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;