Six

The Cause

ROBERT Koch began his search for the cause of tuberculosis in Germany in 1881, just one year before Trudeau read about the Brehmer/Dettweiler sanatoriums. Koch was short, nearsighted, frail in appearance, and, at age thirty-eight, already world famous. He was known for developing a way to stain bacteria with colored dyes for examination under a microscope, as well as for finding ways to culture, or grow, bacteria in a small, round dish with a cover. He had also successfully identified the specific microbe that caused the deadly disease anthrax and proved that a single anthrax germ could grow into a large, lethal colony. Guessing that the same would be true for TB, Koch began his hunt for the world’s greatest mass killer.

He started by taking blood samples from a laborer who had died from miliary TB, a particularly deadly strain of the disease that invades a wide variety of body parts in a matter of days by way of the bloodstream. Koch assumed the TB would be present in the man’s blood. He then injected this material into a number of guinea pigs and rabbits and observed what happened. All the animals, he wrote, “became emaciated rapidly, and died after four to six weeks.” Finally, samples were taken from the animals for study; Koch reported, “Under the microscope all ... animal tissue [samples]...appear faintly brown ... with the [rod-shaped] bacilli, however, [stained] beautifully blue.” He suspected that he was looking at the creature that caused tuberculosis.

Next, Koch set out to prove this. He put some of the blue-dyed bacteria in a culture dish and set them aside to reproduce. After enough had grown, he planned to inject the substance into healthy guinea pigs and rabbits. If they developed TB, he would know for certain that the blue rods were the cause of the disease.

 

Robert Koch was so famous that a drawing of him appeared on a card included with the purchase of chocolate.  

 

Koch soon learned something else about M. tuberculosis. It was incredibly slow to reproduce itself. Most bacteria can double in number every fifteen to twenty minutes, creating a colony large enough to be visible in the culture dish within hours. However, it takes M. tuberculosis between fifteen and twenty-four hours simply to reproduce once. The result was that even after two weeks, nothing had appeared in Koch’s culture dish.

Fortunately, Koch was as patient as he was obsessed. He continued to wait and watch until, several weeks later, a colony of M. tuberculosis began to appear. When he had enough, he injected the bacteria into healthy animals. Every single one developed TB. To be absolutely certain his results were correct, Koch repeated the time-consuming experiment over and over again.

More than a year later, in March 1882, Koch was able to announce his findings to an astonished Berlin Physiological Society. After describing his research, he concluded his talk by saying, “In the future, the fight against this terrible plague of mankind will deal no longer with an undetermined something but with a tangible parasite.”

In addition to revealing the cause of TB, Koch’s discovery produced two other pieces of information. First, he was able to say with certainty how the disease was spread. The germs, he announced, were “expectorated by consumptives and scattered everywhere.” Second, he was able to show that the TB bacillus caused a variety of illnesses in other parts of the body besides the lungs.

Although Koch had already unmasked the anthrax germ (and had had his research verified by other scientists around the world), his new discovery was largely ignored. Most people—including many doctors—simply refused to believe that such a tiny organism could actually cause disease and kill humans. The American Medical Association completely ignored the discovery at its annual meeting later that year. And the New York Times failed to report the news for over a month. When Koch’s discovery was finally mentioned in an editorial, the newspaper mocked Koch and the entire idea that germs were a natural part of our lives by making up a story about a fictional doctor from Wisconsin. This doctor, the editorial claimed, was such an ardent believer in the new germ theory that he had announced the discovery of a microorganism that could be “bred into trousers [so that] men will be fully protected against broken legs.”

 

After his sixteen-year-old sister, Sophie, died of tuberculosis, artist Edvard Munch created many paintings and etchings in her memory.  

 

Fortunately, a few people did take notice. One of them was a New York medical student named Hermann Biggs. Biggs was a twenty-three-year-old graduate student at the time, studying pathology, a field of medical science that looks at the causes and development of diseases. He immediately saw the importance of Koch’s discovery. His senior thesis on sanitary science argued that because dangerous germs were everywhere and could be spread easily, the well-being of a nation depended on the “careful observance of hygienic laws.” In other words, health issues should be as vital a part of our system of laws as, say, international trade, national defense, or economic stability.

Mustering support for this position would be an uphill battle for Biggs, who became professor of pathology at New York’s Bellevue Hospital in 1885. Most doctors had been trained in, and based their practice of medicine on, a belief in the humors of the body. They saw no reason to abandon a theory that was thousands of years old, and seemed to work, in favor of a new theory that had not yet been tested worldwide.

 

New York medical officer Hermann Biggs as he appeared in 1910.  

 

Others feared that the new germ theory would diminish their role as physicians. Until then it had been the doctor’s job to pronounce whether or not a patient had tuberculosis. But now a diagnosis could be made only if M. tuberculosis was found in matter such as the patient’s sputum, mucus and phlegm mixed with saliva and ejected from the mouth. Most doctors weren’t capable of doing these diagnostic tests themselves.

Finally, many doctors were hesitant to embrace Koch’s findings because they were legitimately worried about their patients. If it was true that the TB germ could be transmitted in airborne droplets, then the logical way to stop the disease from spreading would be to quarantine sick patients. The patients would be isolated in sterile wards with other sick and dying people and away from the love and help of their families.

Despite such resistance, the notion that steps needed to be taken to combat tuberculosis finally took hold in the late nineteenth and early twentieth centuries. Many cities and towns already had some health laws on the books. These dealt mostly with disposing of decaying dead animals and vegetable matter, because the resulting foul smells were thought to cause diseases. There were also quarantine laws to keep sick persons with certain fast-spreading diseases, such as diphtheria and cholera, separate from the healthy population.

In 1887 Scotland became the first country to institute a national antituberculosis campaign. Several other European nations followed with regulations of their own. The United States was slow to enact such laws, but that would all change with the help of Hermann Biggs.

When the now thirty-year-old Biggs joined the New York City Health Department in 1888, there were no public health laws to stop the spread of tuberculosis. A year later, Biggs was able to get a modest three-pronged program made into law. The plan called for the inspection of cows for the bovine form of TB, in order to eliminate infected meat and milk. It also required that the personal effects of a tuberculosis patient be burned and any room he or she lived in be disinfected. Finally, the city was required to begin a publicity campaign to educate citizens about TB, specifically on how it was spread and how to avoid becoming infected. Within days this information was printed in leaflets in numerous languages and distributed throughout the poorer areas of the city where the largest numbers of TB infections occurred.

Though pleased to have these laws enacted, Biggs wasn’t finished. One important recommendation had been turned down, although it sounded very logical. Quite simply, Biggs wanted to require doctors to report the names and addresses of all patients with TB.

When it was first proposed, this step set off loud protests from doctors concerned about their patients’ privacy. They knew that most insurance companies denied payment of benefits for anyone who died of tuberculosis. What was to stop these companies, doctors wondered, from combing through the public records to root out the unfortunate victims of the disease?

Fearing that worried citizens would vote them out of office, state politicians joined the doctors in opposing Biggs. Reluctantly, Biggs backed off slightly. Instead of ordering doctors to turn over names and addresses, he requested that they do this voluntarily for the good of the city. Few doctors handed over names, and deaths from tuberculosis in New York City stayed at approximately 6,000 per year into the twentieth century.

Biggs hadn’t given up, though—not by a long shot. He knew that New York City had more than 300,000 tiny, unventilated rooms and apartments, each occupied by six to eight people packed together. Every day these places produced more and more cases of TB. “With every breath,” wrote Ernest Poole of the Charity Organization Society after inspecting several crowded buildings, “I felt the heavy, foul odor from poverty, ignorance, filth, disease.”

Biggs believed passionately that altering unsanitary living conditions and using modern scientific methods would in time result in the defeat of TB. So instead of giving in to the concerns of doctors and politicians, Biggs declared war on the disease.

He turned to the newspapers and fed them a steady stream of information about the dangers of TB and how it was spread. He not only wanted to raise awareness of TB, he also wanted to create a sense of alarm in the minds of the public. It took several years, but by 1905 people came to view tuberculosis as an urgent, life-threatening health crisis. Fearful individuals began to report neighbors and relatives who they suspected had TB. And politicians became more willing to pass tougher health laws.

 

A nurse, medical bag in hand, climbs over New York City rooftops to visit those who are sick.  

 

After laws were passed that required TB patients to safely dispose of spittle, a thriving spit-cup industry was established. This ad for a metal flask with disposable paper inserts appeared in the May 1918 issue of the Journal of the Outdoor Life.  

 

In fact, the campaign worked so well that Biggs’s New York Health Department was given ever-increasing powers to fight the disease. In addition to requiring physicians to report the names and addresses of TB patients, the Health Department was allowed to send nurses into homes to see if any individual had TB. His department was also authorized to have the sickest patients isolated and treated in specially established hospitals. Spitting, a habit embraced at that time by even the most refined people, came under attack. Antispitting laws were enacted, and people with tuberculosis were required to carry and use spit cups with them at all times to capture the potentially lethal sputum.

Biggs also pushed for the use of modern technology. In November 1895 a Bavarian professor of physics, Wilhelm Conrad von Röntgen, had been conducting a routine experiment of passing high-voltage electricity through a glass tube. In the darkened laboratory he’d noticed an unusual light and soon discovered that this light could penetrate solid objects. When he held his hand over it, he could see the bones inside. The use of what Röntgen called X-rays for medical purposes was slow to catch on, but eventually X-ray machines were developed that made images of the inside of the human body. Biggs saw the usefulness of X-rays in diagnosing TB and immediately ordered the newfangled machine.

 

This X-ray from 1895 is the first X-ray ever made. lit shows the hand of Röntgen's wife, Anna. The bump on the second finger from the left is her wedding ring.  

 

The influence of Biggs and his Health Department was soon being felt in a wide variety of nonmedical areas. Because the shabby housing arrangements of the poor were considered hives of infection, a campaign was launched to develop inexpensive but healthy alternatives. The movement was spearheaded by well-known reformers, such as Jacob Riis and Lillian Ward, with Biggs behind the scenes making recommendations for new legislation. New York City’s Tenement House Law was passed in 1901, specifying the number of inhabitants allowed to live together in a space. The law also provided specific minimum requirements for the size of rooms and the amount of light and ventilation they needed to have.

 

(Top) A young girl has a chest X-ray taken at Detroit’s Herman Kiefer Hospital for Communicable Diseases in 1939.  

 

(Below) A doctor and a nurse examine an X-ray of a patient with tuberculosis.  

 

A poster for an early anti-spitting, -coughing, and -sneezing campaign.  

 

Eventually, New York State followed New York City’s lead, setting up a state sanatorium and passing a series of strict health laws. While the new policies were often criticized as cruel and unconstitutional by some doctors and politicians, they seemed to have a positive effect. By 1913 Biggs was able to boast that New York City had reduced TB deaths by 50 percent per year, thus saving an estimated 65,000 lives since the campaign had begun.

Other states noticed the gains being made with Biggs’s policies and began copying New York’s approach. Even European countries sent representatives to, in Biggs’s words, “look to New York for suggestions and directions in new methods in sanitary work.” The local and state antituberculosis campaigns were reinforced by a national organization in 1904. Composed of prominent physicians and influential citizens, the National Association for the Study and Prevention of Tuberculosis sponsored serious scientific studies of the disease, then published and promoted the findings. This organization worked hand in hand with state and local groups in an effort to educate the public and sponsor antituberculosis laws and programs.

One of its most successful programs was the annual sale of Christmas Seals to raise money for the organization. Interestingly enough, the idea was thought up by a Danish postal clerk. In 1904 Einar Holboell, a forty-four-year-old postal worker in Copenhagen, heard that young people were dying of TB because they had no money to go to a sanatorium. He wanted to donate money but knew his small salary meant he couldn’t give very much at any one time. He wondered if a surcharge of a few cents could be added to certain postage stamps, with this money going to fight TB. If enough people chose to buy those stamps, a sizable amount of money could be raised.

In less than a year the program was in place in Denmark and very successful. In 1907, Emily Bissell tested out the idea in Delaware. She designed and printed special holiday seals that would be sold at the post office for a penny each and put on envelopes along with the regular postage stamp. Her first campaign managed to raise over $3,000. Her success led the national tuberculosis association to issue Christmas stamps or seals in 1908. By 1919 proceeds in America amounted to over $19 million per year. All that money went toward the fight against TB.

 

Legendary baseball slugger Babe Ruth helps to sell Christmas Seals in 1921.  

 

The world, it seemed, had at long last joined in a coordinated attack against its biggest killer. The war against TB was so successful that it created a major problem. The already crowded sanatoriums found themselves deluged with requests for treatment by tens of thousands of people. Many TB sufferers were given beds, but millions of others were left uncared for and untreated. These victims of the disease came to be called outsiders.