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46
The general mortality curves in the second diagram of each of the two sexes
are seen to be practically parallel, but whereas after 1896 those of England
descend, those of Prussia are ceasing to descend as rapidly as before. The
conclusion drawn from this by German observers, with some of whom I have
discussed the subject, is that a certain proportion of the cured and restored
cases have ten or more years later died from other causes.
The conclusions I have drawn are, that sanitary measures in England
directed towards the amelioration of dwellings have, since 1866, acted surely
but slowly during thirty-five years in reducing the mortality from tuberculosis
in the two sexes, especially the female, and that probably recent factory and
workshop legislation will bring the male mortality parallel to the female, but
that the special measures against tuberculosis in Prussia have accomplished
this reduction in less than one half the time, namely, in fifteen years, and that
when legislation in Prussia directed to the amelioration of dwellings also comes
into force both the general and special mortality will fall below that of England.
It therefore follows that if England is to continue to lead in the health of her
working classes that she must adopt all the special measures available against
the prevalence of tuberculosis, and especially against the pulmonary form of
tuberculosis or consumption.
In order to appreciate these special measures it is necessary to explain the
reasons for them and especially to bear in mind what consumption really is.
Pathologically pulmonary tuberculosis is dependent upon the access of a
specific microbe to the human subject in a suitable bodily condition, due to
predisposition, partly innate but mainly acquired by deficient quality of air
supply, insufficient nourishment, or exhaustive work. The specific microbe
may be expelled with the sputum in expectorating or with the droplets or spray in
coughing and forcible expiration, and either pass directly from a suffering person
to a predisposed person or else find a temporary and intermediate nidus in the
interior of an inhabited building and ultimately gain access again to a permanent
or temporary inhabitant of the building. In France stress is laid upon the
difference between the communicability of la tuberculose ouverte and la tuberculose
fermée, and preventive treatment in France aims at converting the ouverte into
the fermeé condition. In other words, it is recognised that in the non-expectorating
types of tuberculosis there is little risk of communicability. This
differentiation simplified the position, as then one had to deal only with
pulmonary tuberculosis accompanied with expectoration, to which four
injunctions were applicable, namely, (1) do not breathe forcibly into the face
of another person, but when sighing, yawning, hawking, or coughing do not
fail to hold the hand before the mouth; (2) do not swallow the sputum, and do
not spit upon the surfaces of an enclosed or covered place; (3) if consumptive,
spit only into a proper receptacle specially reserved and prepared for the
purpose; (4) if consumptive, do not sleep with another person. Passing on, one
has to consider the question of diagnosis, notification, disinfection, and sanatoria.
Diagnosis, the first desideratum is the earliest recognition of the disease, and
this must depend upon the highly trained skill of the medical attendant, but it
is evident that if expectoration is present it becomes a matter for the protection
of the public that he should be assisted in making a correct diagnosis, and so
the first conclusion is arrived at (1) that every sanitary authority should provide
facilities for the bacteriological examination of sputum for tubercle bacilli. The
discovery of the tubercle bacillus practically amounts to the voluntary
notification of expectorating pulmonary tuberculosis for those cases in which
the sputum is examined at public expense.