Discussion on the Consumptive at Home

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1906 27: 277The Journal of the Royal Society for the Promotion of HealthG.A. Heron

Discussion On the Consumptive At Home

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JOURNALOF

THE ROYAL SANITARY INSTITUTE

DISCUSSION ON

THE CONSUMPTIVE AT HOME.

Opened by G. A. HERON, M.D., F.R.C.P.,

(MEMBER.)

At Sessional Meeting, London, April 27th, 1906.

IT lias been ufficially communicated to me that this meeting is not

JL intended for doctors alone, and that I am to speak in such a way asnot to make this address a technical one, or as little so as possible.

Now, in the course of the discussion on which we are entering two wordsare certain to occur freduently, tuberculosis and consumption. Tubercu-losis is a disease which may attack any tissue of the human body, from theoutermost layer of the skin to the marrow of the bones. When it attacksthe lungs, tuberculosis in ordinary conversation is called consumption.There is no race of men, no country in the world, of wliich we have anyknowledge, exempt from this disease. Its mortality is very great, no oneknows how great. In this country where statistics are carefully kept, weknow the rate of that mortality. It is the most fatal of all diseases.

According to the Hegistrar-General’s Report there died, in the year 1904,in England and wales alone, from tuberculosis in one form or anotlier,50,000 people; uf these, 40,000 and an odd hundred or so died of

consumption.When you look at a consumptive you see a person who owes his

disease to the fact that he has been infected by another case of tuber-culosis, probably a case of consumption. There is no exception to thisrule; the disease always comes directly or indirectly from another case oftuberculosis. You have heard consumption called a hereditary disease.It is always a hereditary disease, but only in this sense :-We have all



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inherited from our ancestors some physical peculiarity, no one knows whatit is, which makes us susceptible to certain infections, scarlet fever,measles, typhoid fever, typhus fever, cholera, tuberculosis. To all these

infections we are susceptible, because we inherit from our ancestors

that peculiarity which lays us open to those infections. In that sense and

in no other sense, I submit, is tuberculosis a hereditary disease. Now,how does tuberculosis pass from the diseased man to the healthy man ? I

will take an illustration. !~ consumptive goes along the street and hecoughs, and he spits on the pavement. So long as that expecturat,ionis wrapped in its moist envelope it does no harm ; but, by and by, thismoist envelope evaporate, and the solid particles of the expectorationmake dust, and in tllis dust yon have literally tens of thousands of little

living organisms, and they are the cause of all tuberculosis. They belongto the great family of bacteria, and are called tubercle-bacilli. These

organisms are animal parasites, and are exceedingly small. You can putfrom 3,000 to 12,000 of them in the length of an inch, and the3- are aLouta third of their length in breadth. The dust from dried expectoration is,like other dust, w-afted about by the wind; someone passing may inhalethat dust, and with it many of these little organisms which cause con-sumption, and so you may have a healthy man made consumptive. So faras we know, that is the commonest way in which tuberculosis spreads fromman to man. But there are other and not quite such obvious ways 111

which the expectoration of the consumptive is dangerous. When a man

speaks little particles of spray drop from his lips, and we know by obser-yation and by experiment that in the case of a consumptive that spray notinfrequently contains tubercle-bacilli. Again, when a man coughs hespurts out a considerable volume of spray, and observation and experimenttell us that that little cloud of spray may contain considerable numbers oftubercle-bacilli if the cougher be a consumptive. It is only from theexpectoration that infection comes; this is most imhortant, because onthat fact hinges the means for the prevention of consumption. From

gross ignorance a consumptive may spread infection; but I think it ismuch more frequently done because of that more dangerous and commonerform of ignorance which is found in a man who does not quite understandwhat he is sure lle knows. Many men do not apprehend clearly the greatdanger that comes from the expectoration of cunsumptives, and so withthe ignorance of carelessness they make infection in the rooms theyoccupy.

The great cause of the spread of consumption is overcrowding.Where there is the densest residential population, tllere consumption



279

is rifest. The sparser the population the rarer is consumption. Over-

crowding exists to a much grater extent than most of us snspect. Sir

Shirley Murphy, the medical adviser of the London County Council,has published some valuable statistics concerning tenements in the admin-istrative county of London. He shows that its population is 4,53(i,541,and there are 1,019,546 tenements; of these 672,0:~O are tenements offour or fewer rooms. 14~,524 are one-roomed tenements; and oftentimesthere exist in one room a man, his wife, their family and, it may be, alodger! l In tenements of that sort the infection of tuberculosis is most

apt to spread.’B7&dquo; e can to a great extent get rid uf the infective properties of the

expectoration by disinfection properly carried out. But it is unreason-

able to expect that disinfection can be properly carried out in the dwellingsof the extremely poor, unless the work is confided to trustworthy uflicials.

Another great cause of tlle spread of tuberculosis is the abuse of

alcohol. Accepted evidence proves that the person given to alcoholicexcess is much more apt to fall a victim to the infection of tuberculosisthan is the sober person.

I have said that ignorance llas a great deal to tIo with the spread oftuberculosis, as it has to do with the spread of all infective diseases. Of

course, only in one way can we get rid of ignorance, and that is by eclu-cating the people. I wish that we could find in the Education Bill, ofwhich we hear so much, some measure which would make it snre that allchildren, in the last year of school life, would receive instruction in theelements of the laws of health. Above all things I should like to see it

made a law of the reilm that all pupils in our training colleges shouldshow, before the,y receive their certificates of proficiency, a fair knowledgeof the laws of health. Then we might have a chance of having ourchildren taught something of this very Important subject.

I said that overcrowding had a great deal to do with the spread oftuberculosis; to get rid of overcrowding is one of the most troublesomeproblems of the day. We can only get rid of overcrowding by buildingsuitable dwellings within certain districts in large cities and towns; or,

better still, by placing those dwellings in the suburbs of large cities andtowns and taking care tllat speedy and frequent communication shall existbetween those suburban dwellings for the workers and the points in tulle

city where work is most likely to be found.I have also mentioned disinfection as a remedy, and in order to

illustrate what I mean hy disinfection and how it should be carried out,let me take two cases at tlle opposite cads of the social scale. At one end



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of the scale is the rich mau ; at the other end is the poverty-stricken man.Suppose the rich man becomes consumptive. By means of his wealth he cando certainly all that is necessary, and all that we can suggest he should doto cure his disease. He lives in well-aired rooms in a large house. His

rooms are arranged in the most approved style, with .111 that sanitaryscience can suggest; he has no carpets, no curtains, and the floors andwalls of his rooms can be easily disinfected, because they are made so thatthis can be done. His furniture is made so that there shall be no creviceswhere dust can aclumulate, because dust in the rooms of a consumptive isdangerous. The furniture, his clothes, his linen and everything he usescan be properly disinfected. When he expectorates he does so, as it were,under regulation, and with as little danger as possible to himself andothers. He can go out into the grounds of his house; and if he is well

advised he will there build a little hut in which he will live and sleep. Hethus lives the healthy outdoor life which, so far as we know, is tlle life thatwill give him the best possible chance of getting rid of his disease. Withall this, he llas doctors to advise him and nurses to look after him, and hisdisinfection is properly carried out by persons who know their work. Alltllis he does because lie can afford to do it, and because it is necessary thatIle should do it. This comes very near to a counsel of perfectioll ; but itcan be done.

Now let us go down the scale, to the poor man who lives with ]iswife and family in one room. When he is ill what does he do ? He

feels that he is not quite equal to his work, and that what used to beeasy to him is more than he can do. He knows that the time is near

when the only thing that will stand between him and starvation is the

sick fund that he lias from his club. He knows that by and by that toowill come to an end; these are the conditions that he has to face. Do

you think it reasonable to suppose that a man so placed can carry out acomplete system of treatment, such as I tried to indicate would be thecase when the consumptive is a rich nan ’l It is not reasonable to supposeanything of the sort, and no sensible man or woman believes it can bedone. What does the poor man do ’? He goes to the out-patient depart-ment of a hospital (I am speaking only of out-patients) and he getsmedicine and a piece of paper with instructions as to what lie is to do; line

goes home, takes the medicine, and tries to carry out the instructionson the printed paper about disinfection. But huw can he do it ? Thenin a week’s time the consumptive goes back again to the hospital, getsmore medicine, and returns to his home; and so on until, at last, he goesinto hospital, very likely hopelessly ill. Ladies and gentlemen, that is not



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a fancy picture; we have all seen it. If you want to do real good youwill first of all end this pretence of treating consumption, for it is nothingelse than a pretence. No one believes it serves aL useful purpose, unless

you can add to the hospital treatment of out-patients, visitation by trust-worthy people in the sick man’s own rooms. I believe the present daysystem of treatment of consumptives given by our out-patient departmentsdoes more harm than good. How are you going to get this visitation ofthe consumptive’s home ’? We must have three forces working cordiallyand heartily together. The Imperial Parliament should legislate so thatwe can have the money and the men to work out this matter. The local

Sanitary Authorities should be obliged to come under parliameiitarv juris-diction for this purpose. Those are two uf the powers. We want another

one. I think it very important that private benevolence should play agreat part in this matter. People who can give money should give it;those who can give personal service will give what is about as necessary asmoney. If the poor are visited in their houses by those who are notofficials, in addition to receiving the visits of tliose who come in an officialcapacity, I think the work of the oflicial would be made easier and moreefficient than it otherwise would be. I am certain of this, that the bitter-ness of the lot of tllose who find themselves obliged to be brought intoofficial contact with the powers that be, a process which in this country isnot always favourably received by the poor, might he very much lessened bytactful visitation made by unufficial persons of both sexes to the homes ofthe poor to see that what ought to be done is done. The best visitor to do

this work is a good and tactful woman; but man has his place too.There is one more point, and it also is essential. yVe must have

sanatoria in which to place these poor people. I have already indicatedthat with the rich we need not trouble ourselves; they can take verygood care of themselves. This whole question of the prevention of con-sumption seems to me to centre in how you are going to deal with thepoor. If you can remove the sick man from his family, yuu can givehim a better chance of recuvery than he could possibly have in his

wvn home, and you can diminish very materially the risk of those who livein prolonged cuntact with him. You must have sanatoria for this purpose.I said that 50,0(10 people die annually from this disease in England andWales. If you count five living people who are suffering from tuber-culosis for every one who dies, you have, in round figures, a quarter of amillion of people affected by tuberculosis to deal with, and this is, I think,a moderate calculation. Now the names and addresses of all those peopleought to be known to the authorities, whether those invalids are rich or



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poor. The disease ought to be notifies, just as is scarlet fever or anyother infective disease which now comes under the law of notification.The authorities knowing where tuberculosis shews itself should take stepsto induce the infected, rich and poor alike, to go into sanatoria. It is truethat a large number of people leave the sanatoria restored to health andable to work. Statistics from reliable sources have shown this to a degreewhich, I confess, has astonished me. In Germany the insurance societieshave taken the matter up, and have started sanatoria because they thinkit will pay them to do so. They lave, within the last few weeks,published most valuable statistics, in which they show that a very largenumber of consumptives return to work from these sanatoria. Between

1893 and 1903 (inclusive) there were treated in these sanatoria 5,,SI4persons. Of these 1,228 have died, :3,~1~5 were earning their living, andthe rest cannot be traced.

We want to get consumptlves into sanatoria in the early stages of thedisease in their own interest, in the interest of those who are nearest anddearest to them, and in the interest of the whole community. We mustnot make the mistake of supposing that these people are going to be in

the sanatoria for 11 weeks or for li or 12 months, if we are going to aim atthe eradication of t,llis disease. The patients have to be kept there untilthey are well and able to work, or until they become so ill that they haveto be transferred to an infirmary where, they being incurable and the endinevitable, everything possible may be done to make their lot as bearableas it can be made. These are things w-hich, in my judgment, we ought tokeep before us as the means, and the only means, by which, so far as Iknow, we can ever hope to eradicate this disease. Remember we have a

good many facts which prove that we can eradicate disease. It is withinthe memory of some of us that cholera killed thousands in this country.We have eradicated it, because we know what cholera is, and we knowhow to prevent it. I was a house physician in one of tlle largest hospitalsof this country, and saw there many cases of typhus fever at the end ofthe sixties, and I do not remember having seen one case since 18139. I

see many medical men her, and venture to say that there are some ofthem who have never seen a case of typhus fever. A case now and then

crops up, but the disease has been eradicated; and we have eradicated

malaria from this country. It is a reasonable thing to say that we caneradicate tubercular disease, because we know more about it than we knowabout some diseases which we have already eradicated. But if we are to

attempt to eradicate tuberculosis we must provide sanatoria at greatly lesscost than £?50 per bed. That is abuut the luwest price for winch sana-



283

toria for consumptives are now built. It is a fact that verv noon sanatoria.,fit, indeetl, for any class of the community, can he 1>uilt, and have been

built, for mnch less than £100 per hed. In my opinion, no sanatorium

should, exclusive of the price c~F land, cost so much as £l0ll per beel.

Dn. E. S(~L’TR1: (London) endorsed all that Dr. Heron had said, and especially- ,

his concluding remark, that Bve should aim at nothing short of the eradicationof tuberculosis. Pnrliaanent sllould deal with the subject as a national one,

instead of leaving it as a parochial matter to the local authorities. The poor

consumptive could not get fresh air in his own dwelling, and therefore hemust be provided for a time with a dwelling where fresh air was pl(’lLtÏflt!,and he must be under proper supervision. Obviuusly, they could not set towork to help the indiB’idual until they knew who required that lielp; so

that notification was the first essential. Only a small proportion of the totalcases were then notified: it was the most ignorant consumptive who was the mostdangerous, and he was generally the one who refused to be notified for fear thatsomething would l~ahpen to him and he would lose his freedom of action. If the

hospitals. to which sucli patients went, were to ask to be allowed to notify, theseinstitutions woulcl probably get a bad name amongst the people concerned, andthey would cease to attend. The result. would be that the caseo in an early andoften curable stage would be deterred from seeking treatment at a time wlien

most good could be done. If notitication were to be of any real value it must

be made compulsory- and universal. But notification by itself was ;valueless, itwas only a means to an eml. A consumptive should be allowed to remain athome, provided the necessary precautions could be taken (cliiefly a questionof dealing with expectoration) and the correct treatment applied. There was

every- reason why he should not b<> forced away from home..Hut whe re tlese

conditions could not be fulfilled, it was better that the patient should be takento a sanatorium. It would be a great advantage if the patient could be kept inthat institution until he was well, but that might be a matter of years. It

would be desirable to divide the sanatoria into departments, fur those who weresick enough to require constant medical attendance ; for those in whom the

disease had been arrested ; and for those who were apparentty cured and couldbe under observation while being taught some work until it was seen they couldleave with safety.

Dn. T. WwL DuDFtELD (Kensington) insisted on the necessity of com-pulsory notification of consumption; voluntary notificatiun had existed in

Kensington during the last four years, and liad proved a relative failure. Thenotifications scarcely exceeded the number of deaths, and were almost exclusively



284

confined to cases in receipt of poor-law relief reported by poor-law medicalofficers. Scurcely more tlian one in four cases of actual occurrence, he believed,came to his knowledge, and a. large proportion of them was revealed only bycertification of death. The pauper cases reported were usually in the later

stages of the disease, the victims after long struggle having been obliged toresort to the relieving officer and tlm parish doctor by reason of destitution noless than sickness. lie could say little about consumption in the well-to-do

classes, it being a rare thing to hear of their illness until it had ended fatally.There were some 200 deaths in linsington yearly from pulmonary phtliisis,and among them scarcely a dozen of well-to-do peuple. Consumption was, infact, largely a disease of the poor, and they would not be able to do much byway of prevention without compulsory notification to secure knowledge of casesin tlie early stage of the disease. Dr. Heron liad properly enforced the

necessity for sanatoria, and that the sick should gu into them in the early stageof illness and remain foi a long time. Excellent advice indeed if onl3- therewere sanatoria for them ; but fur those above the pauper class there were

practically none. The Metropolitan Boards of Guardians liad provided largelyfor the needs of tlle pauper class, and many sanatarians had long striven, so farin vain, to induce the Asylums Board to utilise some of their spare accommuda-tion for the relief of poor consumptives about tlie pauper class. They could notdo this, of curse, without the authority of the Local Government Board : butthey had shown little desire to undertake the work, and the superior board hadnot manifested any wish to confer the requisite power. The managers had, orsoon would have, ten thousand beds at their disposal, and it had been suggestedthat the two hospitals at Gore Farm, with nearly ~.~,OUO beds, no longer requiredfor convalescent small-pox patients, should be converted for use as sanatoria.The managers were entitled to credit for two good pieces of work, the establish-ment of a, hospital near Littlehampton for tuberculous children, and theestablishment at -Alargate of a hospital for the surgical treatment of tuberculusisin children. On the highest authority it was stated that excellent results badbeen attained at both places. It should never be forgotten that multitudes ofpeople became paupers because they were consumptives. But the LocalGovernment Board had recently stated that they v-ere not prepared to

authorise the Asylums Board to undertake the new duty proposed to them,because of the heavy outlay it would entail : they might not spend ~.100,U00 tosave a million. It was deplorable to reflect on the practical disregard of thewelfare of the community in this matter, seeing tliat t1e great majority ofsufferers and of those who died of consumption, were adults, chiefly males,in the prime of life. Millions had been spent during the last thirty-nveyears on the treatment of scarlet fever and diphtheria, which were mostlydiseases of children under five years of age. The work of the Board in thisdirection had been marvellously successful, and one hoped it would be continueduntil those diseases should have been practically exterminated in London, if



285

that were possible. But s111’(Jly it was not less important that efforts should bemade to reduce the sickness and mortality from consumption, and to prolonguseful lives b,Y giving sufferers the chance of relief in sanatoria. If they couldonly educate those in authority, from Parliament downwards, to realise that thisdisease was preventible, and often cura.ble, it would soon Ie seen that it wastrue economy to spend money freely in preventive and curative measures. Thedisease was becoming less fatal every year, and what they wanted was to liastenthe diminution in prevalence and fatality. By persistent effort and educationof the community, the young especially, in the laws of health, and attentionto salitation, the object in view would be soon attained. There was a greatfield for the education authority in this direction, and it was satisfactory toknow that the work would be put in hand when the future teachers should havebeen taught, and were qualified to teach, tlle elements of hygiene. What theywanted was spread of knowledge of the nature of the disease, of the lneans for

preventing its spread, of the method of cure. When it became fully understoodthat it could be prevented and could be cured, satisfactory results could not failto result from the practical application of such knowledge. He was glad to seethe Chairman of the Metropolitan Asylums Board presiding over that meeting,and only wished they could infuse into that body a little more courage in dealingwith this question. A few years ago a single manager, the late Blr. Brass, keptthe matter before the Board by frequent notices of motion, and shortly beforehis lamented death had nearly won tlle victory. Since then the managers had

lapsed into comparative indifference, having shown no desire to take the

initiative by urging the Local Government Board to endow them with powers todeal effectively with the treatment of sufferers from this terrible disease.

DR. SiiRUDSALL (London) agreed with what had been said by previousspeakers as to what might be done with consumptives provided the conditionswere ideal. But tlle practical point was that they had to be dealt with underpresent conditions. Reference had been made to the uselessness of treatingconsumption in hospital out-patient departments ; he thought it all dependedupon the physician who was in charge of the department. If the physician didnot take a personal interest in his patients, no good would result ; but if on thecontrary he was thoroughly keen on tlle subject, and took trouble with his in-

structions, much good would result. 4ntiseptim had now largely gone out offashion, even in surgery, and he favoured disinfection by soap and water, whichvery few families could not afford. If they could persuade people to throw awaytlleir dirty carpets and curtains, and to wash tlie floors, enormous advance wouldbe made. The best disinfectant was soap and water. A bacillus had not gotwings and could not fl3~, if it were kept moist it was harmless. They should

impress the use of a pot for expectorating. A thing tliat was often overlooked

was tlle use of a handkerchief to wipe the mouth, and that handkerchief wascapable of doing much harm. It was better to use onl3- rags which could be



286

de~troyed, care being taken in employing them not to soil the be d clothes.He also suggested the need of advising the dusting of rooms with a damp duster.If these simple rules were observed it was certain that ultimately the germswould travel into the drains. The great doctrine the doctor had to teach was

cleanliness, and if adopted, it would have a great deal to do with the egter-mination of’ tuberculosis in this country.

11W ss AFUDI) (London) emphasised the nned of some link between the hos-pital and the home, because it was possible for a patient to go to a hospitaland yet be neglected. As to expense, tllis ought to be no expense to the

hospital as the work would be done yoluntariI5’.

DR. HECTOR MACKENZIE (Physician to the Brompton Hospital) said lie

largely agreed with Dr. Heron as to the infective element, but thought Fliiggellad laid too much stress upon the spraying during speaking and coughing.Personally he had very little belief in tliat as a means of spreading consumption.He had spent something like 10,000 hours among coughing consumptiveswithout harm, and the nurses in consumption hospitals, who were often in theline of spray, seemed to run no special risks. If there was any very greatvirulence or infection in the spray, very few of those exposed to it would escape,and consumption would be very much more prevalent than it is. Recent experi-ments of B. Friinlcel had not supported the views held by Fliigge, and showed thatonly a very few bacilli were to be found in the spray collected from consumptives.A number of consumptives coughed into masks during thirty days, and theywere only able to collect about 2,600 bacilli, whereas one single case of con-sumption may discharge in the sputum over 7,20() million bacilli in the course ofa single day. Dried expectoration was by far the most important ell’ment inthe spread of infection, and the spray might practically be neglected. That was

an important point, because there was the danger of the public running awaywith the idea that every consumptive was a sort of leper and someone to beavoided. He had found that persons who had been treated in sanatoria and

cured sometimes experienced difficulty in obtaining employment, people beingafraid to employ them through groundless fear of infection. Hc was glad tohear what Dr. Shrui’sall said about infection : certainly cleanliness was a greatdisinfector. Dirt was one of the means by which tuberculosis was spread, and ifpeople would only keep their houses clean it would be of tlle greatest value as ameasure of prevention. Some people thought that all those who did not entera sanatorium must abandon hope, and he had seen statements to that effect inprospectuses. That was perfect nonsense, because the tendency to cure in manycases of tuberculosis was very strong; some would get well without a.ny treat-ment at all. There wre, of course, many persons who would get treatment ina sanatorium infinitely superior to what they would get at home, but there wereothers wllo were extremely ill -cases which had to be treat.ed continuously



287

in bed&horbar;who were more suitable for home or hospital. For those who only hadslight tuberculosis and were able to work it was sometimes better that theyshould be encouraged to continue at their work. At Brompton they had latelybeen considering how the out-patient department could be extended and in-creased, and the committee which had the matter in lland had the assistance

of Dr. NeNi-sl)oliiie, of Brighton, who had been nominated by The Royal SanitaryInstitute. They felt that notification was one of the most important means ofhelping on the prevention of tlle disease, and they hoped that they would be ableto notify all cases of tuberculosis which come to the hospital from tlle metropo-litan district to the metropolitan medical uiiicers of health, with the hope that ifthey were so notified some action «-ould be possible. He thought it would be

impracticable for hospitals to take up the work of visiting patients in their ownhomes, because patients who came to a hospital like Brompton often came frvnlvery long distances, and visiting and disinfection ought to be carried out, alongwith other educational work, by the medical officers of health and others in thelocality of the homes.

Miss .J08EPTIS (Jewish Board of Guardians) observed that one body in

London, the Jewish Board of Guardians, was taking up systematically the workof supervision of consumptiyes in their own homes. There were tv o health

visitors appointed, and shortly the staff would be increased. They only attempteclto help Jewish patients, and a very large number came to them, so that theyalready had more than they could deal with. Those who asked for lielp weresent to a doctor and be advised as to the proper treatment. The visitors then

endeavoured to supervise the consumptive in his home and teach him the

precautions he should take. Bottles and spittoons were provided, and it was

insisted that they should be used, ; frequent visits were paid and they tried toprevent overcrowding. The Board conditionally helped families to secure largeand more rooms: they endeavoured, v-here possible, to obtain for the consump-tive an apartment for himself, although very often this could not be managed.They had their own sanatorium and also sent patients to others, and their expe-rience was that after patients left these institutions they solon dropped back againand wanted help once more. she was glad to hear of the practice at Brompton,but her experience of some lundreds of’ cases was that the patients were notable, atter six months’ treatment, to do a full day’· work. What was to be done

for them ?~ Did they in Germany keep their patients two and three years ilsanatoria’? l? She had been working at a scheme which she believed was the onlysolution of the problem. i.e., to arrange for persons leaving sanatoria tu go to an

open air colony and to work under the supervision of a doctor, where theycould, if necessary, continue for the rest of their lives. She did not say that

such colonies could be self-snppOJ.ting. but it did at present seem tu be a wasteof money to spend patients to sanatoria. She pointed to the need for dealing insome proper way with advanced cases. People would not go into infirmaries.



288

Besides, what accommodation was provided in infirmuries at the present timefor consumptive cases ? There were very few in London where special wardswere provided ; mostly tliey were placed with otller cases and were a danger tothe other patients. She thought it ought to be, possible for several unions to

join togetller for providing .special accommodation.

THE CIIAIRM:iN (A. C. Scovell, .T.1’.) in proposing a vote of thanks to Dr.Heron, said they were all plea.sed with the lucid aud illuminating address fromwhich they had all learnt so much.

D13,. HERON, in acknowledgment, replied to llliss Josephs, and said the figuresfrom Germany were as follows: 5,841 people treated in sanatoria in 1893, ofthose who liad been traced 3,9:~5 were now at work. That was the gross resultand he would be glad to furnish the particulars. He had avoided the detailed

aspect of disinfectiun designedly, but he quite agreed that cleanliness, fresh airand sunshine were best, although there were other disinfectants which wereuseful. They were all at one in regard to compulsory notification. As towhether a consumptive should be allowed to remain at home; in the present stateof public opinion he could not be removed, but if the public were sufficientlyeducated he did not think they would have to employ compulsion. He did nutknow that rich consuptive patients were rare, but they were not very common.The fact that there were thousands of beds not in use, as mentioned by Dr.Dudfield, was, of course, not to the credit of tlle authority concerned, when theywere wanted so badly for poor consumptives. He quite agreed as to the ad-vising of out-patients, and it was good of Dr. Mackenzie tu speak as he had

done ; but he did not think they would get the present race of out-patients in

hospitals to-day to do much for themselves. They must be taken in band andhelped.

MR. A. C. SCOYELL, J.P., replying to a vote of thanks for presiding, said,in reference to a remark by Dr. Dudfield, that the empty beds of the 8Ietro-politan Asylums Board were reserved for fever and diphtheria. It was quitetrue there were some 2,000 empty at that season of the year when those diseaseswere not prevalent. But all the beds were full at the time of’ year when theywere required, and they were extremely anxious not to have to refuse patientsfor whom by law tlie liospitals uf the Board were established. He thought itdesirable to mention this, as his Board might think him remiss ill not defendingtheir administration. As a matter of fact, individually and collectively, theAsylums Board took a great interest in the question just discussed, and wouldwillingly do whatever tlle law permitted them to do.

Miss GARDNER (London) who had not time to speak, sends the followingnote: I think much useful work might be done in cunnection with tlle patientswho are waiting admission to the Chest Hospitals, if the hospital could refer



289

them to some local visitor, who would report upon the home conditions. Some

patients can afford to wait much more than others, and by a little judiciousadvice and possibly tor help with extra diet, may even improve whilst waiting.Others are going down hill faster and faster, and for their own sake and thatof the community, sliould be induced to go into the infirmary. Possibly if

some such plan were adopted it might also lead to some discrimination beingexercised as to the admission of those who could not possibly improve at home,and yet were hopeful cases if taken in time. I know that this plan is full ofdifhculties from the point of view of the impartial treatment of all patients, andit would mean more trouble to the authorities who admit, but it is not im-

possible. With regard to those patients whu are awaiting admission to a sana-torium, these are generally speaking, hopeful cases. I think a comparativelycheap and efficacious way of dealing with such patients might in many cases beadopted in suitable localities, in their own homes, under the supervision, if

possible, of the district nurses, if not, uf some wise lady visitor who understandssomething of such cases, and would work under a doctors instructions. Take a

small room, vn &dquo;off-room&dquo; would do, remove the window and arrange it carefullyfor the patient’s comfort. Have a diet list and see that it is followd. In con-

junction with tlm local authorities, see to the proper disinfecting of everythingthat is used, and, when the patient is removed to the hospital, of the room.

This plan is not, of course, for the lowest class of patient, but I believe we mightget good results in many cases, and it would act as an object lesson and wouldimpress upon the neighbors the fact that this is an infectious disease. I am

personally prepared to superintend such cases, im this district, as an experiment.I believe that the dimculties are not insurmountable.



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Discussion on the Consumptive at Home