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83
A consideration of all the facts seems to justify the conclusion that
substitution of institutional for domestic relief of the consumptive poor
has been historically a main factor in the reduction of the death rate for
Tuberculosis. In a paper dealing with the same subject at the
American Congress in 1908, Dr. Newsholme repeats with added insistence
that " had it not been for the steadily increasing extent of
institutional treatment of the sick, and especially of the consumptive
sick, which has characterised most of our great centres of population,
we should have experienced not the decline of phthisis which has
occurred, but a great increase in its prevalence." Unfortunately for
this thesis, the feature of modern literature has been a demonstration of
the prevalence both of the infection and its resulting lesions.
The late Dr. Bulstrode, in his report on sanatoria for consumption,
to the Local Government Board in 1908, quotes Sir Shirley Murphy
as suggesting the possibility of a change of type in the disease. After
dealing briefly with such matters as a lessening fertility and virulence
of the parasite, he returns to the idea of improved hygiene.
How can one explain the coincidence of widespread infection and
its close association with increased town dwelling, with the fall in the
death-rate ?
The mortality due to the disease is shown, by a study of occupational
statistics, to occur in industrial towns rather than in rural
conditions of labour. This is well demonstrated by an analysis and
reclassification of the statistics given in the supplement to the sixtyfifth
report of the Registrar General. When we look at the facts as
they appear to be, we have to attempt an explanation of the simultaneous
occurrence of urbanization, general infection, a falling deathrate,
and a high mortality among town dwellers.
A very important point in a disease of such a chronic character as
tuberculosis, is the age at which the first infection and apparent
recovery are found to occur. There is a very close parallel between
the figure obtained by the study of juvenile tuberculosis as shown by
tuberculin methods on the living, with the figure obtained by the study
of the evidence of healed or latent tuberculosis in the bodies of the
dead (both figures approach 100 per cent). The distinction between
infection by the bacillus and the actual presence of disease due
to the bacillus is an important one in this respect That tubercle
infection may exist without the development of tuberculosis is a wellestablished
fact. As a fatal disease pulmonary tuberculosis seems to
cause the greatest number of deaths in the working period of life.
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