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better, as much depends then upon the earning capacity of the younger members of the family. But as
is only too well known the advanced case is even, under the most favourable circumstances, a very heavy
drain upon the family resources in every way. There may be some difference of opinion as to the extent
to which he is a danger to others from the point of view of infection. But at least the fact that he is
more or less confined and limited in his movements, tends to localise the infection to those immediately
around and in constant attendance upon him. Looked at from any point of view, if only the humanitarian,
there does not appear to be any escape from the very real necessity for making provision by means
of institutions whether large or small, for these patients. If they are allowed to remain at home they
will, apart from any question of infection, for economic reasons inevitably drag the general standard of
maintenance of the family down to a point of serious danger to their health. They require skilled medical
and nursing attention constantly, day and night, to ease their last days. It is easy to realise the absolute
impossibility of such provision in the homes of the working classes. In the case of single men and women,
not infrequently found in this condition in common lodging houses, it is usual for them to be sent to
the Pcor Law Infirmaries somewhat earlier than the married, and it is not an unusual experience to
find them there for even a year before death supervenes. In the case of married men and women and
the younger members of families, the dislike of removal to Poor Law Institutions is too well known to
need repetition, and yet as is pointed out elsewhere in this report the accommodation in these institutions
occupied by cases of advanced disease in the pre.war period averaged something like 2,000 beds in the 28
London Infirmaries. There are grounds for believing that patients suffering from advanced disease
are beginning to realise more fully than they did formerly that they are a source of danger as well as a
serious burden upon their families, and that it is their duty to take advantage of institutional accommodation,
if available. To some extent this change of mind is no doubt due to the fact that many patients
nowadays learn from attendance at the tuberculosis dispensaries and the teaching of tuberculosis
officers and nurses more about the nature of the disease. It is also worthy of note in the cases of
those patients sent by the Council to St. George's Home, Chelsea (women) and the Downs Sanatorium
men) that there is a growing tendency for them to remain there until the end.
The question which arises now is whether further institutional accommodation is necessary for
this class of patient and , if so, what form it should take and what number of beds is required. In previous
reports it has been pointed out that the question of additional institutional provision is so intermixed
with the question of existing Poor Law provision that it is very difficult, if not indeed impossible, to deal
with the matter satisfactorily until such time as it is decided whether the large amount of institutional
accommodation available in infirmaries is to be transferred for use as an integral part of the Council's
Tuberculosis Scheme for London. The fact cannot be ignored that if the Council provides a large number
of beds for patients suffering from advanced disease in Non.Pauper Institutions, a possible effect will be
that a certain number of patients will go there who would otherwise have taken advantage of existing
Poor Law accommodation, with the net result that the total amount of accommodation for London will
not have been increased. This would be an unfortunate but a probable, or, at any rate, a possible,
complication. Until, therefore, the question of the future administration and control of the Poor Law
Infirmaries is settled, or at all events until it is definitely decided that the Council is responsible for all
patients suffering from advanced tuberculosis because they are tuberculous, and not the Poor
Law Authorities because they are destitute (as a result of tuberculosis), it is difficult to decide
upon the best course to adopt. The provision of small homes is fraught with much greater difficulties
than their advocates seem to realise. There is (1) the difficulty especially nowadays, of getting
suitable premises, (2) the risk that the home will soon get a local reputation of being a home for
the dying, (3) the not negligible difficulties of getting staff and keeping patients happy which are always
inevitable in small institutions. Under the most favourable circumstances it will in any case be a very
long time before provision by means of small homes can do more than deal with but a small percentage
of those patients who require to be segregated. It will, therefore, become necessary for the Council, if it
decides to make provision immediately for the needs of these cases, to do so by means of the larger
institution. In a previous report on this subject it was suggested that probably something like 1,000
cases per annum would need to be provided for, apart from Poor Law Institutions. One of the greatest
difficulties to be encountered in estimating the number of beds required to deal with 1,000 cases per annum
is the probable length of time the patient will either occupy the bed continuously until death or, on the
other hand, take his or her discharge whilst still very ill. It was suggested that this period should be
taken as six months per patient. In other words the bed would have a working capacity of 2 patients
per annum and therefore 500 beds would appear to be sufficient to meet the present requirements so far as
it is possible to make an estimate from the incomplete data available. It should be added (a) that any
institutional accommodation of this character should be either actually within the County area or as near
as possible thereto ; (b) such institutions must be run on somewhat more elastic principles than sanatoria
or hospitals as they must be homes of rest in the best sense of the word. Their success will be in direct
proportion to the humanity and tact with which they are directed and administered ; (c) it would be an
advantage for such institutions to be used also for cases of middle and chronic progressive disease, because
such cases will come and go and will show marked improvement as a result of their treatment. Anything
of this kind mil tend to keep up an atmosphere of hope and cheerfulness and diminish the possibility
of it being regarded only as an institution for the dying, and this is all to the good in the case particularly
of patients in an advanced stage of the disease.
Provided other conditions are suitable, e.g., readiness of access by ambulance, etc., there does not
appear to be any reason why such institutions should not, if necessary, also deal with cases of the acute
emergency type, and cases of surgical tuberculosis requiring very prolonged open air treatment.
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