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At the turn
of this century, tuberculosis was one of the major problems confronting the
medical profession. Death rates for this disease exceeded 500/ 100,000 of
population in some of our larger cities. As early as 1889, Herman Biggs and
other pioneers pointed out that tuberculosis was communicable and preventable,
on the basis of established facts. Although now, many years later, it seems the
road to progress was clear, almost nothing was done at the time either in
social, economic, public health or medical areas. It required almost superhuman
efforts to bring about an advance. Yet, through endless persistence, some
individuals succeeded in launching a program for which we are thankful today.
Among those who devoted themselves unselfishly to this task was James Alexander
Miller, a Founder of the American Association for Thoracic Surgery.
The history of the struggle to bring about an intelligent approach to
tuberculosis may well upset present medical leaders. If it does, let them not
repeat the performance. In 1897, the New York Board of Health recommended
compulsory reporting of all cases of tuberculosis. Organized medicine, under
the leadership of certain County Societies, and even the usually well-informed
Academy of Medicine, dissented most vigorously from this regulation. It was
maintained that such arbitrary action constituted a gross invasion of
individual liberty.
Doctor Miller clarified the current attitude in his paper "The
Beginnings of the American Tuberculosis Movement."1. To quote:
My own personal experience will afford a glimpse of the situation as it
existed at that time.
In 1903, at
the request of the then Professor of Medicine at the College of Physicians and
Surgeons, Dr. Walter B. James, I was transferred from the relatively aristocratic
surroundings of the Vanderbilt Clinic, to those of Bellevue Hospital. Although
my appointment was on the general medical service, my interest in tuberculosis
had been aroused by a fortunate personal and professional relationship for two
years with Doctor Trudeau in the Adirondacks, who taught me, among many other
things, that my medical school and hospital internship experience had left me
totally ignorant of the basic principles underlying a knowledge of
tuberculosis. For that reason, in addition to my regular work, I soon began to
look into the tuberculosis situation at Bellevue. There was no competition for
no one else was or had been interested in the situation.
I found at Bellevue that in the very crowded Out-Patient Department
hundreds of cases of pulmonary tuberculosis were included in the general
medical clinic. They were almost exclusively advanced cases, in which the
diagnosis was easy and the treatment consisted of a prescription for codliver
oil and a cough mixture. But they were encouraged to come back regularly for we
were a teaching clinic. There was no attempt made to give instruction in the
sanitary disposal of the sputum, no follow-up in the homes, no study of their
social or economic status and no effort to examine the family contacts.
When they became acutely ill these out-patients were advised to enter
one of the overcrowded city hospitals, where they usually died or, if they
improved, were discharged to their home to again visit the dispensary and
repeat the same cycle.
Within Bellevue Hospital itself there was a male and a female ward for
tuberculosis with a total capacity of 80 beds. This was a transient service,
from which within a few days all patients not too sick were transferred to the
custodial care of the other city tuberculosis hospitals; the others stayed
until they died.
This tuberculosis service was a part of what was known as the outlying
service. In addition to tuberculosis, they included the alcoholic wards, the
prison wards, the erysipelas ward and the medical service to the psychopathic
wards, in all comprising 300 to 400 beds.
All of the patients of these outlying services were attended by one
single assistant visiting physician, of whom I was one, who was on duty for a
period of six weeks, when he was replaced by a similar physician for one of the
other three divisions of the hospital and then returned to another six weeks'
service in six months' time.
This visiting physician was assisted by one single intern who likewise
changed every six weeks. Needless to say, the attention which the patients
received was very sketchy and this was particularly so in the tuberculosis
wards, for the acute and urgent cases were in the other services and the
chronic cases had to wait, often in vain, for many of them were never even
examined.
There were
standing orders for a cough mixture, for one quarter grain of morphine in case
of hemorrhage and a regular half ounce of whiskey three times a day for every
patient, with a double portion on the day of their projected transfer to another
hospital.
There were two elderly nurses on duty and these were not graduates, for
the regular and younger nurses shunned the service as was the case with both
the interns and the students.
Such was the sorry picture, which I am not recounting as a particular
aspersion upon Bellevue, but as a record of what was happening all over the
country at that time. The romantic story, of course, is that of the steady
building up of that service until today it is one of the best and most popular
in the hospital for physicians, nurses and students alike, but this too has
happened all over the country, but, .as we take it for granted today, we are
apt to forget the unhappy beginnings of only forty years ago.
Bellevue Hospital -
Out-Lying Service was in building at left of photograph.
Ward which became one
of those in the Out-Lying Service for the communal treatment of tuberculous,
alcoholic and erysipelas patients.
To these pioneers, it was obvious that official edict was no answer to
the problem. The entire community had to be involved. A movement to educate the
public, direct the official effort, provide the adequate patient care and
promote research was sorely needed.
Since a coordinated approach of governmental or public origin was
unlikely, a few hardy individuals set about organizing the effort. In 1902,
after much consultation, a plan was constructed by a group of eminent New York
physicians. It was presented to the Charity Organization Society of New York
for advice and counsel. In line with these plans, the Society appointed a
Committee on the Prevention of Tuberculosis which held its first meeting on
June 16th of 1902. This voluntary charity organization outlined with rare
vision the future course of activity in the field of tuberculosis. Problems of
public education, patient care, clinic operation, and the broader social and
economic factors were considered.
Action was soon forthcoming. An indication of the clarity of thinking
of these early workers is expressed in the 1902 report of the Charity Organization
Society. Robert W. De Forest, President of the Society, said in this report:
"At the close of the year, a movement was initiated which may prove to be of
more importance than any other in which the Society has participated in recent
years. This was the appointment of the Committee on the Prevention of
Tuberculosis, consisting of sixteen representative physicians and sixteen
others who are especially interested in the social aspects of the disease."
The Tuberculosis Committee of the Charity Organization Society
functioned for seventeen years, the last seven under Dr. Miller's chairmanship
(1912 to 1919). During these seventeen years, a basic pattern of action and
accomplishment was established. Within the first year, "A Handbook on
Prevention of Tuberculosis", comprising 300 pages, was completed. Public
diagnostic clinics did not exist at the time, but the Committee urged that two
be established in New York City. In 1903, Dr. Miller organized one of these at
Bellevue.
In the ensuing years, other clinics were opened and their work
correlated under the leadership of Dr. Miller in The Association of
Tuberculosis Clinics of Greater New York. By 1910, this Association was
supervising the work of 22 clinics.
In 1908, a survey by the Committee on Tuberculosis revealed that at the
Blackwell's Island Tuberculosis Infirmary, 430 patients were being housed in
quarters adequate for only 180. The Committee constantly stimulated municipal
authorities to appropriate money for the care of these patients. By 1911, they
had compelled the city to appropriate almost 2 million dollars toward
enhancement of sanitorium facilities.
The dramatic study of the area known as "the lung block" brought to
attention the vital importance of living conditions as a factor in tuberculosis.
The safety of children was always paramount. Education in the control
of tuberculosis came promptly. Teachers suffering from tuberculosis were soon
removed from classrooms. The number of fresh air classes in New York City
reached 62 by 1919.
One of the greatest efforts of the Committee was education of the
general public through churches, unions, settlement houses, etc., using
literature, lectures and exhibits. All this work required financial support. It
became necessary for individuals like Dr. Miller not only to. do the work but
also to raise the necessary funds. The entire story constitutes a bizarre and
lengthy history of devotion to principles.
The effort to enlist governmental support was a lost cause comprising
too little and coming much too late. It is fortunate that a letter came to
Jacob A. Riis from Norway, bearing the Norwegian Christmas Seal Campaign Stamp.
In 1907 he wrote an article published in "The Outlook" telling about
the Norwegian Campaign. A Christmas Seal Campaign was then launched in this
country under the Red Cross. The first Campaign in 1908 returned $135,000. In
1910, the campaign was jointly sponsored by the Red Cross and the National
Association for the Study and Prevention of Tuberculosis. In 1942, total
returns reached 9 million dollars. The Charity Organization Society, through
its Committee on Tuberculosis, received $105,336 in 1919. Clearly, only hard
work carried the entire tuberculosis effort forward.
By 1919, the New York anti-tuberculosis effort had grown substantially
and needed further organization. Dr. Miller was one of the guiding lights who
initiated founding of the New York Tuberculosis Association.
This Association's 50th Annual Report is authority for the following
statement;
In the year 1919, the growing demands for service and the financial
success of the Christmas Seal Campaign naturally led to the idea that perhaps
the time had come for the Tuberculosis Committee to become a separate
organization. After preliminary conferences, President De Forest wrote to Dr.
Miller who had been Chairman of the C. O. S. Committee:
The Society agrees with your proposition that 'the tuberculosis
movement has assumed such proportions as to be able to stand upon its own feet,
independent of the parent organization which in the past has done so much for
it.' We have always been quite as ready to terminate a parental relation when
any of our children have reached majority as to adopt and care for such
children while they needed our support. We are proud of our relation to this
movement, but we would not wish our pride or any interest of our own to stand
in the way of whatever best promoted public welfare. We accept your view that
this can best be attained by a separate organization under the leadership of
yourself and other members of our Committee.
The New York Tuberculosis Association was therefore incorporated and
held its first meeting on December 22, 1919. Dr. Miller, Chairman of the,
Charity Organization Society Committee was elected President.
The monumental difficulties involved in establishing, over the years,
at least some semblance of facilities for care of tuberculosis patients are
well illustrated by Dr. Miller's problems at Bellevue. Although he had been
appointed to the staff in January, 1903, 13 years passed before the importance
of his work was sufficiently recognized for his elevation to the position of
First Director and Visiting Physician in charge of the tuberculosis service.
This occurred on January 25, 1916. He persevered in his work for a total of 23
years under the most adverse circumstances. It was not until 1926 that
authorities saw fit to form a service for the care of tuberculosis patients.
Early in his effort, Dr. Miller had enlisted the aid of Dr. Adrian V. S.
Lambert. Although Dr. Lambert was appointed to Bellevue in November of 1903, 18
years elapsed before facilities were procured by which he could perform the
first thoracoplasty. On this occasion, completion of an 11-rib thoracoplasty by
him signaled the birth of the thoracic surgical service at Bellevue. However,
many more years passed before separate facilities were available to these
tireless workers, enabling them to organize the service and complete the work
in which they were so profoundly interested.
The history
of the struggle against tuberculosis is truly a story of the devotion of Dr.
Miller in particular and of those other individuals with whom he was
associated. It is illustrative of the tenacity of effort which Dr. Miller put
into the project and which subsequently spread as a chain reaction throughout
our nation.
