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The vital and economic value of the tuberculosis sanatorium
i22
PUBLIC HEALTH.
T H E VITAI, AND ECONOMIC V A L U E OF T H E T U B E R C U L O S I S SANATORIUM, BY
PETER BRYCE, M,A., M.D., Chie[ Medical Officer, Department o[ the Interior, Canada. (Continued.) An analysis of these two lists affords much information and food for thought. Up to 14 years of age Ottawa admitted only 18 patients or about I-5th the number of Hamilton, which admitted 86 to the sanatorium, with the result that the total deaths in Hamilton were but 12 as compared with 51 in Ottawa. The large number of children in Hamilton treated so lessened the later eases that o n l y 22 were admitted as compared with 38 in the 15-19 ageperiod in Ottawa. In the next 20-29 period, usually the most prolific in deaths, we find Hamilton with 79 admissions, as compared with 62 eases in Ottawa. Between 30 and 39, Hamilton has 42 , a s compared with 48 cases, and in the later age-periods Hamilton drops to II, as compared to 32 in Ottawa in the 40-49 period, and only 4 as compared with 13 in the period over 5 ° years. The natural and inevitable outcome of such great differences in the proportion of admissions in the early ageperiod is, first, that the treatment of the children can be longer, since it is carried on until the child m a y be said to have outgrown his tuberculous Condition, while he has had the advantage during part of the time of actual attendance in a school class in the institution. A further result, due to the relatively low mortality of the disease in its incipiency in children with early treatment, is the reduced number of deaths, and hence the effects not only on the total for the institution, b u t for the whole city are seen since at least 40 per cent. of the total population is under 20 years of age. The further importance of this is seen in the fact that the number of sanatorium days per patient in Hamilton was 142, as compared with 95 in Ottawa, while the totM deaths were just 12, as compared with 51 . The following figures taken from the city mortality returns for 1916 are of much importance (Table A): The table shows that for the age-period o-19 the deaths in Ottawa were 34, as compared with 15 in Hamilton, and of this number twice as many were cases of tuberculosis of lungs. During the wage-earning period of 20-59, Ottawa had 77 deaths, Hamilton 51 . The results of the great difference in the number of
Aual~sT,
early eases treated extends, however, far beyond the matter of the immediate difference in total deaths. It is first seen in the difference in the cost of the per capita t r e a t m e n t of eases, and second in what m a y be termed the constructive loss due to the much larger number of patients and deaths during the wage-earning period of life. The Table (B) shows that each patient in Hamilton received 142 d a y s ' treatment as compared with 95 for Ottawa, or just a third more, and at a cost of 4oe. less per day. Hamilton gave 14,6o 7 days' more treatment, at an extra cost of o n l y $5,706.78. The explanation of the extra per diem cost of 48e. m a y be fairly ascribed to the fact that 35 per cent. of the total patients were of 14 years or under in Hamilton, as compared with 8. 5 per cent. in Ottawa. If the cost be taken as $1.42 per diem, or the average of the two cities, and we assume that the cost of children is just half this, the following interesting table of cost is obtained where the number of days is also averaged (Table C) : The most serious outcome of this difference of results in sanatorium treatment is seen in the economic loss which Ottawa suffered from having 112 deaths in the wage-earning period between 15 and 59, as compared with 72 in Hamilton. Estimated at $i,ooo, we see a loss at once of $40,000 in a single year, apart from the previous losses through part-time and inefficient labour, the impoverishment of families, and the infection of children in the home. In its local bearing the difference to the municipality in the cost of local maintenance becomes very serious. The Legislature of the Province of Ontario pay a per diem per capita grant which approximates 5 ° c. Owing to the less number of hospital days b y one-third in Ottawa, and the delay in sending patients early to hospital, the following loss actually occurred in Otatwa as compared with Hamilton : ~ Los s in P r o v i n c i a l G o v e r n m e n t G r a n t ......... $6,623.37 Los s i n F e e s f r o m P a t i e n t s . . . . . . . . . . . . . . . . . .... $5,773.o5 Loss i n 48c. p e r d i e m e x t r a cost on 20,245 hospital days . . . . . . . . . . . . . . . . . . . . . . . . $,97I 7.6o ~22,II4.O2
But enough has been given to illustrate adequately the almost inestimable good which results to any municipality which is fortunate enough to have a Sanatorium and a Board in touch with the advanced ideas held b y their superintendent, and who are ready to follow in
I918.
PUBLIC HEALTH.
123
been such serious active trouble t h a t the patient would have run a great chance of dying. In fact, this has happened with a few, but with the majority there had been, previous to enlistment, so much lung tissue replaced by scar tissue, t h a t the patient's ,air capacity or breathing capacity, and therefore his working capacity, was diminished to such an e x t e n t t h a t he could not hold his own with normal men, a n d when, after enlistment; he was compelled to t r y to do so, he had to capitulate, and not till then was the cause of his diminished working capacity :sought for and found."
their application the principles he enunciates. It m a y be of interest as illustrating his intense belief in the curative possibilities of sanatorium treatment to quote the following from Dr. Holbrooke's Annual Report :-" We also have a record of thirty of our expatients who have enlisted and undoubtedly others have enlisted of whom we have no record. Of those who have enlisted it is wonderful how few have had to be discharged for physical unfitness. It seems to me t h a t the training t h a t these men have received must have stood them in good stead."
T A B L E (A) GIVING DEATHS I"RO~ TUBERCULOSIS IN 1916 IN O T T A W A AND H A M I L T O N BY A G E I;ERIODS. 0. Form
of Disease.
H.
0.
o-14 yrs.
tI.
15- yrs.
0. 20-29
H.
0.
yrs.
H.
0.
30-39 yrs.
~nberculosis in lungs Acnte Miliary ...
o 6
3 i
16 I
5 I
31 I
18 o
28 I
Meningeal Abdominal
...... ......
4 2
4 o
2 i
i o
o 3
2 I
o
o
. o
forms ......
2
o
o
o
o
o
I
o
14
8
20
7
35
21
3°
25
Other
25 o .
.
H.
18 o .
0.
4o-49 yrs.
.
8 o .
.
9 o
Total Hospi[al Per capita Days. Days" Stay.
0.
.
.
7 o
7 o
7 o
o
. . o
o
o
o
2
o
o
o
o
18
I2
9
.7
7
7
Total Deaths.
.
H.
6o yrs. and over.
2
TABLE (B) S H O W I N G SANATORIU M EXPENDITURES A N D W O R K
Total Inmates,
H.
50-59 yrs.
DONE.
Total E;vpenditure.
Daily Cost.
Ottawa
......
211
20,245
95
51
$35,569.66
$1.66
Hamilton
......
246
34,852
142
12
$41,276.44
$I.I8
(C) ~ S T I M A T E D C O S T OF P A T I E N T S FOR AN A V E R A G E OF 1 1 8 D A Y S .
Hamilton ...
Ottawa
...
. . . . . . . . .
... ....
7,205.04 26,8o9.6o"
at 7Ie . . . . . . . . . .
...
34,oi4.64 1,5o8.o 4
and over at $1.42 . . . . . . . . .
...
32,339.08
86 or 35%
o f 14 y e a r s
and under
16o or 65%
o f 15 y e a r s
and over at $1.42
I 8 or 8.5% o f 14 y e a r s 193 o r 9 1 . 5 %
o f 15 y e a r s
and under
at I7C . . . . . . . . . .
33,847.12
As bearing upon the very practical question, which this paper is intended to illustrate, I m a y further quote from the same report :-" Our experience with the soldiers has served to confirm me in every opinion I advanced in last year's report. For instance, in the matter of child infection being the serious factor, we have seen soldier after soldier come for t r e a t m e n t with signs of extensive scar tissue, but with very little active trouble. If this extensive involvement had all developed recently, there would have
INFANT MORTALITY. STATISTICS F R O M
REGISTRAR-GENERAL.
In answer to a request made by a County Medical Officer of Health to the Medical Officer of the Local Government Board, the Registrar-General has arranged that he will supply for the year 1918 and in subsequent years a statement of the number of deaths under one year of age in each sanitary area classified by legitimacy as well as sex. This is in addition to the valuable statistical information already supplied to medical officers of health, by the Registrar-General.
PUBLIC HEALTH.
T H E VITAI, AND ECONOMIC V A L U E OF T H E T U B E R C U L O S I S SANATORIUM, BY
PETER BRYCE, M,A., M.D., Chie[ Medical Officer, Department o[ the Interior, Canada. (Continued.) An analysis of these two lists affords much information and food for thought. Up to 14 years of age Ottawa admitted only 18 patients or about I-5th the number of Hamilton, which admitted 86 to the sanatorium, with the result that the total deaths in Hamilton were but 12 as compared with 51 in Ottawa. The large number of children in Hamilton treated so lessened the later eases that o n l y 22 were admitted as compared with 38 in the 15-19 ageperiod in Ottawa. In the next 20-29 period, usually the most prolific in deaths, we find Hamilton with 79 admissions, as compared with 62 eases in Ottawa. Between 30 and 39, Hamilton has 42 , a s compared with 48 cases, and in the later age-periods Hamilton drops to II, as compared to 32 in Ottawa in the 40-49 period, and only 4 as compared with 13 in the period over 5 ° years. The natural and inevitable outcome of such great differences in the proportion of admissions in the early ageperiod is, first, that the treatment of the children can be longer, since it is carried on until the child m a y be said to have outgrown his tuberculous Condition, while he has had the advantage during part of the time of actual attendance in a school class in the institution. A further result, due to the relatively low mortality of the disease in its incipiency in children with early treatment, is the reduced number of deaths, and hence the effects not only on the total for the institution, b u t for the whole city are seen since at least 40 per cent. of the total population is under 20 years of age. The further importance of this is seen in the fact that the number of sanatorium days per patient in Hamilton was 142, as compared with 95 in Ottawa, while the totM deaths were just 12, as compared with 51 . The following figures taken from the city mortality returns for 1916 are of much importance (Table A): The table shows that for the age-period o-19 the deaths in Ottawa were 34, as compared with 15 in Hamilton, and of this number twice as many were cases of tuberculosis of lungs. During the wage-earning period of 20-59, Ottawa had 77 deaths, Hamilton 51 . The results of the great difference in the number of
Aual~sT,
early eases treated extends, however, far beyond the matter of the immediate difference in total deaths. It is first seen in the difference in the cost of the per capita t r e a t m e n t of eases, and second in what m a y be termed the constructive loss due to the much larger number of patients and deaths during the wage-earning period of life. The Table (B) shows that each patient in Hamilton received 142 d a y s ' treatment as compared with 95 for Ottawa, or just a third more, and at a cost of 4oe. less per day. Hamilton gave 14,6o 7 days' more treatment, at an extra cost of o n l y $5,706.78. The explanation of the extra per diem cost of 48e. m a y be fairly ascribed to the fact that 35 per cent. of the total patients were of 14 years or under in Hamilton, as compared with 8. 5 per cent. in Ottawa. If the cost be taken as $1.42 per diem, or the average of the two cities, and we assume that the cost of children is just half this, the following interesting table of cost is obtained where the number of days is also averaged (Table C) : The most serious outcome of this difference of results in sanatorium treatment is seen in the economic loss which Ottawa suffered from having 112 deaths in the wage-earning period between 15 and 59, as compared with 72 in Hamilton. Estimated at $i,ooo, we see a loss at once of $40,000 in a single year, apart from the previous losses through part-time and inefficient labour, the impoverishment of families, and the infection of children in the home. In its local bearing the difference to the municipality in the cost of local maintenance becomes very serious. The Legislature of the Province of Ontario pay a per diem per capita grant which approximates 5 ° c. Owing to the less number of hospital days b y one-third in Ottawa, and the delay in sending patients early to hospital, the following loss actually occurred in Otatwa as compared with Hamilton : ~ Los s in P r o v i n c i a l G o v e r n m e n t G r a n t ......... $6,623.37 Los s i n F e e s f r o m P a t i e n t s . . . . . . . . . . . . . . . . . .... $5,773.o5 Loss i n 48c. p e r d i e m e x t r a cost on 20,245 hospital days . . . . . . . . . . . . . . . . . . . . . . . . $,97I 7.6o ~22,II4.O2
But enough has been given to illustrate adequately the almost inestimable good which results to any municipality which is fortunate enough to have a Sanatorium and a Board in touch with the advanced ideas held b y their superintendent, and who are ready to follow in
I918.
PUBLIC HEALTH.
123
been such serious active trouble t h a t the patient would have run a great chance of dying. In fact, this has happened with a few, but with the majority there had been, previous to enlistment, so much lung tissue replaced by scar tissue, t h a t the patient's ,air capacity or breathing capacity, and therefore his working capacity, was diminished to such an e x t e n t t h a t he could not hold his own with normal men, a n d when, after enlistment; he was compelled to t r y to do so, he had to capitulate, and not till then was the cause of his diminished working capacity :sought for and found."
their application the principles he enunciates. It m a y be of interest as illustrating his intense belief in the curative possibilities of sanatorium treatment to quote the following from Dr. Holbrooke's Annual Report :-" We also have a record of thirty of our expatients who have enlisted and undoubtedly others have enlisted of whom we have no record. Of those who have enlisted it is wonderful how few have had to be discharged for physical unfitness. It seems to me t h a t the training t h a t these men have received must have stood them in good stead."
T A B L E (A) GIVING DEATHS I"RO~ TUBERCULOSIS IN 1916 IN O T T A W A AND H A M I L T O N BY A G E I;ERIODS. 0. Form
of Disease.
H.
0.
o-14 yrs.
tI.
15- yrs.
0. 20-29
H.
0.
yrs.
H.
0.
30-39 yrs.
~nberculosis in lungs Acnte Miliary ...
o 6
3 i
16 I
5 I
31 I
18 o
28 I
Meningeal Abdominal
...... ......
4 2
4 o
2 i
i o
o 3
2 I
o
o
. o
forms ......
2
o
o
o
o
o
I
o
14
8
20
7
35
21
3°
25
Other
25 o .
.
H.
18 o .
0.
4o-49 yrs.
.
8 o .
.
9 o
Total Hospi[al Per capita Days. Days" Stay.
0.
.
.
7 o
7 o
7 o
o
. . o
o
o
o
2
o
o
o
o
18
I2
9
.7
7
7
Total Deaths.
.
H.
6o yrs. and over.
2
TABLE (B) S H O W I N G SANATORIU M EXPENDITURES A N D W O R K
Total Inmates,
H.
50-59 yrs.
DONE.
Total E;vpenditure.
Daily Cost.
Ottawa
......
211
20,245
95
51
$35,569.66
$1.66
Hamilton
......
246
34,852
142
12
$41,276.44
$I.I8
(C) ~ S T I M A T E D C O S T OF P A T I E N T S FOR AN A V E R A G E OF 1 1 8 D A Y S .
Hamilton ...
Ottawa
...
. . . . . . . . .
... ....
7,205.04 26,8o9.6o"
at 7Ie . . . . . . . . . .
...
34,oi4.64 1,5o8.o 4
and over at $1.42 . . . . . . . . .
...
32,339.08
86 or 35%
o f 14 y e a r s
and under
16o or 65%
o f 15 y e a r s
and over at $1.42
I 8 or 8.5% o f 14 y e a r s 193 o r 9 1 . 5 %
o f 15 y e a r s
and under
at I7C . . . . . . . . . .
33,847.12
As bearing upon the very practical question, which this paper is intended to illustrate, I m a y further quote from the same report :-" Our experience with the soldiers has served to confirm me in every opinion I advanced in last year's report. For instance, in the matter of child infection being the serious factor, we have seen soldier after soldier come for t r e a t m e n t with signs of extensive scar tissue, but with very little active trouble. If this extensive involvement had all developed recently, there would have
INFANT MORTALITY. STATISTICS F R O M
REGISTRAR-GENERAL.
In answer to a request made by a County Medical Officer of Health to the Medical Officer of the Local Government Board, the Registrar-General has arranged that he will supply for the year 1918 and in subsequent years a statement of the number of deaths under one year of age in each sanitary area classified by legitimacy as well as sex. This is in addition to the valuable statistical information already supplied to medical officers of health, by the Registrar-General.