it suffer." He adds that the Greeks of his day generally believed in its contagiousness. He asks why consumption, itch, and ophthalmia are common to those who approach near to the persons laboring under these complaints. (Prod/. 1. 7, vii. a.) Hippocrates had previously (400 B. C.) entertained the same ideas. Galen (A. D. 180) says that it is " dangerous to pass the whole day with a consumptive person, and with all people whose diseases generate putrid effluvia." (Galen, iv. 87, 91.) Richard Morton says {Optra Medica, Lugduni, 1697. Phtliisiologica, Lib. II. Cap. 1, p. 27) : " A contagious principle also propagates this disease, for, as I have often found by experience, an affected person may poison a bedfellow by a kind of miasm like that of a malignant fever." He adds that phthisis acquired in this way is more difficult to cure, and shorter in duration, than usual.

Valsalva, who was predisposed to consumption, constantly avoided being present at the dissection of the lungs of persons who had died of that disease (Benj. Rush, Med. Inquiries, p. 95, Vol. II., 3d ed , Phil., 1809) ; and Andral says that Valsalva's immortal pupil, Morgagni, avowed that he had never dared to make more than a very few autopsies of persons who had died of phthisis, for fear, as he said, of catching their disease. He clung to this prejudice all his life, and in one of his letters (De sedibus et causis morborum (22), A. D. 1 761), we read the following sentence :* "Phthisicorum cadavera fugi adolescens, fugio etiam senex."

We learn from Riverius (1656), who gave credence

* As a young man I used to avoid the dead bodies of those who had died of consumption, and now that I am old I still avoid them. 2* to the facts, that it used to be customary for consumptives to nurse women's milk as a means of cure, and that cases were reported where the nursing women contracted disease in this way. (Drake's Dis. of the Int. Val. of N. A., Vol. II, Phil., 1854.)

Riverius also declared contagion to be the " chiefest" cause of phthisis, "for this disease is infectious. We may observe women to be affected by their husbands, and men by their wives, and all the children to die of the same, not only from infection of their parents' seed, but from the company of him that was first infected."

About a hundred years ago a reaction against this almost universal belief set in ; and, as in many other instances in the history of medical opinions, especially those which, from the nature of the case, can never be settled with absolute precision, the pendulum finally swung too far, and after a time the uncertainty and doubts which had slowly arisen, by a gradual transition, finally developed into almost utter scepticism. This was true at least in America and in the northern parts of Europe. The old, well-founded belief, though somewhat modified, never entirely lost its hold in warm latitudes, especially in Southern Europe, and more particularly in Italy, where, to this day, it is widely prevalent. Within comparatively a few years, however, as we shall presently show, the pendulum has begun to swing back again, and probably, before long, more accurate views than ever, based on modern scientific investigations, will be generally accepted.

Briefly to illustrate, we will quote a part of what we have been able to obtain of the views of prominent writers within a hundred years or so.

The famous Professor Wm. Cullen, M. D , of Edinburgh, says in his First Lines of the Practice of Physic, Vol. II. p. 424, 1791: —

" It has been frequently supposed by physicians that phthisis is a contagious disease, and I dare not assert that it never is such ; but in many hundred instances of the disease which I have seen there has been hardly one which to me could appear to have arisen from contagion. It is possible that in warmer climates the effects of contagion maybe more discernible."

Dr. T. Reid, of London, in 1782, thinks that it may be slightly contagious in extreme cases.

Dr. Benjamin Rush (Medical Inquiries and Observations, etc., Vol. I., Phil., 1789), in the earlier editions of his works, seemed to be fully convinced of the contagiousness of the disease, and in illustration gave an account of its spreading from the white proprietors of an estate among the negroes, who were neither overworked nor particularly anxious. In his third edition, however, printed at Philadelphia in 1809, Vol. II. p. 95, he announced that his views on this subject had changed, and brought up arguments to prove that except in rare cases it is not proper to ascribe the causation of consumption to contagion.

Darwin, in 1793, believed that it was contagious, but only in persons nearly allied.

Dr. Heberden, of London, in 1802 (Commentarii de morborum historia et curatione), says : — .

"In England we have very little apprehension of the contagious nature of consumption, of which in other countries they are fully persuaded. I have not seen proof enough to say that the breath of a consumptive person is infectious ; and yet I have seen too much appearance of it to be sure that it is not ; for I have observed several die of consumption in whom infection seemed to be the most probable origin of their illness, from their having been the constant companions or bedfellows of consumptive persons."