The prevention of tuberculosis

Preface

THE promise to write this book as one of a series dealing with the public aspects of Medicine was made in 1906. The greater part of it was written over a year ago, Part I. almost entirely so, the quotations from the Second Interim Report of the Royal Commission appointed to inquire into the Relations of Human and Animal Tuberculosis, with such slight modifications of inference as were necessitated by it, being added subsequently.

Part II. is a restatement of an investigation of which the results were last set forth in the Journal of Hygiene for July 1906. Although necessarily lengthy and full of detail, the argument and conclusion that institutional segregation is the predominant cause of the decline of phthisis in this country has great importance in its bearing on the administrative measures considered in Part III. It is perhaps unfortunate that the argument is continuous from end to end, and that its effect is misconceived when only parts of it are considered disjoined from the remainder. In the absence of this continuity the investigation could have yielded no more than ground for surmise or conjecture. The history of the public health service gives familiar proof of the important place taken by scientific hypothesis among the tools at our disposal. When, however, conclusions can be tested by actual experience, such experience obviously affords a surer basis for administrative action ; and in a matter of such immense importance to public health as the control of tuberculosis, the intricacies of a statistical inquiry embodying historical and international experience are worth undertaking and mastering if, as happens often and is certainly so in the present case, the question cannot be discussed conclusively without it.

The chapters on statistics are indispensable to the main arguments of the book, especially to those in Part II. If, for instance, statistics of phthisis are largely vitiated by transb v .

vi THE PREVENTION OF TUBERCULOSIS

ference between this disease and bronchitis, important reasoning as to the course of phthisis can scarcely be based on them. Where not otherwise stated, the English statistics are derived from the Reports of the Registrar-General of Births and Deaths and from Dr. Tatham's letters therein ; some of these tables have been calculated separately, or readjusted for my special purposes.

The bibliography on p. 415 does not pretend to be complete. It comprises only the papers and books actually quoted in this volume. It is hoped that the index of names of places and persons will form a useful supplement to the subject-index.

This volume is written almost solely from the standpoint of the public health administrator, and is intended primarily for medical officers of health. It is believed, however, that it will also be interesting and useful to all medical practitioners, to many members of Sanitary Authorities and Hospital Committees, to patients themselves, and to that increasing proportion of the public who desire to know more of preventive medicine. As therapeutics in the more limited sense of the word has been entirely excluded from its scope, there appears to be no impediment, except, perhaps, lack of interest, to this wider utility of the discussion of tuberculosis here attempted.

I have to thank my friend H. C. Lecky, M.A., M.B., and H. P. Newsholme, B.A., B.Sc, for reading portions of the manuscript, and for valuable suggestions, and the latter for seeing the volume through the press.

A. N.

LIST OF FIGURES

FIG. PAGB

i . Comparative Magnitude of some of the Chief Preventable Causes

of Death in England and Wales . 5

2. England and Wales, 1904. — Male and Female Death-rates from

Phthisis at different Age-periods . . . 9

3. Deaths from Phthisis at each Age-period per 100 Deaths from the

same Disease at all Ages . . . . .10

4. Deaths from Phthisis at each Age-period per 100 Deaths from all

Causes at the same Age-period . . . .11

5. Relative Death-rates from (a) Phthisis, (b) Bronchitis and Pneu-

monia in England and Wales, the rates for 1901-04=100 . 25

6. Comparison between 1861-70 and 1901 of relative Death-rates at

different Age-periods from Bronchitis plus Pneumonia and from Phthisis . . . . . . .28

7. Relative Death-rates from different Tuberculous Diseases from

1850-54 to 1901-04, the Death-rate in the most recent period in

each instance being stated as 100 . . . • 34

k 8. Section of a Lung chiefly in the first stage of Phthisis . . 46

9. Section of a Lung chiefly in the second stage of Phthisis . . 46

v io. Section of a Lung chiefly in the third stage of Phthisis . . 46

11. Section of a Lung exhibiting Cretaceous Masses . . .46

12. Acinus of the Lung, enlarged ten times . . . .111

13. Death-rates from Phthisis for Males and Females at different Age-

periods in England and Wales, Sheffield, and Birmingham . 166

14. Female Death-rate from Phthisis at each Age-period in 1861-70,

and in 1 891 -1900, that of Males at the same Age-period = 100 . 170

15. Male Death-rate from Phthisis at each Age-period in Urban and

Rural Counties . . . . . ..173

16. Female Death-rate from Phthisis at each Age-period in Urban

and Rural Counties . . . . . . 174

17. Death-rate from Phthisis in Males and Females at each Age-period

in Urban Counties . . . . . . 175

18. Death-rate from Phthisis in Males and Females at each Age-

period in Rural Counties . . . . .176

19. Showing steady improvement in Housing Conditions in Ireland . 227

20. Proportional Phthisis Death-rates and Wheat Prices in the U.K. 233

21. Proportional Phthisis Death-rates and Wheat Prices in Paris . 234

22. Proportional Tuberculosis Death-rates and Wheat Prices in vii viii THE PREVENTION OF TUBERCULOSIS

FIG. PAGu

23. Proportional Phthisis Death-rates and Wheat Prices in Mass.,

24. Proportional Phthisis Death-rates and Cost of Food in the U. K. . 237

25. Proportional Tuberculosis Death-rates and Cost of Food in Prussia 237

26. Proportional Phthisis Death-rates and Cost of Living in England 239

27. Relative Changes in Pauperism and Phthisis Death-rate in

28. Relative Changes in Pauperism and Phthisis Death-rate in

29. Relative Changes in Pauperism and Phthisis Death-rate in

30. Relative Changes in Pauperism and Phthisis Death-rate in

31. Comparison of the Changes in the Death-rates from Typhus and

from Phthisis in Ireland and in England and Wales . 260, 261

32. Number of Total Lepers and of Lepers in Asylums in Norway . 264 23. Rates of Changes in Phthisis Death-rates and in the ratio of

Institutional to Total Deaths in England . . .271

34. Rates of Changes in Phthisis Death-rates and in the ratio of

Institutional to Total Deaths in London . . . 272

35. Rates of Changes in Phthisis Death-rates and in the ratio of

Total to Indoor Pauperism in England . . . .278

36. Rates of Changes in Phthisis Death-rates and in the ratio of

Total to Indoor Pauperism in Scotland . . . 279

37. Brighton. Annual Notifications, Sputa examined, and Admissions

to the Sanatorium . . . . . • 34 1

38. Comparison of Death-rate from Phthisis and other forms of

Tuberculosis at different Age-periods . . . .361

39. Block Plan of Isolation Hospital . . . . -397

Part I Causation Of Tuberculosis

CHAP. PAGE

I. Magnitude of the Evil : A. Mortality . . 3

II. Do. B. Sickness and Economics 13

III. Are the Statistics relating to Tuberculosis Trust-

IV. The History of Phthisis . . . • 35 V. The Morbid Anatomy and Symptoms of Phthisis . 43

VI. The Tubercle Bacillus . . . . 51

VII. Infectivity of Tuberculosis : A History of Views

VIII. Infectivity of Tuberculosis: B. Experimental

Evidence . . . . . • 59

IX. Infectivity of Tuberculosis: C. Statistical and

Clinical Evidence . . . . .62

X. Latency in Tuberculosis . . . -74

XI. Sources of Infection: Minor Sources . . 86

XII. Do. : Dust and Spray . . 89

XIII. Circumstances limiting the Amount of Infection by

Dust and Spray . . . . .101

XIV. The Portals of Infection : A. Infection by Inhala-

XV. The Portals of Infection : B. Infection by Ingestion 115 XVI. Relation of Bovine and Human Tuberculosis . 121

XVII. Evidence of the Occurrence of Bovine Tuberculosis

XVIII. Tuberculosis from Meat and from Milk and other

Dairy Products . . . . . 139

XIX. Domestic Infection . . . . .146

XX. Infection in Attendance on the Sick . .152

XXI. Industrial Infection . . . . . 157

XXII. Personal Influences other than Infection favouring Tuberculosis : Susceptibility to Infection . 161

XXIII. Age and Sex . . . . . .164

XXIV. Personal Conditions lowering Resistance to In-

XXV. Hereditary Disposition to Phthisis . . .182 x THE PREVENTION OF TUBERCULOSIS

CHAP. PAGE

XXVI. Conditions of Environment lowering Resistance to Infection, Social Misery, and Insanitary Circumstances . . . . .191

XXVII. Climate and Soil . . . . .194

Part II

THE MEANS BY WHICH THE REDUCTION OF MORTALITY FROM TUBERCULOSIS ALREADY OBTAINED HAS BEEN SECURED

XXVIII. Introductory ...... 205

XXIX. Tuberculosis and General Health in Various Communities : Virulence, Natural Selection, and Decadence . . . . .210

XXX. Tuberculosis in Urban and in Rural Communities . 220 XXXI. Tuberculosis in Overcrowded Communities . 224

XXXII. Tuberculosis in Communities of Varying Well-being ... . . . . 230

XXXIII. Tuberculosis in Communities of Varying Sanitary

Education and Sanatorium Provision . -252

XXXIV. The General Relations of Tuberculosis and other

Chronic Infectious Diseases to Institutional Segregation ...... 256

XXXV. Tuberculosis in Communities with Varying

XXXVI. The Relative Influence of Institutional Segregation AND OF OTHER MEASURES FOR THE CONTROL

of Tuberculosis ..... 292

Part III Measures For The Reduction And Annihila- Tion Of Tuberculosis

XXXVII. General Scheme of Preventive Measures . .301

XXXVIII. The Early Recognition of Phthisis in relation

to Prevention . . . . . 306

XXXIX. The Medical Practitioner in relation to Preventive Measures . . . . .316 XL. The Consumptive Patient in relation to Preventive Measures . . . . 324 XLI. The Prevention of Indiscriminate Expectoration 331 XLH. The Notification of Phthisis . . . 338 XLIII. The Sanitary Authority in relation to Preventive

Measures against Tuberculosis . . . 351

XLIV. Education Authorities and the Prevention of

Tuberculosis . . . -359

CONTENTS xi

CHAP. PAGE

XLV. The Board of Guardians and the Prevention

of Tuberculosis ..... 366

XLVI. Insurance and Friendly Societies in relation

to the Prevention of Tuberculosis . . 372

XLVII. Dispensaries and the Prevention of Tuberculosis ...... 2>77

XLVIII. The RSle of Sanatoria in the Treatment and

Prevention of Phthisis • . 382

XLIX. The Institutional Treatment of Phthisis from the

Public Health Standpoint . . . 394

L. The Prevention of Tuberculosis arising from

LI. The Co-ordination of Administrative Measures

against Tuberculosis . . . .411

INDEX OF NAMES OF PLACES . . .423

INDEX OF NAMES OF PERSONS . . .424

INDEX OF SUBJECTS .... 427

Part I Causation Of Tuberculosis Terms Employed

Tuberculosis: the general name given to the disease resulting from the invasion of any part of the body by the tubercle bacillus.

General Tuberculosis .

Acute Miliary Tuberculosis Acute Tuberculosis Phthisis

Pulmonary Phthisis Pulmonary Tuberculosis Consumption

Tabes Mesenterica Tuberculous Peritonitis

Tuberculous Meningitis iVcute Hydrocephalus Brain Fever (in part) Lupus .

Caries .

Scrofula

\ Names given to tuberculosis where J- many parts of the body are J attacked simultaneously.

Tuberculosis of the lungs.

Tuberculosis of the peritoneum - and of the abdominal lymphatic glands.

Tuberculosis of the membranes surrounding the brain.

Tuberculosis of the skin, bone, lymphatic glands.

7 Consumption, Tabes (both of Latin origin), and Phthisis (of Greek origin) are all words the literal meaning of which is "wasting."

The term Phthisis has been used sometimes in a sense wider than that of Tuberculous Phthisis or Pulmonary Tuberculosis, e.g. miners' phthisis, knife-grinders' phthisis, etc. In most, if not in all such diseases, tuberculosis forms an important, though possibly superadded, cause of death. Possibility of error from this cause will only affect the statistics of special localities.

Chapter I Magnitude Of The Evil: A. Mortality

TUBERCULOSIS is a disease caused by the destructive lesions set up in the lungs or in other parts of the body by a special bacillus or microbe. The disease is infectious, i.e. is communicable from man to man and from animals to man ; and it never originates in the body apart from the invasion of the special bacillus.

Being an infective disease, tuberculosis comes into the same category as the infectious diseases enumerated in Tables I. and III. Large sums of money very properly are spent each year in the prevention of these diseases ; hitherto but little has of set purpose been spent on measures for the prevention of tuberculosis. We may, therefore, with advantage consider, in the first place, the relative magnitude of these different causes of death. In Table I. are set out the deaths from the acute infectious diseases and from tuberculosis.

Table I. 1 — England and Wales, 1904

Number of Deaths from —

Measles and German Measles

Whooping-Cough

Diarrhoea and Dysentery

Enteric Fever

Diphtheria

Scarlet Fever

Typhus Fever

Small-pox

Pulmonary Phthisis

All other Tuberculous Diseases

12,341

11,909

29,674

3,153

5,763

67,154

41,851 1 8,354

60,205 Thus tuberculous diseases in 1904 caused 60 deaths for every

1 All the statistical material relating to England and Wales contained in this volume is derived from Dr. Tatham's valuable annual letters to the Registrar- General of Births and Deaths, unless otherwise stated.

67 caused by the aggregate of the chief acute infectious diseases. These figures do not bring out fully the relative importance and seriousness of deaths from tuberculosis. Although infantile deaths are regrettable, they do not cause so great a loss to the community and so much distress and suffering to the survivors in a bereaved family as do deaths in early and middle life. The following table is important in this connection : —

Table II. — England and Wales, 1904

Out of every 100 Deaths at all Ages the number occurring at different

Ages from each Cause of Death was — i

20-45.

1 45 _ 6S. j 65 and over.

I

Measles ....

Whooping-Cough .

Diarrhoea

Phthisis ....

99-1

99 '9

93 "5

4-8

O'l

0*2

IO"I

0-3 07

56-5 o-i

... 1

Thus 99 out of every 100 total deaths from measles and whooping-cough, and 94 out of every 100 deaths from diarrhoea, occurred under 10 years of age, while only 5 out of 100 deaths from pulmonary tuberculosis occurred under this age ; and during the working years of life (20-65) 82 occurred out of every 100 total deaths from phthisis, as against no deaths from whooping-cough, less than a half per cent, of the total deaths from measles, and less than 2-§- per cent, of the total deaths from diarrhoea.

If we compare the mortality from tuberculosis with that from infective diseases, other than those enumerated in Table I., we have the following result : —

Table III. — England and Wales, 1904 Number of Deaths fr oi?i —

Influenza .

5,694 (the highest number in any

Puerperal Fever .

1,654

Erysipelas ....

1,206

Syphilis and other Venereal Diseases

1,871 (doubtless understated).

Tetanus (Lock-jaw)

Malaria ....

Anthrax ....

Glanders ....

Hydrophobia

(in 1885 the number was 60 not been so high since).

10,812 it has

All forms of Tuberculosis

60,205

Evidently none of these diseases occupies so important a place as tuberculosis, though in the public administration of the

Fig. i. — Comparative Magnitude of some of the Chief Preventable Causes of Death in England^and Wales country much larger sums are spent in the control of hydrophobia, glanders, anthrax, and puerperal fever than have hitherto been spent in direct measures against tuberculosis.

In the Registrar-General's returns for England and Wales other diseases than those enumerated above are classified as infective, i.e. produced byjinfection received from without. Omitting pneumonia for separate consideration, the number of deaths returned as due to infective diseases in 1904 was 140,431, the total number of deaths from all causes in the same year being 547,784. Of the total (140,431), 60,205 were caused by tuberculosis, 77,966 by the other infective diseases named in Tables I. and III. Rheumatic fever, which is undoubtedly infective, though not classified as such in the official returns, caused 1788 deaths in 1904. Probably most, if not all the diseases of the respiratory organs have an infective origin, and many not recognised as such are tuberculous. Pneumonia in 1904 caused 43,372 deaths, bronchitis 42,188, all other diseases of the respiratory organs excepting pulmonary tuberculosis 8059 deaths. The relative magnitude of the most important preventable causes of death is shown in Fig. 1. The list is not complete, but the most important items are included. Pneumonia and bronchitis have been added, although only partially preventable under present conditions. Cancer has also been added, because, although not directly preventable, many of the deaths from it are pre-

Table IV. — England and Wales, 1904 Death-rate from Phthisis per 100,000 living at each Age-group

Ages.

Males.

Females.

Persons of Both Sexes.

5- ■

All Ag es veritable by early recognition and removal of the diseased parts.

Mortality in Terms of the PopuLxVtion — Death-rates. — In 1904 the death-rate in England and Wales from phthisis was 1*46 per 1000 of population among males and 1*03 per 1000 among females. The death-rate varies greatly at different ages, as will be seen from the table on preceding page, derived from Dr. Tatham's Report to the Registrar-General. In this table the death-rates are stated per 100,000 living at each age-period separately for the two sexes.

The facts in this table can be more clearly seen when set out graphically as in Fig. 2.

The significance of the different age distribution of the phthisis death-rate in the two sexes will be subsequently considered (p. 168). At present we need only record the fact, as bearing on the value of the lives sacrificed to this disease. The age distribution of deaths from phthisis may be stated in three different ways : —

(1) The death-rate from this disease may be given per 1000 or per 100,000 living at each period of life, as in Fig. 2.

(2) The deaths from this disease may be stated in proportion to the total deaths from the same disease at all ages.

(3) Or these deaths may be stated in proportion to the total deaths from all causes at the same age-period.

The first is the only method which can be employed in comparing the age incidence of the disease in different populations. The second and third methods are useful for special purposes. By means of the second method we can ascertain the proportional incidence of deaths from phthisis at different ages, and by the third we can state its importance in proportion to other causes of death at each age-period. From these standpoints the second and third methods tell us more than the first ; for a high death-rate may occur among a relatively small population. Thus the male death-rate from phthisis of 126 per 100,000 at ages over 65 is higher than that of 39 per 100,000 in male children under 5, but the two rates represent an equal percentage (3*1) of the total male mortality from this disease at all ages. In the following table the second and third ratios mentioned above are given for each sex : —

Table V. — England and Wales, 1904 Proportional Mortality from Phthisis

Males.

Females.

Age.

(1) In proportion to IOO Deaths from

Phthisis at all

(2) In proportion to 100 Deaths from all Causes in the

(1) In proportion to 100 Deaths from

Phthisis at all

(2) In proportion to 100 Deaths from all Causes in the

Ages.

same Age-

Ages.

same Age-period.

period.

3*4

5- •

4 '2

2*0

1 '4

9'5

4*3

20 "6

15- •

5'6

26*1

35"4 io-8

38-5 ii'9

25- •

23-1

25'3

32'3

35- •

22'8

28-1

20-3

21'2

45- •

18 '2

13-0

1 1 '2

55- •

IO'I

6-9

4*4

1 '4

3 "2

IOO'O

8-5

The same facts are set forth graphically in Figs. 3 and 4. Comparing the three sets of facts depicted in Figs. 2-4, it will be noted that the highest male death-rate from phthisis occurs at the age-period 45-55, the age-periods 35-45 and 55-65 coming next. The highest proportion of the total male deaths from phthisis occurs at the ages 25-35 an d 35~45 ; and phthisis bears the highest proportion to deaths from all causes at the ages 20-25 and 25-35.

In the female sex the highest death-rate from phthisis occurs at the ages 35-45, 25-35 coming next, the highest proportion to deaths from phthisis at all ages occurs at the ages 25-35, and to deaths from all causes at the corresponding age-period at ages 20-25.

Of the total deaths from phthisis 91*3 per cent, in males and 87*1 per cent, in females occur at the ages 15-65, the working years of life.

Tuberculous Diseases other than Phthisis. — Phthisis is not the only fatal disease due to tuberculous infection. In 1904 m

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_x

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YEARl

' 5- -10

10- 15 -15 -2

- 20- -25

25-35

35-45

45-55

55-65

UP

55 WARDS

Fig. 2. — England and Wales, 1904. — Male and Female Death-rates

from Phthisis at different Age-periods

(Males — continuous line ; females — interrupted line)

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1 \

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u r

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L n_

U- r_ ft"

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5- -10

10- -15

15- -20

20- ■25

25-35

35-45

45-55

6 55-65

5 iRDS

Fig. 3. — Deaths from Phthisis at each Age-period per 100 Total

Deaths from the same Disease at all Ages

(Males— continuous line; females — interrupted line)

ii

ZT

I

1 >

Tj

T_ l.M-l i f

1 Jfefri

_x

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N V

/ J i i2l« 2

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55-65

WARDS

Fig. 4. — Deaths from Phthisis at each Age-period per 100 Deaths from all Causes at the same Age-period the number of deaths caused by each form of tuberculosis was returned as follows : —

Table VI. — England and Wales, 1904 Number of Deaths caused by various forms of Tuberculosis

Males.

Females.

Total.

Pulmonary Phthisis Tuberculous Meningitis Tuberculous Peritonitis\ Tabes Mesenterica J Lupus

Tubercle of other Organs General Tuberculosis .

Scrofula

23,850

3,359

1,064

2,253

18,001 3,030 1,921

834 38

2,062

4,315 109

33,552

26,653

60,205

The death-rate in 1904 from all the tuberculous diseases excluding phthisis was 54 per 100,000 persons, 59 per 100,000 males, and 50 per 100,000 females ; the corresponding figures for all tuberculous diseases being 178, 205, and 153. Thus phthisis accounts for 69*5 per cent, of the total deaths ascribed to tuberculosis.

The age distribution of the deaths from tuberculous diseases other than pulmonary tuberculosis enumerated in Table VI. will be more conveniently discussed in the chapter on Accuracy of Certification.