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The treatment of pulmonary tuberculosis
TREATMENT
OF PULMONARY
TUBERCULOSIS
r2 7
FOWLER: Diseases of t h e L u n g . 1898. GRIFFITHS : Studies in P u l m o n a r y Tuberculosis. 1912. HECKER : Pyorrhoea Alveolaris. 1914. HERSCHELL AND ABRAHAMS : C h r o n i c Colitis. I9I 4. HUTCHISON: Medical Annual, 88. 1915. HUNI'ER : Proc. Roy. Soc. Med., vol: vi., April, 1913. KEII,H : See Proc. Roy. Soc. Med., October 15, 19i 5. KREHL: B a s i s of Symptoms. 1916. LANDOUZY El" LABBE: Cong. I n t e r n a t . T u b e r c . , p. 506. i 9 o S. MCCLURE : See Proc. Roy. Soc. Med., vol. ix., F e b r u a r y i6, i915. MINOR : K l e b ' s Tuberculosis. i9o 9. PI~RY : L a T u b e r c u l o s e P u l m o n a i r e , p. 182. 19io. SMII,H: Clinical ]ourn., 437, 1913TURNER: Practitioner, J a n u a r y , 191o. WII.I(]NSON : T u b e r c u l i n in D i a g n o s i s , p. 86. 1912.
T H E T R E A T M E N T OF PULMONARY TUBERCULOSIS. BY J. E. B U L L O C K , M.D., A c t i n g Tuberculosis Officer for the C o u n t y of N o r t h a n t s .
I WISH in the f o l l o w i n g article to consider some of the phases in the t r 6 a t m e n t of p u l m o n a r y tuberculosis w h i c h come before a C o u n t y Tuberculosis Officer. H e has to seek out, early cases and to send such to. a sanatorium. T h e value and limitations of sanat o r i u m t r e a t m e n t have recently been reviewed a n d fully discussed. I think it wiLll be conceded t h a t if o n l y early cases were sent to a s a n a t o r i u m there would be no question as to the p e r m a n e n t value of s a n a t o r i u m treatment, but m a n y cases beyond thee incipient stage are n o w being admitted. In. m y opinion they m a y derive g r e a t benefit f r o m the experience gained, though, of course, the limitat i o n s of a cure are p r o p o r t i o n a t e l y restricted. A m o n g the w o r k i n g classes it is very difficult to g e t the early case to go to a sanatorium. At the present time men are either at w o r k or serving in the A r m y ; in the latter case signs and s y m p t o m s are arrested by military tr,aining, or the marl breaks d o w n and is discharged with a " r e c o m ' mendation for s a n a t o r i u m treatment." In addition there are m a n y civilians beyond the early stage whose disease is much benefited b y s a n a t o r i u m life and the patient is restored to a fair earning capacity. I impress on patients w h o m I send to a s a n a t o r i u m that they go there for two r e a s o n s : (I) T o learn h o w to live so that they can i carry out exactly the same lines of t r e a t m e n t when they return h o m e ; (2) to g e t Set up in s t r e n g t h so that on leaving they can at least do s o m e t h i n g t o w a r d s earning" their own living. I strive to
I28 T H E
BRITISH
JOURNAL
OF TUBERCULOSIS
send to a sanato.rium only such patients as may reasonably be expected to gain some earning capacity, or, in the case of married women, may be able t o take UP their household duties. These objects can only be maintained if C a r e Comnli.ttees a r e formed to assist such cases by giving financial aid to supplement any limited earning capacity or to provide further accommodation when the home conditions are Overcrowded. It must be remembered that consumption is slow and insidious. in its development, very general in occurrence, and is resisted by maintaining a healthy state of the body. T r e a t m e n t is not a matter of a few months at a sanatorium, it must continue from the m o m e n t the disease is discovered until all signs and symptoms have been absent for something like two years. Thus treatment resolves itself into putting the patient into healthy conditions and maintaining those co,nditions. As a patient must live at home durin ~" the g r e a t e r part of his treatment,, our efforts, should. .be directed towards looking after his home and finding him suitable employment, by which be can earn something towards his maintenance. Suitable occupation for a consumptive is a m o s t difficult thing to find; the chief points to r e m e m b e r are that he will not be able to earn a full wage, and that it is no good his attempting work f o r Which he is not fitted. Some men frighten would-be employers by asking for " a light job in the open air." Now. that allotments are becoming universal, I find capital scope for a man who is really a gardener, but it is useless to expect any profitable work in that line from a clerk or a mechanic ; the clerk must be put into a healthy office, the mechanic can find suitable engineering" work, and in such cases application from the Tuberculosis Officer is often successful in obtaining employment. In the case of the shoe.-hand (the most usual e m p l o y m e n t in N o r t h Northants) o u t d o o r workshops might be instituted adjoining the premises of patients, or in the garden (if such exists) connected with the dispensary building. I have had erected a wooden shelter in the garden of a patient who works there regularly with his wife, earning a good wage at "clicking. ''~ I have other patients who similarly devote a .room in their own houses to their work. Many industries belonging to a neighbourhood might be re-established, piece-work being" given out b y employers on the request of the Tuberculosis Officer. Co.lonies for consumption have been much discussed lately. Farming" which involves regular hours is in my experience impracticable. Industrial traOning colleges would be excellent; in these men and women co{lld be trained in various industries to which 1 Illustrations of this Shelter appeared in the April issue of the BRITISH JOURNAL OF TUBERCULOSIS, pp. 92 and 93,
TREATMENT
OF PULMONARY
TUBERCULOSIS
12 9
they are accustomed. Substantial help m a y be expected f r o m the G o v e r n m e n t in training ex-service m e n . W h e n trained they would either r e m a i n on and ~rain others or they would e a r n their own living outside the colony. Besides the e a r l y and thi~ m o r e p r o n o u n c e d cases there is a third class of patient who m u s t be considered : advanced cases who, owing to lack o f suitable provision in hospitals, have to remain at home. In the w o r s t of these cases it has been s u g g e s t e d that c o m p u l s o r y powers should be g r a n t e d to the Medical Officer of H e a l t h and the Tuberculosis Officer by which, on their joint certificate that the patient is liable to infect others of his ho,usehold, he could be r e m o v e d to some special institution (if such exists), where he can be isolated. I t has been t h o u g h t that the g r o u n d s connected ~vith isolation ho.spitals could be used for this purpose ; there appeaito be m a n y difficulties in c a r r y i n g this out, irrespective of a r r a n g i n g suitable buildings and staff. Before c o m p u l s o r y powers are entertained provision sho.uld be made in a special institution t o which advanced cases can g o on the r e c o m m e n d a t i o n of the Tuberculosis Officer. I f the patient is allowed regulated visits by his relatives he will. recognize that he leaves h o m e for the welfare of his family, he will p r o b a b l y i m p r o v e and wish to stay; but if he do not improve he m a y go h o m e again if he so wishes, r a t h e r than di.e in the institution. M y impression is that in an institution on these lines no compulsion will be needed, and that as m a n y patients will avail themselves of the o p p o r t u n i t y as t h e r e are b6ds to receive th.em. T h e need of such an institution is m o s t u r g e n t if consumptiola is to be stamped out.
A
SCHEME FOR T H E HOUSING CONSUMPTIVE FAMILIES,
OF
BY J A M E S T. N E E C H , M.D.~ D.P.H.~ Medical Officer of Health for the Borough of Halifax, Yorks.
IT must be admitted that although sanatorium treatment has not so far given the beneficent curative results at one time anticipated from it, yet nevertheless it affords the best known treatment for tuberculosis at our disposal. The sanatorium at present is to be viewed first and foremost as a curative institution : it tends to act only indirectly as a preventative agent. Patients are not sent to a sanatorium until they are victims of tuberculosis, and if the disease is to be materially diminished in our midst greater attention will have to be paid to
OF PULMONARY
TUBERCULOSIS
r2 7
FOWLER: Diseases of t h e L u n g . 1898. GRIFFITHS : Studies in P u l m o n a r y Tuberculosis. 1912. HECKER : Pyorrhoea Alveolaris. 1914. HERSCHELL AND ABRAHAMS : C h r o n i c Colitis. I9I 4. HUTCHISON: Medical Annual, 88. 1915. HUNI'ER : Proc. Roy. Soc. Med., vol: vi., April, 1913. KEII,H : See Proc. Roy. Soc. Med., October 15, 19i 5. KREHL: B a s i s of Symptoms. 1916. LANDOUZY El" LABBE: Cong. I n t e r n a t . T u b e r c . , p. 506. i 9 o S. MCCLURE : See Proc. Roy. Soc. Med., vol. ix., F e b r u a r y i6, i915. MINOR : K l e b ' s Tuberculosis. i9o 9. PI~RY : L a T u b e r c u l o s e P u l m o n a i r e , p. 182. 19io. SMII,H: Clinical ]ourn., 437, 1913TURNER: Practitioner, J a n u a r y , 191o. WII.I(]NSON : T u b e r c u l i n in D i a g n o s i s , p. 86. 1912.
T H E T R E A T M E N T OF PULMONARY TUBERCULOSIS. BY J. E. B U L L O C K , M.D., A c t i n g Tuberculosis Officer for the C o u n t y of N o r t h a n t s .
I WISH in the f o l l o w i n g article to consider some of the phases in the t r 6 a t m e n t of p u l m o n a r y tuberculosis w h i c h come before a C o u n t y Tuberculosis Officer. H e has to seek out, early cases and to send such to. a sanatorium. T h e value and limitations of sanat o r i u m t r e a t m e n t have recently been reviewed a n d fully discussed. I think it wiLll be conceded t h a t if o n l y early cases were sent to a s a n a t o r i u m there would be no question as to the p e r m a n e n t value of s a n a t o r i u m treatment, but m a n y cases beyond thee incipient stage are n o w being admitted. In. m y opinion they m a y derive g r e a t benefit f r o m the experience gained, though, of course, the limitat i o n s of a cure are p r o p o r t i o n a t e l y restricted. A m o n g the w o r k i n g classes it is very difficult to g e t the early case to go to a sanatorium. At the present time men are either at w o r k or serving in the A r m y ; in the latter case signs and s y m p t o m s are arrested by military tr,aining, or the marl breaks d o w n and is discharged with a " r e c o m ' mendation for s a n a t o r i u m treatment." In addition there are m a n y civilians beyond the early stage whose disease is much benefited b y s a n a t o r i u m life and the patient is restored to a fair earning capacity. I impress on patients w h o m I send to a s a n a t o r i u m that they go there for two r e a s o n s : (I) T o learn h o w to live so that they can i carry out exactly the same lines of t r e a t m e n t when they return h o m e ; (2) to g e t Set up in s t r e n g t h so that on leaving they can at least do s o m e t h i n g t o w a r d s earning" their own living. I strive to
I28 T H E
BRITISH
JOURNAL
OF TUBERCULOSIS
send to a sanato.rium only such patients as may reasonably be expected to gain some earning capacity, or, in the case of married women, may be able t o take UP their household duties. These objects can only be maintained if C a r e Comnli.ttees a r e formed to assist such cases by giving financial aid to supplement any limited earning capacity or to provide further accommodation when the home conditions are Overcrowded. It must be remembered that consumption is slow and insidious. in its development, very general in occurrence, and is resisted by maintaining a healthy state of the body. T r e a t m e n t is not a matter of a few months at a sanatorium, it must continue from the m o m e n t the disease is discovered until all signs and symptoms have been absent for something like two years. Thus treatment resolves itself into putting the patient into healthy conditions and maintaining those co,nditions. As a patient must live at home durin ~" the g r e a t e r part of his treatment,, our efforts, should. .be directed towards looking after his home and finding him suitable employment, by which be can earn something towards his maintenance. Suitable occupation for a consumptive is a m o s t difficult thing to find; the chief points to r e m e m b e r are that he will not be able to earn a full wage, and that it is no good his attempting work f o r Which he is not fitted. Some men frighten would-be employers by asking for " a light job in the open air." Now. that allotments are becoming universal, I find capital scope for a man who is really a gardener, but it is useless to expect any profitable work in that line from a clerk or a mechanic ; the clerk must be put into a healthy office, the mechanic can find suitable engineering" work, and in such cases application from the Tuberculosis Officer is often successful in obtaining employment. In the case of the shoe.-hand (the most usual e m p l o y m e n t in N o r t h Northants) o u t d o o r workshops might be instituted adjoining the premises of patients, or in the garden (if such exists) connected with the dispensary building. I have had erected a wooden shelter in the garden of a patient who works there regularly with his wife, earning a good wage at "clicking. ''~ I have other patients who similarly devote a .room in their own houses to their work. Many industries belonging to a neighbourhood might be re-established, piece-work being" given out b y employers on the request of the Tuberculosis Officer. Co.lonies for consumption have been much discussed lately. Farming" which involves regular hours is in my experience impracticable. Industrial traOning colleges would be excellent; in these men and women co{lld be trained in various industries to which 1 Illustrations of this Shelter appeared in the April issue of the BRITISH JOURNAL OF TUBERCULOSIS, pp. 92 and 93,
TREATMENT
OF PULMONARY
TUBERCULOSIS
12 9
they are accustomed. Substantial help m a y be expected f r o m the G o v e r n m e n t in training ex-service m e n . W h e n trained they would either r e m a i n on and ~rain others or they would e a r n their own living outside the colony. Besides the e a r l y and thi~ m o r e p r o n o u n c e d cases there is a third class of patient who m u s t be considered : advanced cases who, owing to lack o f suitable provision in hospitals, have to remain at home. In the w o r s t of these cases it has been s u g g e s t e d that c o m p u l s o r y powers should be g r a n t e d to the Medical Officer of H e a l t h and the Tuberculosis Officer by which, on their joint certificate that the patient is liable to infect others of his ho,usehold, he could be r e m o v e d to some special institution (if such exists), where he can be isolated. I t has been t h o u g h t that the g r o u n d s connected ~vith isolation ho.spitals could be used for this purpose ; there appeaito be m a n y difficulties in c a r r y i n g this out, irrespective of a r r a n g i n g suitable buildings and staff. Before c o m p u l s o r y powers are entertained provision sho.uld be made in a special institution t o which advanced cases can g o on the r e c o m m e n d a t i o n of the Tuberculosis Officer. I f the patient is allowed regulated visits by his relatives he will. recognize that he leaves h o m e for the welfare of his family, he will p r o b a b l y i m p r o v e and wish to stay; but if he do not improve he m a y go h o m e again if he so wishes, r a t h e r than di.e in the institution. M y impression is that in an institution on these lines no compulsion will be needed, and that as m a n y patients will avail themselves of the o p p o r t u n i t y as t h e r e are b6ds to receive th.em. T h e need of such an institution is m o s t u r g e n t if consumptiola is to be stamped out.
A
SCHEME FOR T H E HOUSING CONSUMPTIVE FAMILIES,
OF
BY J A M E S T. N E E C H , M.D.~ D.P.H.~ Medical Officer of Health for the Borough of Halifax, Yorks.
IT must be admitted that although sanatorium treatment has not so far given the beneficent curative results at one time anticipated from it, yet nevertheless it affords the best known treatment for tuberculosis at our disposal. The sanatorium at present is to be viewed first and foremost as a curative institution : it tends to act only indirectly as a preventative agent. Patients are not sent to a sanatorium until they are victims of tuberculosis, and if the disease is to be materially diminished in our midst greater attention will have to be paid to