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NOTES UPON HEALTH RESORTS.

SCANDINAVIAN WINTER HEALTHSTATIONS.

(BY A SPECIAL COMMISSIONER.)

V.I

THE ANTI-TUBERCULOSIS MOVEMENT IN NORWAY ANDPUBLIC SANATORIUMS FOR TUBERCULOUS CASES.

No study of Norwegian health stations can be countedsatisfactory and complete which neglects to consider theinfluence and character of the anti-tuberculosis movement.Norway, in spite of its climatic and other advantages, hassuffered much from both leprosy and tuberculosis. Theformer is now rapidly becoming extinct but the latter hasuntil the last decade been steadily increasing.2 The fact is,Norwegians have been slow to develop that "health con-science" and "hygienic mind which are essential to theestablishment and maintenance of rational and effectiveprophylactic measures against tuberculosis. Even still, as

your Commissioner had abundant opportunities of noting,there is a conspicuous lack of observance of many of thoseprocedures and precautions which experiment and experiencehave demonstrated to be essential for the successful con-duct of an anti-tuberculosis campaign. Promiscuous spittingis prevalent everywhere. Spittoons are provided in nearlyall public places but apparently are never or rarely suppliedwith disinfectants. Railway carriages generally possess openreceptacles for sputum. Spittoons are prominent features ininstitutions of almost every kind. I was astonished to finda spittoon by the bedside of each patient in the leper hospitalnear Trondhjem. Scandinavians seem to have an innate

propensity for indiscriminate expectoration. This is due nodoubt in a measure to the catarrhal conditions induced byoverheating of dwellings, excessive smoking, and in someinstances chewing of tobacco. The old-fashioned homesteadsare almost invariably dark and the arrangements for sleepingare still generally devoid of adequate hygienic requisites.Even in modern houses and public establishments of allkinds the temperature during winter is kept so high as tocause considerable discomfort to an ordinary Englishman.

Open-air methods are clearly not so popular in the

Norwegian home as in our own country. Until comparativelyrecently little has been done to prevent the spread of tuber-culous infection and even now the geographical and socio-logical conditions prevailing in Norway make adequatesupervision and the conduct of sanitary reforms matters ofconsiderable difficulty.

ANTI-TUBERCULOSIS MEASURES.

I had the privilege of discussing the anti-tuberculosismovement with Dr. M. Holmboe, the Norwegian StateMedical Director at Christiania, Dr. Andvord, Dr. Somme,and other well-known leaders, and of seeing something ofthe practical efforts which are now being vigorously carriedon with the aim of stamping out this scourge of the people.Norwegian medical practitioners have for long recognised thatjust as leprosy has been almost exterminated by earlyrecognition and segregation of cases, so tuberculosis willhave to be dealt with by the wise application of legislativemeasures and a personal care of the afflicted patients.Norway’s advanced position in regard to its "tubercu-

losis laws" is due mainly to the energy and wisdom ofits chief medical officers, Dr. M. Holmboe of Christianiaand Dr. Klaus Hanssen of Bergen. Norway can justlyclaim to be the first country in the world to adoptlegislative enactments for the compulsory notification of’’ open " tuberculous cases. Since the beginning of 1901infectious tuberculous cases have been reported to the districtmedical officer. If the medical attendant’s instructions arenot complied with the sanitary authority is empoweredto remove the patient to the hospital and necessarydisinfection is carried out at the public expense. Thesalutary effects of legislative measures and educational

1 Nos. I., II., III., and IV. were published in THE LANCET ofApril 25th (p. 1238), May 2nd (p. 1306), 16th (p. 1435), and 30th (p. 1578),1908, respectively.

2 J. Somme: Tuberculosis in Norway and its Sanatoria for Consump-tion, British Journal of Tuberculosis, October, 1907.

efforts are cow becoming manifest. During the three years1902 to 1904 the mortality from pulmonary tuberculosis was.24 per 1000 inhabitants. In the last ten years the mortality’*has fallen more than 15 per cent., the most marked decreasebeing in the urban districts. In Bergen, where the influenceof Dr. Klaus Hanssen is far-reaching, it is said that themortality has decreased 50 per cent. in the course of the-last 11 years. The death-rate varies greatly in the differentdistricts or amts as they are called In Kristian amt duringthe years 1901-05 the mortality varied from 1.6 6 to 2.0per 1000, while in Finmarken it was as high as 4’ 5 per 1000.In interpreting the foregoing statistics it is necessary to

aear in mind the influence of social and national movements.During recent years large numbers of the population havetaken to town life and factory work. Agricultural pursuitsue on the wane. There are now greater facilities for com-munication between districts and outlying hamlets are lessisolated than formerly. A constant stream of emigrationof the vigorous and young is going on to America, the sick.and feeble being left behind. Many of those who havebecome victims of tuberculous disease in the United States.and elsewhere are returned to their native land. As Dr.Holmboe has well pointed out, it is necessary not to over-estimate or to exaggerate the value of the tuberculosislaws, for all too little time has elapsed to allow of a justestimation.3A special committee of the Association of Norwegian

Physicians has been formed, with Dr. Holmboe as chairman,to study the anti-tuberculosis measures in Norway and to:direct the various forms of effort and enterprise available forthe public good. This committee also seeks to link thecampaign in Norway with the international movement whichis now exercising world-wide influence.The Norwegian Women’s Sanitary Association, which

was originally formed to provide for the injured in timeof war and recently has done much to relieve the hard lotof the fisher-folk, has now taken up anti-tuberculosis workand such practical assistance promises to be invaluable. Thejudicious service of this organisation has in chief measureled to the establishment of 11 pleiebjems," on the in-troduction of which Norway may be congratulated. A." pleiehjem" is a nursing-home for advanced consumptivecases. These have been established in various districts ofNorway and seem to meet admirably, and at comparativelysmall cost, the needs of a sparsely populated and far-

extending country with limited means of communication.4"Pleiehjems" have now been established by eight or tencommunes and by some five amts. In Christiania andBergen special wards are provided for consumptives in theState hospitals. The nursing-homes for consumptives haveproved a great boon to the country. They are usuallysmall and homely with, as a rule, only from six toten beds. A trained nurse acts as superintendentand the medical man of the district serves as medicalattendant. The initial cost averages about £50 a bedand the expense of maintenance is comparatively small.These homes were primarily intended for the nursing of"open" and advanced cases of pulmonary tuberculosis likelyto be dangerous sources of infection. About 300 beds arenow available in these institutions. The "pleiebjem" iscertainly a Norwegian institution which might well beadopted by other countries and for certain parts of theBritish Isles and its colonies should be very suitable. Ifinstead of burying funds in stones and marbles and otherneedless extravagances some such country homes couldbe established in this land for cases which the ordinarysanatorium cannot or will not take, a great step would havebeen taken towards the arrest of tuberculosis among ourpeople.Norwegian physicians and statesmen, through their expe-

rience with leprosy-a disease in many ways akin to tuber-culosis-are peculiarly well fitted to approach the practicalconduct of the anti-tuberculosis movement without unduepessimism and devoid of extravagant and irrational hopes.Their reasonable legislative measures, rational philanthropicendeavours, and practical methods in dealing with tuber-culosis all merit high praise and are worthy of serious study.

3 M. Holmboe: "Lungetuberkulosens Cevægelse i Norge, navnlig i desenere aar." Tidsskrift for den Norske Lægeforening, No. 24. Dec. 15th,1907. Kristiania. Accompanying this article are valuable charts andmaps indicating the relative frequency of tuberculosis in the differentdistricts of Norway.

4 M. Holmboe: "Om Pleiehjem for Tuberkulose," Kristiania, Alb.Cammermeyers Forlag, 1901.

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FiG. 1.

Lyster Sanatorium, showing its elevated position on the mountain side abovethe Sogne Fjord.

PUBLIC NORWEGIAN SANATORIUMS FOR CONSUMPTIVES. At present Norway possesses all too few public or State

institutions for the adequate treatment of early necessitousconsumptives. Funds which have been accumulating sincethe Middle Ages, originally provided for the support andtreatment of lepers, are now being devoted to the care ofconsumptives, and as the number of lepers is steadilydeclining it seems likely that before long a still largeramount will be available for the estab-lishment of sanatoriums or at all eventsthe control of tuberculous patients. Theold leper institution at Reknæs has beenconverted into an establishment for con-sumptives and funds originally intendedfor lepers have helped to build the newsanatorium at Lyster.

Lyster Sanatorium.This representative institution is

thoroughly modern, having been openedas recently as November, 1902. It issituated in the western part of Norway, onthe southern slope of the mountain rangebordering the Sogne Fjord. In winter itis very difficult of access and one cannothelp thinking that it would have beenwiser to select a less isolated district. Ithas been built out of the funds of theancient St. Jorgen’s Leper Hospital of

Bergen, and owes its origin to the thoughtand enterprise of Dr. Klaus Hanssen, thesenior physician of the Bergen Hospital.The sanatorium is excellently placed at analtitude of 470 metres above sea level in apeculiarly charming mountainous district(Fig. 1). The climate is sub-Alpine incharacter. During winter the whole

country is snow-clad and frost-bound. At

considerable expense a mountain road and wiretramway have been constructed from the lowerlevel to the sanatorium. The institution consistsof a main building, four summer houses, anisolation house, stables, and necessary offices andouthouses. Accommodation has been providedfor 126 beds and in addition there is room for 12patients in the summer pavilions. There are 18bedrooms, originally designed for four patientsin each. and allowing about 36 cubic metres perbed. Frequently five cases are placed in eachroom, the space allowance then being from 29to 30 cubic metres per patient. There are alsothree bedrooms for four patients each. Twelverooms are provided for single cases, but some ofthese are sufficiently roomy to take two patients.All the bedrooms face south. Separate diningand day rooms are provided for men and women.Good sanitary accommodation is provided foreach sex on every storey and in the basement.In the main building are quarters for themedical director, rooms and offices for theresident staff, medical and administrative, anda laboratory. Heating is arranged for by meansof a low pressure steam system. Hot and coldwater are available throughout. Ample water-supply is provided for lavatories, baths, water-closets, and fire mains. There are modernappliances for steam cooking, electric lightingand ventilation, and an electrically heated dis-infector for the sterilisation of sputum. Theelectrically driven system of ventilation has notbeen required as free natural ventilation can besecured both during summer and winter bymeans of open windows. Sewage is dealt within a septic tank. A plentiful supply of springwater has been brought from the mountains inpipes and is so abundant that it also serves todrive the electric plant which works the tramand provides the lighting. A liegehalle is placedon the south side of the building. The groundsare extensive and adjoin the natural forestregion (Fig. 2).

The isolated and elevated situation of thesanatoriums has added much to the initialcost and of course increases the expense

of maintenance. The total cost has averaged somethinglike kr. 5960, or about £322 per bed, an expenditurewhich compared with some similar institutions outside

Norway must be considered very reasonable. The totalworking expenses for each patient are said to be kr. 2.95, orabout 3s. per day, of which the State contributes kr. 1.75,or about 2s., and the patient or his friends contribute kr. 1.20per day. Those, however, who are able pay kr. 2.95 per day

FIG. 2.

Lyster Sanatorium. South aspect with open-air shelter.

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but of such I understand there are only a few, and theyare granted no additional privileges or special consideration.The sanatorium receives no philanthropic support and has nolegacies. Possibly in the future additional leper funds may berendered available for its assistance. I was favoured with

copies of the annual reports since 1903, exceedingly wellarranged and reflecting great credit on the medical directorand his staff. A report embodying the results of the first fiveyears is in preparation. It speaks volumes that of the 1030

FIG. 3.

View from the grounds adjoining the Fredriksvaern Hospital for TuberculousChildren.

patients who have been under treatment all have beenfollowed up except four. At Bergen there exist an after-carecommittee and a polyclinic on anti-tuberculosis dispensarylines which supervise all cases coming from that town anddistrict. It is well to note that systematistd work hasfor long been very successfully employed as a therapeuticagent on lines very similar to those in use at Frimley andelsewhere in this country. Many patients are employed in the construction of paths of various gradients. During the Ipast five years the male patients havemade wide paths for a distance of some-thing like 4’ 3 kilometres. In the wintersnow work and wood-chopping engagemuch time and attention. The womenduring the summer assist in the care ofthe paths and the grounds and engage ingardening. During the winter a numberof patients are allowed to walk on skisfor one and a half hours after breakfast.

Dr. Emil Grundt, the medical director,to whom your Commissioner is indebtedfor much information, states in regardto this important subject of work for theconsumptive that during the last fiveyears about 30 per cent. of his patientshave been able to engage in work andwithout any ill-effects having been noted.The cases are, of course, carefullyselected. The temperature taken in therectum is considered the safest guide. Ifthe temperature after work is raised to38.2°C. or 38.3°, no notice is takenof it provided that after ten minutes ithas fallen to 37’ 8°. The work of thispremier public sanatorium of Norway isso excellent that all Norwegians maywell be proud of it and should accord toit all the support which it needs as well asdeserves.

Reknæs Sanatorium.This institution, situated near Molde

on the northern shores of the Molde_ 9

Fjord, is a converted leper hospital. It consists ofa wooden structure of two storeys, with a centralportion and two wings, inclosing a courtyard. Thewards are small, accommodating from two to fourpatients in each. Consumptives of both sexes arereceived and usually a few beds are reserved forchildren. The difficulty of access to this sanatoriumduring winter months prevented your Commissioner visit-ing it.

THE OARE OF TUBERCULOUS CHILDREN.

Norway has shown true wisdom in providing for its tuber-culous children, and there can be but little doubt that by anextension of means for dealing adequately with tuberculouslydisposed young subjects lies the best hope for the future Theedu ’ational system in Norway is so excellent that thereshould be but little difficulty in recognising cases in earlystages of the disease. By promptly dealing with such, andalso by the development of greater domestic hygiene and the

separation of children from intimate con-tact with open " tuberculous adults,Norway will accomplish much for its

" coming race."

The Fredriksværn Hospital for TuberculousChildren.

This is the first seaside sanatorium fortuberculous children established in Norway.It was founded as far back as 1892 by aboard, the president of which was the lateQueen Sophia, with funds provided by theRoyal family, numerous private donors,and the "Samlag" of Christiania. Itaffords treatment for cases between 4 and15 years of age. Sufferers from pulmonarytuberculosis are not admitted. The hos-pital is situated two kilometres distancefrom Fredriksværn, a picturesque andcharmingly situated seaside resort nearthe mouth of the Christiania Fjord(Fig. 3). Larvik, about three miles dis-

tant, which can be reached by either road or boat,is its nearest railway town. The climatic conditions arethose of a mild marine station. Experience shows that itpossesses no special advantages over a more elevated inlandstation. Still, the position is convenient of access and itsclose proximity to the shore offers many attractions for thechildren. The hospital consists of a wooden main buildingof two storeys with accommodation for 100 cases, an isola-tion block, and necessary out-buildings. It also possesses

FiG. 4.

The Fredriksværn Hospital for Tuberculous Children. South aspect overlooking theChristiania Fjord.

electric and disinfection equipments. The wards are large,well lighted, and airy, and there are commodious day rooms.There are a satisfactory operating theatre and convenientlaboratory (Fig. 4).The complete cost of the institution amounted to about

kr 200.000, or kr. 2000 per bed-that is, a little more than£108 a bed. The working expenses amount to something likekr. 1 50 for each patient per day. The parents or friendsof the little sufferers only have to contribute kr. 1.00 a day,

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the deficiency being made up by an annual State grant ofkr. 15,000 a year.Up to the present a little more than 1200 cases have been

dealt with since the establishment of the hospital. Ofthese, 27 per cent. have been the subjects of superficialscrofulo-tuberculous lesions. 2 per cent. lupus, 3 per cent.visceral tuberculosis, and 50 per cent. tuberculosis of thebones, joints, and spine.

Dr. Sinding-Larsen, the medical superintendent to whomthe institution is indebted for much of its success, took meover the whole establishment and favoured me with fullparticulars. 5 Treatment is mainly hygienic and dietetic andwhere necessary resort is made to the resources of orthopasdicsurgery. Fortunately there is no time limit. If possiblepatients are kept until they are cured. The averageduration of residence is 300 days. Cases of Pott’s diseaseand hip trouble are often retained for upwards of two years.The results appear to have been most encouraging. No lessthan 83 per cent. are returned as "considerably improved "

and " improved." Only 17 per cent. were "not improved "or died. Of the fatal cases 50 per cent. wera due to

meningitis and miliary tuberculosis. The Fredriksvsern Hos-pital is an institution concerning which Norway may becongratulated.

The Children’s lllarine Hospital at Hagevik.A second seaside institution for tuberculous children

is situated at Hagevik, which is reached from Bergen.Unfortunately, at the time of my winter visit to Norway thedifficulty in reaching this part of the country was so greatthat a visit to it had to be omitted from my programme. Dr.H. G. Gade, the medical superintendent, has, however,kindly favoured me with copies of his reports, which showthat this institution is accomplishing an admirable servicefor the tuberculous children of Bergen and the westerndistricts of Norway. This institution is now being enlargedand will shortly have accommodation for 100 cases.Norway has much to show to the many in this and other

lands who seem to think that little effective work for thetuberculous can be accomplished without an elaborate andexpensive organisation and pretentious, and thus necessarilycostly, establishments. Norway, in spite of financial, socio-logical, and geographical limitations, is accomplishing muchtowards the stamping out of its most deadly scourge. Othercountries should mark and consider the means and measureswhich are proving so satisfactory in this land of the north.

THE BELFAST HEALTH COMMISSION.(FROM A CORRESPONDENT.)

IN a recent communication addressed to THE LANCET

by Colonel T. Walter Harding, chairman of the recentBelfast Health Commission, he states that when comparingthe Belfast death-rate with that of other towns the Com-mission used the Irish Registrar- General’s own estimateswhen comparing Belfast with other Irish towns, andestimates framed according to the method employed bythe English Registrar-General when comparing Belfastwith English towns, while for comparing the Belfast death- rate for a given year or period of years with the Belfastdeath-rate for another year or period of years the Com-mission made use of its own independent estimate of thepopulation of Belfast. In looking carefully into this part ofthe report of the Belfast Health Commission it seems that if,to recall the famous dictum of the late Dr. Farr, "vitalstatistics form the basis of all health reform," they must bebased on facts and not on assumptions, and that if com-parisons are made as to the vital statistics of different placesthey must follow the same data. Now the very bed-rock ofthe vital statistics of any city depends (1) on its populationand (2) on the comparison of its death-rate with that ofother cities.

1. The population of a city in ordinary parlance is usuallygiven as a certain number "at the last census " but in publichealth matters the question often arises, What is its popula-tion in intercensal years ? To quote an example, Belfast was

5 For full details of this interesting establishment and its excellentwork reference should be made to the following, prepared by Dr.Chr. M. F. Sinding-Larsen: ’’Kysthospitalet ved Fredricksværn forScrofulöse Born," Kristiania, Steen’ske Bogtrykkeri, 1901;" and"Beitrag zum Studium der Behandlung der Hüftgelenktuberkulose imKindesalier." Sonderabdruck ans Nordiskt Medicinskt Arkiv, 1905 and1906. Stockholm, Kungl. Boktryckeriet.

6 Aarsberetning for Kysthospitalet i Hagevik for 1906, Bergen, A. S.John Greigs Bugtrykkeri, 1907.

in population 349,180 in 1901 according to the census..What was the number of its inhabitants in 1906? TheBelfast Health Commission in its report admits this "issomewhat difficult to determine," and as evidence of thisit actually supplies us with four different estimates..(1) The Registrar-General for England, assuming that thepopulation has increased since 1901 in the same ratio thatwas exhibited during the last intercensal period, wouldestimate at the middle of 1906 as 397,202. (2) On theother band, the Irish Registrar-General does not, likehis colleagues in Great Britain, estimate the popula-tion of communities in Ireland by assuming that thelast intercensal ratio of increase or decrease has beenmaintained. His estimates are framed as the result ofconsideration of the birth-rate, of the effects of emigrationand immigration, and of any local facts of which he canobtain knowledge, and as a result he, in giving evidence at,the Commission, calculated the population of Belfast at themiddle of 1906 as amounting to 366,220, or 31,000 fewerthan an estimate framed according to the British method.(3) The Belfast corporation thinks this official estimate ofthe Irish Registrar-General is too low and that, as a

corollary, the vital statistics based upon it are too high.The chairman of the public health committee estimated thepopulation as being in 1906 388,159, and the city surveyorarrived at a somewhat similar figure as the result of aspecial inquiry, but in its report the Commission says :-In connexion with these estimates, both of which are largely based’

on the number of "empty" houses in 1906 as compared with thenumber of houses returned as "uninhabited" " in the Census of 1901,.it has to be borne in mind that the term "empty houses" and ., un-inhabited houses" are not synonymous, for the latter term includesbusiness premises unoccupied at night, while the former does not. If’allowance could be made for this discrepancy it might well be thatboth these official estimates would come to be nearly identical with theofficial estimate of the Registrar-General.

(4) Finally, the Commission, apparently not satisfied with.any of the preceding estimates, makes one itself, basedupon the number of births registered each year and con-cludes : " On the whole, therefore, it seems reasonable toassume that the population of Belfast in 1906 was approxi-mately that given in the third column (Table I. showing thepopulation of Belfast, as estimated in different ways,380,500), namely, in round figures, not much more than380,000."

Therefore we find the population of Belfast for 1906 isestimated as 366,220 (Irish Registrar-General), 397,202;(English Registrar-General), 388,159 (Belfast corporation),and "not much more than 380,000" (Belfast Health Com--

mission). Such wide discrepancies (397,202 and 366,220) in-figures warrant the conclusion that the estimate of the

population of a large city like Belfast is, in an intercensalyear, a mere speculation. The exact population will not beknown until 1911 when it is possible that the estimate ofthe recognised Irish authority-Sir Robert Matheson-willturn out to be nearest the truth, inasmuch as his calculationsare based on far more varied data than those employed inany of the other methods. The importance of having a.correct knowledge of the population is shown in Table VIII.in the report of the Commission, where the death-rate ofBelfast in 1906, based on populations as estimated (1) bythe Registrar-General for Ireland, was 20’1; while (2) bythe method of the Registrar General for England and Walesit was 18’ 6 ; and (3) by the number of registered births(the method of the Commission) it was 19’ 4.

2. How can the death-rate of a city like Belfast becompared with that of other cities in intercensal years!"The Commission gets out of this obvious difficulty by usingthe figures of the Irish Registrar-General when comparingBelfast with other Irish towns, but when it comes to com-pare the death-rate with that of English towns it employsthe method adopted by the English Registrar-General.Table IX. shows the death-rates of Belfast, Cork, andDublin, based on populations as estimated by the Registrar-General for Ireland, but even in this respect there is doubt,as the Commission says, "such estimates are much lessliable to inaccuracy in the case of Dublin and Cork thanin the case of Belfast, in view of the less rapid increaseof population in these two registration districts." In com-paring the death-rate of Belfast with English and Scotchcities the Commission bases the Belfast rates upon popula-tions estimated by the same method as. that adopted by theEnglish Registrar-General in order to make them com.

parable-that is, it makes the population of Belfast 397 202.instead of 366,220 as calculated by the Irish Registrar-General. Now there is great room for doubt in regard