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TUBERCULOSIS AND THE WAR: "PREVENTION IS

BETTER THAN CURE"*

By Louis COBBETT, M. A., M. D., F. R. C. Ş., Lecturer on Pathology in the

University of Cambridge; Author of The Causes of Tuberculosis"

While tuberculosis in Great Brit- Sanatoria in the long run do but ain has increased during the war to little toward prevention, and if we such an extent that its death totals over-rate their services in this for the years 1913, 1914, 1915 and direction we are in danger of 1916 stand in the proportion of wrongly believing them to be the 100, 104, 112 and 112, the increase principal equipment needed for need not alarm greatly those inter- prevention. Sanatoria are designed ested in the eradication of the dis- for treatment, not for prophylaxis. ease. The experience of Paris dur- If the latter were their aim, they ing the siege of 1870-71 may reas- would seek out preferably the adsure us. During that siege the tu- vanced and most infectious cases, berculosis rate rose enormously, instead of the moderately early and when normal conditions were cases which they now change from restored it fell just as suddenly. acute to chronic cases. DispensaNevertheless, the present is a desir- ries and most of our other machinable time at which to reconsider ery also do little toward prevenour methods of tuberculosis con- tion. trol.

The writer hopes he will not be While the British tuberculosis

misunderstood; he is not attacking death rate has declined gradually these institutions, which, he recogfor years, there has been some dis- nizes, do good work in their proper satisfaction because the methods

sphere - the alleviation of existing employed to fight the disease in re- suffering cent years have not quickened this decline. This failure to change the

While we should keep prevention course of the death rate is due to

and cure apart in our thinking, it the fact that we have employed

will probably be expedient to fol

low both aims in the same institupurely therapeutic methods, aimed at the cure of the patient and only

tions. . Segregation of advanced indirectly at the prevention of the

cases in institutions devoted wholly disease. The object of this article

to this purpose would stir up costly is to plead the need for keeping hostility. Such a situation may be these two aims apart, at least in

avoided by putting advanced cases thought if not in practice.

into institutions designed for healThe best treatment merely post

ing, where no fast line is drawn be

tween the curable and the incurpones death in many cases and

able, and the hope of recovery is lengthens the patient's period of infectivity. It is to be feared that

common to all. the cures effected and the hygienic The new sanatoria, dealing with education of the incurable will do both early and advanced cases, no more than balance the harm must not compete with one another done by this prolongation of life. in statistics of cures but must make

*Abstract from the British Journal of Tuberculosis, XII, 1 (January, 1918).

efforts to get incurable cases in the more incurables will become posmost infectious stages.

sible. This scheme will require greater The long period of residence will sanatorium facilities than now ex- make it necessary to provide indusist, since more cases will be admit- trial as well as recreative activities ted than at present and since the for inmates. The new sanatoria period of residence will be in- will develop gradually into induscreased. It is practical, however, trial colonies. For those unable to because only a beginning is planned work, glass-covered winter gardens immediately. By degrees as the fa- should be liberally provided. In cilities increase and tuberculosis such institutions it seems possible declines (in its normal fashion) the to make a new beginning by disituation will become more man- rectly attacking tuberculosis at its ageable and the segregation of source.

CONSERVATION OF CHILD LIFE *

DR. W. J. GALLIVAN, Member of Council, State Department of Health,

Boston, Mass. Available statistics on infant mortal- It is planned to make a survey of ity from the warring nations of Europe every city and town, every village and show a decrease in infant deaths of 50 hamlet in the state. This survey will per cent. It is also estimated that this include an exhaustive study of the morgreat saving of young lives will in one tality and morbidity statistics of chilgeneration balance the enormous losses dren under the age of five years, the caused by war so that in twenty years generally accepted period of school age, those European nations which are con- and a compilation of the agencies in serving child life will be as numerically each area which provide continuous, strong as they were at the outbreak of competent medical care.

This survey the war, notwithstanding the immense will disclose the conditions. losses reported.

The remedy for the conditions will Such an

announcement stirs one's be applied by the Committee on Child blood. American communities which Conservation who look upon local have for years looked with complacency boards of health as their strong right upon infant mortality rates in times of arm in this venture. peace much higher than European na- The most profitable field for work is tions are reporting in times of the among babies during the first year of world's greatest war, ought to be life. It is planned to use the excellent shamed into action.

agencies already engaged in baby welAlways a pioneer in matters pertain- fare work, and to stimulate the estabing to health, Massachusetts under the lishment of similar agencies in areas leadership of Dr. Allan J. McLaughlin, where little or no work is being done; State Commissioner of Health, has and last but not least the medical proundertaken the work of child conserva- fession who will be asked to refer to tion.

these agencies cases which are unable The commonwealth has been divided to obtain from privately employed into eight health districts. Each dis- physicians continuous, competent medtrict is presided over by a full-time

ical care. district health officer. To each district In his "Four Years in Germany," has been assigned a nurse, who will Gerard says that much of the commerbe assisted by a corps of volunteer aids. cial success of the Germans during the This machinery will be directed by a last forty years is due to the fact that Committee on Conservation of Child each manufacturer, each discoverer, Life appointed by the State Commis- each exporter knew that the whole sioner of Health.

weight and power of the government * Read before the Massachusetts Association of Boards of Health, Pittsfield, Mass., October 25, 1917. Reprinted from American Journal of Public Health,

mum

en

was behind him in his efforts to increase his business. So in this work of child conservation every agency engaged in baby welfare work will know that the enthusiastic coöperation and expert assistance of the State Department of Health will be behind it in its efforts to conserve child life.

The work of the committee is well under way. In some cities and towns, the survey has been completed and we are ready to go into these cities and towns and say, “In this city last year one hundred babies died. Of this number, ninety died of preventable disease. You have in this city a milk station where the feeding of infants can be supervised, but you have no facilities for expert obstetrical care, including prenatal care. It is imperative that an obstetrical clinic should be established in this city. Every effort will be made by the State Department of Health to establish this clinic either through private or municipal aid."

And so over every square foot of Massachusetts this survey will be made, the condition noted, the remedy recommended, and the solution carried into execution.

The most important factors in child conservation are prenatal care,

obstetrical care, and infant feeding.

A recent report of the Children's Bureau at Washington states that 40 per cent. of infant deaths in this country occur during the first month of hie.

Such a survey as we are making in Massachusetts would undoubtedly disclose the fact that such deaths in large part were due to prenatal conditions, either medical, social or industrial. De Vormandie says that any physician who has several cases of eclampsia occurring in his practice is not doing good obstetrics. The carly recognition of the toxæmia of pregnancy, with its appropriate treatment, has reduced the number of cases of eclampsia so considerably as to be considered one of the achievements of preventive medicine. The Wassermann test to expectant mothers has revealed conditions which under treatment has reduced the number of still births and premature babies. Legislative action alone will prevent the disasters which befall parturient. women who engage in industrial pursuits either by the establishment of a minimum wage or by state aid to such women,

The minimum requirements for the proper conduct of an obstetrical case ought to be standardized by the State Department of Health. Cases which are unable to conform to the minimum requirements ought not to be cared for at home. The items which suggest themselves to me in the list of minimum requirements are careful prenatal supervision including monthly examination of urine; frequent recording of blood-pressure; pelvic measurements particularly in primi-paræ; and perhaps the Wassermann test. The attendance of a hospital trained nurse at time of delivery is not a luxury. Expert assistance in operative cases should be insisted upon. Such mini

attentions to the expectant mothers of the commonwealth would materially assist in lowering our infant mortality rate.

Disorders of nutrition are responsible for the lion's share of infant mortality the world over.

Everybody agrees that breast fed babies never die of enteric disease. Therefore, breast feeding should be universally couraged by attending physicians. Bot. tle fed babies do well only under constant supervision of competent medical

I know of no better way of securing such competent attendance than by bookkeeping methods of death returns.

The mortality rate of children from 1 year to 5 years, the generally accepted period of school age, is principally due to communicable disease and its sequalæ. Proper enforcement of existing regulations for isolation would do much to lower this rate. Teeth and tonsils are recognized as important objects of inspection during this period. Many an arthritic case with its resulting cardiac damage would be averted by early recognition of these sources of infection.

And so, we come to the school age where medical inspection of schools should carry on this work.

Such is the program contemplated. Coördination of existing agencies; elimination of overlapping if any such exist; creation of new agencies where required; publicity of the widest kind to annihilate the superstitions and errors which have prevailed concerning the occurrence of illness; and the punch which an enthusiastic and expert central body can exercise are the weapons relied upon to bring this work to a happy consummation.

men.

INNOCULATION OF MEN ASSISTS SEARCH FOR

TRENCH FEVER CAUSE

Sixty United States soldiers, selected from among 500 volunteers, performed a notable service in the interest of military medical progress recently, when they submitted to inoculation with trench fever for experimental work in discovering means of controlling that disease. Human beings had to be used in these experiments, as it was found that the disease could not be transmitted to animals.

The experiments proved that trench fever is transmitted by the bites of body-lice and that the necessary step toward preventing it is to exterminate lice in the trenches. Trench fever placed ten percent of the British army on the sick list last year. The disease is not fatal, but incapacitates the victim for two or three months.

other states have had Army medical officers assigned to take charge of their venereal disease work.

Thirty-seven states, according to this summary of existing conditions, have regulations or laws requiring reporting of venereal diseases. The states in which the cooperative plan is in operation are, in general, dealing with venereal diseases along the lines of the plan outlined several months ago by the surgeons-general of the Army, the Navy and the Public Health Service (see the Ohio Public HEALTH JOURNAL for January, 1918).

FOLLOW CO-OPERATIVE

SCHEME IN 36 STATES In a summary published in Public Health Reports June 28, it was stated that, up to the date of writing, 24 of the 48 states had completed arrangements to co-operate with the United States Public Health Service in the control of venereal disease, by having an officer of the Public Health Service assume charge of this work in the state, under the joint supervision of the state health department and the Public Health Service.

In addition to these 24 states, of which Ohio is one, it was stated that arrangements of a like nature were being completed as rapidly as possible with 12 other states whose health officials had expressed a desire for such co-operation. Two

CALIFORNIA REPORTS

Nearly three times as many cases of gonococcus infection were reported in California during 1917 as during the preceding year. The total was 2,873 cases in 1917 against 1,091 cases during 1916. The increase in the number of cases of syphilis reported was not so marked, 1,790 cases being reported during 1917 against 1,538 cases reported during 1916. The reports of these cases of venereal disease were received from fortyfive out of the fifty-eight counties of California. The only counties not reporting cases of these diseases were those of very low population in the Sierra Nevadas and other mountainous districts of the state. Nearly all of the large cities reported their cases of venereal disease regularly at the end of each week. It would appear that the old barriers of false modesty regarding the reporting of these cases are gradually breaking down, and the venereal diseases are now being placed on the same plane as any other reportable communicable disease. Bulletin California State Board of Health,

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