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National Association: The Annual Conference
National Association: The Annual Conference This year the proceedings of the Annual Conference of the National Association for the Prevention of Tuberculosis were devoted to considering three main topics : (I) propaganda and publicity methods, (2) open-air schools ill relation to environment and nutrition, and (3) tile equipmeni and activities of a tuberculosis dispensary. The first topic, notwithstanding an excellent paper by Dr V. Dawkins, produced a considerable amount of loose thinking, each speaker taking the opportunity of advocating his own special line of'social amelioration, whether or not this had been shown to eltkct tile progress of tuberculosis. Now the mortality from tuberculosis in this country has been falling since the middle oflast century, but exactly when the fall commenced is not known, and in the absence ofrecords there is no evidence that the fall has in any way been expedited by any specific preventative measure taken to date. If more energy were spent in determining exactly why this fall is occurring, and less time were expended on selfcongratulation and on claiming this result as due to a diversity ofvicarious individual efforts, then, and then only, would it be possible to discover the means of driving tuberculosis from our midst. To-day the part played by the louse in the dissemination of typhus is well known, but this was as yet undiscovered when typhus was disappearing, and it is no hypcrbolc to say that the eradication of typhus from our midst might easily have been ascribed by some filture historian of epidemiology to the advance of industrialism, or its concomitant social uplift, or the like. Better housing, for instance, is acccptcd as part of anti-tuberculosis measures; but, in these transactions, the instance is quoted of moving a population from slums into good houses with an increase of 33 per cent in the rcnt, but no increase in the income, with an increase by 33 per cent in the mortality from tuberculosis ! Good health, built up by various measures of social uplift, it may bc surmised, is of value in tile fight against tuberculosis, as against other diseases, but the only certain known fact is that tuberculosis is infectious ; however poor his or her health, tuberculosis will not occur unless that individual become infected with tubercle. An African negro, on the othcr hand, no mattcr how overflowing his physical hcalth, will certainly fall victim if cxposcd to a medium dose of infection. Not by advocating opcn-air life, physical exercises and vitaministic nutrition was leprosy driven from our midst ! Papers were contributed pointing out how various means of propaganda : the press, the cinema, broadcasting, hcalth weeks and cxhibitions, posters and leaflets, can be utilized in the fight against tuberculosis. But what is needed is not propaganda for the cure of tuberculosis, but a new evangel of prevention, preachers of the gospel that the prcvcntion of tuberculosis is the prevention of the spread of infection of tuberculosis. Sanitation never brought yellow fever under control, until tile part playcd by the mosquito in transmitting the infection was understood. Are we to say to the people : ' You ought to have better homcs; you ought to have better food ; you ought to have more fresh air and plenty of sun in order to prevent tuberculosis ?' Must we continue to use tuberculosis as a stalking-horse for improvcd social conditions,
8')
TUBERCI.E
November 1937
conditions under which a population virgin to tuberculosis would readily succumb if the infection were broaUcast among it ? And then call such a campaign antituberculosis ? One speaker, it is true, gave warning not to mix up tuberculosis with social hygiene in ally propaganda. He was right ; trot he did not go far enough. Tuberculosis should be fought on its own by propaganda based upon the one sure thing wc know about the disease from the view-point of prevention--tuberculosis is an infectious disease. When tile subject of overcrowding was under discussion the Conference was on surer ground. Overcrowding undoubtedly facilitates the transference of infection. Hence we find that the incidence-rate per thousand for tuberculosis varied from 4"4 for persons occupying one room to I. 3 for persons living in over four rooms. Again, in an open-air school, quite apart from the influence of open-air upon the children, the opportunities for transmitting infection are fewer than in ordinary school rooms. Open-air conditions improve bodily metabolism, increase appetite, assist digestion and the circulation of the blood ; but these influences are only beneficial inasmuch as they eliminate tim risk of droplet infection. Open-air and sunshine arc splendid influences in the treatment of infected cases ; they do not stop infection taking place, or our friend, the African negro, would escape the white man's gift. If the last tubercle bacillus were banished from this planet to-morrow, the case for open-air schools would remain undisturbed. Increased activity and brightness in the children, increase in weight and chest measurements, increase in haemoglobin--are not all these needed for building up a healthy and happy nation ? But do they eliminate infection from tubercle ? Improved conditions of living at one of our great public schools are claimed as protecting the boys against tuberculosis ; but the present writer claims five years spent in the eighties of last century at a public school where wastfing and change rooms were not, where diet had to be eked out with a so-called ' home bill,' where ventilation ofclass rooms was not known : yet he cannot- recall a single case of tuberculosis--the infection was not among us. Nevertheless, the papers read describing the ideals for open-air schools are excellent. They must face the sun ; they must be sheltered from storms. Facilities for personal hygiene, including spray baths, school meals, rest periods, physical training and organized games--all these must be provided. And deep breathing exercises and heliotherapy are well advocated. Here pleasure comes from finding well deserved praise accorded to those fine oldtime prancers, Reed, of Staffordshire, and Barwise, of Derbystfire. When telling of the training of the children a valuable point is mentioned : ' What we want is exercise, not exercises : we are going quite mad over exercises.' Though much of value is presented under the beading of nutrition, we find rather staggering the definition which states that nutrition is the stun of processes which ' include the constitution of the food, both qualitative and quantitative, the adequate oxygenation of the blood and the tissues, the efficiency of the processes of digestion, absorption , assimilation, circulation and excretion ; proper exercise of the body ; rest and sleep, freedom from worry, anxiety and emotional disturbance ; general hygiene ; freedom from disease ; snnlight ; fresh air ; and inherited characters. Chief among these is f o o d . . . ' The last sentence is reassuring! It is well to be reminded that the death-rate of tuberculosis, not the sickness incidence, depends on malnutrition ; and that increased weight is not ahvays accompanied by improvement, but improvement in health will always lead to a gain in weight. Diet by itself
November I937
a'UBF. RCLV
83
does not arrest tuberculosis ; but without an adequate diet the disease is likely to run a most unfavourable course. (Surely here we are considering treatment, rather than prevention.) Much is said about the green shy, the fat shy, the meat shy, and faddy appetities, and how to redress these habits ; and o f the diets of value when treating tuherculosis. Then it is refreshing to read that when healthy children were allowed to select.for themselves from among assorted foods, they did much better than other children who were on a scientific diet. This fi'om America : where children cannot attend open-air schools in winter unless attired as Eskimos. Statistics on the value of income in combating tuberculosis are quoted from Beltitst : a group with 25s. to 35 s. income per family per week had a mortality of 25.96 per I,OOO ; this mortality fell regularly to I9"23 for a group with 45 s. to 55 s. family income ; while remaining only i i "52 per i,ooo for the group with a family income of 75 s. or over. The discussiou upon the equipment and activities of a tuberculosis dispensary covered much useful ground concerning equipment, especially with regard to the provision of an X-ray room, and particular stress was well laid upon the tracing and following-up of contacts right into the homes whenever it can be effected. Unfortunately, however, few dispensaries are sufficiently staffed to carry out this tremendously important part of the tuberculosis campaign. Prevention is better than cure. More money and more pity is spent upon those infected than upon the healthy. Surely the unhealthy are less deserving of our money and our pity than the healthy.
CORRIGEND U M
I t E R B E R T J. ROBLA~SON ON BRONCHOGRAPHY FOLLO IVING TIIORACOPLASTY Page 2 : - - T h e caption below case 3 should read as printed below.
Case 3. D u r a t i o n of disease : 3.t, years. Previous t r e a t m e n t : right A . P . ; right p h r e n l e e c t o m y . Before t h o r a c o p l a s t y : weight 7 st. l I {- lb. ; afebrile ; pulse 7 o - 8 0 ; c o u g h fairly t r o u b l e s o m e ; sputtlln 80 g r a m s + + + : B.S.P,. 47.]. Six m o n t h s after : w e i g h t 7 st. 7 lb. ; afebrile ; pulse 7 o - 8 o ; c o u g h n o n e ; s p u t u m n o n e ; B.S.R. 5- After lipiodol : s],'stem of cavities. Itas since d e v e l o p e d a q u a n t i t y of strongly positive s p u t u m a n d has recently h a d a small h a e m o p t y s i s .
8')
TUBERCI.E
November 1937
conditions under which a population virgin to tuberculosis would readily succumb if the infection were broaUcast among it ? And then call such a campaign antituberculosis ? One speaker, it is true, gave warning not to mix up tuberculosis with social hygiene in ally propaganda. He was right ; trot he did not go far enough. Tuberculosis should be fought on its own by propaganda based upon the one sure thing wc know about the disease from the view-point of prevention--tuberculosis is an infectious disease. When tile subject of overcrowding was under discussion the Conference was on surer ground. Overcrowding undoubtedly facilitates the transference of infection. Hence we find that the incidence-rate per thousand for tuberculosis varied from 4"4 for persons occupying one room to I. 3 for persons living in over four rooms. Again, in an open-air school, quite apart from the influence of open-air upon the children, the opportunities for transmitting infection are fewer than in ordinary school rooms. Open-air conditions improve bodily metabolism, increase appetite, assist digestion and the circulation of the blood ; but these influences are only beneficial inasmuch as they eliminate tim risk of droplet infection. Open-air and sunshine arc splendid influences in the treatment of infected cases ; they do not stop infection taking place, or our friend, the African negro, would escape the white man's gift. If the last tubercle bacillus were banished from this planet to-morrow, the case for open-air schools would remain undisturbed. Increased activity and brightness in the children, increase in weight and chest measurements, increase in haemoglobin--are not all these needed for building up a healthy and happy nation ? But do they eliminate infection from tubercle ? Improved conditions of living at one of our great public schools are claimed as protecting the boys against tuberculosis ; but the present writer claims five years spent in the eighties of last century at a public school where wastfing and change rooms were not, where diet had to be eked out with a so-called ' home bill,' where ventilation ofclass rooms was not known : yet he cannot- recall a single case of tuberculosis--the infection was not among us. Nevertheless, the papers read describing the ideals for open-air schools are excellent. They must face the sun ; they must be sheltered from storms. Facilities for personal hygiene, including spray baths, school meals, rest periods, physical training and organized games--all these must be provided. And deep breathing exercises and heliotherapy are well advocated. Here pleasure comes from finding well deserved praise accorded to those fine oldtime prancers, Reed, of Staffordshire, and Barwise, of Derbystfire. When telling of the training of the children a valuable point is mentioned : ' What we want is exercise, not exercises : we are going quite mad over exercises.' Though much of value is presented under the beading of nutrition, we find rather staggering the definition which states that nutrition is the stun of processes which ' include the constitution of the food, both qualitative and quantitative, the adequate oxygenation of the blood and the tissues, the efficiency of the processes of digestion, absorption , assimilation, circulation and excretion ; proper exercise of the body ; rest and sleep, freedom from worry, anxiety and emotional disturbance ; general hygiene ; freedom from disease ; snnlight ; fresh air ; and inherited characters. Chief among these is f o o d . . . ' The last sentence is reassuring! It is well to be reminded that the death-rate of tuberculosis, not the sickness incidence, depends on malnutrition ; and that increased weight is not ahvays accompanied by improvement, but improvement in health will always lead to a gain in weight. Diet by itself
November I937
a'UBF. RCLV
83
does not arrest tuberculosis ; but without an adequate diet the disease is likely to run a most unfavourable course. (Surely here we are considering treatment, rather than prevention.) Much is said about the green shy, the fat shy, the meat shy, and faddy appetities, and how to redress these habits ; and o f the diets of value when treating tuherculosis. Then it is refreshing to read that when healthy children were allowed to select.for themselves from among assorted foods, they did much better than other children who were on a scientific diet. This fi'om America : where children cannot attend open-air schools in winter unless attired as Eskimos. Statistics on the value of income in combating tuberculosis are quoted from Beltitst : a group with 25s. to 35 s. income per family per week had a mortality of 25.96 per I,OOO ; this mortality fell regularly to I9"23 for a group with 45 s. to 55 s. family income ; while remaining only i i "52 per i,ooo for the group with a family income of 75 s. or over. The discussiou upon the equipment and activities of a tuberculosis dispensary covered much useful ground concerning equipment, especially with regard to the provision of an X-ray room, and particular stress was well laid upon the tracing and following-up of contacts right into the homes whenever it can be effected. Unfortunately, however, few dispensaries are sufficiently staffed to carry out this tremendously important part of the tuberculosis campaign. Prevention is better than cure. More money and more pity is spent upon those infected than upon the healthy. Surely the unhealthy are less deserving of our money and our pity than the healthy.
CORRIGEND U M
I t E R B E R T J. ROBLA~SON ON BRONCHOGRAPHY FOLLO IVING TIIORACOPLASTY Page 2 : - - T h e caption below case 3 should read as printed below.
Case 3. D u r a t i o n of disease : 3.t, years. Previous t r e a t m e n t : right A . P . ; right p h r e n l e e c t o m y . Before t h o r a c o p l a s t y : weight 7 st. l I {- lb. ; afebrile ; pulse 7 o - 8 0 ; c o u g h fairly t r o u b l e s o m e ; sputtlln 80 g r a m s + + + : B.S.P,. 47.]. Six m o n t h s after : w e i g h t 7 st. 7 lb. ; afebrile ; pulse 7 o - 8 o ; c o u g h n o n e ; s p u t u m n o n e ; B.S.R. 5- After lipiodol : s],'stem of cavities. Itas since d e v e l o p e d a q u a n t i t y of strongly positive s p u t u m a n d has recently h a d a small h a e m o p t y s i s .