504 



NA TURE 



[September 13, 1906 



Sinte 185 1 statistics sliow a steady decline in the mortality 

 of tuberculosis, and for this the principles of general 

 sanitation have been chiefly responsible. We may expect 

 in the future that this improvement will be maintained by 

 the continued prevention of overcrowding, the enforcement 

 of good ventilation, improvement of insanitary areas, more 

 effective drainage, better cleansing of streets, and the more 

 stringent supervision of meat, cowsheds, dairies, &c. ; but 

 more rapid progress may be made and eventual extinc- 

 tion of the disease attained if more direct measures are 

 employed in an intelligent and comprehensive manner. 



Of more direct measures, hospitals for consumption have 

 no doubt played a part in the decline of phthisis, but any- 

 one acquainted with the conditions of life obtaining in our 

 great centres of population must admit that their sphere 

 of usefulness is but limited. The reasons for this are not 

 far to seek : — firstly, hospital treatment is practically use- 

 less for cases of advanced tuberculosis, and most hospitals 

 refuse admission to patients suffering from a widespread 

 infection ; secondly, patients well fed and passing a restful 

 e.xistence in hospital under the best hygienic conditions 

 rapidly break down on again returning to their homes, 

 where such favourable conditions are impossible. The 

 recognition of this latter fact has led to the erection of 

 sanatoria in various parts of the country, where patients 

 may continue for a time to build up their powers of resist- 

 ance after leaving hospital, and where they may by 

 graduated exercise under proper medical supervision steadily 

 fit themselves for the more arduous work of ordinary life. 



At the present time the number of sanatoria is limited, 

 and hopelessly inadequate for the work. Efforts are, how- 

 ever, being made all over the country to increase their 

 number, but the cost of building and the cost of maintain- 

 ing an efficient sanatorium is a practical difficulty with 

 which we are faced at the outset. The King's Sanatorium 

 at Midhurst, perhaps the most perfect of its kind in the 

 world, cost approximately loooZ. per bed. Having regard 

 to the number of beds required all over the country, a cost 

 anything approaching these figures is prohibitive. The 

 Open-air League, however, has directed its attention to 

 this point, and has as one of its principal objects the 

 erection of sanatoria at a cost estimated at not more than 

 100!. per bed, including complete equipment and the free- 

 hold of the ground. At Woodilee and Gartloch Asylums 

 (Scotland) wood and iron sanatoria have been erected at a 

 cost of goi. per bed. If satisfactory headway is to be made 

 we must have more sanatoria, and from the nature of the 

 case they must be erected as cheaply as possible. 



.Another philanthropic body, under the presidency of 

 H.R.H. Princess Christian, called The National Com- 

 mittee for the Establishment of Sanatoria tor Workers 

 Suffering from Tuberculosis, having similar objects in 

 view, recently purchased 250 acres of land in Kent, and 

 is about to build a sanatorium for poor patients ; the com- 

 mittee expects that the institution will be self-supporting, 

 without endowment from local rates or private charitable 

 subscriptions. These organisations are working along the 

 right line and doing splendid work, but so great is the 

 number of tuberculous patients (80,000 in London alone) 

 that they are only able to touch the fringe of this 

 tremendous problem. 



Hitherto sanatorium treatment has mainly consisted of 

 fresh air, rest in bed, full diet, and graduated exercise 

 under constant medical supervision. .Such a life is not a 

 very healthy moral existence; it produces the "sanatorium 

 habit," which renders one who has acquired it morally 

 unfit, as he is already physically, for the more strenuous 

 life to which he must sooner or later return. In order to 

 counteract the emasculating influence of sanatorium life as 

 hitherto pursued, to reduce the cost of maintenance, and 

 in order to provide work for patients who would otherwise 

 lead an indolent and purposeless life, various schemes have 

 been proposed. 



The Open-air League intends to found farm colonies in 

 connection with its sanatoria where patients cured, but 

 as yet unfit to return home, may occupy themselves in 

 farming, in the cultivation of vegetables, and other similar 

 light occupations. An intermediate stage is thus created 

 during which the patient is braced up physically and morally, 

 and his tendency to relapse reduced to a minimum. 

 Hospitals and sanatoria, however, under their rules exclude 



NO. 1924, VOL. 74] 



cases of advanced tuberculosis. Such cases under hospital 

 treatment remain stationary or get worse, and merely 

 occupy beds which may be more usefully employed in the 

 treatment and cure of patients less extensively infected. 

 Advanced cases, then, added to the many who for various 

 reasons prefer to remain at home, are under no control, and 

 constitute a constant and very real menace to the health 

 of the general public. How to reach these patients and 

 bring them under proper medical supervision is in most 

 localities a great difficulty, yet until it is dealt with all 

 hope of eradicating tuberculosis may be abandoned. In 

 London there appears to be no organisation as yet which 

 will undertake this necessary work. The difficulty has 

 been met in Scotland by the founding of " dispensaries for 

 tuberculosis," and this example has been followed in France 

 and Belgium. In Germany, too, similar institutions 

 (Wohlfahrtstellen fiir Lungenkranke) have been founded. 

 The functions of a dispensary are briefly these : — 

 (i) Medical examination of patients. 



(2) Inquiry by a medical man or nurse into the history 

 of the illness, the home conditions, the economic condition 

 of the family, the suitability of the accommodation for 

 home treatment. 



(3) Arrangements for providing medical treatment and 

 nursing of patients that could be treated at home without 

 risk of infection. ' 



(4) Dispensing of medicines and disinfectants. 



(5) Selection of cases suitable for hospital treatment. 

 The type of dispensary which might well be copied by 



other cities is the Royal Victoria Dispensary, founded 

 eighteen years ago by Dr. R. W. Philip in Edinburgh. 

 The excellent work done by this pioneer institution has 

 been of incalculable benefit to the community. 



By these means the campaign is carried into the very 

 homes of the patients, and an attempt is made to limit 

 at its source the constant stream of more or less advanced 

 cases of tuberculosis which appear daily in the out-patient 

 departments of our hospitals. 



The cost of such dispensaries is not great ; Dr. Philip 

 estimates it at 500Z. to 1000!. per annum for a city of 

 300,000 inhabitants. It might be paid out of the rates, 

 and the dispensaries, for administrative purposes, should be 

 under the control of the medical officer of health. 



Pulmonary tuberculosis has been recognised in Scotland 

 by the Local Government Board as an infectious disease 

 within the meaning of the Public Health Act (Scotland), 

 i8g7; consequently the obligations of the local authority 

 with regard to infectious disease are extended to phthisis, 

 and much more efficient control is established. 



Under the Infectious Diseases Act (1889) the Local 

 Government Board can invest local authorities with similar 

 powers. In Sheffield these powers have been obtained in 

 a modified form, and in Manchester and some other locali- 

 ties notification of tuberculosis has been tried with success. 



Surely the time has now arrived when the powers 

 possible under the Infectious Diseases Act should be more 

 generally employed. A system of voluntary notification has 

 been inaugurated in Manchester ; this was at first limited 

 to public institutions, but in 1900 medical men were invited 

 to notify the cases occurring in their private practice. The 

 system has worked well, and has been of immense benefit 

 in affording opportunities for visiting the homes of the 

 patients and instructing them in the principles of disinfec- 

 tion, ventilation, and the proper disposal of sputa, &c. It 

 cannot be doubted that some system of notification (volun- 

 tary or compulsory) is imperative if efficient control is to 

 be obtained. It is not contended that notification by itself 

 has any administrative value, but if efficiently followed up 

 by adequate preventive measures it would alter the whole 

 aspect ol affairs ; on the other hand, application of the 

 provisions of the Public Health .Act to tuberculosis is 

 impossible unless some system of notification is employed. 



Many new cases of infection arise from ignorance of the 

 infectivitv of tuberculosis, and from an absence of any 

 knowledge as to how best to live without spreading infec- 

 tion. To combat this local authorities have distributed 

 leaflets conveying simple instructions for the everyday life 

 of tuberculous persons, and various philanthropic bodies 

 {e.g. the Open-air League) have this education of the public 

 as one of their chief objects. 



Brighton, however, under the able leadership of Dr 



