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.
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.
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.
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.
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.
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:
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.
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,
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.
[17] The substance of two lectures at the Summer School on Tuberculosis, Trudeau Sanatorium, Saranac, N. Y., July, 1919.