Public health and insurance: American addresses

by Sir Arthur Newsholme

FOOTNOTES:

[16] An address to the Political Economy Club, Johns Hopkins University, Jan. 19, 1920.

CHAPTER IX
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.