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The following is the special report on pulmonary tuberculosis, and measures to be taken in dealing
with it, made to the Public Health Committee on June 14th, 1910 :—
Gentlemen,—As a result of your instructions, I beg to submit the following report on the
precautions now taken in this Borough to prevent the spread of pulmonary tuberculosis, together
with suggestions as to their improvement.
Before entering into what we are already doing and what additional preventive measures we
might undertake, it is advisable to give a short account of the cause and nature of disease and
state briefly the position of scientific opinion on the subject. The causes of tuberculosis have been
fully entered into in previous reports, but for completeness it will be no harm to re-state them.
In describing the causes of any disease it is usual to refer to them as predisposing and
" exciting " —the soil and the seed. Neither of these factors can be neglected in dealing with
disease, though the importance of each varies with the particular disease, and also with the advance
of scientific knowledge. At present more stress is being laid on the exciting causes, though the
others are not being neglected, and this is probably due to the fact that the general improvement in
health due to sanitary legislation and education is steadily proceeding and will proceed more or less
automatically. On the other hand, the special causes of infectious disease, including tubeiculosis,
have only comparatively recently been discovered, and generally require special treatment, which
must vary from time to time as our knowledge increases.
The widespread nature of tuberculosis is not generally appreciated by the laity, and it is only
the pulmonary form, known as phthisis, which, on account of its obvious symptoms and ravages, is
usually considered when formulating preventive measures. A sharp line, however, cannot be
drawn between the various forms of tuberculosis, for one form is always liable to give rise to another,
and every tubercular focus in our bodies is a potential source of danger.
A recent investigation goes to show that about 50 per cent of the general population are
infected with tuberculosis, though only a small number of these develop definite symptoms of
disease. Some investigators go so far as to state, as the result of post-mortem examinations, that
only about 2 per cent, of the population are quite free from tuberculous infection during some
period of their lives.
The presence of these latent foci of infection explains the occurrence of some cases of
phthisis in which an obvious source of infection cannot be traced. "While we are robust and in
good health they do not develop and we are not aware of their existence, but as soon as privation or
excesses, or other causes, lower our health and resisting power, the bacilli, imprisoned in these
places, break loose and produce the well-known symptoms of consumption.
Infection thus acquired in childhood may not appear till middle life.
Now among predisposing causes you will find poverty, bad and insufficient food, overcrowding
and want of fresh air, over-work, ignorance, alcoholism and heredity generally mentioned. As
some of these causes, such as poverty, insufficient food, &c., are beyond our control as a municipality,
and others involving overcrowding and want of fresh air are appreciated and being gradually dealt
with, I do not purpose to discuss them further, but will deal with the exciting cause, for it is here
that we are in a position to do a great deal more than we are doing.
The immediate cause of the disease is a micro-organism known as the tubercle bacillus. It is
extremely small, and can only be detected by the most powerful microscopes. As far as we know,
it does not exist in nature outside the animal body, and can only be made to grow on artificial
media with difficulty. It may gain entrance into the body by swallowing or inhalation, and, if by
the former, it passes through the wall of the intestinal canal, sometimes causing ulceration in its
passage, but generally becoming arrested in the lymph glands, which act as our first line of defence.
Here the bacillus may be killed at once or proceed to multiply, and in doing so may simply form
a small nodule, which eventually becomes encapsuled and innocuous, or else may spread to other
parts of the body. The disease in this region is known as tabes mesenterica or abdominal tuberculosis.
If the bacillus proceeds to the brain coverings, you get tubercular meningitis, or to the joints, you
may get hip disease, with "white swelling" of the knee, &c., or spinal disease. When the bacillus
is inhaled, it generally, but not invariably, goes to the lungs and settles there, producing pulmonary
tuberculosis or phthisis. Now the prevailing opinion is that inhalation is by far the commonest
method, since much larger quantities can get into the system at one time, and with this opinion I
am in accord, though there is no doubt that in some cases the bacillus may reach the lungs by the
roundabout way of the alimentary canal.
Since therefore inhalation is the main method of the reception of the bacillus in the body, we
may inquire whence these large numbers of bacilli arrive. They undoubtedly come from the
coughing, spitting, and sneezing of consumptive patients. It has been proved over and over again
that there are enormous numbers of bacilli in the sputum of phthisical patients, and I wish to note
here that there are two distinct phases in which they may be inhaled. This may occur while
the bacilli are fresh or dried. It is now known that for a couple of yards or more round every
consumptive patient during and immediately following the act of coughing and sneezing the air is
tilled with little droplets of spray containing bacilli, and it is these droplets which may be inhaled
before they have had time to settle. It seems that they are more virulent or active while wet, and
this shows the importance of consumptives sleeping as much as possible quite alone. In the second
phase the bacilli may at once sink to the floor and get dried, in which condition they may live for
months, and though capable of giving rise to the disease, are not considered so dangerous as when
damp.
At present there is no accurate method of calculating the actual number of cases of phthisis in
Bermondsey, as we have not compulsory notification, but adopting the proportion of cases to deaths
which is generally accepted by authorities, viz., 5 to 1, we get the number of cases in Bermondsey
as 220 X 5 = 1,100, and from personal experience and observation I believe this is considerably
understating the probable number.