Volume XVII

No. II

T

1. BEGINNINGS

Strictly speaking, the beginning of the tuberculosis campaign in the United States dates back to the pioneer vision and effort of Dr. Edward Livingston Trudeau at Saranac Lake, N. Y. It is true that institutions for the treatment of tuberculosis had been started prior to Trudeau's breakdown with the disease. As early as 1857 the Channing Home, named after the famous Unitarian divine, had been established in Boston, and in 1875 Dr. Joseph W. Gleitsmann established the first private sanatorium at Asheville, N. C. It remained, however, for Trudeau to sense the significance of Koch's momentous discovery and become the first apostle not only of the curability, but also of the prevention of tuberculosis. The establishment of the Adirondack Cottage Sanitarium (now known the world over as the Trudeau Sanatórium) in 1884 and later, of the Saranac Laboratory was in reality the beginning of the campaign against tuberculosis in the United States.

As might have been expected the first emphasis of the tuberculosis movement was laid upon cure. Early research and writings as well as the early institutions all stressed this one feature. Slowly but surely the sanatorium movement, particularly for the treatment of persons of moderate means, began to take root and, following Trudeau's example, institutions were established in various parts of the country for working men and working women. All of these institutions made provision for treatment at moderate costs within the range of the patient's ability to pay, or received patients through the city or county poor authori

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ties of their home commur Sanatorium, established Mass., through the visic Bowditch, was the firs tuberculosis could be c Loomis Sanatorium es Liberty, N. Y., White Fav tablished in 1901 in Wh Memorial Sanatorium ( Denver, Colo., Gaylord tablished in 1904 at W all fruits of that early ..opme Dr. Trudeau and foste.ca by Dr 3owditch. In 1898 Dr. Bowditch secur the establishment through the Massachu s Legislature of the first state institution. the treat of tuberculosis on the American content. The significance of this step, in vi.w the present emphasis upon public responsibility for institutional care, can hardly be phasized.

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2. THE PREVENTIVE MOVEMENT The second phase of the campaign against tuberculosis, that is, the emphasis laid upon the prevention and control of disease as contrasted with the cure, owes its beginnings largely to the far-seeing ability and service of Dr. Lawrence F. Flick of Philadelphia. Within less than ten years after the bacillus had been announced to the world, Dr. Flick had organized the first association for the prevention of tuberculosis, the Pennsylvania Society for the Prevention of Tuberculosis, formed in 1892. Dr. Flick's personal experience with tuberculosis convinced him that not only could the disease be cured without special climatic advantages, but that it could be prevented by proper education and public health control. For several years he was almost a voice "crying in the wilderness." Few people responded to his efforts. Here and there physicians such as Dr. Edward O. Otis of Boston, Dr. William H. Welch of Baltimore, Dr. Hermann M. Biggs of New York, Dr. S. Adolphus Knopf

of New York or Dr. Trudeau himself were in hearty accord with Dr. Flick's somewhat advanced views. As early as 1898 Dr. Flick conceived a national tuberculosis association, although the actual realization of his dream was not perfected until six years later.

Following Dr. Flick's pioneer efforts at organization, however, other groups in the larger centers of population began to take interest in the organization and educational phase of the tuberculosis campaign. Associations or committees were developed in Rochester (1897), New York (1902), Boston (1903), Buffalo (1904), Baltimore (1904), and elsewhe

In 1 3, due again to the enthusiasm and inte of Dr. Flick, the Henry Phipps Instith. St.

Treatment and Prevenwas established and enMr. J ✓ Phipps of Philadelphia. This institution nding primarily for research as the ition of any progressive tuberculosis mo' at, marked a new era in the developmen the campaign against tuberculosis in ca. Its accomplishments both in ridical pathological research on the one hand, and in sociological research on the other, have influx nced the development of the entire tuberculosis movement in the United States.

The formation of the National Tuberculosis Association (originally known as the National Association for the Study and Prevention of Tuberculosis) was brought about by the interest and effort of Dr. Flick and the Henry Phipps Institute, and by the activities and enthusiasm of the late Sir William Osler and William N. Welsh and their colleagues associated with them at the Johns Hopkins University and the Maryland State Board of Health, together with such workers as Dr. Knopf, Dr. Bowditch, Dr. Otis, Dr. Alfred Meyer and others. On Jan. 28, 1904, on the occasion of the first tuberculosis exhibit in America in Baltimore, the initial meeting for the purpose of considering a national tuberculosis association was called. Two months later at another meeting held in Philadelphia, it was definitely decided upon by the group present, consisting of many of the leading physicians of America, that a national association should be formed, and in June of 1904 on the occasion of the annual meeting of the American Medical Association, the National Association for the Study and Prevention of Tuberculosis became a reality with Dr. Edward Livingston Trudeau, the pioneer of the American movement, as its first president.

Turning aside a moment from the consideration of the history and development of the National Association, let us take up some of these earlier activities in the movement for the prevention of this disease that have proven most significant.

Foremost among these should be mentioned the pioneer efforts of Dr. Hermann M. Biggs in the reporting and registration of living cases of tuberculosis. Acting upon the axiomatic principle in epidemiology that to control a

communicable disease the foci of infection must be known to the health authorities, as early as 1894 Dr. Biggs began an agitation for the reporting of living cases of tuberculosis. At that time there were no morbidity statistics on this disease available in the United States. The opposition met was intense, but after a few years of effort, in 1897 Dr. Biggs, who was the Deputy Commissioner of Health in New York City, secured the passage of a special ordinance requiring the reporting of this disease. This action is significant not only in that it marks the first effort to collect further data on tuberculosis, but more particularly in that it marks a definite beginning of activity against tuberculosis on the part of the health department of the largest city in America. From the initial step inaugurated by Dr. Biggs there has developed the precedent upon which has been based practically the entire institutional movement against tuberculosis at the present time. As a result of this movement public funds to the extent of no less than $20,000,000 to $30,000,000 annually are now being contributed for the treatment and prevention of tuberculosis.

Another early phase of the tuberculosis movement is the dispensary or clinic. The first clinic devoted exclusively to tuberculosis became a part of the New York Throat, Nose and Lung Hospital under the direction of Dr. Edward J. Bermingham in 1894. It was not, however, until in the first years of the Twentieth Century that this vital agency in the control of tuberculosis began to be appreciated. As the effectiveness of registration laws became more apparent and as the number of cases known to the health authorities increased, the necessity for providing facilities for diagnosis and a modicum of home treatment became apparent. Out of this need, due again to the initiative of Dr. Biggs, the first municipal dispensary for the treatment of tuberculosis was established in 1904. The success of this pioneer effort is witnessed to-day in almost every large center of population in the United States.

3. GROWTH OF ORGANIZATION IN THE UNITED STATES AND PRESENT STATUS

When the National Association for the Study and Prevention of Tuberculosis, following its organization in 1904, opened its first office in 1905 with Dr. Livingston Farrand as Executive Secretary, there was practically no such thing as an organized movement against tuberculosis. Here and there sporadic efforts had been started. In Boston, New York, Philadelphia, Chicago, Baltimore, Columbus, Ohio, Buffalo, Rochester and a few other cities some signs of activity were apparent. West of the Mississippi River practically no organization had been attempted, if one may except the private sanatorium movement in the Southwest. There were approximately 100 institutions, public, private and semi-philanthropic, in existence on January 1, 1905. There were only 18 special tuberculosis

dispensaries and less than a half dozen really active associations, although there were probably 18 so-called associations and committees in existence. The entire amount of money spent by the campaign against tuberculosis in 1905, if one may call these scattered efforts a "campaign," would probably aggregate a few hundred thousand dollars a year including the cost of maintenance of institutions and all other expenses. The total budget of the associations, representing the propaganda and organization effort against tuberculosis, did not total $50,000 a year.

To-day there is an active businesslike state association in every state of the Union and in the District of Columbia, as well as in the outlying territories of Hawaii and the Philippine Islands, with a certain amount of effort in Porto Rico, the Canal Zone, Alaska and elsewhere. In addition there are nearly 1,100 local associations, many of them with full-time executives, scattered throughout the United States in practically every large center of population. The budget of these organizations in 1920 will aggregate $4,000,000.

Coincident with the development of associations for the prevention of tuberculosis has been the growth of institutions for the treatment and control of this disease. One of the first activities of most of the associations has been to secure a public or private sanatorium or hospital. The growth of this activity as contrasted with that of 1905 may be visualized thus:-There are at the present time over 600 hospitals and sanatoria for the treatment and prevention of tuberculosis in the United States. Their aggregate bed capacity is in the neighborhood of 50,000. The annual expenditures of these institutions is considerably over $20,000,000.

The growth of dispensaries and clinics, is also significant. From a handful in 1905, this movement has grown until there are to-day over 500 such agencies, most of them with well-trained staffs of physicians and nurses in charge. The traveling clinic has besides brought facilities for diagnosis, advice and treatment to thousands of communities where the stationary institution could never reach.

The development of tuberculosis and public health nursing in America within the last fifteen years is one of the most interesting chapters in social work of the last fifty years. The first tuberculosis nurse in the United States began duty in Baltimore in 1904. From that pioneer beginning has developed not only a very large staff of nurses devoting most of their attention to tuberculosis patients in their home, but also, to a marked degree, the entire public health nursing movement. It is difficult to ascertain how many tuberculosis nurses there are at the present time in the United States. So many so-called tuberculosis nurses are doing work other than with tuberculosis cases, while general public health nurses, on the other hand, are devoting considerable attention to this disease. Estimating, however, from such data as may be secured, one may safely say that not less than 6,000 nurses in

the United States at the present time are giving considerable attention in their daily routine to tuberculosis cases in their homes or clinics.

The history of the open-air school in the United States dates from 1908. The first school of this sort was established in Providence, R. I., by Dr. Ellen R. Stone. To-day the open-air school movement embraces not only tuberculous children, but anemic and malnourished ones ar considerable number of no. ell. If one were to include ry all types of fresh-air clas ooms for these al would no

three groups of childre doubt run up to 3,000 a is difficult to ascertain open-air schools and clas ones springing up almost

4. THE FUNCTION OF TF

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D CROSS SEAL mpaign against s has been due als. This an

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Much of the success of tuberculosis in the United to the Red Cross Christm nual holiday messenger ha, ·fforde the means for financial si pp, but also one of the principal education al channels through which the message of tuberculosis has been brought to the American people.

As the National Association began to develop, it very wisely adopted the policy in its early days of forming independent and autonomous state and local anti-tuberculosis associations, maintaining that the function of the national body was not to dictae, bit rather to supervise and standardize local and state activities.

The increasing number of associations, however, forced upon the National Association the responsibility of providing for these new societies both means of support and also programs of work. Up to the advent of the Red Cross Seal, this was an extremely difficult thing to do. In 1910, following two years of independent effort on the part of the American Red Cross, the National Association for the Study and Prevention of Tuberculosis and the Red Cross formed an alliance to handle the Christmas Seal sale. This was the most significant step in the development of the entire tuberculosis movement in America. As a result of this alliance, the National Association was furnished at once with the facilities whereby it could provide money to finance its state and local associations and could at the same time standardize programs of work. This two-fold accomplishment was brought about by the adoption of certain definite policies, chief among which may be mentioned the following: first, that the major portion of the proceeds derived from the Christmas Seal Sale shall remain in the community where the seals are sold; second, that the National Association shall be the exclusive appointing agency on behalf of the American Red Cross; third, that its agents in turn shall appoint subagents only within definitely designated territory, that is, usually within state boundaries; and fourth,