3. Adequate institutional provision for all classes of cases; the sanatorium for the curable; the hospital for the advanced and hopeless, and dispensaries for early diagnosis and as centers for that all-important field of action, education and treatment in the homes of the poor.
The developments of the years have not served appreciably to modify the main features of this program. Emphasis has shifted from time to time and will continue so to shift, but the fundamentals remain more firmly established than ever.
In developing the movement in this country, the most effective means of stimulating action in our various communities has been the voluntary association for the prevention of tuberculosis. In organizing these societies the local community has been recognized as the essential centers of action. The effort has been made, therefore, to obtain in every community of considerable size an organization embracing elements both medical and lay which shall charge itself with the task of securing adequate official treatment of the tuberculosis problem as it there presents itself.
In many of our commonwealths such organizations can best be brought about through the action of a State society, whose special function becomes one of organization and of securing desired legislation. In other cases the initiative is local in origin. Where State societies exist, these act as co-ordinating agents for the affiliated local societies, and the National Association for the Study and Prevention of Tuberculosis acts as a clearing house for them all.
It will be seen at once that such organization is but preliminary, and would be entirely futile, did it not result in preventive measures of a definite sort. There is, however, no other index equally valuable of the vigor and growth of this movement in the United States. Speaking from the national point of view, the organized campaign in this country has been in existence exactly seven years. In 1905 there were in the entire country but twenty-one of these societies, while at the present time there are no less than 660, working in co-operation and presenting a united front to the enemy. There is no considerable area that does not contain some such center of intelligent action.
The carrying out of the program outlined a moment ago is the special function of the organized movement. In the development of this program it is historically interesting that it was institutional provision for tuberculosis that first obtained support. It was the sanatorium for the cure of curable cases with its peculiar appeal which first engaged attention. From our present point of view, it was perhaps not the logical beginning, but it was certainly the obvious and perhaps the most fortunate point of attack. The sanatorium with its promise of restoring to a wage-earning capacity those unfortunates who formerly had been regarded as doomed to a speedy and inevitable death, was peculiarly fitted to arrest public attention and to engage public support.
As the movement for sanatorium establishment developed momentum, attention turned to the need of special dispensaries as logical centers of preventive work. Time will not permit even an outline of this phase of the problem. Suffice it to say that with the first general survey of the movement in the United States, six years ago, there were in the country but eighteen dispensaries exclusively devoted to tuberculosis. There are today more than 400 such foundations and their number is increasing at a rapid rate. All those who deal hand to hand with the problem become impressed at once with the fact that tuberculosis is pre-eminently a disease of social life, of living and working conditions. In the absence of adequate institutional facilities it is unavoidable that the problem should be attacked in the homes and workshops of the people, and with such weapons as may be at hand or which can be devised. With early diagnosis and careful instructive nursing supervision, much can be done even in the distressing conditions which characterize the crowded and poorer quarters of our great cities. The center of activity in this field is everywhere the dispensary, and the elaboration of its function to include supervision in the homes of indigent patients has been one of the most interesting and important of recent developments.
The third and possibly the most important aspect of institutional provision was the last to be taken up with energy. Every survey of our equipment during recent years has served to emphasize the shocking lack in our facilities for the care of advanced cases of tuberculosis. It has become increasingly evident that as centers of infection the consumptive in the advanced stages presented the most serious problem. Equipped as we were, with a healthily growing movement along educational, sanatorium and dispensary lines, the time seemed ripe for a vigorous attack on this point of weakness. The result has been that during the last four years there has been a concentration of energy in this direction and a notable advance has been made. Without pausing to specify various kinds and degrees of hospitals and sanatoria for the treatment of tuberculosis in the United States, it is encouraging to note that we now have over 500 in the country, as compared with 111 seven years ago. The number of beds contained in these institutions is approximately 30,000, a number small when compared with the need, but encouraging when compared with the situation but a few years since.
The third feature of the program already mentioned, that of legislation, is less susceptible of numerical expression, but it is in many ways the most fundamental and most significant of advancing intelligence. The principle of compulsory notification and registration has been insisted upon from the outset, and it has now come to be fairly generally accepted in all parts of the country. With few exceptions the more important States provide for registration by enactment either of the Legislature or of the State health authorities. In most of our larger cities local regulations are also on the statute books. Unfortunately the enforcement of these regulations is far behind their expression, but the situation is rapidly improving, and the example of such cities as New York in initiating the principle, and of Cleveland in demonstrating its possibilities, is of inestimable value.
In dealing with the question of public hospital establishment, the best adapted political unit has caused much embarrassment where a given community is not large enough to support an independent institution. Federal provision is agreed upon as being out of the question. The State as such is in most instances regarded as having the same limitations to a lesser degree as the national government. It is fairly generally accepted that where the municipality is of sufficient size it should accept responsibility for its problem. In those sections where communities of lesser population are the rule, the county is now in the focus of attention.