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Compiler's general conclusions
130
COMPILER'S GENERAL CONCLUSIONS. The wide application of modern forms of intensified treatment leads one to ask how far an improvement in the ultimate results can be measured up to date ; and indeed how far such an improvement may influence our policy of after-care. A survey of follow-up statistics of sanatorium ex-patients and of patients on the dispensary register in consecutive year-groups reveals that since 1920 the mortality rate from tuberculosis has steadily decreased. An analysis of the after-history of survivors has been made by means of a special statistical investigation on following up separately the plus-minus and plus-plus cases. A prognostic classification has been suggested for further statistical investigation of this aspect of the tuberculosis problem. Therapy has succeeded in increasing the number of survivors and also of the arrested cases ; but in a large proportion this arrest is only conditional. Complete recovery depends mainly upon the maintenance of such conditions as enable the benefits of treatment to be retained. This is the essential consideration in planning the environment which will follow discharge from sanatoria. The more therapy succeeds in making tubercle-positive cases tubercle-negative, the more necessary it becomes to retain the recovery if the cost of prolonged and intensified therapy is not to be lost, by establishing after-care departments in sanatorium schemes. As long as the middle group of chronic cases continues to constitute a problem, just so long must a scheme for their re-employment and after-care be regarded as a complement of the whole regime of therapy. The restoration of working capacity for the tuberculous is supposedly the ultimate objective of all measures for care and treatment. Statistics have confirmed that the great majority of those who survive the dangers of the first years of illness must nevertheless seek their living in circumstances which have little or no regard for their physical condition. The tuberculous working man who survives from year to year must work in order to exist, although it is well known that certain stress and strain may seriously impair the benefits of treatment. The tuberculous members of the population must be regarded as a real factor in the economic system of the nation. Under the present system it may be shown that they constitute a very heavy charge on the budget of the community. Organised rehabilitation and re-employment are important not only for the well-being of the tuberculous worker but also for the economic well-being of the Community.
131 The rehabilitation of the tuberculous and their incorporation in the industrial economy of the nation may be said to constitute a special problem. It demands the development of the science of estimating working capacity and its study in relation to individual physical conditions and actual working conditions. I t may not be too much to say that with the increasing pace of industry, a centre for such work is becoming more and more necessary in every industrial scheme. The preliminary work that has been done shows that rough calculations are of little use in this science which is yet in its infancy. The economic value of the sub-standard worker can only be assessed by his employment in industry where his physical and economic efficiency can be controlled by continuous clinical care. Permanent employment in sheltered conditions with such care is the first essential for a good scheme for the employment of the tuberculous. The period of such rehabilitation should begin as "industrial convalescence." This is followed by re-employment under conditions where the benefits of therapy are consolidated rather than tested by strain. The re-employment of the tuberculous depends upon the degree of stabilisation in general physical condition that can be attained by treatment. The recovered case may be able to achieve a degree of stabilisation which will allow return to work in normal life. The invalid however must be cared for, either in hospitals or homes where the risk of infection is minimised. Those most in need of sheltered conditions of employment are those who constitute the group known as middle cases. From their condition they are unemployable in normal industry. For such persons industrial settlements have developed as a combination of treatment and employment. I t has brought into being a new type of institution, one that secures for the substandard worker a smooth path through all the various phases of medical, social and industrial convalescence. Sheltered industries are most satisfactory for the re-employment of the tuberculous where an industrial plant is set up under hygienic conditions and fully mechanised. In this way the full advantage of the machine in compensating physical handicap are developed and thus even those suffering from severe disablement may be brought within the scope of a plan for re-employment. It has been proved possible to build up such a scheme at no greater cost than relief by public assistance. Indeed the cost to the community is considerably less in infection as well as money. The care of the tuberculous is inevitably a heavy charge and the present scheme is by no means efficiently used. To add to the normal measures for the combat of tuberculosis a plan for rehabilitation and re-employment will not be so much an additional expense as a method of guaranteeing the ultimate result of costly treatment to be good. E. BRIEGER. Caldecote, Cambridge,August 1937.
COMPILER'S GENERAL CONCLUSIONS. The wide application of modern forms of intensified treatment leads one to ask how far an improvement in the ultimate results can be measured up to date ; and indeed how far such an improvement may influence our policy of after-care. A survey of follow-up statistics of sanatorium ex-patients and of patients on the dispensary register in consecutive year-groups reveals that since 1920 the mortality rate from tuberculosis has steadily decreased. An analysis of the after-history of survivors has been made by means of a special statistical investigation on following up separately the plus-minus and plus-plus cases. A prognostic classification has been suggested for further statistical investigation of this aspect of the tuberculosis problem. Therapy has succeeded in increasing the number of survivors and also of the arrested cases ; but in a large proportion this arrest is only conditional. Complete recovery depends mainly upon the maintenance of such conditions as enable the benefits of treatment to be retained. This is the essential consideration in planning the environment which will follow discharge from sanatoria. The more therapy succeeds in making tubercle-positive cases tubercle-negative, the more necessary it becomes to retain the recovery if the cost of prolonged and intensified therapy is not to be lost, by establishing after-care departments in sanatorium schemes. As long as the middle group of chronic cases continues to constitute a problem, just so long must a scheme for their re-employment and after-care be regarded as a complement of the whole regime of therapy. The restoration of working capacity for the tuberculous is supposedly the ultimate objective of all measures for care and treatment. Statistics have confirmed that the great majority of those who survive the dangers of the first years of illness must nevertheless seek their living in circumstances which have little or no regard for their physical condition. The tuberculous working man who survives from year to year must work in order to exist, although it is well known that certain stress and strain may seriously impair the benefits of treatment. The tuberculous members of the population must be regarded as a real factor in the economic system of the nation. Under the present system it may be shown that they constitute a very heavy charge on the budget of the community. Organised rehabilitation and re-employment are important not only for the well-being of the tuberculous worker but also for the economic well-being of the Community.
131 The rehabilitation of the tuberculous and their incorporation in the industrial economy of the nation may be said to constitute a special problem. It demands the development of the science of estimating working capacity and its study in relation to individual physical conditions and actual working conditions. I t may not be too much to say that with the increasing pace of industry, a centre for such work is becoming more and more necessary in every industrial scheme. The preliminary work that has been done shows that rough calculations are of little use in this science which is yet in its infancy. The economic value of the sub-standard worker can only be assessed by his employment in industry where his physical and economic efficiency can be controlled by continuous clinical care. Permanent employment in sheltered conditions with such care is the first essential for a good scheme for the employment of the tuberculous. The period of such rehabilitation should begin as "industrial convalescence." This is followed by re-employment under conditions where the benefits of therapy are consolidated rather than tested by strain. The re-employment of the tuberculous depends upon the degree of stabilisation in general physical condition that can be attained by treatment. The recovered case may be able to achieve a degree of stabilisation which will allow return to work in normal life. The invalid however must be cared for, either in hospitals or homes where the risk of infection is minimised. Those most in need of sheltered conditions of employment are those who constitute the group known as middle cases. From their condition they are unemployable in normal industry. For such persons industrial settlements have developed as a combination of treatment and employment. I t has brought into being a new type of institution, one that secures for the substandard worker a smooth path through all the various phases of medical, social and industrial convalescence. Sheltered industries are most satisfactory for the re-employment of the tuberculous where an industrial plant is set up under hygienic conditions and fully mechanised. In this way the full advantage of the machine in compensating physical handicap are developed and thus even those suffering from severe disablement may be brought within the scope of a plan for re-employment. It has been proved possible to build up such a scheme at no greater cost than relief by public assistance. Indeed the cost to the community is considerably less in infection as well as money. The care of the tuberculous is inevitably a heavy charge and the present scheme is by no means efficiently used. To add to the normal measures for the combat of tuberculosis a plan for rehabilitation and re-employment will not be so much an additional expense as a method of guaranteeing the ultimate result of costly treatment to be good. E. BRIEGER. Caldecote, Cambridge,August 1937.