View report page

7
(f) " In New York there were, Dr. Hermann Biggs states, available in 1906, from 2,100 to 2,200
beds chiefly for the care of advanced cases of phthisis, whereas 15 years ago the number of beds specially
devoted to this purpose was ' scarcely more than a quarter of this number, certainly not in excess of
one third.'
" It does not appear from a study of the statistics relative to the behaviour of pulmonary tuberculosis
in New York which will be found in the section on Notification (Part III.) that this gradual
increase from, say, 700 beds to 2,000 for advanced tuberculous cases, together with the other preventive
measures practised in New York under the vigorous generalship of Dr. Hermann Biggs, has materially
augmented the rate of fall in the death rate from that malady.
(g) " As regards Brighton the chart furnished does not suggest that the amount of isolation,
practised in the fever hospital, together with the educational course with which it has been attended,
has, as yet, exercised an easily detectable influence upon the death rate from pulmonary tuberculosis in
that town.
(h) " Apparently Dr. Newsholme takes the view that a patient suffering from pulmonary tuberculosis
is only potent for harm as a distributor of tubercle bacilli for a period of twelve months.
Doubtless Dr. Newsholme has satisfactory evidence for this belief, but my own view would be more in
accord with that of Sir Hugh Beevor, who suggested three years, on the basis of his London experience, as
the duration of the infective period. On this assumption he presented the problem as follows—
" ' Let the numbers of the phthisical in institutions be supposed in England now to be 33%
and the length of their stay to be one third of a year, then if their bacilliferous propensity lasts
three years, the amount of segregation is only effective to the extent of 3 or 4 per cent, of total
bacilliferous propensity of total phthisical population.
Such a small amount, if such it be, is surely evidence that the detention in institutions and
declension of phthisis are not cause and effect. An infectious year of illness is a limitation
unknown to me.'
" I gather, however, from Dr. Newsholme's reply to these comments that he inclines to the view
that the bacilliferous period is probably longer than a year.
(i) " It would not seem that if this thesis of segregation influence be as great as is claimed for
it there is any room left for the operation of tuberculous milk and meat."
The evidence up to the year 1908, clearly suggested that if segregation was to be credited with a
share in bringing about decline of the phthisis death rate, the rate of that decline should be augmented
during the next ten years. In fact, the reverse of this has proved to be the case, the rate of decline
instead of increasing has slowed down and apparently is now rising, and it seems clear, therefore, that
other factors must have operated (Appendix III.).
(5) The migration theory.—Dr. Hamer suggested in 1912 that while there can be no doubt that the
decline in the tuberculosis death.rate betwen 1860 and 1900 was favourably influenced by the great
improvement in the social conditions of the community, these influences should be coupled with the fact
that during the same period a large number of tuberculous patients annually left our shores for the
Colonies and other countries where they either survived or died. In any case the great majority of them
did not return home, and therefore to that extent our tuberculosis death.rate considerably benefited.
Furthermore the retardation in the decline of the tuberculosis death rate in more recent years is
due to the fact that this exodus of tuberculous patients abroad has practically ceased, owing to the fact
that we have for some years past provided on a larger and larger scale for the treatment of these patients
in sanatoria and hospitals in this country, and, in addition, the Colonies and other countries have
prohibited such pat ents from entering their territory. Therefore, they die at home, and hence their
influence upon the tuberculosis death rate.
Arguing upon the same lines, the tuberculosis death rate in Ireland between, say, 1860 and about
1900, gradually rose, instead of falling as in England and Wales, because the general public health conditions
of the country improved much more slowly and a large emigration of the population took place,
which consisted mainly of the young and fit men and women.
The more recent improvement in the tuberculosis death rate in Ireland—i.e., particularly since
about the year 1900, is due to the fact that the country has become much more prosperous in the last
fifteen to twenty years. Not only are the housing conditions better and the standard of living much
h'gher, but the increased prosperity of the country has tended to restrict considerably the emigration
of young and fit men and women.
With regard to this theory, there can be no doubt that the general improvement in the health
conditions of the people must have exercised some beneficial effect directly and indirectly in reducing
the tuberculosis death.rate. Many critics, however, experience some difficulty in accepting the further
statement that the exodus of tuberculous patients from this country during the years when the tuberculosis
death.rate consistently fell was such that, as this exodus gradually ceased, it was associated with
an arrest of the decline of the tuberculosis death.rate.
This theory would of course imply that the retention of that proportion of the tuberculous
poulation, whatever it was, in this country which formerly emigrated, has been more than sufficient to
counterbalance all the other agencies at work which should make for the continued decline of the tuberculosis
death.rate, and more particularly those special measures such as institutional treatment wh;ch
have been put into operation since 1900 for the welfare of the tuberculous patients.
(6) Karl Pearson, in his pamphlet entitled " The Fight against Tuberculosis and the Death Rate
from Phthisis," published in 1911, severely criticises the statistical data upon which Sir Arthur Newsholme
bases many of the conclusions arrived at in his book, " The Prevention of Tuberculosis," and
in particular the theory that " institutional segregation is the predominant cause of the decline of phthisis