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Co-operative tuberculosis work in Italy
550
[September, 1020
TUllEHCLE
showed 0. large percentage of pneumococcal peritonitis. In the sputum oC theso children the pneumococcus constituted the most abundant organism. Jlebert ' calls attention to the common occurrence of non-tuberculous pulmonary fibrosis in children, and describes three cases, (1) of basal fibrosis with 0. tendency to cure, (2) of apical fibrosis, and (il) of fibrosis with commencing bronchiectasis. The non-tuberculous cases often give 0. history of broncho-pneumonia. after measles or pertussis, and nrc particularly prone to intermittent attacks of bronchitis between October and May. Later some die from lobar pneumonia, from lobular pneumonia. or Irom acute bronchitis. Occasionally they contract tuberculosis (fibro-tuberculous discase-e-Clark, Hadley and Chaplin.P) In conclusion the following statements seem justifiable : (1) Mnny cases of ill-health after pneumonia and infectious disease among children arc duo to unresolved pneumonia produced by a chronic pneumococcal infection, and arc not tuberculous. (2) Bronchiectasis of the internal moiety of the lower lobe, or of the whole lobo, is more likely to follow attacks of chronic or indurative basal pneumonia; disseminated patches of broncho-pneumonia. 0.1'0 more liable . to produce areas of diffuse bronchial dilatation. (B) After removal of enlarged tonsils and adenoids, the expediency oC surgical interference should again be discussed if tho lower lobe alone is solid, honey-combed with bronchiectatic abscesses nod dilated bronchi, and also nccompanled by symptoms of septic absorption. Residues nfter apical pneumonia, alter pleuritic and purely bronchitic lesions, are outside the scope of the present paper.
CO-OPERATIVE rrUDEnCULOSIS 'VORK IN ITALY. By \V"r. ClIAHI,m; \V IIITE , M.D, Chie/oJ Rf,ll ('rou IllITl'lII' of TllbeTwloai',l"ral/re: Director A.Il.C. Tllberr"lo,i, Unit. Italy; Metliral Director 1'IIbcTclIlo'i' [league of J>ittallllrol,.
IT was an extraordinary development oC the war thnt citizens should bo allowed tho privilege of studying and taking part in the control oC tuberculosis-a malady ns old as the human race-s-in the country oC another nation. It was tho 1I10re extraordinary, in that thoro is no adequate method established for handling this disease. France was the ~l'en.t gathering-place and battle-ground for 0.11 the allied armies, and in H114 Prance took the field herself so suddenly that sho had no tiruo to sort out the tuberculous among her mobilised troops' thus it was found by the end of the first year that many had been callcll to tho colours whilst suffering from tho disease. A complete mobilisation of men in any conn try would give the same result. Many early cases had become advanced. many advanced. cases had become Car advanced, bctore Prance had timo to recover her breath alter ber rush to stem tho tide or Gerrnnna pouring through Belgium. Arter provision was ninde for Prench • Lancet, 191f'l, 1, 7M.
& ..
Fibroid Diacnsea
or Lung," l~O.J.
September, 19201
TUBERCLE
551
wounded, and hospitalisation apportioned to tho wounded of the Allies, very meagre facilities remained for housing the tuberculous. 'I'he demand became more nnd more urgent. Publicity, much exaggerated, was given by the l)ress to what was but a natural consequence of repeated processes of segregation. Tuberculosis cases which went unrecognised when scattered through the entire population became increasingly conspicuous when, by repeated processes of segregation, they were first brought together into the concentrated mass of the army, and then wore isolated in tuberculosis sections, or else discharged because of the disease, which rendered them useless for fighting. The American press was flooded with unintelligent articles, which, while they undoubtedly gave stimulation to the whole world's tuberculosis movement, did so at the expense of Prance, and put into the hands of the enemy a new means of propaganda in the repeated statement that the American soldier who might escape the German bullet must SUCCUlll b to the French tubercle bacillus. One result, however, was that the American Red Cross, anxious to help in every way, and the Rockefellcr Foundation, interested in tuberculosis for the first time in its existence, sent Commissions to co-operate with the French in handling their tuberculous population. Under the guise of education they indulged in much publicity. 'I'his, in the course of time, reached the Italians, who made an official appeal for help. The task was turned over to the American Red Cross, and a special commission was appointed which, after many months of delay, finally reached Romo a few weeks before the rout of the Austrians by General Diaz, . Amidst the unrest that followed, the Commission studied the task set before it. The intense pre-occupation of war was gone; the opportunity of applying American methods, possible during that pre-occupation, was over. Fortunately, perhaps, for international friendliness, the Commission was forced to seek a new basis on which to work. The atmosphere of the country was changed. Though the emergencies created by the war still remained, war budgets were no longer possible. Army hospitals rapidly passed back into civilian hands; army construction work was stopped. Interrupted pre-war plans and post-war plans began to occupy a conspicuous place. Military control quickly lapsed and a new atmosphere crept down with the cannon Iroui the bare mountains, where Italy had made her glorious defence, to tho plains where her peace-time activities are fostered. A host of questions puzzled tho Commission. What Wcre •tho essentials of tuberculosis work which were universally applicable? What equipment did Italy possess? \Vhat was tho next step she must take? In what way could America help her? \Vhn.t platform was available upon which two proud countries could work together, of which tho one had sacrificed her all in tho great struggle Cor the salvation of tho world, and the other had suddenly risen to a position of. new importance in tho world's affuirs ? \Vhat could Americn. gain in return for work in Italy to maintain the balance of Iriendship ? Wus it possible to deviso n plan oC co-operation in a great welfare movement which could escape such individual and international complications us shortly nfterwards were thrashed out in Paris by n. group of selfish and unselfish arbitrators of world affairs? It was a delicate undertaking, as arc all such attempts to do welfaro
552
'l'UDERCLE
[September, 1020
work in 0, foreign country. It was especially so in Italy. On the other hand, the value of helpful co-operation between two countries, which exchange 80 large 0. group of population , made every effort worth while. Some success was gained, but fuilure often occurred where it was least expected. The choice of nn efficient staff for such n Commission Was in itself n diflicult task in 0, country which was handicapped by an ignorance of European conditions and languages, and which had already given its most eflicient workers to the army. Once chosen, the first step was to educate it. 'l'hose members not on active duty, for example the public health nurses, wero set to studying the language, while the field workers were despatched to outlying regions to gather as much informntion as possible of local conditions and equipment. Meanwhile the division of statistics collected, tabulated, and charted 0.11 the figures available at the time, and special studies were undertaken of housing, education, child labour, child 'welfare, and emigration. To any strange worker in 0. foreign country the complexity of the central government and the relations existing between the large national organizations present 0. difficult problem. \Vith the gathering of infonnation this complexity in Italy became conspiouous. . At the seat of government in Rome wero to be found the headquarters of the Servizio di Sanita of the Department of Wnr, tho Servizio della Pubblica Sanitn or the Department of tho Interior, the Headquarters of the Italian Ilcd Cross, and tho Headquarters of one of the National Organisations dealing with tuberculosis, each of which felt that it was the sole avenue through which the American Commission should work. It was, however, obviously impossible to work with anyone national central group to the exclusion the others, nor could a way be Iound to obtain complete co-operation between these different bodies. After frequent consultation with Italian leaders, therefore, it was decided to adopt the principle of peripheral organisation, in tbo hope tho.t in ll. small local body the representatives of rival national bodies would consent to act in amicable relations. I'uulng this into practice, wo soon found that the exchange of ideas on constructive programmes brought us a generous return. Local organisations interested in tho tuberculosis problem, with their supporting dispensaries, organisations thnt were seeking to establish school hygiene, organiso.tions that were building constructive child-welfare programmes, all when approached showed themselves ready to meet us with n spirit of confidence which promised to bring success to our effort and to secure, it Was hoped, permanent co-operative nctivity for both America and Italy. \Vo chose five of the sixty-nine provinces-Genoa, Perugia, Cagliur! n·nd Ho.ssnri in Sardinia, Palermo in Sicily-as types of broad fields of orgnnisation. 'Ve selected nineteen towns or cities, ranging from Naples to Pipcuo, for smaller community organisation, In every case the pre-requisite was an Italian committee of volunteers already formed, or in process of Iormation, with purposes nnd plans of its own, which was willing to further their progress by consultation and combined investment. '!'heso committees were placed upon a formal business basis. Suitable constitutions nnd by-laws were laid down, om cera elected, sub-committees appointed and assigned to definite activities, and executive sccrctlll'ies-
of
September, HJ20]
TummcLE
553
until then almost unknown in Itnly-e-engaged and Bet to work. Each locality was carefully studied and co-ordinate plans wero formulated and adapted, including hospitals and sanatoriums, dispensaries and public health visitors, school hygiene and open-air schools, statistics, teaching of general hygiene, etc. At the outset the principle was laid down that wo were there in nn advisory capacity only. 'Vo had no intentions of attempting an offensive AI demonstration" of American methods. 'Ve placed our knowledge, om equipment, our personnel, our funds nt the disposal of the Italians. In turn wo were rewarded by evidences of their confide nco in us, or their respect for our advice, of their integrity, punctiliousness, and superior wisdom in the use of funds, and of their great intelligence and determination to further the welfare of their people. There are many interesting and nearly perfect pieces of work going on in Italy, but progress is delayed for the moment by the lack of registration, of laboratories, of nursing, and of the principle of co-ordination. It must, however, bo said on' behalf of Italy, that while in the north she has kept pace in progress with other countries, in the south she has inherited a. problem with which she cannot adequately cope for many years unless America or England, her lifelong friend, come to her assistance. Now roads, railroads, aqueducts, houses, must bo built, water-power must be developed, drainage installed, trees planted, The swamps must be drained, a systematic control of emigration must be established to prevent the depletion of whole villages (now a usual occurrence), and, above nil, Dew and better schools must be provided. Although the death-rate in southern Italy from many diseases is low, yet tho squalor of the villages makes life in them to us unthinkable. Tho only possible centre of reconstruction is the schoolhouse. 'l'he communal school, the provincial school, tho Asili of the" Associazione nazionale pcr gl' Interessi del l\Iezzogiorno," the schools for tho contatlini in the Agro Homano-these are the influences which are already helping these backward peoplo to climb out of the depths into which centuries of misgovernment have plunged them: these are the candles to light them out of their ignorance, their suspicion, their poverty, their squalor. In many rural districts in the United States, in our mining towns or foreign population, in many mountain communities, we too must deal with similar problems, and we nrc finding that it if! from the schoolhouse that regenerative influences start. Such enormous problems require an expenditure far beyond the present resources of Italy, but for America and England to give her tho help she needs in establishing her schools would not be n charity; it would be an excellent investment. So long a.s she sends so great a number of her people to the United States and to tho British Colonies, it is possible to say to her, .. It is our duty to share the expense of educating your people." Offered in such away, as one step in international co-operation toward tho welfare of the world, Italy would not find it humiliating to accept our nsaistance. This principle we have tested by the work of our Commission and we believe that it is the basis for international welfare work, in which nt least, let us hope, the day Cor intense nntionnlization is over.
[September, 1020
TUllEHCLE
showed 0. large percentage of pneumococcal peritonitis. In the sputum oC theso children the pneumococcus constituted the most abundant organism. Jlebert ' calls attention to the common occurrence of non-tuberculous pulmonary fibrosis in children, and describes three cases, (1) of basal fibrosis with 0. tendency to cure, (2) of apical fibrosis, and (il) of fibrosis with commencing bronchiectasis. The non-tuberculous cases often give 0. history of broncho-pneumonia. after measles or pertussis, and nrc particularly prone to intermittent attacks of bronchitis between October and May. Later some die from lobar pneumonia, from lobular pneumonia. or Irom acute bronchitis. Occasionally they contract tuberculosis (fibro-tuberculous discase-e-Clark, Hadley and Chaplin.P) In conclusion the following statements seem justifiable : (1) Mnny cases of ill-health after pneumonia and infectious disease among children arc duo to unresolved pneumonia produced by a chronic pneumococcal infection, and arc not tuberculous. (2) Bronchiectasis of the internal moiety of the lower lobe, or of the whole lobo, is more likely to follow attacks of chronic or indurative basal pneumonia; disseminated patches of broncho-pneumonia. 0.1'0 more liable . to produce areas of diffuse bronchial dilatation. (B) After removal of enlarged tonsils and adenoids, the expediency oC surgical interference should again be discussed if tho lower lobe alone is solid, honey-combed with bronchiectatic abscesses nod dilated bronchi, and also nccompanled by symptoms of septic absorption. Residues nfter apical pneumonia, alter pleuritic and purely bronchitic lesions, are outside the scope of the present paper.
CO-OPERATIVE rrUDEnCULOSIS 'VORK IN ITALY. By \V"r. ClIAHI,m; \V IIITE , M.D, Chie/oJ Rf,ll ('rou IllITl'lII' of TllbeTwloai',l"ral/re: Director A.Il.C. Tllberr"lo,i, Unit. Italy; Metliral Director 1'IIbcTclIlo'i' [league of J>ittallllrol,.
IT was an extraordinary development oC the war thnt citizens should bo allowed tho privilege of studying and taking part in the control oC tuberculosis-a malady ns old as the human race-s-in the country oC another nation. It was tho 1I10re extraordinary, in that thoro is no adequate method established for handling this disease. France was the ~l'en.t gathering-place and battle-ground for 0.11 the allied armies, and in H114 Prance took the field herself so suddenly that sho had no tiruo to sort out the tuberculous among her mobilised troops' thus it was found by the end of the first year that many had been callcll to tho colours whilst suffering from tho disease. A complete mobilisation of men in any conn try would give the same result. Many early cases had become advanced. many advanced. cases had become Car advanced, bctore Prance had timo to recover her breath alter ber rush to stem tho tide or Gerrnnna pouring through Belgium. Arter provision was ninde for Prench • Lancet, 191f'l, 1, 7M.
& ..
Fibroid Diacnsea
or Lung," l~O.J.
September, 19201
TUBERCLE
551
wounded, and hospitalisation apportioned to tho wounded of the Allies, very meagre facilities remained for housing the tuberculous. 'I'he demand became more nnd more urgent. Publicity, much exaggerated, was given by the l)ress to what was but a natural consequence of repeated processes of segregation. Tuberculosis cases which went unrecognised when scattered through the entire population became increasingly conspicuous when, by repeated processes of segregation, they were first brought together into the concentrated mass of the army, and then wore isolated in tuberculosis sections, or else discharged because of the disease, which rendered them useless for fighting. The American press was flooded with unintelligent articles, which, while they undoubtedly gave stimulation to the whole world's tuberculosis movement, did so at the expense of Prance, and put into the hands of the enemy a new means of propaganda in the repeated statement that the American soldier who might escape the German bullet must SUCCUlll b to the French tubercle bacillus. One result, however, was that the American Red Cross, anxious to help in every way, and the Rockefellcr Foundation, interested in tuberculosis for the first time in its existence, sent Commissions to co-operate with the French in handling their tuberculous population. Under the guise of education they indulged in much publicity. 'I'his, in the course of time, reached the Italians, who made an official appeal for help. The task was turned over to the American Red Cross, and a special commission was appointed which, after many months of delay, finally reached Romo a few weeks before the rout of the Austrians by General Diaz, . Amidst the unrest that followed, the Commission studied the task set before it. The intense pre-occupation of war was gone; the opportunity of applying American methods, possible during that pre-occupation, was over. Fortunately, perhaps, for international friendliness, the Commission was forced to seek a new basis on which to work. The atmosphere of the country was changed. Though the emergencies created by the war still remained, war budgets were no longer possible. Army hospitals rapidly passed back into civilian hands; army construction work was stopped. Interrupted pre-war plans and post-war plans began to occupy a conspicuous place. Military control quickly lapsed and a new atmosphere crept down with the cannon Iroui the bare mountains, where Italy had made her glorious defence, to tho plains where her peace-time activities are fostered. A host of questions puzzled tho Commission. What Wcre •tho essentials of tuberculosis work which were universally applicable? What equipment did Italy possess? \Vhat was tho next step she must take? In what way could America help her? \Vhn.t platform was available upon which two proud countries could work together, of which tho one had sacrificed her all in tho great struggle Cor the salvation of tho world, and the other had suddenly risen to a position of. new importance in tho world's affuirs ? \Vhat could Americn. gain in return for work in Italy to maintain the balance of Iriendship ? Wus it possible to deviso n plan oC co-operation in a great welfare movement which could escape such individual and international complications us shortly nfterwards were thrashed out in Paris by n. group of selfish and unselfish arbitrators of world affairs? It was a delicate undertaking, as arc all such attempts to do welfaro
552
'l'UDERCLE
[September, 1020
work in 0, foreign country. It was especially so in Italy. On the other hand, the value of helpful co-operation between two countries, which exchange 80 large 0. group of population , made every effort worth while. Some success was gained, but fuilure often occurred where it was least expected. The choice of nn efficient staff for such n Commission Was in itself n diflicult task in 0, country which was handicapped by an ignorance of European conditions and languages, and which had already given its most eflicient workers to the army. Once chosen, the first step was to educate it. 'l'hose members not on active duty, for example the public health nurses, wero set to studying the language, while the field workers were despatched to outlying regions to gather as much informntion as possible of local conditions and equipment. Meanwhile the division of statistics collected, tabulated, and charted 0.11 the figures available at the time, and special studies were undertaken of housing, education, child labour, child 'welfare, and emigration. To any strange worker in 0. foreign country the complexity of the central government and the relations existing between the large national organizations present 0. difficult problem. \Vith the gathering of infonnation this complexity in Italy became conspiouous. . At the seat of government in Rome wero to be found the headquarters of the Servizio di Sanita of the Department of Wnr, tho Servizio della Pubblica Sanitn or the Department of tho Interior, the Headquarters of the Italian Ilcd Cross, and tho Headquarters of one of the National Organisations dealing with tuberculosis, each of which felt that it was the sole avenue through which the American Commission should work. It was, however, obviously impossible to work with anyone national central group to the exclusion the others, nor could a way be Iound to obtain complete co-operation between these different bodies. After frequent consultation with Italian leaders, therefore, it was decided to adopt the principle of peripheral organisation, in tbo hope tho.t in ll. small local body the representatives of rival national bodies would consent to act in amicable relations. I'uulng this into practice, wo soon found that the exchange of ideas on constructive programmes brought us a generous return. Local organisations interested in tho tuberculosis problem, with their supporting dispensaries, organisations thnt were seeking to establish school hygiene, organiso.tions that were building constructive child-welfare programmes, all when approached showed themselves ready to meet us with n spirit of confidence which promised to bring success to our effort and to secure, it Was hoped, permanent co-operative nctivity for both America and Italy. \Vo chose five of the sixty-nine provinces-Genoa, Perugia, Cagliur! n·nd Ho.ssnri in Sardinia, Palermo in Sicily-as types of broad fields of orgnnisation. 'Ve selected nineteen towns or cities, ranging from Naples to Pipcuo, for smaller community organisation, In every case the pre-requisite was an Italian committee of volunteers already formed, or in process of Iormation, with purposes nnd plans of its own, which was willing to further their progress by consultation and combined investment. '!'heso committees were placed upon a formal business basis. Suitable constitutions nnd by-laws were laid down, om cera elected, sub-committees appointed and assigned to definite activities, and executive sccrctlll'ies-
of
September, HJ20]
TummcLE
553
until then almost unknown in Itnly-e-engaged and Bet to work. Each locality was carefully studied and co-ordinate plans wero formulated and adapted, including hospitals and sanatoriums, dispensaries and public health visitors, school hygiene and open-air schools, statistics, teaching of general hygiene, etc. At the outset the principle was laid down that wo were there in nn advisory capacity only. 'Vo had no intentions of attempting an offensive AI demonstration" of American methods. 'Ve placed our knowledge, om equipment, our personnel, our funds nt the disposal of the Italians. In turn wo were rewarded by evidences of their confide nco in us, or their respect for our advice, of their integrity, punctiliousness, and superior wisdom in the use of funds, and of their great intelligence and determination to further the welfare of their people. There are many interesting and nearly perfect pieces of work going on in Italy, but progress is delayed for the moment by the lack of registration, of laboratories, of nursing, and of the principle of co-ordination. It must, however, bo said on' behalf of Italy, that while in the north she has kept pace in progress with other countries, in the south she has inherited a. problem with which she cannot adequately cope for many years unless America or England, her lifelong friend, come to her assistance. Now roads, railroads, aqueducts, houses, must bo built, water-power must be developed, drainage installed, trees planted, The swamps must be drained, a systematic control of emigration must be established to prevent the depletion of whole villages (now a usual occurrence), and, above nil, Dew and better schools must be provided. Although the death-rate in southern Italy from many diseases is low, yet tho squalor of the villages makes life in them to us unthinkable. Tho only possible centre of reconstruction is the schoolhouse. 'l'he communal school, the provincial school, tho Asili of the" Associazione nazionale pcr gl' Interessi del l\Iezzogiorno," the schools for tho contatlini in the Agro Homano-these are the influences which are already helping these backward peoplo to climb out of the depths into which centuries of misgovernment have plunged them: these are the candles to light them out of their ignorance, their suspicion, their poverty, their squalor. In many rural districts in the United States, in our mining towns or foreign population, in many mountain communities, we too must deal with similar problems, and we nrc finding that it if! from the schoolhouse that regenerative influences start. Such enormous problems require an expenditure far beyond the present resources of Italy, but for America and England to give her tho help she needs in establishing her schools would not be n charity; it would be an excellent investment. So long a.s she sends so great a number of her people to the United States and to tho British Colonies, it is possible to say to her, .. It is our duty to share the expense of educating your people." Offered in such away, as one step in international co-operation toward tho welfare of the world, Italy would not find it humiliating to accept our nsaistance. This principle we have tested by the work of our Commission and we believe that it is the basis for international welfare work, in which nt least, let us hope, the day Cor intense nntionnlization is over.