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At home and abroad
150
TUBERCLE
the Committee is doing the little it can to provide relief and foster a spirit of reconciliation. In Poland a. unit is at work fighting typhus and distributing clothes to supplement the rags in which the population is dressed. The Com-
[December, 1919
mittee (Ethelburga House, 91, Bishopsgate, E.C. 2) appeals for help to those of us who can still eat good meals by warm fires. Volunteers for work are asked for as well as funds to provide the relief.
AT HOME AND ABROAD. PREVENTIVE MEDICINE IN ENGLAND. hard times are ahead big efforts are being put forward, and rightly so, to deal with the treat. (FroJl~ our Social Correspondent.) In considering the present condition and meut of the tuberculous sick. But let not the be made of assuming that by such immediate prospects of the public health mistake m easures anything appreciable is being done 'services there are several points which need specially emphasising. Fiutly, the prevalence to eradicate tuberculosis. of preventable disease is inexorably mixed up A Valuable Publication. with the state of the publio purse and the For the purpose of taking stock of the means employed to liquidate the public debts, present situation and future prospects of preto keep the publio ooflers full, and to expend the ventive medicine, no better or cheaper publicamoneys therein in an econom ioal manner. Secondly, no one is going to banish preventable tion could be found than .. An Outline of the Practice of Preventive Medicine," just pub. disea se by the regulatrons of a bureaucracy, 'rhe elimination of controllable disease must lished by the Minister of Health (Cmd. 863 come by eradicating the fundamental causes price 6d. net), from the pen of Sir Georg~ Newma.n. There are 124 well printed pages of such disease. 'i'hese lie rooted chiefly In the ills of the social system of to-day, and in which the whole subject is comprehensively dealt with. (H is a pity a. few more Were cannot be got rid of appreoiably by the not added, even though tbe price had heen ordinances of the authorities and the manu. raised, to give an index.) 'i'he survey in. facture of schemes. Their nature and the proper method of attacking them must be clades .all aspects of the practice of preventi\'e appreciated by the people at large. 'fhirdly, the medicine: its history, present state, and future prevention of disease should not he confused in developments. Sir George Newman's facile pen any sort of way with the treatment of the sick. covers a very wide field. In fact any shortConsideration of the school medical service com ings the book has are not due to a lack of and of infant welfare work shows how these wealth of detail but rather arise from the fact systems are rising above the mere treatment of that there is not a clear and coherent theme It should be .. cases" and are developing true preventive running through the book. influences. But the same cannot yet be said read in order to induce thought and guide for most of the current schemes for combating the reader to find out for himself the quickes~ tuberculosis. In faot from the point of view way for progress and reform. Every scheme ever advocated in recent decades finds a place of the prevention of tuberculosis the school medical and infant welfare services accomIn these pages . No precept ever laid down plish milch more than do the majority of to aid in the uplift of diseased humanity is measures aimed directly agaiust this disease. omitted. Further, it contains many up-toTbe old adage that .. prevention and cure go date facts of great statistical importance. As hand in hand with one another," though not an inventory of the physical condition of the perhaps completely incorrect; is misleading and English people it is invaluable, and it is full harmful. of references to other publications. The Iollowlug extracts are taken from the When these essential princIples of reform are grasped it becomes apparen t that th oeradication two pages specially devoted to tuberculosis ;_ .. We notify tuberoulosis in a general way of preventable disease Is more a politioal than a medical matter, Hitherto the infective nature (92,000 fresh cases in 1918), but we are failing of tuberculosis has dominated the outlook of to treat it etIectually. Even notification is those busying themselves about its prevention often neglected and too la.te to be of Use. • • • and control. This should be so no longer, The tuberculosis dispensary must be 80 used larllely because an infection with tuberculosis as to be available as (a) a receiving house and iB tbe common lot of man In most countries. diagnosis centre; (b) a clearing house and It follows that other factors than mere inobservation centre; (cl a treatmllnt centre for fection must be the important causes of the certain cases; (d) a clinic for examination of morbidity and mortality due to this infection, contacts; (e) a centre for following up and and that a.ttacklng merely the bacterial agent is after care; (/) a bureau of information and l~rgoly a tilting at windmills, Naturally at a education • • • • The training.colony method tlms when tuberculosis is on the Increase and and the village settlement should be extended.
December, 1919J
TUBERCLE
.. The policy for dealing with tuberculosis mnst be fundamentally preventive, and mu st recognise that latent tuberculous infection is so widespread as to be almost universal. Thero are grounds for believing that its seeds ar e sown chiefly in childhood. Housing, industrial life and the milk supply must be considered, and public education, gener al sanitation, ch eap bread, :and a hygienic way oflife • . . . Some authorities neglect entirely all following up of cases, all true prevention, even their housing obligations, and have never given a thought to the relation of the nutrition and physical well-being of the people in their charge to the incidence of tuberculosis among st them. •••• There are only 250 tuberculosis officers in the whole country, only 20,000 available beds, only half a dozen colonies , , .. l\Iuch remains W be done. The standard of diagnosi s in tuberculosis, the scope and duties of the tuberculosis 'officer and nurse, the management of residential institutions, the education of tho patient and his after-care, the relation, of the disease to industry and tuberculous milk , the Investigation of high local incidence, the subject of non-pulmonary and surgical tuber. culosis-all these questions call for careful attention, and some for immediate action. " Theory and Practice. We have been told repeatedly that bad housing conditions, defective education of doctors ' and the warm stagnant a.ir people are co~tent to breathe inside factories ,and offices are three potent causes of consumption ; and it Is fairly easy to prove the truth of these contentions. Here are three factors producing preventable disease which are of paramount importance. From the point of view of preventive medicine each must be examined quite apart from the consideration of the treatment of the sick. Taking them in order: Is the provision of go?d houses at .80 re&sona.ble ra.te being a.ccomphshed? It IS estimated that the housing accommodation urgently wanted at once will not be completed under W years unless things soon begin to move more quickly. Yet there is at present no indication of a quickening pace. The cost 01 materials continues to soar; labour continues to show discontent: Several local authorities. besides the NatIOna.l Excheq.uer, have already found serious obstacles in timing money for example Birkenhead and Acton. Again 'the red tape of officialdom, and its extravagance cannot be overcome bya.ppolnting more supermen, or a fresh set, to goad into actlon those who are contending all the time Ss:laiDst economic laws. Someone has to find the money to pay a reasonable. re.turn on the capital expendituro of house building, and the mOflt reasonable plan would be for the users of the bouses to find it. Ye~ the present metbods of attempHng to meet the cost of housing heightens prices, depresses the general level of wages, and hinders production I and they make houses dearer by putting rates and tases upon them as soon as they are built. Those who strive towards the eradication of tuherculosls must take economic laws into
151
consideration. Again, many of the present schemes for the housing of workers, when they become deeds instead of paper plans and promises, will perpetuate some of the housing defects of to-day and add to such ugly conurbations, such suppurating wens as greater London and the ~bnchester district. These contravene in several ways Nature's laws for keeping people healthy, besides which local self-government, extolled as a feature to encourage the advance of preventive medicine, Is impossible in such places . Effort should be more constantly directed to the means wherehy industries and dwellings can be so placed as to create small garden cities, and so arranged n.s to lead to industries being more definitely controlled· by the workers themselves, and to the home being ruled in a more thorough aud complete fashion by its own inmates. The Need for Knowledge. All who desire to have their interest in medical education stimulated, should read Sir James Mackenzie's recent book, .. The Future of Medicine," and another Government publication from the pen of Sir George New. man, namely, his" Notes on lIIedical Education in England," 1918 (Cd, 9124, pr ice 9d. net). The ma.jority of doctors still leave the schools inadequately trained in the diagnosis and treatment of the common disea.ses, and this is especially so in regard to tuberculosis. The tea.ching hospitals and their physicians do not find sufficient room for such instruction in their curriculum. Serious errors continue to be made as a consequence of these shortcomings, and they are certainly harmful to the welfare of a large number of patients. But mistakes in these respects also react unfavourably upon preventive medicine. They are now, fortunately, widely appreciated. But the appropriate remedies to overcome them are not easy to discover. One obvious reform not hitherto much employed. is to seek the advice oL experienced general practitionere, The cultivation of a greater love for fresh indoor air is almost more important than obtaining the opportunity of getting it, because ample opportunities for enjoying it will not be reached before an active and Widespread demand for this amenity, this necessity for sound health, is forthcoming. Yet the mandate of those in authority will not give, as some seem to think, any appreciable impetus to such & demand. It must spring from fuller knowledge, from an ampler education of the people. This wider education, of adult as well as of child, cannot be a.ttained by the provision of more Stateaided schools, even were the conditions of the public funds in a better state for making such provision than it is to.da.y. Many oL the adulta of to- day , because of social conditions, are not fitted for self -government, and are not capable of attaining to fuller knowledge. They ha.ve no proper opportunity to exercise their minds to learn their wants, and discover the best methods of fulfilling them. Government from above and expenditure of ill. gotten public moneys on schemes of the paternal kind will make matters Worse Instead of better.
152
TUBERCLE
Once the workers get knowledge of how to lead healthy lives and opportunities to lead them, then very little government of any kind will be neeessary, All this goes to prove the assertion that the prevention of controllable disease is really more llo political lind economic than llo medical matter. .PREVENTIVE MEDICINE IN IRELAND. (From our own Correepondent.) Report oj the Interdepartmental Committee. The Irish Press have given considerable -notice to the recent Report of the lul.ardepartmental Committee dealing with t,be Immediate practical steps which should be taken for the provision of residential treatment for discharged soldiers and sailors suflerlng from tuberculosis. Reference is made to the separate report of the Medical Commissioner of the Irish National Health Insurance Commission which emphasisea the difference between the conditions existing in Ireland and those in other parts of Great Britain. It is pointed out that owing to the absence of accommodation many advanced cases of tuberculosis amongst exllervice men have been treaied in the sanatoriums for e&rly cases. No doubt the strain on these institutions has been considerable but they were opened to ex-service men without hesitation and in many cases the civillan populabion have suffered in consequence. The most urgent problem in Ireland is the provision of suitable accommodation for advanced cases, and the Government must show their interest in ex-service men by providing money for this purpose. There are a dozen sanatoriums scattered over the country where there is ample land for the erection of additional accommodation and this is work which could be under. taken &tonce. This plan would have the double advantage that the patients would be fairly convenient to their own homes and would not foel that in the last stap;es of their illness they "Were ending their days in Ilo hospice for the dying. There would be the further advantage that from the administrative point of view this arrangement would undoubtedly prove not only efficient but economical. There is good reason to hope tha.t local
[December, 1919
authorities would not shirk their responsibilinif the Government treated them fairly in the matter of adequate ca.pital. grants for the purpose of assistin,'t in providing the necesSllt:" accommodation. The last thing to be contemplated is thill' these men who have fought for their country and helped to bring the war to a. victorious end and whose hopeless condition, in many cases, is the result of the terrible tria.ls endured. should be allowed to end their da.ys in a Poor Law hospital. It is very problema.tical whether" training institutions" under medical supervision. and " village communities" will ever be taken up in Ireland. The number of patients amongst soldiers is small compared with that in England, where such institutions a.s the Papworth colony are already doing good Work: and it is perhaps questionable whether the mentality of the Irish would be adaptable to these proposals. New Public Ilealth Oouncil. The first meeting of the new Public Health Council, established under the :r.Iini!'try of Health Act, was held October 2. The Chairman, Dr. E. Coey Bigger. gave an adrni.....bla address, pointing out the unsatisfactory coodition of the public health service 01 the country and indicating on general lines the extent of the problem of health reform to be considerod by the Council. The main function of this body in to advise the Minister of lIealtb who in this case is the Chief Secretary f"; Ireland, as to the steps to be taken for the improvement of the health of the people. a.nd i'is to be hoped tba.t amongst the first questions w be tackled will be that of the prevention and treatment of tuberculosis. That it is one of great urgency and im or. ta.nce can admit of no doubt. To mention %n1r a few facta. the death rate from tuberculosis i$ 2'2 per 1,000 compared with·1"6·per.1 000 of tbe popula.tion in England; in other '\VOrd~ 10,000 die annually from this disea.se· the! notification of tuberculosis is only permissive. with the result that, with the exception of Belfast, it is not generally adopted. and thC! accommodation for the proper isolation aad treatment of infective cases outside the Poor Law institutions is a. negative quantity.
LETTERS. CLJ.SSIFICATION OF CASES OF PULMONARY TUBERCULOSIS. DEAR EDIToR,-In the first number of TUBERCLE" a. classification of pulmonary tuberculosis ba.sed on that of Turban Gerhardt Is put forward by Dr. John Guy. The Turba'n Gerhardt classification is purely anatomical, and in my opinion should be discarded; it is open to llo gross amount of personal error, and' serves no useful purpose. A Stage III Turban Gerhardt case may be qUite Ilo promising one, whereas !lo Stage I Turban Gerhardt may' go steadily downhill to die In a month or two.
To get a uniform standard, surely it is bcs$ to eliminate the personal element as mUch I i possible. and utilise to the full whatever de:i.. nite points there are, On this assuIllpti\lo. I suggest and have for some years used as th. first broad division:(1) Those in whose sputum tubercle bacilli have at Borne time been found. (2) Those in whose sputum tUbercle bacilli have never been found. Provided tha.t sputum examinations al'f made with sufficient frequency, say at. 1~&S' once a month, this division will give. for th. positive cases at all events, strictly e<>mparal>l. statistics no matter who the doctor is.
TUBERCLE
the Committee is doing the little it can to provide relief and foster a spirit of reconciliation. In Poland a. unit is at work fighting typhus and distributing clothes to supplement the rags in which the population is dressed. The Com-
[December, 1919
mittee (Ethelburga House, 91, Bishopsgate, E.C. 2) appeals for help to those of us who can still eat good meals by warm fires. Volunteers for work are asked for as well as funds to provide the relief.
AT HOME AND ABROAD. PREVENTIVE MEDICINE IN ENGLAND. hard times are ahead big efforts are being put forward, and rightly so, to deal with the treat. (FroJl~ our Social Correspondent.) In considering the present condition and meut of the tuberculous sick. But let not the be made of assuming that by such immediate prospects of the public health mistake m easures anything appreciable is being done 'services there are several points which need specially emphasising. Fiutly, the prevalence to eradicate tuberculosis. of preventable disease is inexorably mixed up A Valuable Publication. with the state of the publio purse and the For the purpose of taking stock of the means employed to liquidate the public debts, present situation and future prospects of preto keep the publio ooflers full, and to expend the ventive medicine, no better or cheaper publicamoneys therein in an econom ioal manner. Secondly, no one is going to banish preventable tion could be found than .. An Outline of the Practice of Preventive Medicine," just pub. disea se by the regulatrons of a bureaucracy, 'rhe elimination of controllable disease must lished by the Minister of Health (Cmd. 863 come by eradicating the fundamental causes price 6d. net), from the pen of Sir Georg~ Newma.n. There are 124 well printed pages of such disease. 'i'hese lie rooted chiefly In the ills of the social system of to-day, and in which the whole subject is comprehensively dealt with. (H is a pity a. few more Were cannot be got rid of appreoiably by the not added, even though tbe price had heen ordinances of the authorities and the manu. raised, to give an index.) 'i'he survey in. facture of schemes. Their nature and the proper method of attacking them must be clades .all aspects of the practice of preventi\'e appreciated by the people at large. 'fhirdly, the medicine: its history, present state, and future prevention of disease should not he confused in developments. Sir George Newman's facile pen any sort of way with the treatment of the sick. covers a very wide field. In fact any shortConsideration of the school medical service com ings the book has are not due to a lack of and of infant welfare work shows how these wealth of detail but rather arise from the fact systems are rising above the mere treatment of that there is not a clear and coherent theme It should be .. cases" and are developing true preventive running through the book. influences. But the same cannot yet be said read in order to induce thought and guide for most of the current schemes for combating the reader to find out for himself the quickes~ tuberculosis. In faot from the point of view way for progress and reform. Every scheme ever advocated in recent decades finds a place of the prevention of tuberculosis the school medical and infant welfare services accomIn these pages . No precept ever laid down plish milch more than do the majority of to aid in the uplift of diseased humanity is measures aimed directly agaiust this disease. omitted. Further, it contains many up-toTbe old adage that .. prevention and cure go date facts of great statistical importance. As hand in hand with one another," though not an inventory of the physical condition of the perhaps completely incorrect; is misleading and English people it is invaluable, and it is full harmful. of references to other publications. The Iollowlug extracts are taken from the When these essential princIples of reform are grasped it becomes apparen t that th oeradication two pages specially devoted to tuberculosis ;_ .. We notify tuberoulosis in a general way of preventable disease Is more a politioal than a medical matter, Hitherto the infective nature (92,000 fresh cases in 1918), but we are failing of tuberculosis has dominated the outlook of to treat it etIectually. Even notification is those busying themselves about its prevention often neglected and too la.te to be of Use. • • • and control. This should be so no longer, The tuberculosis dispensary must be 80 used larllely because an infection with tuberculosis as to be available as (a) a receiving house and iB tbe common lot of man In most countries. diagnosis centre; (b) a clearing house and It follows that other factors than mere inobservation centre; (cl a treatmllnt centre for fection must be the important causes of the certain cases; (d) a clinic for examination of morbidity and mortality due to this infection, contacts; (e) a centre for following up and and that a.ttacklng merely the bacterial agent is after care; (/) a bureau of information and l~rgoly a tilting at windmills, Naturally at a education • • • • The training.colony method tlms when tuberculosis is on the Increase and and the village settlement should be extended.
December, 1919J
TUBERCLE
.. The policy for dealing with tuberculosis mnst be fundamentally preventive, and mu st recognise that latent tuberculous infection is so widespread as to be almost universal. Thero are grounds for believing that its seeds ar e sown chiefly in childhood. Housing, industrial life and the milk supply must be considered, and public education, gener al sanitation, ch eap bread, :and a hygienic way oflife • . . . Some authorities neglect entirely all following up of cases, all true prevention, even their housing obligations, and have never given a thought to the relation of the nutrition and physical well-being of the people in their charge to the incidence of tuberculosis among st them. •••• There are only 250 tuberculosis officers in the whole country, only 20,000 available beds, only half a dozen colonies , , .. l\Iuch remains W be done. The standard of diagnosi s in tuberculosis, the scope and duties of the tuberculosis 'officer and nurse, the management of residential institutions, the education of tho patient and his after-care, the relation, of the disease to industry and tuberculous milk , the Investigation of high local incidence, the subject of non-pulmonary and surgical tuber. culosis-all these questions call for careful attention, and some for immediate action. " Theory and Practice. We have been told repeatedly that bad housing conditions, defective education of doctors ' and the warm stagnant a.ir people are co~tent to breathe inside factories ,and offices are three potent causes of consumption ; and it Is fairly easy to prove the truth of these contentions. Here are three factors producing preventable disease which are of paramount importance. From the point of view of preventive medicine each must be examined quite apart from the consideration of the treatment of the sick. Taking them in order: Is the provision of go?d houses at .80 re&sona.ble ra.te being a.ccomphshed? It IS estimated that the housing accommodation urgently wanted at once will not be completed under W years unless things soon begin to move more quickly. Yet there is at present no indication of a quickening pace. The cost 01 materials continues to soar; labour continues to show discontent: Several local authorities. besides the NatIOna.l Excheq.uer, have already found serious obstacles in timing money for example Birkenhead and Acton. Again 'the red tape of officialdom, and its extravagance cannot be overcome bya.ppolnting more supermen, or a fresh set, to goad into actlon those who are contending all the time Ss:laiDst economic laws. Someone has to find the money to pay a reasonable. re.turn on the capital expendituro of house building, and the mOflt reasonable plan would be for the users of the bouses to find it. Ye~ the present metbods of attempHng to meet the cost of housing heightens prices, depresses the general level of wages, and hinders production I and they make houses dearer by putting rates and tases upon them as soon as they are built. Those who strive towards the eradication of tuherculosls must take economic laws into
151
consideration. Again, many of the present schemes for the housing of workers, when they become deeds instead of paper plans and promises, will perpetuate some of the housing defects of to-day and add to such ugly conurbations, such suppurating wens as greater London and the ~bnchester district. These contravene in several ways Nature's laws for keeping people healthy, besides which local self-government, extolled as a feature to encourage the advance of preventive medicine, Is impossible in such places . Effort should be more constantly directed to the means wherehy industries and dwellings can be so placed as to create small garden cities, and so arranged n.s to lead to industries being more definitely controlled· by the workers themselves, and to the home being ruled in a more thorough aud complete fashion by its own inmates. The Need for Knowledge. All who desire to have their interest in medical education stimulated, should read Sir James Mackenzie's recent book, .. The Future of Medicine," and another Government publication from the pen of Sir George New. man, namely, his" Notes on lIIedical Education in England," 1918 (Cd, 9124, pr ice 9d. net). The ma.jority of doctors still leave the schools inadequately trained in the diagnosis and treatment of the common disea.ses, and this is especially so in regard to tuberculosis. The tea.ching hospitals and their physicians do not find sufficient room for such instruction in their curriculum. Serious errors continue to be made as a consequence of these shortcomings, and they are certainly harmful to the welfare of a large number of patients. But mistakes in these respects also react unfavourably upon preventive medicine. They are now, fortunately, widely appreciated. But the appropriate remedies to overcome them are not easy to discover. One obvious reform not hitherto much employed. is to seek the advice oL experienced general practitionere, The cultivation of a greater love for fresh indoor air is almost more important than obtaining the opportunity of getting it, because ample opportunities for enjoying it will not be reached before an active and Widespread demand for this amenity, this necessity for sound health, is forthcoming. Yet the mandate of those in authority will not give, as some seem to think, any appreciable impetus to such & demand. It must spring from fuller knowledge, from an ampler education of the people. This wider education, of adult as well as of child, cannot be a.ttained by the provision of more Stateaided schools, even were the conditions of the public funds in a better state for making such provision than it is to.da.y. Many oL the adulta of to- day , because of social conditions, are not fitted for self -government, and are not capable of attaining to fuller knowledge. They ha.ve no proper opportunity to exercise their minds to learn their wants, and discover the best methods of fulfilling them. Government from above and expenditure of ill. gotten public moneys on schemes of the paternal kind will make matters Worse Instead of better.
152
TUBERCLE
Once the workers get knowledge of how to lead healthy lives and opportunities to lead them, then very little government of any kind will be neeessary, All this goes to prove the assertion that the prevention of controllable disease is really more llo political lind economic than llo medical matter. .PREVENTIVE MEDICINE IN IRELAND. (From our own Correepondent.) Report oj the Interdepartmental Committee. The Irish Press have given considerable -notice to the recent Report of the lul.ardepartmental Committee dealing with t,be Immediate practical steps which should be taken for the provision of residential treatment for discharged soldiers and sailors suflerlng from tuberculosis. Reference is made to the separate report of the Medical Commissioner of the Irish National Health Insurance Commission which emphasisea the difference between the conditions existing in Ireland and those in other parts of Great Britain. It is pointed out that owing to the absence of accommodation many advanced cases of tuberculosis amongst exllervice men have been treaied in the sanatoriums for e&rly cases. No doubt the strain on these institutions has been considerable but they were opened to ex-service men without hesitation and in many cases the civillan populabion have suffered in consequence. The most urgent problem in Ireland is the provision of suitable accommodation for advanced cases, and the Government must show their interest in ex-service men by providing money for this purpose. There are a dozen sanatoriums scattered over the country where there is ample land for the erection of additional accommodation and this is work which could be under. taken &tonce. This plan would have the double advantage that the patients would be fairly convenient to their own homes and would not foel that in the last stap;es of their illness they "Were ending their days in Ilo hospice for the dying. There would be the further advantage that from the administrative point of view this arrangement would undoubtedly prove not only efficient but economical. There is good reason to hope tha.t local
[December, 1919
authorities would not shirk their responsibilinif the Government treated them fairly in the matter of adequate ca.pital. grants for the purpose of assistin,'t in providing the necesSllt:" accommodation. The last thing to be contemplated is thill' these men who have fought for their country and helped to bring the war to a. victorious end and whose hopeless condition, in many cases, is the result of the terrible tria.ls endured. should be allowed to end their da.ys in a Poor Law hospital. It is very problema.tical whether" training institutions" under medical supervision. and " village communities" will ever be taken up in Ireland. The number of patients amongst soldiers is small compared with that in England, where such institutions a.s the Papworth colony are already doing good Work: and it is perhaps questionable whether the mentality of the Irish would be adaptable to these proposals. New Public Ilealth Oouncil. The first meeting of the new Public Health Council, established under the :r.Iini!'try of Health Act, was held October 2. The Chairman, Dr. E. Coey Bigger. gave an adrni.....bla address, pointing out the unsatisfactory coodition of the public health service 01 the country and indicating on general lines the extent of the problem of health reform to be considerod by the Council. The main function of this body in to advise the Minister of lIealtb who in this case is the Chief Secretary f"; Ireland, as to the steps to be taken for the improvement of the health of the people. a.nd i'is to be hoped tba.t amongst the first questions w be tackled will be that of the prevention and treatment of tuberculosis. That it is one of great urgency and im or. ta.nce can admit of no doubt. To mention %n1r a few facta. the death rate from tuberculosis i$ 2'2 per 1,000 compared with·1"6·per.1 000 of tbe popula.tion in England; in other '\VOrd~ 10,000 die annually from this disea.se· the! notification of tuberculosis is only permissive. with the result that, with the exception of Belfast, it is not generally adopted. and thC! accommodation for the proper isolation aad treatment of infective cases outside the Poor Law institutions is a. negative quantity.
LETTERS. CLJ.SSIFICATION OF CASES OF PULMONARY TUBERCULOSIS. DEAR EDIToR,-In the first number of TUBERCLE" a. classification of pulmonary tuberculosis ba.sed on that of Turban Gerhardt Is put forward by Dr. John Guy. The Turba'n Gerhardt classification is purely anatomical, and in my opinion should be discarded; it is open to llo gross amount of personal error, and' serves no useful purpose. A Stage III Turban Gerhardt case may be qUite Ilo promising one, whereas !lo Stage I Turban Gerhardt may' go steadily downhill to die In a month or two.
To get a uniform standard, surely it is bcs$ to eliminate the personal element as mUch I i possible. and utilise to the full whatever de:i.. nite points there are, On this assuIllpti\lo. I suggest and have for some years used as th. first broad division:(1) Those in whose sputum tubercle bacilli have at Borne time been found. (2) Those in whose sputum tUbercle bacilli have never been found. Provided tha.t sputum examinations al'f made with sufficient frequency, say at. 1~&S' once a month, this division will give. for th. positive cases at all events, strictly e<>mparal>l. statistics no matter who the doctor is.