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APPENDIX.
TREATMENT OF TUBERCULOSIS IN LONDON.
Report by the Medical Officer of Health on the arrangements for the Treatment of
Tuberculosis in London.
31st December, 1919.
I submit a report by Dr. F. N. K. Menzies on the arrangements for the treatment of Tuberculosis
in London. The report deals with the subject in its various aspects under the following heads :—
1. Introduction.
2. Dispensaries.
3. Institutional Treatment.
4. After.Care.
5. Appendices.
In the Introduction to his report Dr. Menzies summarises in an eminently impartial way the views
concerning the various influences which have been held to favour tuberculosis prevalence. The conflict
between the Contagionists and the Localists which raged, at first more particularly in respect to enteric
fever and cholera, in the closing decades of the nineteenth century, has been continued during the last
20 years, and attention has in that period more especially been concentrated upon tuberculosis. The
Contagionists ever laid stress upon the germ, while their opponents held " that something more was at
issue than the mere circumvention of a bacillus." The Contagionists emphasied the risk of direct
infection by sufferers, or in many diseases by apparently healthy carriers. Their opponents, when
consideration was being lim'ted to the case of tuberculosis, either preferred to describe the disease with
Dr. Coghill as only " conditionally infective " or with Sir Hugh Beevor as "sub.infectious" ; or, again
they declared with Dr. Hermann Biggs that " the difference between pulmonary tuberculosis and contagious
diseases must be especially emphasised " ; or they claimed, on evidence such as that appealed to
by Dr. Arthur Ransoroe in his work on " Tubercular Infective Areas," that certain local conditions are
necessary to give virulence, outside the human body, to the organised germ of the disease ; or, finally,
they were content to affirm with Bulstrode that there " is still much to be learnt," and were prepared
to keep an open mind as to the possibilities of further enlightenment in the future such, for example,
as might result from the discovery of some unknown intermediary necessary to secure the transference
of infection from man to man.
The forcefulness, however, of the great contagionist Robert Koch impressed upon the world for
the time being (i.e., from the later " nineties " until his death in 1910) an altogether unjustifiably exaggerated
sense of the importance to be attached to contagion; but by a curious irony the recorded
Tuberculosis death.rate which declined uniformly up to the time of discovery of the tubercle bacillus,
then began to show a tendency to maintain a steady rate and recently even to rise, and these latter
changes occurred during the period in which there has been wide acceptance and vigorous application of
Koch's views.
In the days before the discovery of the tubercle bacillus sufferers from consumption were as a
rule recommended " change of air." There is an aphorism of Celsus which has now been before the world
for nearly 2,000 years, to the effect that " the worst air for a disease is that in which it originated "; and
for centuries before this the ancient physicians acted on the principle of sending consumptives to the
sea or to pine woods. During the latter half of the last century, with vast extension of facilities for transit,
greater use than ever before was made of some form of climatic treatment, various highlands being now
recommended in addition to localities previously resorted to. Unfortunately, with the dissemination of
Koch's contagionistic doctrines, the possibility of obtaining treatment of this kind was gradually restricted,
and in recent years the tuberculous patient has been more and more closely hemmed in, as it were, by
a " ring fence." Dr. Bulstrode, in 1908, confidently predicted that with the growth of sanatorium
treatment, and the associated retention of sufferers (who would in earlier years have gone abroad) in this
country, the recorded death.rate from tuberculosis would rise, and this has, in fact, proved to be the case.
That matters should have come to this pass, and the great hopes raised by Koch's discovery should so
far have proved well.nigh illusory, is a cause of grave disappointment, and the considerations bearing
upon the subject set out by Dr. Menzies in the introductory section of his report deserve the most careful
study.
As regards dispensaries the report, which has been prepared in collaboration with Dr. J. E. Chapman
of the Ministry of Health, shows that a large amount of work has been done in these institutions in London
during the past six years. It will be remembered that in May, 1912, when the duty of framing Tubercu.
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