Historians of the control of tuberculosis regard Hermann
Biggs as the model public health administrator, and as the most brilliant strategist and successful
tactician in the campaign that controlled tuberculosis. The soundness of his public health
administration briefly impressed itself upon a wider medical public a decade ago; when workers moved to
control the insurgence of multidrug-resistant Mycobacterium tuberculosis in
New York City in the early 1990's, they used Biggsian procedures and relied on Biggsian statue law from a
Biggs was trained as a pathologist and his professional career, during its formative period in the
1880's and 1890's was laboratory-based. This account stresses the role that Biggs, the keen student and
practitioner of laboratory diagnosis, played in the success of Biggs the public health administrator.
Hermann Michael Biggs was born in the hamlet of Trumanburg, in
the township of Ulysses, New York, on 29 September 1859. Although his adult career was to be spent
managing, with consummate skill, the medical and social politics of New York City, his upbringing was
entirely Upstate. Biggs attended the recently founded Cornell University in Ithaca, beginning in 1879
and graduating with an AB degree in 1882. With extraordinary prescience, Biggs chose as his AB thesis
topic "Sanitary Regulations and the Duty of the State in Regard to Public
Health;" he wrote "even now, within the last month, there has come to us, across the seas from
Germany, the announcement of what promises to be the grandest discovery of the age – discovery of a
parasite as the cause of tuberculosis by Dr. Koch of Berlin."
Biggs had not yet received his Cornell degree when he matriculated at Bellevue Hospital Medical
College in 1881. During his two years as a medical student, he attended the lectures of Joseph D. Bryant
in anatomy, the younger Austin Flint in physiology, Edward G. Janeway in medicine, and William H. Welch
in pathology. Biggs was also fortunate in the influence that Bryant exercised in his career in New York
and that Welch exerted on a national and international level. Biggs was, from the start, a member of the
loose guild surrounding Welch that transformed American medicine into a scientific profession.
After a year as a house officer at Bellevue, Biggs followed the promise announced in his AB thesis.
He spent a year at the Physiological Institute of the University of Berlin where Robert Koch had
demonstrated, only two years earlier, that a bacillus was the cause of tuberculosis. He spent a second
year in Greifswald, Germany before returning to the Carnegie Laboratory in New York City. His year at
the Carnegie Laboratory was full of significant events: he investigated a typhoid outbreak in a suburb
of Philadelphia, translated Hüppe's Methods of Bacteriological
Investigation, and visited Pasteur's laboratory in Paris as the medical attendant to the first
American rabies vaccine patients.
Career as a Pathologist
These experiences had prepared Biggs
exceptionally well as a laboratorian when he took his first professional appointment as pathologist in
1886. He served as Pathologist to the Work House and Almshouse Hospital and Assistant Pathologist to
Bellevue Hospital. He later became Consulting Pathologist to the Department of Health and, finally,
Director of the Bacteriological Laboratory in the Department of Health. During this period, Biggs did
substantial laboratory-based bacteriological work on topics other than tuberculosis. These
pre-tuberculosis laboratory initiatives included the bacteriologic diagnosis of cholera. Biggs detected,
monitored, and controlled the spread of a cholera outbreak (1892) within weeks of the Hamburg steamship's
arrival in New York.
In 1893, Biggs and William H. Park introduced bacteriological surveillance of convalescent
diphtheria patients. In 1894, the Bacteriological Laboratory moved on to develop its own diphtheria
antitoxin. Biggs and Park studied the antitoxin's efficiency: in 1893-1894 the diphtheria death rate
had been 151/100,000; after application of the antitoxin, in 1895-1896, the death rate fell significantly
His introduction of the Widal test for the diagnosis of typhoid fever demonstrated Biggs' shrewd
insight into the value of laboratory testing in the coordination of public health surveillance with
private medical practice. Biggs advanced the following rationale for making the Widal test available to
all practitioners in New York City: "[It] being distinctly understood that this action of the Department
is for the purpose of gaining information on this important subject and at the same time of placing at
the command of physicians, opportunities for observing the results". This demonstrative coupling
emanated from the understanding of real medical practice that Biggs had gained from working as a clinical
The Anti-tuberculosis Campaign
Biggs had already committed his "Plan of
Campaign" against tuberculosis to paper in 1893. It consisted of two phases, each consisting for four
elements. The first, less invasive phase followed a sequence: (1) educate people about the communicable
nature of tuberculosis; (2) instruct in measures that render sputum "innoxious"; (3) employ
bacteriological sputum examination for early diagnosis; and (4) disinfect rooms of tubercular patients
before they were again occupied. As earlier with the Widal test for typhoid, point (3) demonstrated that
rapid, clinically relevant availability of accurate, decisive laboratory test results, would be a major
element in the anti-TB campaign.
The second four-part sequence in Biggs' Plan of Campaign upped the sociopolitical ante
considerably: (5) establish public hospitals for the segregation, isolation, and treatment of the
consumptive poor; (6) forbid employment of tubercular persons in occupations that expose to others; (7)
prevent dissemination of infection by tubercular sputum in places of assembly; and (8) inspect dairy
cattle and destroy those found to be tubercular. Over the next two decades Biggs realized this ambitious
second phase of the plan in its entirety.
Laboratory Testing and Case Reporting as Part of the Campaign
battle in the first half of the anti-TB campaign was over-reporting of cases. With T. Mitchell Prudden
and HP Loomis, Biggs had presented the argument for mandatory case reporting as essential to "The
administrative control of tuberculosis" in their Report on the Prevention of
Pulmonary Tuberculosis to the Board of Health of New York City. He established a registry of
reported cases of tuberculosis in 1894 and obtained a compulsory reporting ordinance three years later,
successfully lobbying the New York State Legislature to vote down bills rescinding the reporting
ordinance in the next two legislative sessions. The major practical obstacle to case reporting was
physician resistance. A fascinating debate of Biggs' initiative was held, out of town, at the College of
Physicians of Philadelphia on 12 January 1894. The vote of the College members present was against
While Biggs sought, insisted on, and defended mandatory notification, he avoided directly
confronting the medical community for noncompliance. Instead, he offered free sputum examination from
the Bacteriological Laboratory of the NYC Department of Health for both public and private patients. He
held the stick of the reporting mandate in reserve and extended the carrot of clinically relevant, timely
and accurate laboratory diagnosis. Sputum samples from private physicians' practices were dropped off at
pharmacies from which they were fetched after 5 PM by laboratory couriers. The specimens were brought to
the Bacteriological Laboratory, stained that evening, and the results "for acid-fast bacilli" reported by
telephone or pneumatic tube to the contributing physicians before 10 AM the next day. In this way, the
physicians got their diagnostic results, the laboratory got its surveillance specimens for culture, and
the Department of Health got its cases. Biggs the clinical pathologist achieved what Biggs the political
administrator could only demand.
The free smears become the major source of detected cases from the private sector. They overcame
physician opposition by both demonstrating to practitioners from their own clinical experience that
tuberculosis was communicable, and providing a diagnostic value in exchange for the violation of
physician-patient confidentiality that notification clearly was. Smear results also had the salutatory
effect of undermining physicians' confidence in the adequacy of clinical (and later radiographic)
diagnosis of tuberculosis (or its absence). Biggs and his public laboratory become the arbiters of a
gold standard of diagnosis for the most widespread and important of endemic infectious diseases.
Mobilization of Civic Resources to Control Tuberculosis
As Biggs began
the second phase of his campaign with an anti-spitting ordinance (1897), he made the following argument
for the extensive commitment of resources, and restriction of personal freedom, that he was to implement:
"all other communicable and preventable diseases sink into relative insignificance". Tuberculosis in New
York City was the leading cause of death with a mortality of 10,000/yr (280/100,000); tuberculosis caused
57% of all deaths in 25-45 year-old age group, where the 2:1 man:woman ratio magnified the economic
dislocation that this mortality provoked.
In 1902, Biggs began using Blackwell Island Hospital for "the consumptive poor and morbid cases" to
isolate tuberculosis patients. The next year, when phase two really began to pick up tempo, the North
Brother Island Sanatorium was added. At the same time, Biggs put into action Calmette's innovation of
visites domisiliares by a public health nursing service. The public health
nurses followed up all reported smear-positive cases with assessments of patients in their real living
circumstances. To provide a therapeutic basis for managing the population identified and characterized
in this way, Biggs added the Clinic for the Treatment of Communicable Pulmonary Disease. Finally, to
isolate the infectious among the identified population more effectively, he won the establishment of the
New York City Municipal Sanatorium ("the San") at Otisville, NJ.
Only when this effective treatment infrastructure was in place and working well, did Biggs make his
final, most dramatic move: detention of the obdurately uncooperative infectious patients. By this time,
he had created the political will to fund accurate diagnosis and require, by law, treatment of every
Interestingly, the challenge to Biggs' compulsory measures that made it to the United States
Supreme Court was not argued against his detention of obdurate humans but against his elimination of
infected cows. In 1905, the Court held in favor of Biggs in Liberman vs. Board of Health of City of New
York, that the Board's agents could force inspection of dairy cattle and destroy those found to be
In 1929, Biggs' biographer, Charles-Edward Winslow, concluded that by 1910 "Biggs had completed the
outline of machinery for the official administrative control of tuberculosis practically as it stands in
the world today". In 2000, TR Frieden, BH Lener, and BR Rutherford affirmed "with the exception of
short-course chemotherapy, Biggs' approach included all the elements of the WHO's (1994) recommended
program of tuberculosis control".
At the 6th International Tuberculosis Conference in 1908, Robert Koch observed to the
admiring author of the Cornell AB thesis of a quarter century earlier: "You will agree, my dear Biggs
that most of these bacteriological and serological studies have come from Germany. For my own part, I
must admit with shame that we in Germany are years behind you in their practical application. You have
done marvelous work."
Biggs' Later Career New York and International:
The steps of Biggs'
later career proceeded in two directions: development of the public health capacity in New York City and
New York State; and organization of international public health initiatives.
In the first direction of his later career, he founded the NYC Division of Child Hygiene in 1908.
To lead it, he appointed the pioneer pediatrician S. Josephine Baker. Together they achieved
Pasteurization of the NYC milk supply by 1911. The next year, Biggs extended the laboratory diagnosis
and compulsory reporting, developed for tuberculosis a decade before, to the sexually-transmitted
"social" diseases: syphilis and gonorrhea. Over the next three years, he reorganized the New York State
Department of Health, whence he directed the public health response to the 1918 influenza epidemic. He
succeeded in establishing a new, more comprehensive State Laboratory under AB Wadsworth, and shepherded
into force the Health District Law of 1921. Within a year of his own death (28 June 1923), Biggs used
comparative death rate data, collected by district, in sophisticated comparative models that would not be
copied until the work of the Federal Centers for Disease Control compared state data in the last third of
the 20th century.
The second direction of Biggs' later career involved development of international public health
initiatives. His first opportunity came through his pathology professor, William Welch, who co-opted him
into the new Board of Scientific Directors of the Rockefeller Institute. Seeing the need for an American
national organization to cooperate with other countries' interventions against tuberculosis, Biggs
collaborated in the founding of the National Association for the Study and Prevention of Tuberculosis.
In 1917, Biggs was commissioned by the Rockefeller Foundation to study tuberculosis in wartime France
with a Francophone Rockefeller collaborator, AR Dochez. Finally, in the aftermath of the First World
War, Biggs was an American Representative in the founding of the International Red Cross.
Hermann Biggs' administrative successes in public health and
his presence at the creation of the International Public Health Initiatives of the Rockefeller Foundation
and the International Red Cross's Programs, shaped Biggs' place in medical history. However, this review
of his exceptionally productive life points to the foundations of his later success within his early
career. The sure foundation of Biggs' initiatives and success in the control of tuberculosis was his
training and practice as a pathologist and laboratorian. Hermann Biggs' success rested in part on his
keen understanding of laboratory quality, its role in medical practice, and its incomparable advantage in
public health control of infectious disease.