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(2) Acute, Emergency, etc., Cases.—The most satisfactory arrangements for cases of this kind
can usually be made in modern hospitals. Cases of pleurisy, haemoptysis, etc., require specially skilful
nursing, day and night, and in addition specially skilled medical supervision. Therefore, the arrangements
for the provision of these beds should be similar to those for observation purposes and might well
be in the same hospitals. If a minimum reserve of beds is considered desirable it would suffice to put
this figure at one male and one female bed per hospital, i.e., 12 beds in all. In order to facilitate
the immediate removal of cases of this character to beds reserved for this purpose at the several
hospitals, an arrangement should be made for such cases to be admitted immediately at the request
of the tuberculosis officer.
(3) Middle and Chronic Progressive Cases.—Many cases of this group have been sent during recent
years to sanatoria with the result that they have occupied beds unsuitable for their treatment. But
many more have not been provided with any form of institutional treatment, with unfortunate results
to themselves and to the community generally. They are frequently engaged in unsuitable occupations,
such as indoor work (tailors, shoemakers, cconfectionery makers, etc.) and owing to the irregularity of
their work, due to frequent ill.health, their lives and the lives of those dependent upon them, represent
a gradual progress downhill, often resulting in poverty, much hardship and real distress. Finally, if
single, they are often found in common lodging houses, or if married in an overcrowded one or two room
tenement dwelling, and not infrequently they die in infirmaries and other public institutions (vide table
showing deaths from tuberculosis in institutions). In truth they represent the most difficult medicos
cial problem in connection with tuberculosis. It will have been noted that here again tuberculosis
officers differ in their opinions as to the best plan for dealing with such cases ; some favouring the large
institution, others the small local home. The fact that the patient is generally perfectly well able
to get about to a limited extent and that after a short period of rest, good, regular food, together
with skilled nursing and medical attention, he invariably feels immensely stronger and better, is another
very real difficulty as it is only natural that he should then desire to resume his usual life at home
and at work. But experience clearly shows that another breakdown in the near future is inevitable,
the interval depending largely upon the occupation of the patient; the capacity for earning a
decent livelihood with consequent power to purchase good food in sufficient quantity and to pay rent
for decent home accommodation ; and the common sense to keep under regular medical supervision,
to cease work and to return to institutional treatment when there is evidence that it is required.
Any attempt to deal with cases of this kind by means of either small local homes or large institutions
alone is doomed to failure. Something more is undoubtedly required and that something includes (a)
the provision of a suitable occupation, under medical supervision, in an open air factory or workshop ;
(b) the provision of a decent home with adequate light, ventilation, separate bed or bedroom, etc.; (c)
some means of supplementing the earning capacity of the patient and his family (if married) while he is
undergoing institutional treatment and while he is still capable of work, however limited. If these
conditions are fulfilled the question of whether the cases are treated, during the period when the patient
is unable to work, either in a large institution or a small local home appears to be of minor importance.
The solution of these difficulties is mainly dependent at present upon the extent to which Borough
Councils and Voluntary Committees are prepared to take up the problem locally as a question of after
care. Where a local committee is able and willing to establish a factory or workshop under the medical
supervision of the tuberculosis officer, where suitable work can be carried out under open air conditions,
during the long periods when the great majority of these patients are able to do a certain amount of work
daily, and live under decent conditions in their own homes, there does not appear to be any objection to
such schemes being undertaken in each Borough or Dispensary area. On the other hand there are
certain to be areas where neither Borough Councils nor Voluntary Committees will be able or willing to
undertake such provision, and in that event some provision by means of large institutions of what one
might call the hospital.sanatorium type will become necessary. It is suggested that such institutions
large or small need not necessarily be entirely reserved for this class of patient. It would be an immense
advantage in the case of large institutions if they were fitted up with workshops at which suitable trades,
such as basket making, etc., and open air occupations such as market gardening, etc., could be taught.
The patient after a period of rest and recuperation, together with careful education as to how to take care
of himself and how to avoid infecting others, would in many instances be able to carry on successfully
for a much longer period of time, and would be a less serious danger to the community. It would also
probably be safe to hazard the statement that under such conditions quite a number of the patients
would reach a quiescent stage of the disease and live for a considerable period of years.
(4) Advanced Cases.—One of the most striking facts which emerged from the inspection of the
work of the tuberculosis dispensaries was the small number of cases of advanced disease known to each
tuberculosis officer in his own dispensary area. It was a rare event to come across a tuberculosis
officer who could put his hand upon 30 cases, and if this number is taken as an average for each of
the London dispensaries it will be seen that not more than 1,000 cases are known to all the tuberculosis
officers in London. That there are many more than 1,000 persons in an advanced stage of the disease
at any moment in London is certain from other facts in our possession and to which reference will be made
in another section of this report.
With reference to the treatment of these cases, tuberculosis officers again have the same difference
of opinion ; some favouring small local institutions in the immediate vicinity of the patients' homes and
others the larger and more centralised institutions. The difficulties referred to in cases of chronic progressive
disease are not of the same nature as those which arise in cases of very advanced disease. The
patient is probably hardly able to get about. He is often on the verge of starvation owing to utter
inability to do any regular work of any kind. If married, his condition and that of his family may be no