Page:EB1922 - Volume 32.djvu/810

784

good hygienic conditions, with ample and easily assimilated food, rest while the disease is acute, absence of worry or fatigue, graduated exercise later, and education in the mode of life to be followed are details of first importance. Drugs are chiefly of value in the treatment of symptoms and complications. The introduction of tuberculin by Koch raised vast hopes which have not been fulfilled. Numerous varieties of tuberculin have since been manufactured and employed which still fall short of the anticipations of their originators. Sir Almroth Wright placed tuberculin therapy on a more scientific basis: his opsonic theory giving promise of a means of scientific ad- ministration and control. In 1887 Sir Robert Philip introduced the scheme known as the Edinburgh system for the coordination of efforts, applicable to all phases of the tuberculosis problem. It has the tuberculosis dispensary as the centre of its activities, with trained physicians and nurses for educating, treating and directing the patient, examination of contacts, distribution of patients requiring institutional care to the tuberculosis hospital or sanatorium where advanced cases can be segregated, and early cases receive curative treatment. Later, facilities are given for continued aftercare or treatment and training in a farm colony. The scheme is a practical and comprehensive one and has been the pioneer of other analogous efforts elsewhere. The value of this coordination of methods cannot be sufficiently emphasized.

Marcus Paterson by graduated exercise has shown how much may be safely and advantageously done by auto-inocula- tion of the patient by his own tuberculin. Varrier-Jones at Papworth has demonstrated the value of the tuberculous colony with facilities for treatment of pulmonary tubercle in all stages of the disease, and where prolonged segregation in village settlements is encouraged under reasonable conditions. The patient is trained and his labour subsidized. The value of rest in the treatment of all forms of acute tuberculous disease has inspired surgical interference for securing more complete rest to the diseased and damaged lung in the hope of procuring cure. Forlanini demonstrated the feasibility of introducing by injection gas into the chest to secure the collapse and rest of a tuberculous lung. This manoeuvre, introduced into Great Britain by Lillingston and others, has proved of considerable value in carefully selected cases. This method of treatment is known as the induction of artificial pneumothorax and has proved of dramatic value in the treatment of many patients who were in an apparently hopeless condition.

In non-pulmonary conditions such as tuberculous disease of the bones, joints and glands, for long the condition was regarded as a local disease, comparable to a malignant tumour. This " tuberculome " conception, aided by the discovery of anaes- thetics and antiseptics led often to extensive operations being undertaken with a view to the extirpation of infected tissues. The results in the more severe conditions were frequently unsatisfactory, the mortality both direct and indirect high, deplorable orthopaedic results frequent, sinus formation and subsequent secondary infection common. The present trend of surgical opinion is avoidance where possible of severe radical measures and the adoption of conservative treatment. While the disease is acute the patient is kept at rest, the part affected immobilized, orthopaedic measures are employed to prevent or correct the severe deformities which are frequent in tuber- culous lesions of the bones and joints, tuberculous abscesses are evacuated, preferably by aspiration. Later, when ambulatory treatment is permissible the lesions are suitably immobilized in appropriate splints. Institutions for these cases should be specially designed and staffed and situated in suitable localities at the seaside or in the country. Auxiliary methods of treatment such as heliotherapy (sun treatment), X-ray treatment, etc., play an important part. As treatment is necessarily lengthy it should be associated with education for children, technical training for adolescents, and occupation for adults. In this way the monotony of long enforced recumbency is relieved and the moral of the patient preserved. The value and low mortality of such treatment may be illustrated by Table i. showing the results achieved at the Treloar Cripples' Hospital, at Alton.

TABLE i. Analysis of results of treatment of patients suffering froi surgical tuberculosis at the Lord Mayor Treloar Cripples'

Hospital, Alton, Hants., from the opening of the

Hospital in Sept. 1908 to Jan. 31 IQ2I.

Spine.

920

810

674

22

24

68

27

503-2

Hip.

880

768

710

18

2

25

13

413-1

Knee.

333

34

282

7

II

7

334-7

Other.

354

315

265

16

5

19

9

259-8

2487

2197

1931

63

3i

123

56

382-5

During the decade 1910-20 greatly increased public interesi was manifested in serious and organized endeavours to dea with the tuberculosis problem. In England and Wales prioi to the passing of the National Insurance Act, 1911, it wa; competent to sanitary authorities, under the powers of sectior 131 of the Public Health Act, 1875, to provide dispensaries am residential institutions for the treatment of persons suffer in;; from tuberculosis, and some authorities had initiated a campaign of prevention and treatment. At the beginning of 1912, 1,500 beds in institutions had thus been provided by British sanitary authorities for treatment of tuberculosis; 57 sanitary authorities also had contracted for use of beds in private sanatoria; 30 tuberculosis dispensaries had been established by local author- ities; and 50 by voluntary effort. The need for a national campaign assisted by. contributions from the British Exchequer became evident. This heed was recognized by the National! Insurance Act, 1911, which included provision for " sanatorium benefit " of insured persons. Under this Act and the Financei Act, 1911, a capital sum of 1,500,000 was made available ini the United Kingdom for the treatment of tuberculosis. After: the passing of the National Insurance Act ' a departmental committee on tuberculosis was appointed to report upon the consideration of the problem in its preventive, curative and other aspects. The recommendations of this committee had an important influence on subsequent policy. Compulsory notification of pulmonary tuberculosis was enforced in 1912, and of all forms the following year. In July 1912 domiciliary treatment of insured patients suffering from tuberculosis was approved by the Local Government Board. Schemes for the institutional treatment of tuberculosis became gradually formu-j lated. The extent to which official schemes had been brought into operation in England and Wales may be gathered from the following figures. On April i 1921, the number of approved; dispensaries was 41 1 ; officers and assistant officers for tubercu- losis, 341; residential institutions, 418; the number of beds available in these institutions was 17,352; the total gross main- tenance cost of tuberculosis schemes for 1919-20 was i,953)99 2 - The amount of Government grant for 1919-20 was 619,941. All this was accomplished notwithstanding the severe setback to anti-tuberculosis endeavour which was an inseparable effect of the World War.

On July I 1919 the powers of the Local Government Board in rela- tion to the tuberculosis schemes of local public-health authorities and of the Insurance Commissioners in relation to the administra- tion by the Insurance Committees of the sanatorium benefit of insured persons under the National Insurance Act 1911 devolved upon the Minister of Health, and one central department was made responsible for the guidance and supervision of the work of the two classes of local bodies principally concerned (apart from Poor L authorities) in the conduct of measures for the prevention and treat- ment of tuberculosis. The National Health Insurance Act, 1920, was further designed to simplify administration by providing for the discontinuance of sanatorium benefit within 12 months of the passing of the Act, and insurance patients needing institution treatment for tuberculosis may obtain it at the hands of the local authorities under the schemes undertaken for the provision of such treatment for the population generally of their respective areas. This transfer of authority came into force on May I 1921. . Tuberculosis Act 1921 carried this legislation a step further by enabling local authorities to provide approved schemes for t treatment of all patients suffering from all forms of tuberculosis, and on their failing to do so empowered the Ministry of Health to deal with the matter, debiting the cost to the authorities concerned.