North Western Tuberculosis Society

December, 1933]

C~TI~AL

AND

LOCAn Au'rIIOlUTIES

clinics a n d m a k i n g 5,102 e x a m i n a t i o n s . I u one neglected area with no resident doctor, 26 new cases were discovered, m o s t of t h e m w i t h advanced a n d active disease. St. Boniface S a n a t o r i u m , w h i c h had only been open for three m o n t h s at t h e b e g i n n i n g of t h e year 1932, h a s been filled d u r i n g t h e whole year a l m o s t to capacity, with adults a n d children from t h e contributor)" area, u n o r g a n ised territory a n d t h e cities: A t t e n t i o n is d r a w n to t h e very h i g h percentage of I n d i a n s in t h e province of 5Ianitoba, which h a s a m a r k e d influence on the tuberculosis death-rate, bIanitoba s t a n d s second h i g h e s t in respect of the proportion of I n d i a n

137

population, B r i t i s h C o l u m b i a only exceeding it, a n d B r i t i s h Columbia h a s a h i g h e r tuberculosis death-rate. If t h o s e of m i x e d i n d i a n blood were included, Bhmitoba would r a n k first, a n d Dr. Stewart believes t h a t , were all d e a t h s of persons w i t h pure or m i x e d I n d i a n blood counted out, t h e M a n i t o b a death-rate would drop from 61 to 30 per 100,000 population. E v e n as it is, t h e tuberculosis death-rate in M a n i t o b a is considerably lower t h a n t h e average for Canada. The whole report a m p l y justifies Dr. S t c w a r t ' s c l a i m t h a t t h e year u n d e r review was a m a x i m u m )'car all along t h e line, in b o t h work a n d results.

SOCIETIES. lqORTt[ WESTERN TUBERCULOSIS SOCIETY. T h e opening m e e t i n g of t h e session was held in M a n c h e s t e r on T h u r s d a y , Octobcr 19, Dr. P. IIeffernan, :President, was in t h e Chair. Seven new m e m b e r s were elected a n d t h e Treasurer, Dr. G. H. L e i g h presented his a n n u a l financial s t a t e m e n t , "Lfter w h i c h t h e p r e s i d e n t . g a v e his I'residential Address on. " S o m e P r o b l e m s in t h e Work of a T u b e r c u losis Officer." This was a w i t t y and t h o u g h t ful c o m m e n t a r y on m a n y m a t t e r s of interest, a n d was illustrated by clinical reports a n d s ~ i a g r a m s of cases t h a t h a d been referred to h i m as tuberculous b u t were actually found to be suffering f r o m other diseases, s u c h as m o r b u s cordis, bronchitis a n d bronchiectasis, spirochmtosis, syphilis a n d m a l i g n a n t disease. Dr. Heffernan, b e g i n n i n g with t h e well. k n o w n q u o t a t i o n from " I o l a n t h e , " referred to t h e fact t h a t tuberculosis officers, like o t h e r people, n a t u r a l l y fell into two classes--liberal a n d c o n s e r v a t i v e - - u s i n g t h e s e t e r m s in t h e universal scnse w i t h o u t reference to politics. There were those who took thcir opinions r e a d y . m a d e or second-hand, a n d those who, on t h e other h a n d , were curious and inquisitive. IIe desired to m a k e a plea for those who were born liberals ; whose outlook was realistic a n d original ; who valucd m e n as higher t h a n m a c h i n e s ; who regardcd m e n and women as realities a n d h u m a n i t y as a n a b s t r a c t i o n - - t o those t h e c a t e g o r i c a l i m p e r a t i v e : " Do y o u r best for your p a t i e n t s , " stood supreme. W e were proud, he said, to belong to the great public h e a l t h service of this c o u n t r y a n d he did not in a n y way, u n d e r v a l u e t h e organised work done by tim tuberculosis service, b u t a s c l i n i c a l officers t h e y h a d a special responsibility tow a r d s each individual patient with regard to diagnosis a n d t r e a t m e n t . T h e y ndeded to be particularly careful t h a t t h e y treated their r p a t i e n t s as sufferinoc t h u m a n bcinos who c a m e to t h e m for h e a l i n g r a t h e r t h a n as. cannon-fodder in t h e fight for the f u t u r e h e a l t h of t h e Community. Iwenty-five to t h i r t y )-ears ago a diagnosis of p u l m o n a r y tuberculosis was

rarely m a d e u n t i l t h e disease h a d reached t h e stage whcu t r c a t m e n t was of little avail, b u t to-day t h e r e was t h e risk t h a t t h e p e n d u l u m h a d s w u n g to t h e opposite extreme, a n d individuals were s o m e t i m e s diagnosed a n d notified on slender evidence. T h e best working policy was t h a t medical practitioners in case of doubt s h o u l d refer t h e i r p a t i e n t s to the tuberculosis Officer. IIe in his t u r n s h o u l d be professionally c o m p e t e n t , a n d have at h i s disposal adequate t e c h n i c a l facilities, e.g., suitable X-ray e q u i p m e n t , t h e services of a n efficient laboratory a n d hospital beds. T h i s ideal h a d ill fact been achieved ill m a n y p a r t s of tbe c o u n t r y . I n h i s own practice he h a d noticed t h a t d u r i n g t h e past few years of t h e cases referred to h i m by medical practitioners 53 per cent. were f o u n d to besuffering from n o n - t u b e r c u l o u s conditions. Cases referred to tuberculosis officers w h i c h proved to be n o n tuberculous were m a i n l y found to have diseases of the h e a r t and circulatory s y s t e m a n d o t h e r respiratory diseases. I n case of doubt, a p a t i e n t s h o u l d be p u t on t h e s a n a t o r i u m regime of rest, good food a n d fresh air which were good for nearly all ailing people. ~Iany cascs were e n c o u n t e r e d in w h i c h t h e history, s y m p t o m s 9 a n d physical findings m i g h t be equivocal a n d in w h i c h t h e differential diagnosis u l t i m a t e l y depended upon t h e pathologist a n d bacteriologist. W h a t was callcd " c l i n i c a l i n s t i n c t " was in reality t h e subconscious s y n t h e s i s of years of clinical experience. We possessed no esoteric knowledge, nor trade secret by m e a n s of w h i c h t h e o r d i n a r y p a t h s of in~'estigation could be short-circuited. T u r n i n g to t r e a t m e n t , I)r. IIeffernau referred p a r t i c u l a r l y to the improved outlook for advanced cascs in w h o m working capacity could oftcn be restored, a n d life prolonged a h n o s t to its ordinary limit, w h c r c a s fifteen years ago s u c h cases would have been doomed to certain d e a t h w i t h i n two years. IIe believed t h e c h a n g e was m a i n l y due to t h e increased i m p o r t a n c e a t t a c h e d to rest a n d immobilisation of t h e affected part, particularly by collapse-therapy. T h i s change in t r e a t m e n t a n d in t h e type of p a t i e n t s suitable for treatm e n t , necessitated considerable a d j u s t m e n t s in

,138

TUBERCLE

our views a n d activities, a n d it was here t h a t t h e slmrp division between t h e reactionaries a n d t h e progressives was b r o u g h t out w i t h e x t r a o r d i n a r y clarity. There was little d o u b t m h i s m i n d t h a t m a n y tuberculosis officers disliked t h e m o d e r n developments. T h e y still believed t h a t it was exceptional for a T.B. plus case to become p e r m a n e n t l y arrested, a n d desired to keep t h e available I:eds for T.B. m i n u s cases. It was a s o u n d biological principle to " c h e r i s h y o u r exceptions " a n d every a d v a n c e t h a t h a d been m a d e in applied biology h a d been achieved in t h i s way. The developments in m o d e r n m e t h o d s of t r e a t m e n t in p u h n o n a r y tuberculosis h a d placed u s on t h e h o r n s of dil e m m a . As public h e a l t h officers we a i m e d at t h e total eradication of tuberculosis, b u t t h e very success of our t r e a t m e n t of advanced cases m i g h t add to t h e potential source of infection. T h e death-rate from tuberculosis in t h i s

[December, 1933

c o u n t r y h a d been halved in the p a s t t w e n t y five years, b u t was t h e proportion of t h e allergic population less or greater titan it was twenty-five y e a r s ago? We h a d to m a k e u p o u r m i n d s w h a t we really wanted, t h a t is, w h e t h e r we desired to eliminate t u b e r c u l o u s disease or t u b e r c u l o u s infection. H e wondered wllether t h e s e objects were m u t u a l l y exclusive or c o m p l e m e n t a r y , a n d w h e t h e r t u b e r c u l o u s infection, as d i s t i n c t from t u b e r c u l o u s disease. could be e l i m i n a t e d by a n y m e a n s s h o r t of getting rid of all t h e t u b e r c u l o u s persons as soou as t h e i r condition was recogniscd. I~ w a s notable t h a t t h e ]?reneh, who were essentially realists, f r a n k l y accepted an acquired i m m u n i t y to tuberculosis as their objective, p u t t i n g t h e i r f a i t h iu B . C . G . t i e would not offer a personal opinion on t h i s m a t t e r , b u t it was one w h i c h deserved t h e a t t e n t i o n of every t h o u g h t f u l person.

CORRESPONDENCE. To the Editor of " Tubercle." DE~R S n : , - - D r . P e t e r W. E d w a r d s , 5Iedical S u p e r i n t e n d e n t , Ctaeshire Joint S a n a t o r i u m , near ~ l a r k e t D r a y t o n , Salop, h a s been invited a n d is prepared to give a series of s h o r t intensive P o s t G r a d u a t e Courses of a practical n a t u r e on m o d e r n m e t h o d s of t h e r a p y in tuberculosis of t h e respiratory s y s t e m with special reference to collapse therapy. I n Dr. E d w a r d s ' s Sanat o r i u m there is a b u n d a n t m a t e r i a l for t h e full d e m o n s t r a t i o n of Artificial P n e u m o t h o r a x a n d allied procedures. M e t h o d s of s a n a t o r i u m a d m i n i s t r a t i o n will also be d e m o n s t r a t e d . :No class will exceed four m e m b e r s in n u m b e r a n d m a y be less. Suitable a r r a n g e m e n t s for board a n d residence can be m a d e w i t h i n a c o n v e n i e n t dist a n c e of t h e s a n a t o r i u m . T h e difficulty experienced by m a n y full t i m e Medical Officers in finding time to get a w a y to P o s t G r a d u a t e Courses is recognized, and every effort wilt be m a d e to m e e t t h e c o n v e n i e n c e of i n t e n d i n g m e m b e r s . As they will be intensive no course nccd exceed three days if m o r e time c a n n o t be spared by t h e m e m b e r s . D e t a i l s of date, expenses. &c., will be sent on application being m a d e to t h e H e n . Secre. t a r y for P o s t G r a d u a t e Courses a t t h e ,~bove address. Yours faithfully, WILLIA3I BRAWl),

S, Highway Court, J3eacopsfield, Bttcks. Oclgber, 27, 1933.

lion. 8ecretary for J'os~ Graduate Courses.

S m , - - A c c o r d i n g to a roport puMished in several of t h e n e w s p a p e r s of t h e 19th i n s t a n t , o n e of t h e s p e a k e r s at a recent m e e t i n g o f ' t h e B r i t i s h D a i r y F a r m e r s ' Association i n f o r m e d

his audience t h a t , " t h e talk of conveying bovine tuberculosis to h u m a n beings by milk was all h u m b u g . " To protect t h e public from this m i s l e a d i n g a n d i n a c c u r a t e s t a t e m e n t xvc desire to p u t on record t h e followingpropositions as established beyond reach of challenge : - (1) T h a t raw m i l k as at present distributed for h u m a n e o n s u n l p t i o u shows on a n average, presence of living tubercle bacilli in some 6 to 7 per cent. of t h e s p e c i m e n s e x a m i n e d . (2) T h a t a b o u t 2,000 children die a n n u a l l y from t u b e r c u l o u s infection of bovine origin, while m a n y o t h e r s suffer disabling a n d deforming illnesses. (3) T h a t t h e s e disasters are duo m a i n l y , if n o t entirely, to tile infection of children t h r o u g h t h e m i l k supply ; a n d (4) T h a t p a s t c u r i s a t i o n properly performed, or failing t h i s , boiling of t h e milk, reduces t h e risk of t u b e r c u l o u s a n d other milk-borne infections to t h e v a n i s h i n g point. F o r t h e s e propositions t h e r e exists a body of w e l l - a u t h e n t i c a t e d evidence, a n d t h e public interest d e m a n d s t h a t t h e y shall be plainly s t a t e d a n d a u t h o r i t a t i v e l y affirmed. W e are, Sir, Your obedient servants, I ) x w s o x OF PEx.','. IIORDER, 3IOY~nL~. M e m b e r s of the~ People's L e a g u e [ FR~:I)~mldI;. T. G. }{OBDAY. of t t c a l t h ' s Bo-~- WILLIA.~t G. SAV.~GE, vine T u b e r , ' u l o - | M.D. sis C o m m i t t e e . )

The People's League of t[eallh (/~,.c.}, 12, Slratford Place, W.1. Oclober 26, 1933.