THE CAUSATION OF TUBERCULOSIS AND THE MEASURES FOR ITS CONTROL IN
ENGLAND[17]
My task is to attempt to give a bird’s-eye view of “The Methods of
Controlling Tuberculosis in England,” and to revaluate, as far as
is practicable, in the light of many years’ study of the disease,
the relative value of the measures which historically have been
followed by the greatly reduced mortality from tuberculosis. The
subject teems with difficulties, and as you are aware there is no
unanimity of opinion when tuberculosis is thus considered. This is
the more surprising in view of our present accurate knowledge of the
pathology of disease caused by bovine and human tubercle bacilli, and
in view of the fairly general unanimity of opinion as to the methods
of control which are needed to secure still more rapid reduction
of the devastations of tuberculosis. This general opinion may, I
think, be summarised in the statement which I have made elsewhere,
that the removal or diminution of infection from each single case of
tuberculosis reduces correspondingly the prospect of further cases,
but that tuberculosis will not be completely controlled until every
tuberculous patient receives such care throughout the whole course of
his life, as will ensure his welfare and will obviate the likelihood
of his infecting others.
It is noteworthy that the English death-rate from pulmonary
tuberculosis—which is responsible for 71 per cent. of the total
mortality from tuberculosis, and which is practically always due to
infection from a human source,—declined in males between 1871-75
and 1876-80 by 7.2 per cent.; in the next quinquennium by 9.8 per
cent.; between 1881-85 and 1886-90 by 8.3 per cent.; in the next
quinquennium by 9.5 per cent.; between 1896-1900 and 1901-05 by 7 per
cent.; and between 1901-06 and 1906-10 by 9.7 per cent. Evidently a
large share of the reduction of the death-rate from phthisis occurred
before it was generally regarded as an infectious disease, and before
sanatoria were in existence for its treatment. It should be added
that since the possibilities of infection have been realised and
the need for treatment of the disease has been appreciated, there
has in no part of the world, so far as I am aware, been an adequate
application of known methods of prevention and treatment.
We must look elsewhere, therefore, than to intentional measures
directed against tuberculosis for an explanation of its decline
during the period before Koch discovered the tubercle bacilli
and before the significance of this discovery was appreciated;
and attempt to appreciate the relative value of the factors of
decline operating before and since our outlook on the disease was
fundamentally changed.
Certain facts stand out beyond controversy, and on these
administrative control must necessarily be based.
_Basic Facts as to Tuberculosis_
1. Tuberculosis is a chronic infectious disease with a low degree of
infectivity. Circumstances favouring infection have a high degree of
importance; but tuberculosis does not develop in the absence of the
tubercle bacillus. No infection, no disease.
2. Tuberculosis may remain latent in the system for many years, and
there is strong reason for thinking that the infection of a large
proportion of early adult tuberculosis was acquired in childhood.
3. The two types of tubercle bacilli, bovine and human, are
stable both in character and in degree of virulence, and are not
interchangeable so far as can be shown by protracted experimentation.
The human type of bacillus is the chief source of infection of
mankind, though bovine infection is not negligible.
Out of 98 children between the age of 2 and 10 years who had died in
various hospitals from all causes unselected, 18 or 18.4 per cent.
were found to have been infected by tubercle bacilli of the bovine
type, and 81 or 81.6 per cent. by tubercle bacilli of the human
type. (Report on Investigations made in the Laboratory of the Local
Government Board, Annual Report of the Medical Officer of the Local
Government Board, 1913-14, p. lix.)
4. Animal experimentation shows that in animals of the same
species the extent of tuberculosis produced depends to a large and
probably to a dominant extent on the number of tubercle bacilli
introduced into the system. Although doubtless there are variations
in susceptibility in families, and in each individual at different
periods, there is little doubt that in the main the same rule holds
good for mankind.
5. Experience shows that dusty occupations, indoor occupations,
alcoholism, over-fatigue, an attack of acute illness, especially of
influenza, measles, or enteric fever, increase the danger of minimal
doses of tubercle bacilli, and serve to bring latent foci of disease
into activity.
_Explanations of the Decreasing Death-rate from Tuberculosis_
In the light of the above facts, how is the steady and continuous
decline in the death-rate from tuberculosis during the last fifty
years to be explained?
(_a_) No support is given by animal experiment to the assumption
that the types of human bacillus infecting mankind have declined in
virulence; and changes in the severity of consumption historically
or currently in different races of mankind are equally explicable on
the ground of differences in social misery, in sanitary conditions
and associated heavier dosage of infection and neglect of treatment.
(_b_) The facts do not appear to me to be reconcilable with the
assumption that natural selection has increased human resistance
to infection by tuberculosis; though, were this so, it would
not justify refraining from every possible effort to control
infection and to treat every tuberculous patient by the best known
methods. Tuberculosis is an ancient disease, there being evidence
of it in Egyptian mummies 1000 years B.C.; and any selective
agency has, therefore, had ages for its operation. If the steady
decline—approximating 2 per cent. per annum in the death-rate from
pulmonary tuberculosis in England during the last thirty or forty
years—has resulted from the acquirement of racial immunity, it is
remarkable that a somewhat similar decline has occurred almost
simultaneously during the last forty years in Great Britain, Germany,
and America; while in France, Norway, and Ireland there has been
little if any decline, or it has occurred only in very recent years.
To assume that susceptibility to the tubercle bacillus in the course
of its natural history has diminished in England, and that Ireland
has not shared in this privilege would be to add one more to Irish
grievances! This assumption does not fit in with international
facts; which point rather to the conclusion that, during the period
in question, unsatisfactory sanitary and social circumstances,
including opportunities for massive and protracted infection, have
continued to a greater extent and for a longer time in Ireland and
France than in Great Britain, America and Germany.
(_c_) If the assumption of increasing racial immunity does not
consist well with all the facts, more perhaps can be said in favour
of the unproved hypothesis that a high proportion of the population
are from time to time temporarily immunized by small doses of
tubercle bacilli; and their resistance to larger doses of infection
thereby increased. Experimentally calves inoculated with small doses
of tubercle bacilli remain during the next year or two unaffected by
much larger doses of tubercle bacilli, unlike calves not submitted
to this treatment. Tubercle bacilli are somewhat widely distributed,
though they occur chiefly in the immediate environment of careless
consumptive patients; and it is conceivable that minimal doses of
bacilli may arouse the resistance of the cells and fluids of the body
and prepare them to resist successfully larger doses of infection.
This is consistent with the fact that while one in about ten deaths
from all causes is caused by tuberculosis, a majority of the total
population are shown by pathological evidence to have been at one
time or another infected by tuberculosis, and yet have either
never been ill, or have recovered, usually without the existence of
tuberculosis being detected or even suspected. Obviously this is
satisfactory evidence that mankind is relatively resistant to the
infection of tuberculosis.
The fact just mentioned naturally leads to the question: what
determines the result when tubercle bacilli invade the human subject?
Assuming fairly uniform virulence of tubercle bacilli, the result for
an infected person depends on two factors: the dosage of infection,
and the resistance of the cells and fluids of the invaded person;
and evidently increase in the dosage of infection and lowering of
personal resistance may have identical effect in determining serious
disease. Of the importance of the already mentioned factors which
lower personal resistance to disease,—often also at the same time
increasing infection,—there can be no doubt.
It is impossible in most instances to set out separately
circumstances increasing infection from circumstances lowering
resistance. During the last three or four decades there has been
improvement in respect of the factors lowering resistance to attack,
but there has been simultaneously a great decline in opportunities
for infection on a massive scale, as a result of habits of greater
cleanliness, especially in regard to spitting, of diminished
overcrowding of population, and of increased treatment and the
incidental segregation of advanced cases of disease in hospital beds.
_Hospital Treatment of Consumptives_
I have seen no reason for revoking the conclusion expressed in 1908
in a lecture to the Washington International Congress on Tuberculosis
that historically the hospital treatment and coincident segregation
of patients suffering from pulmonary tuberculosis has been an
important and probably a dominant factor in producing the national
decline in the death-rate from tuberculosis in the countries in which
a decline has been experienced. This explanation fits in with our
knowledge of the disease, and with the analogous history of leprosy;
and it is supported by the fact that by complete segregation of
infected from non-infected cattle tuberculosis can be eliminated at
will from a herd of cattle. It is remarkable, as I have elsewhere
set out in much detail, that improved general health, increased
well-being, and sanitary education have operated in Great Britain,
Germany, Belgium, Denmark, and Massachusetts side by side with great
decrease in the death-rate from pulmonary tuberculosis; while up to
very recent years the same influences in France, Norway, and Ireland
have produced little or no decrease in the national death-rate from
tuberculosis. And similarly no constant relation can be shown between
the degree of sanitary and social well-being in different countries
and cities, and the amount of mortality imposed by tuberculosis. How
is it that in some countries a high degree of domestic overcrowding
is associated with a low and declining phthisis death-rate and
conversely that a persistently high phthisis death-rate may occur
with a less but still diminishing degree of overcrowding? The
explanation is contained, I maintain, in the following statement:
_A given amount of domestic overcrowding with a large amount of
institutional segregation of consumptives is associated with less
tuberculosis than when overcrowding is less but accompanied by only a
small amount of institutional segregation of consumptives._ The data
as to institutional segregation are difficult to obtain; but there is
sufficient evidence to show that in countries which have experienced
a large reduction in the death-rate from tuberculosis a large
proportion of hospital treatment for many years has been provided
for consumptives, while in countries which have not experienced
this decline such provision has been absent or imperfect. In London
about 56 per cent., in county boroughs 35 per cent., in other urban
districts 21 per cent., and even in rural districts of England near
16 per cent. of all deaths from pulmonary tuberculosis occur in
hospitals (poor-law institutions, general and special hospitals, and
asylums). Prior to the patient’s death he has had on an average at
least three months, and probably in the aggregate more nearly five or
six months, residential treatment, and this at the stages of disease
in which there is the greatest discharge of infective material, in
which owing to feebleness the patient is least able to control its
hygienic disposal, and in which—had the patient been treated at
home—the relatives would be especially liable to receive massive
infection, and would be enfeebled by overwork and anxiety, or by the
malnutrition associated with poverty.
Some writers have failed to visualize the fact that the segregation
of a minority of the total cases of pulmonary tuberculosis for a
portion of their illness can have had a marked influence on the
prevalence of this disease. They appear to be judging tuberculosis
by the same measure as they would apply to smallpox, which in an
unprotected community spreads rapidly if a few cases are overlooked.
The case of tuberculosis, like that of leprosy, is governed by the
considerations that both these diseases as a rule require intimate
and protracted contact for their spread, and that in both diseases
there may be prolonged latency before active disease develops.
A hypothetical illustration may serve to elucidate the order of
magnitude of the influence exercised by institutional segregation.
Let us assume—as is probably the case in England—that one-fifth of
the cases of pulmonary tuberculosis are treated during one-third of
a year institutionally under conditions in which they will not be
liable to spread infection. Let us assume further that each of these
cases has an infectious lifetime of three years. Thus one-fifth of
the cases are deprived of their power to spread infection during
one-ninth of their period of “open” disease. It being assumed that
personal infection causes pulmonary tuberculosis and that segregation
is efficient, segregation to the extent indicated above should secure
a reduction in the death-rate from pulmonary tuberculosis of 100/(5 ×
9) approximately 2 per cent.
In actual fact the decline in the English death-rate from pulmonary
tuberculosis since 1871 has been at a rate slightly under 2 per cent.
per annum.
_Koch’s Endorsement of Segregation View_
An extract from an article written by Robert Koch shortly before his
death may be permitted (Epidemiologie der Tuberkulose Zeitschr. für
Hyg. und Infektious Krankheiten. 4. XVII, 1910).
I am entirely in agreement with Newsholme that the allocation of
consumptives to institutions for the sick, as freely as possible
and for as long as possible, is the most active means of avoiding
infection and the consequent spread of phthisis.
In my experience, too, phthisis has shown the most marked decline
in those places where comprehensive measures have been taken for
bringing consumptives into hospitals, and the converse has been the
case where the converse conditions prevail. It is indeed obvious
that in no other way can the danger of infection, which a phthisical
patient constitutes, be so effectively removed as by isolation in
hospital. Strong support of this method is afforded by leprosy,
where good results in attacking the disease have been obtained by
following the same principle.
In addition to this factor there is a second, which also plays a
very important part, viz., housing.
A hypothesis explanatory of a given phenomenon should be consistent
with all the associated facts. We have seen that the hypothesis
that segregation of consumptives is an important factor in the
reduction of the death-rate from pulmonary tuberculosis agrees (1)
with our knowledge of the tubercle bacillus, and (2) with veterinary
and agricultural experience; also (3) that,—although exact data
are unobtainable,—the degree of segregation when ascertainable
is consistent with the degree of decline in the death-rate; (4)
it is important to note also that this hypothesis is consistent
with the otherwise anomalous facts that although the proportion of
the population subjected to urban conditions of life has steadily
increased, and the number of persons per inhabited room remains much
greater in towns than in country districts, the death-rate from
pulmonary tuberculosis in England has declined as much in them as in
country districts; and that notwithstanding the greater overcrowding
in towns, the urban is rapidly falling to the level of the rural
death-rate from this disease. The town dweller’s better and more
frequent treatment in hospitals is an important factor in overcoming
the handicap of urban conditions of life, including overcrowding and
preponderance of indoor and dusty occupations.
It is desirable to supplement the above statement by some remarks on
_Improved Housing as a Means of Reducing Tuberculosis_
Not infrequently the thoughtless remark is made that given
improved housing sanatoria and hospitals for consumptives would be
unnecessary. The frequent occurrence of tuberculosis in well-to-do
families shows the absurdity of this statement. It is true that
tuberculosis is more prevalent among the poor living in small
tenements that among the well-to-do; but there is no consistent
proportion between the degree of overcrowding in different districts
or towns and the death-rate from tuberculosis. Improved housing
and institutional treatment for tuberculosis cannot properly be
regarded as alternatives. They are necessary complements to each
other, and there must be increased expenditure in both directions,
if tuberculosis is to be more rapidly reduced in amount. There are
in fact two housing problems—for the healthy, and for the sick. The
most rapid method of improving housing for the healthy is to remove
the sick, and especially the tuberculous sick to a hospital. This is
being done year by year to an increasing extent. In England and Wales
in 1870, 8.3 per cent., and in 1912 21.6 per cent. of all deaths
from all causes occurred in public institutions. It is difficult to
exaggerate the practical relief implied in these figures in respect
of satisfactory housing, especially in its functional aspect. Apart
altogether from the tuberculosis problem much of the decline in
the general death-rate must be attributed to the skilled treatment
which a large proportion of the total population have received in our
hospitals of various types.
I may, I think, claim to have answered in part the question asked
at an earlier stage of this address, as to the causes of the steady
decline in the death-rate from tuberculosis in recent decades. I do
not claim that any one factor has brought about this result. I do not
claim that it has been caused entirely by diminution of opportunities
of infection; but I deprecate the view that improved nutrition and
other conditions diminishing susceptibility have played a predominant
part. The facts of international hygienic history rebut this view.
Although segregation of patients in institutions has played a great
part in bringing about the result, diminution of domestic infection
as the result of more cleanly habits has doubtless had an important
influence; as has also the reduction of industrial dust.
It is significant that general hygiene and improved care of the
sick—quite apart from any intention to segregate—were associated
with a large reduction in the death-rate from tuberculosis before
the importance of reducing infection was fully appreciated; and that
since the necessity for direct measures against tuberculosis was
realised, since such measures have been begun, however imperfectly,
in many countries, and since anti-tuberculosis educational
propaganda has been somewhat active, there has been no increase
in the rapidity of decline of the death-toll of tuberculosis. Of
course, it cannot be seriously—though it is foolishly—argued from
this fact that such direct measures are futile. Every year there
has been increasing migration of masses of people into towns, with
a corresponding increase of undesirable domestic overcrowding
and of indoor occupations. If, therefore, such anti-tuberculosis
measures as have been adopted,—whether direct measures or general
sanitary measures,—had been associated with an absence of decline or
with actual increase in the death-rate from tuberculosis it might
still be that these measures have achieved much. Many conflicting
agencies are at work, and it might well be that the apparent lack
of success of the measures taken is due to the increased operation
of countervailing influences. The importance of direct action for
the control of tuberculosis must be judged not solely by necessarily
imperfect statistical measurement on the basis of a few years’
observation, but _by ascertaining that the proposed measures are in
accord with our knowledge of the natural history of the disease_. As
we have seen, both comparative and human pathology assure us that
tuberculosis is a communicable and therefore a preventible disease,
and point the way to the means for securing this end.
Before describing the direct measures which have been adopted for the
control of tuberculosis, it should be added that in no country have
these been in operation sufficiently long, and in no country have
they been so adequately applied, as to render it practicable to apply
statistical measurement of their value; meanwhile these measures
must be judged in the light of our knowledge of the pathology of
tuberculosis.
_Notification of Tuberculosis_
If every tuberculous patient were intelligent, and willing and able
to follow the advice given by his doctor, if he consulted his doctor
for the first symptoms of illness, if his disease were recognized
by the doctor at its earliest recognizable stage, and if the doctor
in every instance gave the right advice and made the necessary
examinations of all “contacts,” no occasion would arise for the
intervention or assistance of Public Health Authorities, except in
providing bacteriological facilities and institutional accommodation.
In actual fact these conditions are not secured for the majority of
patients; and the private practitioner, however willing, is seldom
in a position to remedy the domestic and industrial insanitary
conditions which favour infection and lower resistance to infection.
Hence notification of cases of tuberculosis was advocated for many
years by pioneer medical officers of health who secured voluntary
notification by doctors of a considerable proportion of the total
cases in their districts, and in a few instances secured compulsory
notification by local enactment, before any general regulations on
the subject were made. It is noteworthy that in this early period a
town like Brighton, which had voluntary notification with sanatorium
provision for patients willing thus to be treated, secured the
notification of a larger proportion of total cases than another town
in which notification was compulsory, but no sanatorium accommodation
had been provided. The point is mentioned as emphasizing the general
principle that compulsory measures in public health, if they are to
be successful, require to be associated with full provision for the
action which should follow the compulsory enactment; which provision,
as in this case, may be a direct inducement to compliance with the
enactment. In view of the change of central policy involved and of
the unpreparedness of most local authorities to give the assistance
needed for notified cases, the general enforcement of notification
of tuberculosis was brought about in stages; in 1909 poor-law cases
of consumption were made notifiable throughout England and Wales,
hospital cases in 1911, consumption in the general community in 1912,
and all forms of tuberculosis in 1913.
It was not anticipated that complete notification of cases would
be obtained for some years, but a review of English national
experience of notification of tuberculosis up to the present time
necessitates the confession that there has been failure to secure
the coöperation of an unexpectedly large proportion of the medical
profession in this public-health duty. Many cases have never been
notified and in a large number of other cases notification has been
belated; Dr. Barwise, County Medical Officer of Health of Derbyshire,
obtained information as to 417 deaths certified during 1917 to be
due to tuberculosis, and found that of this number 39 per cent. had
never been notified, and that over 70 per cent. had either not been
notified or died within twelve weeks of notification. This may be an
exceptionally bad experience; but the duty of notification in many
areas is only imperfectly performed, and no adequate steps are being
taken to diminish this default.
As notification is the first step towards coördinated measures for
the patient and in the interest of the public health, the causes
of delay in notification and of failure to notify deserve further
examination.
_Causes of Failure in Notification_
1. The patient himself commonly is responsible for much delay in
the recognition of his disease. A large proportion of consumptive
patients refrain from applying for treatment until disease is
fully established, and until they are incapacitated for work.
Not infrequently this means that the patient does not consult a
doctor until a few months or even weeks before his death. Until the
conditions of general medical practice are altered, and every person
has the right to state-paid medical consultations, belated recourse
to medical advice will continue.
With this there is badly needed further education of the public as to
seeking advice for protracted colds and coughs, or for other symptoms
suggestive of tuberculosis; and a wider hygienic propaganda as to
housing, overcrowding, dusty indoor occupations, expectoration, etc.,
is also called for.
2. Under present conditions of medical practice, early diagnosis
of tuberculosis often fails to be secured, even when the patient
places himself under medical care. It is to the private practitioner
that most patients resort, and the early recognition and treatment
of disease depends primarily (_a_) on his skill, (_b_) on his not
being so overworked as to be unable to devote adequate time to the
examination of each patient coming under his care, and (_c_) on
his willingness to refer doubtful cases for consultation with the
official tuberculosis officer of each area. These officials have
only existed during the last few years; their work was partially in
abeyance during the four and a half years of war; and apart from
this, they have not always succeeded in persuading the private
practitioner that their coöperation is to be welcomed and that they
are not agents for depriving him of his private patients. This
assumed antagonism between private and public medical practice is one
of the most serious difficulties in securing more rapid progress in
anti-tuberculosis work.
3. For nearly every sanitary area gratuitous facilities are now
provided for the examination of sputum for tubercle bacilli, and yet
in many areas there is grave neglect to utilize this provision, and
patients with chronic phthisis may be treated during long months
or even years for “winter cough,” “bronchitis,” etc., without
adequate physical examination of sputum. The diagnosis of pulmonary
tuberculosis ought, it is true, to be made before tubercle bacilli
are found in the sputum, and failure to recognize the disease prior
to this implies that the disease has already become serious; but
in fact a very large proportion of consumptive patients for many
months have tubercle bacilli in their sputum, before the diagnosis of
tuberculosis is made.
4. When, as in some areas, the medical officer of health or the
tuberculosis officer takes little, if any, useful action after
notifications have been received, the practitioner has an excuse
for not notifying subsequent cases. He can argue with some cogency
that notification has no value _per se_; its utility depends on the
action which follows on notification. Unless useful action follows
on notification, default in notification has little practical
importance.
_Public Health Action Following Notification_
Under the English Tuberculosis Regulations the medical officer
of health or an officer of the local authority acting under his
instructions is required to make such inquiries and take such steps
as may be necessary or desirable for investigating the source of
infection, for preventing the spread of infection, and for removing
conditions favourable to infection. The action required includes
_inter alia_
1. Attention to the personal hygiene of the patient, including
instruction in the necessary precautions as to coughing and
expectoration.
2. Any assistance needed to ensure for the patient
(_a_) Skilled medical attendance and nursing as required while he is
treated at home;
(_b_) Institutional treatment when required;
(_c_) Supplementation of the convalescent patient’s funds, when
needed, to obviate the necessity for him at once to embark in
full-time work; to provide additional bedroom accommodation when
needed; and to ensure that the patient and his family are not
undernourished or overworked.
3. Remedial action for any insanitary conditions of the home, such as
uncleanliness, dampness, overcrowding; or of the patient’s workplace,
especially for dusty occupations.
4. Examination of home contacts with the patient.
The last named item may conveniently be considered further at this
point.
_Examination of Contacts_
This branch of tuberculosis work is most important. Often the first
notified case is not the first clinical case of tuberculosis in a
given family; and from the standpoint of prevention the detection of
such cases of longer standing is important. Examination of contacts
also frequently discovers patients in an earlier and more curable
stage of disease than the notified patient.
It is important that all home contacts of each notified case of
tuberculosis should be examined; and one of the most important
functions of the tuberculosis officer is to arrange for this. The
examination may be carried out by arrangement at the tuberculosis
dispensary; but otherwise, at the home of the invaded family. When
there is a medical practitioner in attendance his coöperation and
presence should as a rule be invited.
Such systematic examination of the household not only is more
efficient in discovering sources of continuing infection than the
desultory examination of a few contacts,—which often still represents
the extent of this important work,—but it has in addition a greater
educational effect on the public; and general recourse to such
systematic observations would rapidly improve the prospect of
satisfactory control of tuberculosis.
Even when examination of contacts is practised after notification
of a case of pulmonary tuberculosis, it is too often neglected
after notification of non-pulmonary cases. This represents a
great public-health loss; the majority of cases of non-pulmonary
tuberculosis are caused by infection of human source, and this source
often is an unrecognized case of pulmonary tuberculosis in the
patient’s family.
_Scope of Tuberculosis Schemes_
Prior to the general enforcement of notification of tuberculosis
in England excellent local work had been done in a relatively
small number of areas in direct efforts to control the spread of
tuberculosis, in addition to the previous general measures, such as
improved sanitation, better housing, more satisfactory nutrition, and
especially the hospital treatment of a large proportion of advanced
and acute cases of tuberculosis. The Report of the last Royal
Commission on Tuberculosis appeared in 1911; and although precautions
against human infection by tuberculous cows’ milk are still very
incomplete, the pasteurisation or boiling of milk is more generally
practised than in the past.
Local Authorities prior to 1911 had power to build sanatoria or
otherwise provide institutional accommodations for the treatment
of tuberculous patients; relatively little had been done in most
areas. In 1911 the Finance Act provided a sum of £1,116,000 for the
erection of sanatoria in England and Wales, and this, with money
provided by local rates, has led to rapid increase in accommodation
for the residential institutional treatment of tuberculosis. In
England in 1911 local authorities, other than poor-law authorities,
had about 1300 beds for the institutional treatment of tuberculosis,
while there were 4,200 beds in private sanatoria and voluntary
institutions. In 1917 the total available beds numbered 12,441, of
which about one-half had been provided by local authorities.
In 1911 the National Insurance Act was passed and came into operation
in July, 1912. This provided a special “Sanatorium Benefit.”
The Departmental Committee appointed to make recommendations as to
detailed direct measures against tuberculosis, reported in April,
1912, that any scheme which is to form the basis of an attempt to
deal with the problem of tuberculosis should be available for the
whole community, and that its organization should be undertaken by
the large local authorities (the councils of counties and county
boroughs). These recommendations were at once adopted by the
Government, which undertook to provide out of the national exchequer
one-half of the net cost of approved local schemes for the general
treatment of tuberculosis. Local authorities were invited at once
to prepare schemes for institutional treatment, residential and
non-residential, domiciliary treatment remaining in the hands of
private practitioners, of poor-law doctors, and of doctors engaged in
the contract work under the National Insurance Act (“panel doctors”).
The last named are in medical charge of the large mass of the
wage-earners of the community, comprising roughly one-third of the
total population, in so far as their treatment at home is within the
power of a practitioner of average competence. The schemes proposed
for each area comprised,
1. The appointment of a tuberculosis officer, usually a whole-time
official, who was required to have had special experience in the
diagnosis and treatment of tuberculosis, and who as a rule was an
officer in the public-health department under the administrative
supervision of the medical officer of health, but independent in his
clinical work;
2. The establishment of tuberculosis dispensaries, at which patients
were treated, consultations as to doubtful cases held, and contacts
examined;
3. The provision of beds in residential institutions for curable and
for acute and advanced cases;
4. The organization of arrangements for “following up” and
“after-care.”
During 1912 and 1913 advance was made in these directions. In 1911
there were 25-30 tuberculosis dispensaries: in 1917 their number
had increased to 371. In 1914 the onset of the Great War prevented
further development of tuberculosis work and seriously crippled and
reduced the efficiency of work already initiated; and this increased
as the military demand for medical officers and institutions became
greater. It may be stated generally that in only a relatively
small number of areas have fairly complete arrangements for the
institutional treatment of tuberculosis come into operation; and
that even in these areas the arrangements have been at work for only
a limited period. It is evident, therefore, as already pointed out,
that no argument as to the utility of these arrangements can be based
on the facts that the death-rate from tuberculosis has not declined
with increased rapidity in recent years, and that women during the
war, especially at the working years of life have experienced an
increased death-rate from this disease.
_Tuberculosis Dispensaries_
The tuberculosis officer is the essential element in the dispensary;
and in rural districts he may be said to carry the dispensary under
his hat. The dispensary if properly organized should serve as the
centre of official anti-tuberculosis measures. The medical officer of
health receives the notifications of recognised cases whether they
are attending the dispensary or not; and it simplifies administration
if the home supervision of all tuberculous patients notified to
the medical officer of health, and not only of dispensary patients,
is placed under the supervision of the tuberculosis officer. At
the dispensary itself the tuberculosis officer examines patients,
makes records of their condition, and of all facts bearing on their
welfare, and recommends the special form of continued treatment
adapted to their condition. This may be domiciliary, or given at the
dispensary, or in a sanatorium, or in a hospital. A dispensary which
does not supervise and treat a large proportion of the total notified
cases, including especially patients before and after they have
received treatment in a residential institution, is not fulfilling
its possibilities of utility.
At the dispensary is organized also the examination by the
tuberculosis officer of “contacts,” and of school children suspected
to be tuberculous; though it is often necessary to arrange for this
officer to make similar examinations at patients’ homes. At the
dispensary consultations with private practitioners are conveniently
held; though in this instance also the tuberculosis officer should
arrange when this is desired for the consultations to be held at the
patient’s home.
The dispensary alone cannot ensure the welfare of the tuberculous
patient. It is necessary that the tuberculosis officer should have
consultations concerning difficult cases with the medical staff
of general and special hospitals. To segregate the treatment of
tuberculosis from that of other diseases means reduced efficiency of
the tuberculosis officers and lowered quality of treatment.
_Tuberculosis Dispensaries should become Parts of General
Dispensaries_
Public Health and School Authorities have already established many
centres at which hygienic instructions and medical treatment are
given for mothers and their young children when ailing, or with a
view to the prevention of future illness; for tuberculosis; for
venereal diseases; and for various ailments of school children.
In England in addition there is poor-law provision (sometimes at
dispensaries) for patients dependent on official charity. Evidently
the multiplicity of authorities, local and central, concerned in
this medical work, is not conducive to efficiency; and it will,
we hope, soon disappear. Similarly it will be in the interest of
efficiency, as well as of economy, to provide for the treatment of
the above-named groups of cases in a common Medical Institute for
each defined area, at which also it will be advantageous to arrange
for much of the treatment of insured persons. By this means it will
become practicable to arrange for consultations between experts in
different departments of medicine, to the advantage of all concerned.
It will be contrary to the communal interest if the resources of
voluntary hospitals in large towns are not also utilised in official
medical work. Many of these hospitals have specialised departments
(e.g., X-ray, eye, ear, throat, skin, and other special clinics), the
use of which ought to be obtainable, even though for many years it
may not be practicable to arrange for all hospitals to be financed in
part at least out of rates and taxes.
The tuberculosis officer in order to be able to treat his dispensary
patients with adequate knowledge, and in order to advise as to the
form of treatment—in a residential institution or not,—most fitted to
the patient’s case, must know the sanitary and social circumstances
of the patient’s industrial and domiciliary life. He must, therefore,
have reports on these circumstances respecting each patient. This
raises the general question of the relation of the tuberculosis
officer to the medical officer of health. The medical officer of
health is officially responsible for controlling the tuberculous
patient and his environment from a public health standpoint. As the
tuberculosis officer also needs the information acquired in the
inquiries which it is the duty of the medical officer of health to
make personally or by an authorized agent, coördination of the work
of the two officers is evidently required; and this need cause no
difficulty when the tuberculosis officer is an officer in the Public
Health Department of which the medical officer of health is the chief
administrator.
_The Home Visitation of Patients_
This is important, (_a_) to inquire into the social circumstances
of each patient; (_b_) to instruct him in detail as to the carrying
out of instructions for treatment and in the hygiene of his life;
(_c_) to make a sanitary survey of the dwelling house, and especially
of the patient’s bedroom, and to advise as to any needed reforms;
and (_d_) in certain cases to give actual assistance in nursing the
patient.
The report on these inquiries should be seen by both the medical
officer of health and the tuberculosis officer, and on them in
conjunction with the tuberculosis officer’s knowledge of the medical
condition of the patient, the subsequent course of supervision and
treatment will depend.
Home visitation can be carried out by nurses attached to the
dispensary or by inspectors of the public health department. The
latter will usually be more competent in detecting and remedying
sanitary defects in the home; the former in encouraging the patient
to carry out the needed requirements in personal hygiene and nursing.
Many visitors are equally competent in both directions; and as the
number of women specially trained in tuberculosis work increases this
will more generally be the rule.
The dispensary should be the active working centre from which
home visitation is undertaken; and this is especially important
in “following up” work. Following up is needed for persons who
have been examined once, concerning whom there is doubt as to
their freedom from disease and who fail to present themselves for
later examination. It is needed also for patients who have been
under treatment and neglect to continue it; and for patients who
after having been treated have been discharged and fail to report
themselves at intervals as directed. It is important to have
efficient arrangements for ascertaining these leakages and for making
the necessary inquiries. The method of securing this will vary
according to local circumstances; but the following example given by
Dr. Chapman of an official method may be placed on record:
When a patient is instructed to attend again at the dispensary his
name is noted in a diary under the date upon which he is asked
to attend. In some instances a definite time is fixed for the
appointment so as to save the patient’s time. The names of all
patients who attended the dispensary upon the day appointed are
ticked off as they are seen, and at the end of the day the names of
patients who have failed to attend remain on the list. Letters are
then sent reminding these patients of their engagement and making
another appointment. If they still fail to attend they are visited
by the dispensary nurse or the health visitor. Failure to attend
may be due to relapse, and, when this is likely, an early visit of
inquiry by the nurse is advantageous.
Examination of a register kept for facilitating work of this kind
showed that the majority of the patients followed up attended
subsequently, and that in the cases of the remainder non-attendance
as a rule was satisfactorily explained.
In areas having, as yet, no adequate system of following up, an
appreciable percentage of patients usually cease to attend during the
course of treatment at a dispensary, and many are lost sight of after
discharge from a sanatorium. The value of the work of a dispensary
and of after-care work is materially impaired in the absence of
a system of “following up.” As schemes develop, more stress will
doubtless be generally laid upon this branch of the dispensary
function.
_“Sanatorium Benefit.”_
Under the National Insurance Act the annual sum of 1s 3d (30 cents)
was set apart for each insured person; as the result of subsequent
bargaining with medical practitioners 6d of this was devoted to
the domiciliary treatment of tuberculosis patients (payable on the
number of panel patients on each doctor’s list, not on the number
of his tuberculous patients), the remainder being payable to local
authorities who undertook the provision of institutions for the
treatment of tuberculous insured patients.
Thus the “Sanatorium Benefit” comprises
_A_. Domiciliary treatment.
_B_. Institutional treatment.
(_a_) Non-residential—Dispensaries.
(_b_) Residential—Sanatoria,
Hospitals,
Convalescent Homes and
“Farm Colonies.”
Soon after the passing of the National Insurance Act in 1911
representations were made that tuberculosis affected non-insured as
well as insured; that treatment of insured could have only partial
success so long as non-insured members of the same household were
neglected; and that this was work for public health authorities which
they were already partially undertaking. It was evident that the
inextricably interlaced measures for the prevention and the treatment
of tuberculosis must accrue to the whole population; and the mistake
of the National Insurance Act was remedied to the extent that
Public Health Authorities were informed that the National Treasury
was prepared to pay one-half of the approved expenditure incurred
by these authorities in establishing schemes for the treatment of
tuberculosis available for the entire population. Such schemes
were proceeded with, as already indicated; but there remained the
fact that insured persons who had paid their weekly quota and were
therefore entitled to “Sanatorium Benefit” usually interpreted this
as a right to three months’ treatment in a Sanatorium. The choice of
persons to receive treatment in a Sanatorium lay with Local Insurance
Committees appointed under the National Insurance Act, who generally
acted on the advice of the tuberculosis officer; but influences
other than medical led to the unsatisfactory use of institutional
treatment. A large number of patients were sent to and retained
in sanatoria for prolonged periods, who might have been adequately
treated at home, or who should have been in hospitals. Satisfactory
results for sanatorium treatment were not secured under these
conditions; and there will probably be no material improvement until
the Sanatorium Benefit is withdrawn as a special benefit under the
National Insurance Act, and the treatment of tuberculosis becomes an
obligatory duty of Public Health Authorities, with a minimum standard
of provision to which all must attain.
_Residential Institutions_
The extent to which these have been provided in England since 1911
has already been stated. The number of beds available in 1917 was
12,441, in addition to some 9,000 beds in poor-law institutions,
which in 1911 were occupied by consumptives. From the point of
view of the provision required in residential institutions for the
treatment of tuberculosis the following classification is useful. It
is confined to pulmonary cases:
Group _A_—Cases in which permanent improvement or recovery can
usually be anticipated.
Group _B_—Cases in which only temporary, though possibly prolonged,
improvement may be anticipated.
This group will include
1. Patients who may be expected to recover considerable ability to
work, as a result of protracted treatment.
2. Patients admitted for a short term for educational treatment.
3. Patients with advanced disease, many of whom improve greatly
under institutional treatment.
Group _C_—Advanced cases requiring continuous medical care and
nursing.
Group _D_—Cases requiring Special Observation.
1. Patients admitted for the purpose of diagnosis.
2. Patients needing to be watched, before the best form of continued
treatment can be determined.
Emergency cases, e.g., patients with haemoptysis, and patients
requiring surgical treatment may come within any of the above groups.
Of the 12,441 beds probably 5,000 are in the hands of voluntary
organizations, and are intended for patients in group _A_, though
for the reasons set out on pages 208 and 223 they contain a large
proportion of patients in the other groups. It appears not unlikely,
however, that the total accommodation, official and voluntary,
for patients in group A has reached one bed per 5,000 population,
the accommodation recommended by the Departmental Committee on
Tuberculosis as immediately advisable. This accommodation is unevenly
distributed and much of it is being utilised for patients coming
within groups _B_, _C_, and _D_. All the evidence available shows
a great need for additional beds for patients coming within the
last-named groups. The Departmental Committee recommended that the
total needs of the community might be assumed to amount to one bed
to 2,500 population for all stages of pulmonary tuberculosis, in
addition to poor-law accommodation. This means a provision of some
14,000 beds in addition to the 9,000 poor-law beds, or a total
provision of about one bed to 1,500 population.
If we include cases of non-pulmonary tuberculosis it may be safely
assumed that each community should aim at having available for the
treatment of tuberculosis at least one bed per 1,000 inhabitants.
Fewer beds may suffice for sparsely populated communities, and more
will be needed in some towns.
In England various existing institutions have been utilised in the
treatment of tuberculosis.
1. Emphasis has already been laid on the large number of beds in
_workhouse infirmaries under the Poor-Law Authorities_. Of the
historical, as well as of the present value of this accommodation
for advanced cases of tuberculosis in the poorest section of the
population—which is most seriously exposed domestically to massive
infection,—there can be no doubt.
But there has been prejudice against the use of this accommodation
for insured persons, and such use is legally precluded; and since
the passing of the National Insurance Act additional provision has
been made by Public Health Authorities, and ere long the whole of
the present poor-law accommodation should come under public health
authorities.
2. Detached pavilions of _hospitals for infectious diseases_ have
also been employed for the treatment of tuberculosis, and experience
has demonstrated that in well-conducted institutions consumptives are
not exposed to risk of acquiring acute infectious diseases.
The use of these institutions favours economy of administration. It
possesses the advantage that patients are, as a rule, more accessible
to their relatives than in a sanatorium; and this renders patients
suffering from progressive disease more willing to remain in the
institution than they would otherwise be. Patients can advantageously
be placed in such an institution for observation, before deciding
whether prolonged treatment in a distant curative sanatorium is
indicated.
Occasionally empty _smallpox hospitals_ have also been employed for
the institutional treatment of tuberculosis; but if this plan were to
be generally adopted, tuberculosis work would be seriously crippled
if smallpox became epidemic. The treatment of consumptives in a
smallpox hospital should only be permitted for patients who could be
at once transferred and who can be at once vaccinated.
_General hospitals_ are well fitted to deal with the following
classes of cases of tuberculosis:
(_a_) Patients admitted for observation, with a view to diagnosis;
(_b_) Patients admitted to ascertain the form of treatment best
adapted for the patient’s needs;
(_c_) Emergency cases, e.g., haemoptysis;
(_d_) Patients requiring surgical aid for intercurrent diseases;
(_e_) Patients with advanced disease admitted for special purposes;
(_f_) Patients with non-pulmonary tuberculosis, requiring special
surgical treatment.
In approving arrangements for the treatment of pulmonary tuberculosis
in a general hospital, it should be made a condition that they shall
not be received into general wards of the hospital in which there are
persons suffering from other diseases, unless for a sudden emergency,
or for a short period for operative treatment, or unless there is no
expectoration, or if this, on repeated examinations has been found to
be free from tubercle bacilli.
_Sanatoria and Combined Institutions_
To ensure efficiency in a sanatorium a resident physician is, as
a rule, necessary; and this is desirable also for a tuberculosis
hospital. Smaller authorities may be unable to combine together
or to provide alone an institution with about 100 beds, which is
generally regarded as the unit best adapted to secure a well-placed
and efficiently organized institution, with due regard to economy of
administration. To provide such a unit, and even apart from this,
the desirability of treating patients in all stages of disease in
the same institution should be considered. Experience in England
has shown that this combination presents no medical administrative
difficulties, provided that the type of sleeping accommodation
for patients consists chiefly of rooms for one or two patients
or of small wards. With such an arrangement, if a section of the
institution consisting of one or two bedded rooms or small wards is
devoted to patients needing special nursing, irrespective of the
stage of disease, efficiency is secured, the special needs of each
class of patients can be met, and—this is especially important—the
patient with advanced disease cannot infer the hopeless character
of his illness from his place in the institution. Such a combined
institution affords the medical and administrative advantage that the
tuberculosis officer can, as a rule, watch his patients throughout
the whole course of their treatment, both in the residential
institution and at the dispensary.
In choosing a sanatorium an area of at least twenty acres should be
available; and at least one-fifth of an acre should be allowed per
patient. For a hospital a smaller area is permissible. There should
be a floor-space of at least 64 square feet for each patient; and the
centres of the heads of adjacent beds should not be distant less
than 8 feet measured against the wall. Experience appears to show
that in a large sanatorium one nurse will generally be adequate for
every twelve patients. In a hospital for advanced patients, or in a
combined institution a larger staff may be required.
_Observation Beds_
There is but little systematised experience as yet of the employment
of observation beds; a difficulty arising from the fact that the
tuberculosis officer under most local tuberculosis schemes has
not been sufficiently in touch with the medical officers of the
residential institutions to which he sends patients. There are
practical difficulties in the provision of observation beds on the
dispensary premises, including the difficulty of due regard to
economy of administration in the nursing and treatment of three or
four in-patients at a dispensary. Whatever arrangements are made for
such beds, it is desirable that the tuberculosis officer should have
access to the patients treated in them.
_General Observations on Treatment in Sanatoria_
In 1911 the extent and limitations of the utility of sanatorium
treatment of tuberculosis were already fairly well recognized by
physicians; and it is unfortunate that in connection with the
passage of the National Insurance Act this treatment acquired a
somewhat political aspect, and became the subject of much popular
misapprehension and exaggeration. Disappointment necessarily followed
on the sending of patients to sanatoria for treatment with a view to
cure at a stage of disease when anything beyond ephemeral improvement
was impossible. The patients who, under present conditions, are
admitted to sanatoria come roughly into two groups:
First. Patients with limited disease and little or no systemic
disturbance. Comparatively few patients who now enter sanatoria come
within this group.
Second. Patients with more extensive or acute disease. In a large
proportion of cases within the first group the immediate result
of sanatorium treatment extending over three to six months is the
complete restoration of general health and working capacity with
arrest of disease. In a large further proportion of cases in the same
group there is recovery of working capacity and apparent restoration
of general health without complete arrest of disease.
For patients coming within the second group a similar period of
treatment in a sanatorium results:
(_a_) In restoration of general health and working capacity with
arrest of disease in only a small proportion of cases;
(_b_) In recovery of working capacity and apparent restoration of
general health without arrest of disease in a fair proportion of
cases; and
(_c_) In the remainder, disease progresses steadily with or without
temporary improvement in general health.
The subsequent history of sanatorium patients varies greatly. Some
of them maintain their health indefinitely on return to their
ordinary life. Others who have been discharged with arrested disease
ultimately relapse, even if they live under excellent environmental
conditions; and such relapses are excessive among those who return to
unsatisfactory conditions of life and work.
Among patients discharged from a sanatorium without arrest of the
disease a small proportion ultimately recover completely, but the
majority relapse at a date which is earlier or later in accordance
more or less with the conditions under which they live and work and
the severity of their disease.
The experience of the last few years has been that only a small
proportion of the patients admitted to sanatoria are cases in which
arrest of the disease can be anticipated; and this will continue
until the disease is more generally detected at an earlier stage than
at present, and the sanatorium treatment is prescribed and continued
solely in accord with the medical needs of the patient.
The conditions of local administration of the Sanatorium Benefit
under the National Insurance Act have led to a very high proportion
of consumptives being treated in sanatoria with a view to cure,
who might advantageously have received educational treatment for a
few weeks and then have been treated at home or at a tuberculosis
dispensary. Furthermore, a large number of patients with advanced
disease have been sent to sanatoria for whom treatment in a hospital
was more appropriate.
_Educational Work of Sanatoria_
Apart from the question of cure, which with belated treatment can
only be expected in a minority of cases, the sanatorium serves an
important purpose, not only in restoring patients to a considerable
degree of health and working capacity for a longer or shorter
time, but also in educating the patients how to live and conduct
themselves. A stay in a sanatorium for a short period—a month or
six weeks—under doctors and nurses who realise the value of this
work—would there were more of these!—secures the training of the
patient on lines beneficial to his future health and enables him to
obviate all danger for others.
In such a short stay in a sanatorium what may be called tuberculosis
discipline can be and is acquired when the sanatorium is
satisfactorily administered; and the patient thus disciplined is in
a much more favorable position for securing his own welfare and that
of others than the undisciplined patient, just as the soldier who has
had routine drill under a competent instructor is more efficient
than the untrained recruit.
The preceding remarks as to the treatment of tuberculosis in
sanatoria illustrate certain well-known features in the natural
history of this disease. In the majority of instances of disease
recognised under present conditions we are dealing with a slowly
progressing disease. This sometimes become spontaneously arrested;
occasionally it may be arrested or its course delayed under
medical treatment at home associated with manageable changes in
domestic and industrial life. In still further instances it may
be arrested by treatment in a sanatorium; while for other cases
sanatorium treatment, however prolonged, is followed by only
temporary improvement, and the chief benefit thus received is that
of training as to mode of life, which might have been secured by a
much less protracted stay in the institution, followed by measures
supplementing sanatorium treatment. We have further to recognise
the fact that, under present conditions of social life and medical
practice, many tuberculous patients will slowly, by intermittent
stages, but none the less surely, die from tuberculosis in the course
of one, three or five years. Regard must be paid to this fact if our
total measures for the control of tuberculosis are to be successful.
_Hospital Treatment_
This fact emphasizes the importance of adequate hospital treatment
for all patients acutely ill or bed-ridden, who cannot be
hygienically treated at home; and the importance becomes evident of
exercising _complete supervision over and provision for the whole
of the sick life of the consumptive, whether he is trending towards
complete recovery or to death_.
Such complete supervision and provision necessitates further
development in three directions in which beginnings have already been
made:
_Industrial Colonies_
These are the provision of “Farm or Industrial Colonies,” the
adaptation of domestic dwellings to meet the special needs of
consumptives, and the more complete organization of “Care” and
“After-care” arrangements.
In a large proportion of cases, the patient on leaving the sanatorium
is unable at once to embark on full work without risk of early
relapse, or to refrain from this without endangering his nutrition
and that of his family. His work, furthermore, may be unsuitable for
a consumptive.
This has led to many tentative efforts to train the consumptive
in a suitable occupation while under sanatorium treatment, or in
an industrial colony which should preferably be attached to or in
close communication with a sanatorium, in order that the patient
may continue under skilled medical supervision. The graduated labour
which forms part of the routine method of treatment in many sanatoria
can be made a preparatory stage in this industrial training.
The training may be made to merge into the pursuit of an actual
livelihood; and then the sanatorium becomes an industrial colony.
Market gardening, pig-keeping, forestry, and other occupations
may be thus pursued for protracted periods, if the patients are
suitably selected. The ex-patients continue to live under protected
conditions, earning part at least of their livelihood. Attempts
in this direction are not likely to have wide success unless the
patient is re-instated in his family; and the most promising efforts
are those which install the ex-consumptive with his family in a
cottage near a sanatorium, where he can remain under partial medical
supervision, while engaged in his daily work. It remains to be seen
to what extent such arrangements are practicable on a considerable
scale, and the experiments now being made will be watched with
interest.
_Special Dwellings and Help in Support_
An alternative to the “colony” proposal, which will probably be found
practicable in a much larger number of cases is to arrange for the
ex-patient to be housed at his home under special conditions and
for his work to be graduated according to his physical condition,
assistance being given by way of payment of rent, or otherwise to
ensure that the patient and his family live under satisfactory
conditions. Proposals have been made by Dr. Chapman in a report
to the English Local Government Board that in connection with new
housing schemes a certain proportion of the houses erected should
have rooms providing free perflation of air reserved for consumptive
patients. If with this is combined the assistance indicated above,
the risk of the ex-patient relapsing will be materially reduced, and
the risk of other members of the family becoming consumptive may be
obviated.
Whatever methods are employed, the principle already enunciated must
be maintained that the patient in his own interest and in that of his
family must be the subject of uninterrupted care and supervision.
In securing this end _Care Committees_ play a valuable part. Owing to
the war their development has been retarded; but a local scheme for
such supervision and assistance as the members or agents of a Care
Committee can give forms an essential part of a complete tuberculosis
scheme.
These Committees are formed of non-official persons, inasmuch as a
large share of their work is at present beyond the scope of official
possibilities, outside the poor-law organization; they can help,
(_a_) in obtaining appropriate work for the ex-patients;
(_b_) in supplementing his wages;
(_c_) in providing separate sleeping accommodation for the patient,
additional food or clothing, or in loaning out an additional bed or
bedding;
(_d_) in aiding the family during the absence of the patient
in a sanatorium, and thus reducing the temptation to terminate
institutional treatment prematurely, and
(_e_) in encouraging each patient to take the necessary precautions
and to adopt the special treatment recommended for him.
Some of these activities overlap into the activities of the
tuberculosis officer and of the visiting nurse of the local
authority; but there need be no practical difficulty in adjusting
this. It is important that Care Committees should act in coöperation
with local authorities, insurance committees, and charitable
agencies, and should have representatives of these bodies on them.
The medical officer of health and tuberculosis should also be
ex-officio members of their committee.
_Summary_.—The preceding review of the problem of tuberculosis may be
summarised in a few final statements.
1. Our knowledge of tuberculosis, if fully applied by combined attack
on the disease by all known methods, is adequate to secure a great
reduction in its prevalence, if not its absolute abolition.
This is true, although certain problems respecting tuberculosis
still need elucidation, e.g., as to improved methods of treating the
diseases, and of increasing individual immunity during exposure to
protracted infection.
2. Domestic protection is at once practicable against infected cows’
milk; and control of this source of infection at its source is also
practicable.
3. Of the circumstances favouring the development of pulmonary
tuberculosis industrial dust and domestic overcrowding are the most
potent. More detailed and systematic supervision of factories and
workshops is needed, followed by general adoption of remedies, which
would increase industrial efficiency as well as reduce tuberculosis.
4. Tuberculosis is especially a “bedroom infection.” But improvement
in housing is a dual problem, and it is a blunder to assume that
improved housing, so long as the healthy and tuberculous sick
continue to be housed together, will produce a rapid decline in the
prevalence of tuberculosis. Hospital provision for the sick is as
necessary as improved general housing.
FOOTNOTES:
[17] The substance of two lectures at the Summer School on
Tuberculosis, Trudeau Sanatorium, Saranac, N. Y., July, 1919.