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Health organisation of the league of nations
TUBERCLE
d i s t i n c t a t five or six d a y s . The writer, t h e r e f o r e , p o i n t s ou~ t h a ~ g l y c e r i n e i n 50 p e r c e n t . s t r e n g t h as a d i l u e n t for ~ u b e r c u l i n , as h a s b e e n a d v o c a t e d r e c e n t l y , is u n s a t i s f a c t o r y o n t h i s account, since many tuberculin reactions a r e i n t e r p r e t e d o n t h e b a s i s of i n d u r a t i o n a l o n e . T h i s is e s p e c i a l l y m i s l e a d i n g w h e n t h e r e s u l t s of t h e t e s t a r e i n t e r p r e t e d o n t h e f o u r t h or f i f t h d a y o n l y , by w h i c h t i m e m o s t , if n o t all, of t h e redness has disappeared. D E B E R N A D I N I S , V., and D ' A L E S SAN DRO, g . R a p p o r t i f r a le a l t e r a z l o n i ematologiche e umorali indotte dalla malaria e dalla tubercolosi. Lotta Centre la T~bercolosi, 1983, 8, 891. The writers carried out the cutir e a c t i o n i n 18 p a t i e n t s w i t h p u l m o n a r y
[March, 1933
t u b e r c u l o s i s w h o w e r e t h e s u b j e c t s of active benign tertian malaria, and o b t a i n e d a p o s i t i v e r e s u l t in o n l y t h r e e cases. T h e y c o n c l u d e t h a t m a l a r i a i n its a c t i v e s t a g e p r o d u c e s a c o n d i t i o n of a n e r g y as in m e a s l e s a n d o t h e r i n f e c t i o u s diseases which create a predisposition to t u b e r c u l o s i s . A s t u d y of n i n e t u b e r c u l o u s p a t i e n t s in a s a n a t o r i u m w h o h a d h a d a r e c e n t a t t a c k of m a l a r i a s h o w e d t h a t m a l a r i a did n o t e x e r c i s e a n y a n t a g onistic action on tuberculosis, but on the contrary one case was unfavourably affected b y t h e c o i n c i d e n c e of t h e t w o infections. On the other hand, when the a c u t e s t a g e of m a l a r i a h a s s u b s i d e d , tuberculosis pursues its course according t o t h e n a t u r e of t h e a t t a c k a n d t h e r e s i s t a n c e of t h e i n d i v i d u a l .
HEALTH ORGANISATION OF THE LEAGUE OF NATIONS. PREVENTION OF TUBERCULOSIS.--GENERAL PRINCIPLES.
I~ 1931, the Health Committee of the League of Nations appointed a Reporting Committee, with Dr. E. Burner, Deputy Director of the Pasteur Institute at Tunis, as Secretary. The other members were 9 Professor L4on Bernard, Dr. C. Hamel, Dr. A. S. MacNalty, and Dr. W. B. Soper. The Secretary prepared a report ca the General Principles Governing the Prevention of Tuberculosis. This report was examined by the Reporting Committee at The Hague, in September, 193~, and discussed by all the members of the Health Oommittee at its nineteenth session. Its conclusions have been formally adopted by the Health Committee (Quarterly Bulletin of the Health Organisation of the League of Nations, Vol. I, No. 4, December, 1932). It has assumed its final form as a result of ths written comments on the first draft by the other members of the Reporting Committee, and it has been edited to represent the views of the Health Committee. The exceptional value of this report depends largely on the uniformity of presentation which only unity of authorship can provide, as well as on t h a t diversity of outlook which can best be assured by the cordial cooperation of a mixed editorial body. The author has conducted a personal inquiry into the organisation of the tuberculosis campaigns in Germany, Austria, Denmark, France, Great Britain, Italy, Holland and Yugoslavia. Documentary material obtained at first hand from the public health authorities of Belgium, Spain, Norway, Sweden and Switzerland was also drawn on. The report deserves a close study in the original, and the following running
commentary can only serve as an introduction, in the sure and certain hope that it will whet the appetite for more. In the first chapter, which deals with tuberculosis as a social disease, the author ventures the opinion, that it is more deeply embedded in the social body than any other infectious disease. " Directly one begins to study it, one feels that to stamp it out it would be necessary to revolutionise society." In this connection the author quotes the prophetic words written by Virchow in thai, eventful year of 1848, when all Europe was rocking with the upheaval of the new social revolution : " Why, in Europe, have both isolated diseases and epidemics assumed a much more benign character than in the Middle Ages, where one epidemic followed another? Solely because those classes of the population who were formerly excluded almost entirely from the enjoyment of life's blessings have come into their own." Dr. Burner is as emphatically cheerful and certain about the decline in the death-rate from tuberculosis in practically every country as he is the reverse when he discusses the morbidity-rate. " T h a t is the chief question to which the hygienist requires an answer, and t h a t is the question about which he knows least." Opinions on this point are, indeed, sadly at variance. In Germany alone, one authority has put the ratio of deaths to living patients at 1 to 3"5, while another has put this ratio at 1 to 10. The discussion of this subject ends with the pregnant comment: " The test of anti-tuberculosis organisation will be the establishment of morbidity statistics." In his comments on the decline in the tuberculosis mortality, Dr. B u r z e t draws
March, 1933]
LEAGUE
OF
attention to the curious fact that, generally speaking, it is greater for males t h a n females in towns and urban districts, but less in agricultural districts. This observation does not, however, apply to E o g l a n d and Wales 9 There are m a n y criteria by which the civilisation of a c o u n t r y c a n be judged. Dr. Burner's criterion is good statistics. I n this connection he states t h a t " t h e tuberculosis mortality appears to be falling chiefly in countries in which the statistics are most reliable, and to be increasing in those in which they cannot yet be considered so." Recent observations on the present German industrial crisis suggest that it has not yet had the effect of increasing tuberculosis 9 The facts even warrant the paradoxical conclusion that, so long as enough food is obtainable, the decline in the tuberculosis mortality continues as in times of prosperity, despite the lowering of the standard of living, because unemploym e n t involves enforced rest. " We should, however, guard against hasty conclusions 9 The long-distance effects of the depression will only appear in the course of time 9 The publication quoted (a m e m o r a n d u m on the economic depression and public health published by the League of Nation's Health Section) discloses, however, this significant fact : that u n e m p l o y m e n t pay is sufficient, at a pinch, to feed the unemployed, provided they lay out from 60 to 75 per cent 9 of their money on foodstuffs, the quality of which is deteriorating day by d~y, t h a t they buy no new clothes, and that their rent is not too high. Finally, reports for 1932 already reveal a whole n u m b e r of facts which justify the apprehension of a deterioration of public h e a l t h comparable to that caused by food restrictions during the war." The terrible evidence of the effect of malnutrition on the tuberculosis death-rate during the war shows that in England the increas~ amounted to 13 per cent., chiefly among the insane and prisoners, in Holland to 30 per cent,, in Italy to 35 per cent., and in Germany and Austria to 70 per cent 9 These are, indeed, ominous warnings at the present time 9 Dr. Burner quotes and stamps as a fatalistic m y t h the following sententious and seemingly philosophical judgment : " The regularity and constancy of the decline of the tuberculosis mortality, from numerous causes, some more or less potent, operating at different points in time and space and interwoven with the social environment, are a thing so marvellous that, since it can be ~scribed neither to the providential concurrence of so m a n y counterbalancing factors, nor to the unaided efforts of man, it has finally been viewed as reflecting the imperturbable onward m a r c h of a cosmic process." To this sonorous pronouncement on the imperturbable onward m a r c h of a cosmic process, Dr. Burner replies with evidence showing that the decline is being hastened by the progress of science and medicine, and the work o[ anti-tuberculosis institutions. W h e n Dr. Burner, in his report, whose conclusions have been formally adopted by the Health Committee of the League of Nations, comes to the problem of tuberculosis in country
NATIONS
districts, he shows how scarcity of labour and its arduous character in the country predispose to tuberculosis 9 There is also the return to the country of tuberculous soldiers and domestic servants whose disease has been contracted in the towns 9 F u r t h e r , the notoriously bad rural hygiene, and above all bad housing, are greatly to blame. Dr. B u r n e r ' s remedy for this state of affairs is the adaptation to the special circumstances of rural life in the various countries of those general methods of prevention whose value is reeognised. As an instance of what can be done in rural areas he refers to the health demonstration conducted in Sweden, a complete account of which has been given by Neander in Acta Tub. Scand. (vol. vii, fuse. 34, 1931). i n the discussion of the agencies for the prevention of tuberculosis, the opening sentence runs : " The pivotal agency of social hygiene is the dispensary." F u r t h e r on it is stated that the real work of the dispensary is done for the most part outside the dispensary itself. " Its main function is epidemiological research, and its essential agent is the visiting nurse." W h a t of t r e a t m e n t in dispensaries? " Out of consideration for the doctors, dispensaries do not, as a rule, give t r e a t m e n t . Re-insuffiations are regarded as t r e a t m e n t . Such are the principles which are nowadays accepted, or rather, which have so far been accepted ; for they are now being seriously questioned. The advance made in treatment, artificial pneumothorax and chrysotherapy, will inevitably modify the prevailing conception of t h e dispensary 9 Dr. Burner goes on to point out that pressure on hospital and sanatorium beds tends to push the pneumothorax patient into the dispensary and " i n France, several specialists are inclined to permit the out-patient system, even for the establishment of pneumothorax-- in some cases at l e a s t - - a n d , a forliori, for re-insuffiations." This means that the dispensary physician m u s t be properly equipped for this task: " Even reinsuffiation cannot be entrusted to doctors having no experience." It may be added in parenthesis that at the Centre La~nnec in Paris about 400 re-insuffiations are given every week. Dr. Burner's conclusions with regard to this vexed problem of treatment in the dispensary are as follows : - " The gener~d scheme of dispensary work m u s t be modified ; to its essential preventive duties there should be added therapeutic work w i t h i n such limits as circumstances require, since this work is of value in prevention." This opinion is, however, somewhat modified a little f u r t h e r o n , where the following passage 9
.
.
occurs :--
" Even though the preventive value of t r e a t m e n t is acknowledged, it cannot be a d m i t t e d that this is the Iorm of preventive work for which the dispensary is planned. Would not therapeutic work and the truly medical, and wholly legitimate, satisfaction it affords the doctor be likely to lessen his zeal for that preventive action which is
TUBERCLE
possible only if t h e dispensary spreads its activities afield; m i g h t it n o t adversely affec~ t h e patient, u n r e m i t t i n g work of epidemiologieal inquiry ? I n s t e a d of m e r g i n g the t h e r a p e u t i c with t h e preventive work, would it n o t be better to orgauise t h e m c a 2arallel lines? That is, to a t t a c h t h e dispensary to gold-salt a n d p n e u m o t h o r a x t r e a t m e n t centres, j u s t as it is a t t a c h e d to hospitals.. . " T h i s discussion of t h e dispensary is completed by a reference to t h e travelling dis. pensary, a n d as a n illustrative case, t h e work of the travelling dispensary of Chiavari in Italy is described. The section dealing with s a n a t o r i a is quite short. Accordiugto t h e a u t h o r , it is generally a d m i t t e d t h a t there ought, in a n y country, to be as m a n y beds available for tuberculous p a t i e n t s as there are d e a t h s from tuberculosis d u r i n g the year. I n t h e U.S.A., two beds arc d e m a n d e d per death. B u t where claims foe f u n d s clash between t h e dispensary a n d the s a n a t o r i u m , Dr. Burner shows a definite preference for t h e former. " W e m u s t a s s u m e t h a t t r e a t m e n t in sanatoria, in spite of its increased value, cannot eradicate tuberculosis . . . . We m u s t , therefore, concentrate our efforts on prevention by m e a n s of dispensaries, a n d endeavour to reduce t h e n u m b e r of cases which need to be a d m i t t e d to institutions. E i t h e r t h e c a m p a i g n against tuberculosis will never come to a n end, or t h e n u m b e r of beds will become larger t h a n necessary after having for so long been inadequate. T h a t day will come in t e n or twenty or t h i r t y years or more, b u t come it will . . . . The future tendency should be to spend more on dispensaries and less on s a n a t o r i a . " I n t h e fifth chapter, devoted to conclusions, Dr. B u r n e r m a k e s an interesting c o m p a r i s e n between t h e history of leprosy a n d tha~ of tuberculosis. Leprosy was s u b d u e d in E u r o p e by t h e progress of general civilisation a n d t h e practice of isolation. :Nowadays, in countries where it is still rife, it yields only to improved s t a n d a r d s of living, particularly in t h e m a t t e r of food a n d personal cleanliness, to isolation u n d e r suitable conditions, a n d to preventive m e a s u r e s applied to t h e whole population. Similarly, in Dr B u r n e r ' s opinion, tuberculosis will yield only to social hygiene, i.e., preventive medicine a n d the medical care of t h e c o m m u n i t y as a whole. I n t h i s conneetiou he notes t h a t schools provide t h e m o s t effective of
[March, 1933
all m e a n s for i n c u l c a t i n g in t h e public m i n d t h e knowledge a c c u m u l a t e d in t h e sphere of hygiene. The present world crisis forms a convincing background to Dr. B u r n e r ' s a r g u m e n t t h a t anti-tuberculosis work is becoming increasingly i n t e r n a t i o n a l in character. " T h e W a r left its m a r k on t h e tuberculosis m o r t a l i t y curves of all countries, w h e t h e r belligerent or neutral, p r o d u c i n g a s h a r p rise. Tuberculosis c a n be finally s t a m p e d o u t or reduced to a m i n i m u m only in a n a t m o s p h e r e of prosperity a n d security." W i t h regard to t h e a l l - i m p o r t a n t problem of finance there is an e l e m e n t of confusion in t h e following two passages : - " We have given particulars of e x p e n d i t u r e in various countries ; t h e working expenses of dispensaries and sanatoria, t h e contribution m a d e by i n s u r a n c e funds. I n those countries in w h i c h anti-tuberculosis action is m o s t effective, the total expenditure, so far as it c a n be estimated, is approximately two shillings, two m a r k s or two gold francs per i n h a b i t a n t . There is a striking concordance between these figures in countries where t h e organisation appears to be working s a t i s f a c t o r i l y " {p. 656}. " N e v e r t h e l e s s it is a remarkable coincidence t h a t in several i m p o r t a n t countries in w h i c h t h e c a m p a i g n a g a i n s t tuberculosis is m o s t efficiently organised, a n d in w h i c h t h e death-r~te from tuberculosis is regularly decreasing, t h e total e x p e n d i t u r e m a y be e s t i m a t e d at about 1'50 gold francs per i n h a b i t a n t per a n n u m " (p. 6631. The report concludes with a series of aphorisms, of which t h e following are samples : - " I n the present state of our knowledge, since heredity is a negligible factor in t h e c a u s a t i o n of tuberculosis, the prevention of infection m u s t be regarded as t h e p r i m a r y activity in t h e c a m p a i g n a g a i n s t t h i s disease." " R e s e a r c h work on questions of n u t r i t i o n , especially those of i m p o r t a n c e to t h e people, production, t r a n s p o r t , price a n d cooking of foodstuffs, a n d food r a t i o n s from t h e standpoint of q u a n t i t y a n d quality, should be m a d e use of to assist in p r o p h y l a x i s . "
Quarterly Bulletin of the Health Organisa. tion of the League of Nations. Vol. I, bTo. 4, December, 1932.
SOCIETIES. T H E T U B E R C U L O S I S ASSOCIATION. A ~EETING of t h e Tuberculosis Association was held in L o n d o n on F r i d a y , J a n u a r y 20. At t h e first session Professor S. Lyle C u m m i n s spoke on TUBERCULOSIS IN SOUTH AFRICAN ~'~TIVES. He said t h a t this special liability of negroes to c o n s u m p t i o n h a d long been recogniscd.
T h o m a s Yom~g, in his book published in 1815, insisted on this k n o w n liability as a n argum e n t for t h e i m p o r t a n c e of removal from a w a r m to a cold c l i m a t e as " t h e least a m b i g u ous of all t h e remote causes of the disease . . . its effect being seen in negroes who settle in E n g l a n d . " J u s t twenty-five years ago, the speaker himself, fresh from a period of service in t h e equatorial provinces of t h e S u d a n
d i s t i n c t a t five or six d a y s . The writer, t h e r e f o r e , p o i n t s ou~ t h a ~ g l y c e r i n e i n 50 p e r c e n t . s t r e n g t h as a d i l u e n t for ~ u b e r c u l i n , as h a s b e e n a d v o c a t e d r e c e n t l y , is u n s a t i s f a c t o r y o n t h i s account, since many tuberculin reactions a r e i n t e r p r e t e d o n t h e b a s i s of i n d u r a t i o n a l o n e . T h i s is e s p e c i a l l y m i s l e a d i n g w h e n t h e r e s u l t s of t h e t e s t a r e i n t e r p r e t e d o n t h e f o u r t h or f i f t h d a y o n l y , by w h i c h t i m e m o s t , if n o t all, of t h e redness has disappeared. D E B E R N A D I N I S , V., and D ' A L E S SAN DRO, g . R a p p o r t i f r a le a l t e r a z l o n i ematologiche e umorali indotte dalla malaria e dalla tubercolosi. Lotta Centre la T~bercolosi, 1983, 8, 891. The writers carried out the cutir e a c t i o n i n 18 p a t i e n t s w i t h p u l m o n a r y
[March, 1933
t u b e r c u l o s i s w h o w e r e t h e s u b j e c t s of active benign tertian malaria, and o b t a i n e d a p o s i t i v e r e s u l t in o n l y t h r e e cases. T h e y c o n c l u d e t h a t m a l a r i a i n its a c t i v e s t a g e p r o d u c e s a c o n d i t i o n of a n e r g y as in m e a s l e s a n d o t h e r i n f e c t i o u s diseases which create a predisposition to t u b e r c u l o s i s . A s t u d y of n i n e t u b e r c u l o u s p a t i e n t s in a s a n a t o r i u m w h o h a d h a d a r e c e n t a t t a c k of m a l a r i a s h o w e d t h a t m a l a r i a did n o t e x e r c i s e a n y a n t a g onistic action on tuberculosis, but on the contrary one case was unfavourably affected b y t h e c o i n c i d e n c e of t h e t w o infections. On the other hand, when the a c u t e s t a g e of m a l a r i a h a s s u b s i d e d , tuberculosis pursues its course according t o t h e n a t u r e of t h e a t t a c k a n d t h e r e s i s t a n c e of t h e i n d i v i d u a l .
HEALTH ORGANISATION OF THE LEAGUE OF NATIONS. PREVENTION OF TUBERCULOSIS.--GENERAL PRINCIPLES.
I~ 1931, the Health Committee of the League of Nations appointed a Reporting Committee, with Dr. E. Burner, Deputy Director of the Pasteur Institute at Tunis, as Secretary. The other members were 9 Professor L4on Bernard, Dr. C. Hamel, Dr. A. S. MacNalty, and Dr. W. B. Soper. The Secretary prepared a report ca the General Principles Governing the Prevention of Tuberculosis. This report was examined by the Reporting Committee at The Hague, in September, 193~, and discussed by all the members of the Health Oommittee at its nineteenth session. Its conclusions have been formally adopted by the Health Committee (Quarterly Bulletin of the Health Organisation of the League of Nations, Vol. I, No. 4, December, 1932). It has assumed its final form as a result of ths written comments on the first draft by the other members of the Reporting Committee, and it has been edited to represent the views of the Health Committee. The exceptional value of this report depends largely on the uniformity of presentation which only unity of authorship can provide, as well as on t h a t diversity of outlook which can best be assured by the cordial cooperation of a mixed editorial body. The author has conducted a personal inquiry into the organisation of the tuberculosis campaigns in Germany, Austria, Denmark, France, Great Britain, Italy, Holland and Yugoslavia. Documentary material obtained at first hand from the public health authorities of Belgium, Spain, Norway, Sweden and Switzerland was also drawn on. The report deserves a close study in the original, and the following running
commentary can only serve as an introduction, in the sure and certain hope that it will whet the appetite for more. In the first chapter, which deals with tuberculosis as a social disease, the author ventures the opinion, that it is more deeply embedded in the social body than any other infectious disease. " Directly one begins to study it, one feels that to stamp it out it would be necessary to revolutionise society." In this connection the author quotes the prophetic words written by Virchow in thai, eventful year of 1848, when all Europe was rocking with the upheaval of the new social revolution : " Why, in Europe, have both isolated diseases and epidemics assumed a much more benign character than in the Middle Ages, where one epidemic followed another? Solely because those classes of the population who were formerly excluded almost entirely from the enjoyment of life's blessings have come into their own." Dr. Burner is as emphatically cheerful and certain about the decline in the death-rate from tuberculosis in practically every country as he is the reverse when he discusses the morbidity-rate. " T h a t is the chief question to which the hygienist requires an answer, and t h a t is the question about which he knows least." Opinions on this point are, indeed, sadly at variance. In Germany alone, one authority has put the ratio of deaths to living patients at 1 to 3"5, while another has put this ratio at 1 to 10. The discussion of this subject ends with the pregnant comment: " The test of anti-tuberculosis organisation will be the establishment of morbidity statistics." In his comments on the decline in the tuberculosis mortality, Dr. B u r z e t draws
March, 1933]
LEAGUE
OF
attention to the curious fact that, generally speaking, it is greater for males t h a n females in towns and urban districts, but less in agricultural districts. This observation does not, however, apply to E o g l a n d and Wales 9 There are m a n y criteria by which the civilisation of a c o u n t r y c a n be judged. Dr. Burner's criterion is good statistics. I n this connection he states t h a t " t h e tuberculosis mortality appears to be falling chiefly in countries in which the statistics are most reliable, and to be increasing in those in which they cannot yet be considered so." Recent observations on the present German industrial crisis suggest that it has not yet had the effect of increasing tuberculosis 9 The facts even warrant the paradoxical conclusion that, so long as enough food is obtainable, the decline in the tuberculosis mortality continues as in times of prosperity, despite the lowering of the standard of living, because unemploym e n t involves enforced rest. " We should, however, guard against hasty conclusions 9 The long-distance effects of the depression will only appear in the course of time 9 The publication quoted (a m e m o r a n d u m on the economic depression and public health published by the League of Nation's Health Section) discloses, however, this significant fact : that u n e m p l o y m e n t pay is sufficient, at a pinch, to feed the unemployed, provided they lay out from 60 to 75 per cent 9 of their money on foodstuffs, the quality of which is deteriorating day by d~y, t h a t they buy no new clothes, and that their rent is not too high. Finally, reports for 1932 already reveal a whole n u m b e r of facts which justify the apprehension of a deterioration of public h e a l t h comparable to that caused by food restrictions during the war." The terrible evidence of the effect of malnutrition on the tuberculosis death-rate during the war shows that in England the increas~ amounted to 13 per cent., chiefly among the insane and prisoners, in Holland to 30 per cent,, in Italy to 35 per cent., and in Germany and Austria to 70 per cent 9 These are, indeed, ominous warnings at the present time 9 Dr. Burner quotes and stamps as a fatalistic m y t h the following sententious and seemingly philosophical judgment : " The regularity and constancy of the decline of the tuberculosis mortality, from numerous causes, some more or less potent, operating at different points in time and space and interwoven with the social environment, are a thing so marvellous that, since it can be ~scribed neither to the providential concurrence of so m a n y counterbalancing factors, nor to the unaided efforts of man, it has finally been viewed as reflecting the imperturbable onward m a r c h of a cosmic process." To this sonorous pronouncement on the imperturbable onward m a r c h of a cosmic process, Dr. Burner replies with evidence showing that the decline is being hastened by the progress of science and medicine, and the work o[ anti-tuberculosis institutions. W h e n Dr. Burner, in his report, whose conclusions have been formally adopted by the Health Committee of the League of Nations, comes to the problem of tuberculosis in country
NATIONS
districts, he shows how scarcity of labour and its arduous character in the country predispose to tuberculosis 9 There is also the return to the country of tuberculous soldiers and domestic servants whose disease has been contracted in the towns 9 F u r t h e r , the notoriously bad rural hygiene, and above all bad housing, are greatly to blame. Dr. B u r n e r ' s remedy for this state of affairs is the adaptation to the special circumstances of rural life in the various countries of those general methods of prevention whose value is reeognised. As an instance of what can be done in rural areas he refers to the health demonstration conducted in Sweden, a complete account of which has been given by Neander in Acta Tub. Scand. (vol. vii, fuse. 34, 1931). i n the discussion of the agencies for the prevention of tuberculosis, the opening sentence runs : " The pivotal agency of social hygiene is the dispensary." F u r t h e r on it is stated that the real work of the dispensary is done for the most part outside the dispensary itself. " Its main function is epidemiological research, and its essential agent is the visiting nurse." W h a t of t r e a t m e n t in dispensaries? " Out of consideration for the doctors, dispensaries do not, as a rule, give t r e a t m e n t . Re-insuffiations are regarded as t r e a t m e n t . Such are the principles which are nowadays accepted, or rather, which have so far been accepted ; for they are now being seriously questioned. The advance made in treatment, artificial pneumothorax and chrysotherapy, will inevitably modify the prevailing conception of t h e dispensary 9 Dr. Burner goes on to point out that pressure on hospital and sanatorium beds tends to push the pneumothorax patient into the dispensary and " i n France, several specialists are inclined to permit the out-patient system, even for the establishment of pneumothorax-- in some cases at l e a s t - - a n d , a forliori, for re-insuffiations." This means that the dispensary physician m u s t be properly equipped for this task: " Even reinsuffiation cannot be entrusted to doctors having no experience." It may be added in parenthesis that at the Centre La~nnec in Paris about 400 re-insuffiations are given every week. Dr. Burner's conclusions with regard to this vexed problem of treatment in the dispensary are as follows : - " The gener~d scheme of dispensary work m u s t be modified ; to its essential preventive duties there should be added therapeutic work w i t h i n such limits as circumstances require, since this work is of value in prevention." This opinion is, however, somewhat modified a little f u r t h e r o n , where the following passage 9
.
.
occurs :--
" Even though the preventive value of t r e a t m e n t is acknowledged, it cannot be a d m i t t e d that this is the Iorm of preventive work for which the dispensary is planned. Would not therapeutic work and the truly medical, and wholly legitimate, satisfaction it affords the doctor be likely to lessen his zeal for that preventive action which is
TUBERCLE
possible only if t h e dispensary spreads its activities afield; m i g h t it n o t adversely affec~ t h e patient, u n r e m i t t i n g work of epidemiologieal inquiry ? I n s t e a d of m e r g i n g the t h e r a p e u t i c with t h e preventive work, would it n o t be better to orgauise t h e m c a 2arallel lines? That is, to a t t a c h t h e dispensary to gold-salt a n d p n e u m o t h o r a x t r e a t m e n t centres, j u s t as it is a t t a c h e d to hospitals.. . " T h i s discussion of t h e dispensary is completed by a reference to t h e travelling dis. pensary, a n d as a n illustrative case, t h e work of the travelling dispensary of Chiavari in Italy is described. The section dealing with s a n a t o r i a is quite short. Accordiugto t h e a u t h o r , it is generally a d m i t t e d t h a t there ought, in a n y country, to be as m a n y beds available for tuberculous p a t i e n t s as there are d e a t h s from tuberculosis d u r i n g the year. I n t h e U.S.A., two beds arc d e m a n d e d per death. B u t where claims foe f u n d s clash between t h e dispensary a n d the s a n a t o r i u m , Dr. Burner shows a definite preference for t h e former. " W e m u s t a s s u m e t h a t t r e a t m e n t in sanatoria, in spite of its increased value, cannot eradicate tuberculosis . . . . We m u s t , therefore, concentrate our efforts on prevention by m e a n s of dispensaries, a n d endeavour to reduce t h e n u m b e r of cases which need to be a d m i t t e d to institutions. E i t h e r t h e c a m p a i g n against tuberculosis will never come to a n end, or t h e n u m b e r of beds will become larger t h a n necessary after having for so long been inadequate. T h a t day will come in t e n or twenty or t h i r t y years or more, b u t come it will . . . . The future tendency should be to spend more on dispensaries and less on s a n a t o r i a . " I n t h e fifth chapter, devoted to conclusions, Dr. B u r n e r m a k e s an interesting c o m p a r i s e n between t h e history of leprosy a n d tha~ of tuberculosis. Leprosy was s u b d u e d in E u r o p e by t h e progress of general civilisation a n d t h e practice of isolation. :Nowadays, in countries where it is still rife, it yields only to improved s t a n d a r d s of living, particularly in t h e m a t t e r of food a n d personal cleanliness, to isolation u n d e r suitable conditions, a n d to preventive m e a s u r e s applied to t h e whole population. Similarly, in Dr B u r n e r ' s opinion, tuberculosis will yield only to social hygiene, i.e., preventive medicine a n d the medical care of t h e c o m m u n i t y as a whole. I n t h i s conneetiou he notes t h a t schools provide t h e m o s t effective of
[March, 1933
all m e a n s for i n c u l c a t i n g in t h e public m i n d t h e knowledge a c c u m u l a t e d in t h e sphere of hygiene. The present world crisis forms a convincing background to Dr. B u r n e r ' s a r g u m e n t t h a t anti-tuberculosis work is becoming increasingly i n t e r n a t i o n a l in character. " T h e W a r left its m a r k on t h e tuberculosis m o r t a l i t y curves of all countries, w h e t h e r belligerent or neutral, p r o d u c i n g a s h a r p rise. Tuberculosis c a n be finally s t a m p e d o u t or reduced to a m i n i m u m only in a n a t m o s p h e r e of prosperity a n d security." W i t h regard to t h e a l l - i m p o r t a n t problem of finance there is an e l e m e n t of confusion in t h e following two passages : - " We have given particulars of e x p e n d i t u r e in various countries ; t h e working expenses of dispensaries and sanatoria, t h e contribution m a d e by i n s u r a n c e funds. I n those countries in w h i c h anti-tuberculosis action is m o s t effective, the total expenditure, so far as it c a n be estimated, is approximately two shillings, two m a r k s or two gold francs per i n h a b i t a n t . There is a striking concordance between these figures in countries where t h e organisation appears to be working s a t i s f a c t o r i l y " {p. 656}. " N e v e r t h e l e s s it is a remarkable coincidence t h a t in several i m p o r t a n t countries in w h i c h t h e c a m p a i g n a g a i n s t tuberculosis is m o s t efficiently organised, a n d in w h i c h t h e death-r~te from tuberculosis is regularly decreasing, t h e total e x p e n d i t u r e m a y be e s t i m a t e d at about 1'50 gold francs per i n h a b i t a n t per a n n u m " (p. 6631. The report concludes with a series of aphorisms, of which t h e following are samples : - " I n the present state of our knowledge, since heredity is a negligible factor in t h e c a u s a t i o n of tuberculosis, the prevention of infection m u s t be regarded as t h e p r i m a r y activity in t h e c a m p a i g n a g a i n s t t h i s disease." " R e s e a r c h work on questions of n u t r i t i o n , especially those of i m p o r t a n c e to t h e people, production, t r a n s p o r t , price a n d cooking of foodstuffs, a n d food r a t i o n s from t h e standpoint of q u a n t i t y a n d quality, should be m a d e use of to assist in p r o p h y l a x i s . "
Quarterly Bulletin of the Health Organisa. tion of the League of Nations. Vol. I, bTo. 4, December, 1932.
SOCIETIES. T H E T U B E R C U L O S I S ASSOCIATION. A ~EETING of t h e Tuberculosis Association was held in L o n d o n on F r i d a y , J a n u a r y 20. At t h e first session Professor S. Lyle C u m m i n s spoke on TUBERCULOSIS IN SOUTH AFRICAN ~'~TIVES. He said t h a t this special liability of negroes to c o n s u m p t i o n h a d long been recogniscd.
T h o m a s Yom~g, in his book published in 1815, insisted on this k n o w n liability as a n argum e n t for t h e i m p o r t a n c e of removal from a w a r m to a cold c l i m a t e as " t h e least a m b i g u ous of all t h e remote causes of the disease . . . its effect being seen in negroes who settle in E n g l a n d . " J u s t twenty-five years ago, the speaker himself, fresh from a period of service in t h e equatorial provinces of t h e S u d a n