Commentary: Donald Budd Armstrong (1886–1968)—pioneering tuberculosis prevention in general practice

Early in the medical career of Donald Budd Armstrong (1886– 1968), a leaning toward public health was evident. In 1912, he graduated MD from the College of Physicians and Surgeons, Columbia University (known colloquially as P&S). It is a fair assumption that his interest in public health was stimulated by Haven Emerson, grandnephew of Ralph Waldo Emerson and a lecturer in physiology and clinical medicine at the College. Emerson had switched to lecturing in public health in 1913, founded the Columbia Institute of Public Health in 1921, and became a major figure in academe as a protagonist of public health. 1 Armstrong, as a student during the Emerson years, followed suit in focusing his interests on public health. In 1910, academic studies in the field had been introduced at the University of Michigan. In 1913 William Sedgwick, at the Massachusetts Institute of Technology (MIT), had joined with the Harvard faculty Milton Rosenau (Professor of Preventive Medicine) and George Whipple (statistician and sanitary engineer) to establish the first school of public health in the United States. 2 In that year, Armstrong was awarded the degree of Master of Science in Public Health from MIT. Degrees in hand, Armstrong set up practice in New York City and also busied himself—a term we use advisedly—with various activities of the City Public health Department. In the next several years he chaired the Association for the Health of the Poor, the Departments of Street Cleaning and Sanitation, the Department of Social Welfare, and the Committee on Food Supply, all the while lecturing to medical students at New York University, to aspiring teachers at Columbia’s Teachers College, and to the students of City College. By 1916, he was involved nationally. He had assumed the chairmanship of the Sociological Section of the American Public Health Association, served as the Assistant Secretary of the National Tuberculosis Association, and then as its Executive Officer. Given such broad and intense activity in public health matters it is no surprise, in that same busy year, to find him accepting the position of Executive Director of the Framingham Community Health and Tuberculosis Demonstration (FCHTD) in Massachusetts. This demonstration project is the central topic of this annotation. A brief review of the level of understanding of tuberculosis in the United States up to and throughWorldWar I might be useful in evaluating the Framingham undertaking. 3 The idea of sanatoria for affected patients that would provide isolation, good food, and rest was realized in 1875 in Asheville, North Carolina. In 1882, Robert Koch’s momentous discovery of the tubercle bacillus had added the cogent rationale for isolating affected patients to prevent transmission, and in 1884 another sanatorium opened at Saranac among the lakes of Northern New York. By 1907, Von Pirquet had developed a diagnostic test for tubercular infection, later supplanted by Mantoux’s intradermal test. The partial or total collapse of an affected lung by artificial pneumothorax was perhaps the first active intervention pursued for treating tuberculosis. It remained in vogue through World War II and for a while thereafter. We are not aware of any trial that showed artificial pneumothorax to be an effective treatment, but onemust allow that it was only in the 1930s that R.A. Fisher’s brilliant devices of random assignment of subjects together with blinded observers and analysts had provided the critical tools for sound trials of effectiveness. 4 The first major step forward in the modern era of treatment of tuberculosis, the encore to Fleming’s penicillin, was the development of streptomycin by Silman Waksman in 1952. The effect of the new antibiotic, critical as it was, was somewhat undercut when the mycobacterium was found rapidly to develop resistance and the serious side-effect of deafness. Quite soon, however, streptomycin combined with other medications (PAS and then isoniazid) provided an effective treatment that could be long sustained. To return to our subject, Armstrong at Framingham in 1917, 5,6