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Rh it would be excessively costly, for in many herds one half the animals or even more are believed to be tuberculous, though not necessarily the sources of tuberculous food. Unless the danger is proved to be very much greater than there is any reason to suppose, “stamping out” may be put aside. Efficient inspection involves the administrative control of slaughterhouses, cowsheds and dairies. The powers and regulations under this head vary much in different countries; but it would be useless to discuss them at length until the scientific question is settled, for if the reality of the danger remains doubtful, oppressive restrictions, such as the compulsory slaughter of tuberculous cows, will not have the support of public opinion. Whatever measures may be taken for the public protection, individuals can readily protect themselves from the most serious danger by boiling milk; and unless the source is beyond suspicion, parents are recommended, in the present state of knowledge, so to treat the milk given to young children. A great deal has been done in most countries for the dissemination of popular knowledge by forming societies, holding conferences and meetings, issuing cheap literature, and so forth. It is an important item in the general campaign against tuberculosis, because popular intelligence and support are the most powerful levers for setting all other forces in motion. In Ireland, where an attempt had been made to deal with the question by arousing the interest of all classes, tuberculosis exhibitions have been held in nearly every county, together with lectures and demonstrations organized by the Women’s National Health Association; and an organized attempt was made in the autumn of 1910 in England, by a great educational campaign, to compel the public to realize the nature of the disease and the proper precautions against it.

The improved outlook in regard to the arrest or so-called “cure” of tuberculosis is mainly derived from the improved methods of diagnosis, thus enabling treatment to be undertaken at an earlier and therefore more g favourable stage of the disease. The physical signs in early stages of the lung affection are often vague and

inconclusive. A means of diagnosis has therefore been sought in the use of tuberculin. The methods are three: (1) The subcutaneous injection method of Koch; (2) the cutaneous method of Von Pirquet; (3) the conjunctiva method of Wolff-Eisner and Calmette. The first method depended on the reaction occurring after an injection of “old tuberculin.” It is unsuitable in febrile conditions, and has now been relegated to the treatment of cattle, where it has proved invaluable. In Von Pirquet’s method a drop of old tuberculin diluted with sodium chloride is placed on a spot which has been locally scarified. The presence of tuberculosis is demonstrated by a. local reaction in which a hyperaemic papule forms, surrounded by a bright red zone. Reaction occurs in tuberculosis of the bones of joints and skin. Von Pirquet in 1000 cases obtained a reaction in 88% of the tuberculous, and 10% of those clinically non-tuberculous. In the latter there may have been latent cases of tuberculosis. In the conjunctiva or opthalmo-reaction of Calmette and Wolff-Eisner the instillation of a drop of a dilute solution of tuberculin into the conjunctiva is followed in the tuberculous subject by conjunctivitis. The reaction generally appears in from 3 to 12 hours, but may be delayed to 48. In a series of cases observed by Audeoud a positive reaction was obtained in 95% of 261 obviously tuberculous cases and in 8·3 % of 503 cases which presented no clinical symptoms. Very advanced cases fail to react to any of these tests, as do general miliary tuberculosis and tuberculous meningitis. As well as the three methods mentioned above the occurrence of a “negative phase” in the phagocytic power of the leukocytes following an injection of Koch’s tuberculin T.R. may be said to be diagnostic of tuberculosis. Another valuable aid in diagnosis is that of the X-rays. By their help a pulmonary lesion may be demonstrated long before the physical signs can be obtained by ordinary examination.

To discuss at all fully the treatment of the various forms of tuberculosis or even of consumption alone would be quite beyond the scope of this article. It must suffice to mention the more recent points. The open-air treatment of consumption has naturally attracted much attention. Neither the curability of this disease nor the advantages of fresh air are new things. Nature’s method of spontaneous healing, explained above, has long been recognized and understood. There are, indeed, few diseases involving definite lesions which exhibit a more marked tendency to spontaneous arrest. Every case, except the most acute, bears signs of Nature’s effort in this direction; and complete success is not at all uncommon, even under the ordinary conditions of life. Perhaps it was not always so: the ominous character popularly attributed to consumption may once have been justified, and the power of resistance, as we see it now, may be the result of acquired immunity or of the gradual elimination of the susceptible. However this may be, the natural tendency to cure is undoubtedly much assisted by the modern system of treatment, which makes pure air its first consideration. The principle was known to Sydenham, who observed the benefit derived by consumptives from horse exercise in the open air; and about 1830 George Boddington proposed the regular treatment of patients on the lines now generally recognized. The method has been most systematically developed in Germany by the provision of special sanatoria, where patients can virtually live in the open air. The example has been followed in other countries to a certain extent, and a good many of these establishments have been provided in Great Britain and elsewhere; but they are, for the most part, of a private character for the reception of paying patients. Germany has extended these advantages to the Working classes on a large scale. This has been accomplished by the united efforts of friendly and philanthropic societies, local authorities, and the state; but the most striking feature is the part played by the state insurance institutes, which are the outcome of the acts of 1889 and 1899, providing for the compulsory insurance of workpeople against sickness and old age. The sanatoria have been erected as a matter of business, in order to keep insured members off the pension list, and they are supported by the sick clubs affiliated to the institutes. They number forty-five, and can give three months’ treatment to 20,000 patients in the year. The clinical and economic results are said to be very encouraging. In about 70% of the cases the disease has been so far arrested as to enable the patients to return to work.

In England, where more than 14 millions of the population belong to friendly societies, it is estimated that the sick pay of consumptive members costs three times as much as the average sick pay to members dying of other causes. An effort has been made by the National Association for the Establishment and Maintenance of Sanatoria for Workers Suffering from Tuberculosis to establish such sanatoria, together with training for suitable work during convalescence, the gradual resumption of wage-earning being resumed while in touch with the medical authorities.

The important features of the sanatorium treatment are life in the open air, independently of weather, in a healthy situation, rest and abundance of food. The last has been carried to rather extravagant lengths in some institutions, where the patients are stuffed with food whether they want it or not. The sanatorium movement on the German model is rapidly extending in all countries. For those who are able to do so advantage may be taken of the combined sanatorium and sun treatment. In certain high altitudes in Switzerland, which are favoured by a large amount of sunshine and a small percentage of moisture, much benefit has been derived from the exposure of the unclothed body to the sun’s rays. The power of the sun in high altitudes is so great that the treatment can be continued even when the snow is on the ground. Not only is the sun-treatment applicable to pulmonary tuberculosis, but also to the tuberculosis of joints, even in advanced cases. The treatment has to a great extent replaced surgical procedure in tuberculosis of joints, but it requires to be persevered in over a considerable period of time. It should be remembered that the benefits of fresh air are not confined to sanatoria. If the superstitious