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Miss C., aged 18 ; a case of somewhat advanced consumption. Home conditions described by her
doctor as follows—
The family, which consists of the parents and 7 children, share a fairly small house with three
other families. The patient's family possess one fair sized bedroom with two windows, one of which
opens about two inches at the bottom; a very small and dark back bedroom, dirty, dilapidated and
stuffy, having one window and containing a dirty double bed; and a very small kitchen with a smaller
scullery leading from it; the latter has a window overlooking a yard, but it is blocked by a chair to
prevent children facing out. The whole family of 9 occupy the larger bedroom, the patient sharing a bed
with three other clildren; the youngest child is a baby of 14 months. An intimate friend of the patient's,
who lived on the flat below, recently died of pulmonary tuberculosis.
The late King asked, apropos of tuberculosis—"If curable, why not cure? If preventable, why
not prevented ? "
While conditions such as those just described continue to exist the answer is not difficult to find.
My remarks so far have not perhaps been in a particularly cheerful strain; however, there is a
reverse to the medal. For since we know that the failure of sanatorium treatment by no means lies
entirely at the door of the sanatorium, but rests rather with our faulty system of home treatment,
or, as it is usually termed, after-care, the lines for further effort are clearly defined. The failure of
home treatment implies no reflection upon the work of practitioners and tuberculosis officers, but for
whose labours matters would be much more unsatisfactory then they are. But the medical profession
are handicapped by conditions inherent in the life of the working classes which paralyse their efforts.
As a patient said to me recently, " I cannot earn a penny. How can I get better on advice and bottles
of medicine? I want more to eat." No appreciable progress is possible until the social side of the
problem is seriously dealt with. It is not too much to say that the treatment of tuberculosis, other than in
institutions, lies primarily in the domain of the social worker. This truth finds expression in the element
which constitutes the brighter side of my subject, namely the steady development of “After-care.”
It is the role of after-care agencies to render the social circumstances of patients such that medical
science can give effective assistance. After-care work is many sided; grants in money or in kind in
aid of families suddenly bereft of the wage-earner, and to those who, as the result of prolonged illness,
are reduced to living on a pittance which spells semi-starvation, the renting of a room, or more commonly
the gift of a bed for the use of the consumptive when over-crowding renders any degree of segregation an
impossibility, the canvassing of employers with a view to finding employment which shall be within the
capacity of a tuberculous patient, and subsidising of this work should it not give the worker a living wage.
In default of experience many after-care committees can do little more than set in motion the machinery
of private benevolence or official relief. In London one of the first steps is to mobolise the activities
of the C.O.S., a body to whom the tuberculous poor are greatly indebted. To judge by my experience
it is voluntary effort and philanthropy that carry the greater part of the burden of the treatment of the
tuberculous working classes. I except, of course, patients in residence in a sanatorium or in poor-law
institutions.
After-care
and relief.
The following, for instance, is a familiar course of events—Mr. W., a packer, aged 30, married,
has a wife and three young children to support. Has been found to be suffering from consumption
in its early stages; prospects of complete recovery are favourable granted prompt treatment. Offered
a bed at a sanatorium, he refused it on the grounds of difficulty at home. Enquiry proved the stumbling
block to be the usual question of the support of dependents. Referred to the C.O.S.; the necessary
assistance was at once forthcoming and the patient left home for the sanatorium without anxiety.
A type of report coming from patients in this group which is disquietingly common at the present
time is represented by the following—
A.R., a discharged soldier, recently discharged from a sanatorium. The tuberculosis officer
writes, “he does not seem up to doing any serious work and certainly is not so well as when he left
the sanatorium. He should do all right with light occupation in the country ; can anything be done?”
This man has a wife and one child of 9 years ; his income consists of a pension of 32s. a week, which, after
payment for rent allows him 27s. per week for the support of himself, his wife and his child. The family
live in one room ; the house is in a court in a poor neighbourhood ; and their circumstances are indicative
of poverty. Satisfactory progress of the patient cannot be expected.
If, as there is reason to believe, London is representative of the country generally, there are
thousands of men invalided from the services on account of tuberculosis, who, unable to find employment
suited to their particular requirements, are living upon pensions which, in many instances, are inadequate
for the maintenance of themselves and their families.
One has only to compare the experiences of patients resident in areas in which an active after care
organisation is in being with those in districts in which this essential unit is actually or practically
non-existent, to appreciate the valuable services rendered by a well-organized unit dealing with social
conditions. Dr. Meek, of Frimlev, has recently published some striking evidence on this point
from the records of the Lady Almoner's department of the Brompton Hospital.
The duties of an after-care officer are highly skilled. As in other walks in life efficiency can
come only from sound training; a thorough knowledge of social science is essential. For success,
every patient must be the subject of individual study: As Miss Bompas, of Brompton Hospital, once
said to me, “The whole future of a patient may turn on the discovery of a half-forgotten uncle, who
on being approached, offers to a young consumptive shop assistant a home and suitable employment
in some rural district.” Personal assistance of this character requires time, patience, knowledge, money
and infinite tact. I would like to see centres established for the training of after-care workers. They
could be realised to-day in the Almoner's Department of some of our leading hospitals. The social worker
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