WITH THE INCREASE IN TUBERCULOSIS from war causes, the time has come to consider how our methods of dealing with it may be improved. The chief error now made is that attention is focussed on the curative side of treatment and not on the preventive side.

The best initial  preventive step would doubtless be universal vaccination against it, as for small-pox, but this is not yet possible, and even though vaccination against small-pox is general, cases are still isolated; while neither isolation nor vaccination is practised in tuberculosis. Compulsory segregation for infective cases is bound to come sooner or later. 

Inadequacy of the ‘health visit’

Under the dispensary system, the tuberculosis officer makes his headquarters a tuberculosis dispensary which serves as a “sorting house.” The time of the officer is devoted to diagnosis and curative treatment, rather than prevention. He sees and treats such patients, and examines such contacts, as are willing to go there, and gives opinions about others that may be sent by doctors in the neighbourhood. 

The preventive treatment is carried out by medical officers of health, sanitary inspectors, nurses and health visitors, who visit the homes of notified cases, investigate home conditions and give advice in a more or less conventional way.

But it often happens that a child has been notified, or a young adult, when the chief source of infection is one of the patient’s grandparents, a relative staying in the house, or a lodger, and in such a case the health visitor, who is bound to presume that the case notified is the one  requiring the visit, does very little good.

For example, a notified tuberculous father may be given a room to himself, while his wife, who has chronic tuberculosis and is the source of his infection, is sent to sleep with, and infect, the children.  Or a child with enlarged glands is removed from the company of other children, some of whom have glands equally large (but unnoticed), and sent to sleep with the tuberculous grandmother.

I may mention also the case of two children, with wealthy parents living in a large country house. Both children had tuberculous  glands of the neck; they had been sent away in the care of their nurse and the cows of the vicinity had been persecuted, but without result. The source of infection was the nurse, who had physical signs of phthisis on both sides, and who had suffered from cough, sputum, and occasional haemoptysis for some years. “Nanny” was regarded as a sort of family institution, and this source of infection, common among the children of the well-to-do, had been entirely overlooked.

According to figures collected for the purpose I find that in about 35 per cent of notified cases the customary “health visit” does little or no good, while in 2 per cent it is, or may be, harmful.

Tuberculosis officers should visit in person

In order to combat tuberculosis effectively the tuberculosis officer must visit personally the home of every notified case there to investigate the home conditions and examine contacts. No doubt this entails much trouble and needs tact and diplomacy, but anything short of it will be useless; no amount of assiduous outpatient work can replace it.

To free the tuberculosis officer for preventive work, the outpatient dispensary could well be carried on by practitioners in the neighbourhood, paid as part time assistant tuberculosis officers. The treatment is almost entirely symptomatic, and mainly for cough or dyspepsia – two symptoms which a practitioner has much experience of. It could easily be arranged also that tuberculin, and other of the more experimental remedies, should only be issued in consultation with the tuberculosis officer.

A further important step for the prevention of tuberculosis would be the provision of more isolation hospital accommodation. We probably have already sufficient sanatoria, if properly used and pooled. The hospitals would be used also for observation, but some of the beds tacitly reserved for isolation.

Some of the present Voluntary Aid Detachment hospitals might be readily adapted to this purpose later on. The number of  highly infective cases requiring isolation is not large; I estimate that in South Devon 60 beds, 30 for each sex, would suffice for the purpose. Most of us can deal with a small dose of tubercle bacilli, but few can resist a large dose