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problems with which only the Federal government can properly deal.

This statement is not meant to seek credit for the National Tuberculosis Association and its work, but to show that however much it may have done in the past the work now to be done is more comprehensive, and involves elements which private effort cannot reach. But it is desirable to continue the earnestness and unselfishness which have been so important in the splendid results so rapidly accomplished thus far. This is provided for by the formation of the Advisory Council spoken of in Section 2, which will give the Surgeon General the right to call upon the highest authorities in the country for advice and help in working out the problems of the Public Health Service. The compensation is trilling, but this identification with the interests of the nation will ensure the most loyal service, and the advice and support thus made available will be invaluable.

The National Tuberculosis Association will of course continue its efforts, and will steadily and freely do whatever lies in its power; but the highest service it can render the cause to which it is devoted is to secure the passage by Congress now of this bill.

January 18, 1919.

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S. 1597—Memorandum To provide a Dizision of Tuberculosis in, and an advisory council for, the United States Public Health Service, and for other purposes.

Section 1 of this bill provides for the establishment in the United States Public Health Service of an additional division to be kuowni as the Division of Tuberculosis which shall be in charge of a commissioned medical officer of the Public Health Service, detailed by the Surgeon-General, who shall be while thus serving an Assistant Surgeon-General on the same basis as the other Assistant Surgeous-General, provided by the law of 1912, on duty at the Bureau.

The object of this section is to provide a special administrative division of the United States Public Health Service, the duty of which shall be to study tuberculosis, its causes and prevention, and demostrate methods for its suppression. In connection with the necessity for establishing such a division, the following is submitted :

Tuberculosis as a cause of death and disability: Tuberculosis is still the greatest single cause of death in the mortality sheets of this nation. According to the returns of the United States Census Bureau for 1916 tuberculosis caused 101,396 deaths in the registration area of the United States which comprises 70 per cent. of the total population. The total number of deaths for the calendar year 1916 was 1,001,921. Tuberculosis thus caused 10.1 per cent. of all deaths. If the same death rate from tuberculosis prevailed in the area of the United States outside of the registration area, the

total number of deaths in the entire United States from this disease was approximately 145,000. Moreover, tuberculosis is a disease which attacks the young and those in the prime of life, as 74 per cent of those dying from tuberculosis are less than 45 years of age. Tuberculosis, therefore, is essentially a disease of youth and of early middle age, causing the deaths of thousands upon thousands at the time when they should be at the height of energy and usefulness and, through its long duration and debilitating course causing hundreds of thousands, nay millions, of other persons to be a charge upon the nation at the very time when we have need of the entire fund of national man-power for the purpose of reconstruction, rehabilitation and recuperation if this nation is to play its part the healing of the gigantic wounds left by the war.

The effect of tuberculosis on military manpower: The effect of tuberculosis as a factor in depreciating national man-power is well shown in the figures of the physical examination of the draft. Over five per cent. of all examined, or more than one in twenty were found unfit for military duty because of tuberculosis, while many thousands subsequently developed tuberculosis after induction in the military service and were discharged. If we were to apply the figures the prevalence of tuberculosis found during the physical examinations incident to the selective service law to the whole population of the draft age, it may be estimated that there are approximately one million cases of tuberculosis in the population of the age groups between 21 and 31. With these figures concerning the prevalence of tuberculosis in this country and its prominence as a cause of death in the national mortality statistics, ti is no wonder that tuberculosis has been known as the “Great White Plague.”

Tuberculosis —- A prezentable disease: Tuberculosis, though transmissible from man to man and also from the lower animals to man, is a preventable disease. Its cause is known: much information has been acquired as to its means of spread and methods for control. It is to be regretted that hitherto no definite steps have been taken by Congress to wage war against this terrible enemy of national life and prosperity. By giving specific direction and facilities to the national health agency to take such steps as will result in concerted and cooperative effort to suppress and prevent tuberculosis, a great forward movement will be made in stopping the ravages of this discase. It is still the greatest single waster of human national resources in the category of diseases.

Relation of the Public Health Service to Tuberculosis: Under the law approved August 14, 1912, the Public Health Service may study and investigate the disease of man and the conditions influencing the propagation and spread thereof and under the law approved February 15, 1893, the Public Health Service is required to cooperate with and aid State and municipal boards of health* * ** vent the introduction of contagious and in

to pre

fectious diseases into the United States from For these reasons it is believed that there is foreign countries and into one State or Ter- urgent need at this time for the taking up at ritory or the District of Columbia from an

once by the National Government of the tuother State or Territory or the District of

berculosis problem as an essential part of the Columbia; and * * * * to make such addi

after-the-war reconstruction, and the estabtional rules and regulations as are necessary

lishment of a division of Tuberculosis in the to prevent the introduction of such diseases

Public Health Service under the provisions of into the United States from foreign countries, or into one State or Territory or the District

this act is the first logical step toward this

end. of Columbia from another State or Territory or the District of Columbia. The authoriza- Section 2 of this bill provides that there tion of the Public Health Service to undertake shall be an advisory council for consultation anti-tuberculosis work is therefore ample un- with the Surgeon-General of the Public Health der the law.

Service relative to the scientific work to be Up to the present time all of the activities inaugurated by the said Service and the of the Public Health Service relating to the methods of performing it, and that the present investigation of the diseases of man are being advisory board of the Hygienic Laboratory conducted under the division of scientitic re- shall be abolished. Under the act approved search, while cooperative work in the preven

July 1, 1902, section 5, an advisory board of tion of the interstate spread of disease and its

the Hygienic Laboratory was created for conintroduction from foreign countries into the United States is carried on by the division of

sultation with the Surgeon-General of the

Public Health and Marine Hospital Service Domestic and Interstate Quarantine and Division of Foreign and Insular Quarantine, re

relative to the investigations to be inaugurated spectively, in the Bureau. While of necessity

and the methods of conducting the same in tuberculosis has been considered in the work that institution. The board consists of five of these divisions, it has not been practicable

members, especially skilled in laboratory work, because of insufficient funds and facilities to not in the employ of the Government, and devote the intensive study to this great prob- three others in Government services, the Army, lem which it has long merited. Tuberculosis the Navy and the Department of Agriculture. is such an important cause of deaths and dis- This board has jurisdiction only over invesability that if a serious effort is made to re- tigations to be undertaken at the Hygienic duce to proper limits the needless annual toll

Laboratory. The act of 1912, however, has of thousands of lives because of its ravages,

greatly increased the scope of the investigathere is imperative need of a division in the Public Health Service which shall devote all

tions which may be conducted by the Service of its time, energy and funds to the solution

and the same need exists for consultation with of this great problem. Although tuberculosis

competent authorities by the Surgeon-General has long been the object of study and much

in regard to such investigations as in more knowledge has been acquired of the disease.

technical matters of laboratory research. The that knowledge still has many gaps to be filled.

effect of this section is to increase the number For instance, we are still far from having com

of members on the board and to broaden the plete information regarding such important scope of the advisory powers of the board so points as the chief port of entry of the infec

that instead of giving the Surgeon-General tion into the body, the conditions causing advice solely in matters relating to the consusceptibility, or relative immunity, the rela

cuct of investigations at the Hygienic Laborative value of various preventive measures, the

tory they may give the benefit of their advice mechanism by which immunity to tuberculosis

and experience in regard to the entire field of is created and the arrest or cure of the disease public health investigation. effected. We are still without any specific

In view, therefore, of the increased scope treatment for tuberculosis or without any

of the functions of the Public Health Service means of increasing individual resistance by since the passage of the law of 1902, and the the use of serums or vaccines. Yet, there is need too for an advisory council with special reason to believe that by intensive study of

relation to the problem of tuberculosis it bethese subjects hopeful results are to be secured. comes eminently desirable to increase the funcBesides this, there is great need for coordinat- tions of the present advisory board of the ing and correlating the work of national, state

Hygienic Laboratory so as to cover all public and local agencies for the prevention and con

health investigations undertaken by the Service, trol of tuberculosis. The work of coordinat- and to add to its membership so that all fields ing such agencies in unquestionably the proper

of public health research may be covered. Secfunction of the Federal Government as tuber- tion 2 provides for an increase in the memberculosis must be regarded as a national not a

ship of the advisory board from eight to ten local health problem. · For the universal pre- and, moreover, by abolishing ex-officio mem- valence of tuberculosis throughout the coun- bers gives a wider field of selection so that all try not only wages war on national vital branches of public health work may be reprebut the disease is spread through interstate sented on the board. An advisory board orchannels because of the migrations of those

gauized on these lines should be of the greatest affected with it.

aid to the National Government.

ESSAYS ON

ON TUBERCULOSIS XIV. SOME PUZZLES OF INFECTION. PART TWO: ADULT DISEASE AS A MANIFESTATION OF CHILDHOOD INFECTION

BY ALLEN K. KRAUSE, M. D. During the last ten or fifteen years the minor affections that from time to time affect opinion has become almost universal that us all. Whence then comes this startlingly manifest tuberculous disease in human beings abrupt and widespread scattering of tubercle is the expression of an infection that for a bacilli that precipitates perfectly healthy people considerable time has lain dormant in the into the most malignant and most fulminant body before addressing itself to the attention form of illness that tuberculous disease can of the infected individual. This view best fits take? Nine times out of ten autopsy will the facts that every day experience presents reveal their source, and this source is a surto us. One of the most striking and longest prisingly uniform finding in all such unfornoted features of tuberculosis as a clinical tunates. Almost invariably it is an old and disease is its tendency to relapse. A patient much-scarred focus of tubercle that gives may knowingly have had tuberculosis with

every appearance of having been well invested symptoms from it, may have recovered entire- and well taken care of for years that has ly from his disabilities; and may have again finally ulcerated and discharged its contents returned to his daily routine and have carried into a vein or into the main lymphatic trunk this on in a normal manner. For years such a of the body. Quiet, unobtrusive, nestled in a person may have remained in apparent health, thick and competent envelope of protective only again to fall ill with what is undoubtedly tissue, yet with an inherent capacity for untuberculosis. When we come to examine him told mischief, it had lain hidden for years, the more common occurrence is to find that his unknown to its possessor and in a location trouble is in the identical spot that it was that would have made it inaccessible to physyears before. We therefore do not imagine ical examination of the living patient. I have that he has again become ill because he has myself seen abdominal lymph nodes as large more recently acquired another tuberculous as my fist, thoroughly tuberculous, with layer infection from without. Evtry fact and every upon layer of dense scar tissue, with here and probability points out to us that for some there patches of cheesy necrosis, that so far reason or other an old focus of infection that as known had never caused the adult patient was incompletely healed has taken on any inconvenience, until the time came when activity to the extent of disturbing the patient's they went through the thoracic duct and the balance of health.

catastrophe hurried the patient on to death, This is a crude example, and one perhaps Once the tubercle bacilli were in a position to that will run the least likelihood of being exert their influence on the body they did so disputed, of the fact that in man at least tu- rapidly, completely, and with finality, but so berculous infection can, and often does, slum- long as they were barred out from the rest ber for years, it may be, and that when the of the body by dense capsules of scar-tissue, signs of its presence again become more tucked away in a remote place, they remained prominent they may put themselves forward obscure and unsuspected. exactly where they were a long time before. Every practitioner in tuberculosis will have Illustrations of this quiescent tendency of as his patients young men who in the full tubercle are not all so plain. There are many vigor of youth and uninterrupted health have different degrees of quiescence; there are many indulged in organized athletics and who at the different degrees of activity; there are also end of a hard race or some other unusual many different manifestations of the presence physical strain have suddenly suffered a pulof tubercle within us that, once manifest monary hemorrhage,-a startling warning disease does come, lead us to presume that that they are not the perfect physical specimens tubercle bacilli implanted long ago are only that their ruddy exterior would lead one to spbeginning to make themselves felt.

pose. And then every such practitioner will In every general hospital people are every now and again find that within these athletes' now and then being brought to the wards lungs anatomic changes are present to such an acutely ill with a disease that we diagnosti- extent that one can speculate only in terms of cate,-or as frequently fail to do so, -as gen- years to account for so much structural eralized military tuberculosis, a condition that damage. These men must have been a long is brought about by a sudden eruption of tu- time coming to the fateful race when at last bercles throughout the body. As a rule such the strain was too great even for their wellpatients have never before been known to controled infection. Some will tell you that have had tuberculosis, for if they had been to their knowledge they have never been sick. they would be refused entrance to a general If this story is correct then the changes that hospital. As a matter of fact, before their have gone on in a badly involved lung must acute illness many have been in perfect health, have taken a long time,-years, undoubtedly,-and it is not uncommon to have them tell us to develop; tuberculous infection does not work that they have always been healthy and free very rapidly without throwing a man into acute from disease except perhaps the more transient illness, an illness that he hears from promptly.

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Not long ago I saw a girl of eighteen years suppose that the character of the tuberculous who told me that until recently she had always process at any particular time plays a more been in perfect health except for an attack important part (within limits) than its extent. of typhoid fever two years ago. She undoubt- But over and above everything else we cannot edly had typhoid fever then because at the help wondering, that, if under our eyes over time she was operated upon for a perforation a long time the process does not grow and of the bowels. At any rate she was so vi- yet continues to set up symptoms, how long gorous and healthy that at the outbreak of the it must have been in attaining such dimensions war she undertook a man's work in the car- as we first detected. Many instances make us shops of the Baltimore and Ohio Railroad. almost perfectly certain that almost a lifetime The work agreed with her so well that after of infection preceded the outbreak of manifest six months of it she weighed five pounds more disease, and that the symptoms of disease than ever before in her life. She felt well originate from foci of infection that were and kept well, until of a sudden one night, established years before altogether apart from shortly after she had received a beating from other foci from later infection from without, her mother and had been struck on the right if these can in fact occur. side of her chest, she had a pulmonary hae

Besides such cases as I have cited above, morrhage. From this time on she became

which on the basis of long standing infection acutely ill. Physical examination within two weeks of her haemorrhage revealed that her

are “catapulted” as it were into manifest

tuberculosis, there right lung was very extensively involved with

others who take tubercle. She had a large cavity at the apex

more leisurely and a more long-suffer

ing road in getting there. A little under and almost complete tuberculization of the

weight their whole lives long, little rest of the lung. Taking into consideration her story such massive changes in the lung

paler and flabbier than they ought to be, with

less endurance and elasticity than they should could not have been the result of a week or

have and consequently less able to perform a month of acquaintance with the tubercle bacilus. Her initiation to tuberculosis must have

their work than they should be, they come to been the culmination of years of infection.

us at last with cough finally established and

tubercle bacilli in their sputum or râles definiAt about the same time I saw an unusually tely noticeable and persistent, or certain other intelligent young man who protested that until stigmata that leave no doubt that the effects two or three months before he had always been of the tubercle bacillus are emerging above in perfect health. But now he felt weak and the surface. It used to be the fashion,---and had been oppressed by an unusual fatigue since that too not so long ago-to aver that these he had caught "cold" a short time ago. He were the individuals who were constitutionally had no cough, he did not spit or "raise." But inferior,—perhaps born so,--and who because his weakness bothered him. Yet at the time of their inherited nervous instability and poor he was not acutely ill and was trying to carry digestion and abnormally irritable circulation on his work. This young man at the first were more open to infection by the tubercle examination was also found to have extensive bacillus, and, therefore, given the opportunity, cavitation of the apex with astonishing invol- acquired the infection with its consequent vement of the rest of the lung. He has since symptomatic manifestion. But to-day we are developed cough, sputum with tubercle bacilli, not so sure of this post hoc. propter hoc haemorrhages and spontaneous pneumothorax method of interpretation. In the last decade with a fistulous communication between his we have acquired the ability to detect tuberpleural space and the bronchi. Judged by signs culous infection even though we cannot put the damage in his lungs is no more extensive our finger on the spot that has become fertile than when he was first seen,—that is, it soil for the bacillus and we have learned with occupies no greater volume,-yet disease is the x-ray to find anatomic tuberculous change now galloping apace in the infected tissues. even though this produces no signs that are And there can be no doubt that during health, detectable on physical examination. We have for years perhaps, this man had tuberculous found therefore that many of these chroninfection which spread and anatomically left ically "under-par" and "substandard" indivits marks. Yet for years he remained in iduals have marked tuberculous infection withhealth. There cannot be less doubt that his out focalizing and localizing signs and symptuberculous disease was the ultimate mani- toms of disease. And are becoming festation of this years'-long infection.

accustomed to thinking that their vicious Patients come to us with a definite volume

constituton is not so much the cause of their

tuberculous infection that may later manifest of lung occupied by the tuberculous process. We treat them for a long time, perhaps for

itself, as that it is the product and effect of a

tuberculous infection which has long been in years, and during this protracted period of existence but which for some reason or other treatment find that their tubercle does not

has not bespoken its presence more eloquently. increase in extent. They still remain ill, it is true, but it is remarkable that they continue To deny or even to question that a large to be ill and the amount ui iung involved does proportion of patients for the first time come not increase; or that they improve or even to the attention of the physician with active become well and the volume of infection does tuberculosis that is the result of an infection not diminish. All of us have noted this oc- that took root many months or years before currence frequently; and to explain it we must would be to cast doubt on one of the most

we

or

solid facts and one of the most common ex- with our students to practise this procedure, periences that our acquaintance and knowledge which is highly desirable from the point oi of tuberculosis patients furnishes. But in

view of adding something to our knowledge thus stating the proposition we are far from of tuberculosis. Nevertheless to-day is too categorically fixing for the gencrality of mant

close to the time when we began to appreciate kind a particular period of life in which there

the probable significance of our new knowloccurs that particular infection that later eventuates in disease, --in the great majority of

edge. And there is no man alive who can cases, in adult disease.

affirm that he has had even a handful of paDuring the last ten or fifteen years, or the

tients in whom he has carefully noted the period in which we have become increasingly

development of childhood infection without certain that adult pulmonary tuberculosis is

disease, in whom he has for years kept careful the flowering of a seed that in many instances

track of the behavior of this obscure infection, was planted years before, we have also become

-its persistence at one particular spot or its convinced that most human beings receive

migration from point to point, -and in whom their first tuberculous infection in child

he has in later adult life seen manifest tuberhood, before they have attained the

culosis develop in the area of the original inage of fifteen. We have already discussed this

fection or of the final destination of the phase of the situation and have been at some

original infection. Dur records of such biopains to show that the evidence in favor of it

graphical occurrences are at present almost is as compelling as is any that we possess

non-existent. But they are not unobtainable. about any of the threads of a badly tangled

And there is no greater service that our great skein.* Vo matter what our individual bias,

hospitals and city dispensaries could contribute no matter how discordantly the idea refuses to the proper apprehension of a major problem to fit in with all the other pieces of the

that awaits solution than that of carefully tuberculosis puzzle, we must accept as a perfect

studying and keeping in touch with the incertainty the fact that the greater number of

fected yet comparatively healthy children that children become infected with tubercle bacilli, are continually coming under their observation.

Supported by all the resources of their well orWe have then, to start with, two undeniable

ganized medical and social service equipments and easily demostrable actualities about tuber

they have it in their power to follow for years, culous infection; two actualities about which, as regards the peculiar merits of each alone,

if need be, many of their patients; and after there is no room for controversy. The first

twenty or thirty or forty years such agencies is that infection for the first time usually

could have enough information at hand to

give us a fairly definite answer to the question occurs in childhood. The second is that it is

of the development of adult tuberculosis from a common peculiarity of the outbreak of adult disease that this is undeniably the culminating

first and original childhood infection.

Now while I believe that no one can prove phase of an infection that has begun a long

this scientifically and that therefore no one time before its presence is appreciated. Many

should erect it into a law, I am nevertheless students, perhaps the greater number of them, of tuberculosis have naturally sought to bring

convinced that it does, at least on occasion, these facts into causal relation with each other,

occur. I knew a young man of about twenty

three years, whose mother died at his birth. and out of their efforts has arisen the doctrine of the childhood beginning of what later

He was brought up in large part in his grand

mother's home. During his first years his eventuates in adult disease. Not a few speak

grandmother had consumption to a degree sweepingly and with but little qualification about adult pulmonary disease as a condition

that kept her most of the time in bed, indoors,

as was then the custom, with windows down that always has its birth in childhood infec

tight and room heated to the point of comfort tion, and this idea is continually gaining more

for an invalid. As an infant, this man had and more adherents. Before beginning my argument

spent much of his time creeping on the floor this

of his grandmother's room and playing around proposition. I am loath to prejudice it by venturing an opinion about it, one way or the

her bed. At the age of about four he deveother. As a matter of fact I may immediately

loped a "lumpy" neck and this was attended confess that I have no fixed opinion about it;

to surgically. Ten years went by when with nor do I understand how any man can have a

the oncoming of adolescence he became ill scientific opinion about it. Studies or obser

with what was manifestly tuberculosis of the vations that would lead us to dogmatize that

kidney. Again he was operated upon and his
kidney was

removed.

Almost another teni manifest adult tuberculosis in even the greater number of cases (and not all) is the later

years elapsed and meanwhile the boy, notwith

tanding his physical handicaps, had passed development of a childhood infection are

through school and college so successfully wofully insufficient. The lives of comparatively few human beings have been carefully ob

that he was within a few months of finishing served from early years to later, with the fate

a technical course at college at the head of of tuberculous infection in them continually

his class, when—unnatural fatigue, a little in mind. It is probable that some time in the

fever, cough, expectoration and all the familiar future more and more will thus be under

earmarks of pulmonary disease. And after scrutiny, and to-day we are beginning to plead

three or four years of manifest tuberculosis

of the lungs he died. See February number.

When we come to build up tire most probable

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