1899

THE CRY OF THE CONSUMPTIVES

GRADUALLY is the true knowledge with regard to consumption-its causes, prevention, and cure-being disseminated; and gradually, but all too slowly, are efforts being put forth to grapple with the evil. These efforts, which are pitifully inadequate, are almost entirely of a private character, and it is in the hope of further stimulating public interest, and, if possible, of influencing to some extent our attitude, as a nation, towards a matter of such urgency that the writer, following up his articles in the January and March numbers of this Review, again ventures to approach this subject.

But before breaking fresh ground I would like to touch on one or two points in those articles which, judging from the many questions asked, seem by some to have been misunderstood. It was not by any means my intention to convey the idea that the site of a sanatorium is a matter of no consequence. My object was to point out that it is hopeless to leave climate to cure consumption; that it can be cured in any climate-the fashionable climates (High Alps, Italy, Egypt, &c.) are by no means the best; that in all healthy countries and ours is a healthy country-sites can be found which are in the best sense suitable. I said: 'Go to the highlands of Scotland, the lowlands of England, or to the bogs of Ireland, and plant your sanatoria there.' Some people have taken this quite literally, and seem to think that in Ireland a bog is the best place on which to build a sanatorium. Generally, I meant that all parts of Briternia (Great Britain and Ireland) are suitable in which to cure consumption. Further on I described what I take to be an ideal site for a sanatorium, where there would be present as many helping factors and favourable conditions as possible. By locating a sanatorium well, we create a 'climate' of our own-that is, we get a protected place, at a fair altitude, lying well to the sun, with pure bracing air about it, and with trees near, among which the patients may walk when wind or sun are too strong. All the rest that I said was meant to convey the idea that, if you cannot get an ideal site, you should go on curing consumption all the same in the best shanty you can rig up, in the most suitable place at your disposal.

1 Consumptives are now coming from South Africa and Australia to this country for treatment.

It is a matter of some importance that a consumptive be cured in the climate in which he will afterwards have to live. It would not be to his advantage to go to a warm climate (even if there were sanatoria in such places, which there are not) to recover, as, on his return, it is more than likely that he would always, as winter came on, be harking back to sunnier climes. The one essential of climate pure air-oxygen and this is to be had at home as well as abroad; in fact, the air and oxygen of the British Isles are the most suitable in the world for British consumptives.

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One other point I wish to refer to. I did not mean that the short directions given for patients should take the place of sanatorium treatment. They were but meant for those who are absolutely unable to gain admittance into one of the few good sanatoria. A well-known doctor, writing to a medical journal, advocates the treatment by the local practitioner of those patients who have luxurious homes. This is a great mistake. These patients have broken down in their luxurious homes. If they are to be fair to themselves they must go to a sanatorium, away from all the excitements, distractions, and detrimental influences of home life; for who in a luxurious home will deny himself and live the quiet, hard life a consumptive should live; and who will be there constantly to see that he does it? Besides, if a patient gains weight at home he will likely be in a flabby condition, as is more or less the case with those who are treated on lying-out verandahs. I take it that the quality of the blood corpuscles is of no less importance than their quantity. A consumptive is not likely to have healthy blood corpuscles-but rather degenerate, if one may so express it-who lounges and lies about all the time on verandahs, which are bad for patients who are very ill, and as bad for patients who are recovering. It is not altogether desirable that patients should gain in weight without making progress in other directions at the same time. The patient's whole system needs to be toned and invigorated by graduated walking -under the most careful supervision of the physician—and the patient thereby strengthened and put into' condition.' All this would be hard to accomplish anywhere but at a properly conducted sanatorium; so that consumptives, who can, would be wise to place themselves in such a sanatorium as soon as they can possibly gain admission. It is, unfortunately, becoming every day a matter of greater difficulty to obtain a room, in anything like reasonable time, at any of the better places. There is no fear of the patient being unduly depressed there-in fact, the whole tone of such a place is one of hopefulness and encouragement-nor is there any danger of infection, for probably no place is freer from bacilli than a properly kept sanatorium.

While on matters but indirectly bearing on the subject of the present article, I would like to say a few words about ventilation.

A doctor who takes the Encyclopædia Britannica-a work now twenty years out of date on such subjects—as his guide, in a paper read before the Liverpool Architectural Society, says: 'In climates like that of Great Britain . . . in winter open windows cannot be borne, at any rate in hospitals for consumptives.' This is opposed to experience, for there are at least a dozen Consumption Hospitals and sanatoria in this country-some in England, some in Ireland, and some in Scotland-in which during the whole of last winter the windows were kept open night and day, with the most gratifying results. That is the necessity for the proper treatment of consumption. There are no bad results whatever to be feared. With or without the guidance of a doctor, there is no danger from such constant exposure in this climate. The patient needs pure air, and needs it in all its natural simplicity. He must live in it-bathe in it continually. Our climate is never too rigorous for outdoor life, and it is never too rigorous for the open window. It is the fact that consumptive patients do not receive any injury from this; that they are quite comfortable under it-the amount of bed-clothing being adjusted to circumstances; and that they soon get so to like the process that they cannot bear to have the windows closed. That is in this country-not in some problematical place. Of course there is discretion to be used. For instance, in the very coldest of winter it is not necessary to have all the windows full open, as the cold air of winter circulates much more quickly than the warmer air of summer. Then when the weather is extremely cold, at such times the room is slightly heated by hot-air pipes, the attendant comes into the patient's room a few minutes before getting-up time and closes the window, so that the patient has not to dress in a too cold room. Also the attendant may close the windows for a little before the patient returns after his walk, or at bedtime, so as to slightly warm the room; but the patient is in honour bound to open the windows when he comes in. With these slight exceptions, the rule in a good sanatorium is 'Open windows continually.' 2

It is too late in the day to advocate heated, or filtered, or forced air ventilation and closed windows for sanatoria. A paper was read at the recent Sanitary Congress at Southampton advocating such means of ventilating sanatoria, and, as far as reported, no one present raised an objection to the views put forward. That is obsoletism. We are past all that. The most up-to-date places are dispensing with such methods. We want the pure unadulterated breath of Heaven admitted, fully and directly, at all times, to consumptives; and the only, and best, ventilation a sanatorium needs is constantly

2 If one has to live in a town where there is plenty of fog and smoke, the windows should be opened just the same. It is infinitely better to breathe fog containing a sufficiency of oxygen, than to breathe fog with a deficiency of oxygen, as is the case in closed rooms.

opened windows. Surely that kind of ventilation is easily and cheaply enough come at-and it does the consumptives actual good, and not harm, as other systems do. Whatever may be said in favour of systems of forced ventilation for ordinary hospitals and crowded buildings, for sanatoria, at any rate, they are out of the question. The consumptive's life, not only when in sanatorium, but ever afterwards, depends on his being hardened, and on his getting to love an open-air life of any and every degree of inclemency, which the habit of living in houses has civilised out of him. This result can never be attained by the hot-house treatment some people recommend. On every count, closed, forced, filtered, or heated ventilation is inadmissible in a sanatorium.

The pernicious hospital treatment of working-class consumptives is still almost universally carried out in this country. True, we have a few sanatoria, and a few more are on the way, but there are probably at the present moment not more than 1,250 beds in all the chest hospitals and sanatoria in this country, which, to give the patients a reasonable chance of recovery, can in a year afford accommodation for but 2,500 out of our 250,000 consumptives. The greater number of these beds are in London and the large townsthey should be in the country-and are of the chest hospital type, with five to twenty beds in one room. If we exclude those in the large towns-perhaps seventy-five per cent. of the total number, which do not offer a fair chance to the patient-we can have some idea of the woeful inadequacy of our means for the treatment of consumptives. A great many of these beds are only for paying patients, and are therefore not available for the poor. This army of consumptives is therefore thrown back on other means of treatment. What are these? For those who can afford to pay, and who can therefore always get treatment of some kind, more or less beneficial, there are foreign sanatoria-or, if ill-advised, there is Egypt, the Cape, or the Canaries; or there is the attendance of their own medical man, and treatment at home. For those who cannot afford these meansperhaps 200,000 consumptives-there but remains outdoor or indoor treatment at our ordinary hospitals and infirmaries, or outdoor treatment at some chest hospital. The general public has no idea of the absolute uselessness and futility of these, the only means of treatment open to the poor; nor can they know the misery and the despair that invariably follow such treatment. Dr. Heron, speaking at Ipswich on the 3rd of February of this year, said

that the present system of treatment of consumptives in the out-patient departments of the hospitals in our large cities is little better than a farce; that the consumptive sees the physician for a minute or so perhaps; that the physician prescribes some drugs for the patient, who then goes back to live-perhaps halfstarve, in a slum; that to call this the proper treatment of consumption is a cruel mockery.

Or take Dr. Léon Petit's picture: 3

Harassed by want, driven by the necessity of supporting his family, the consumptive in the working class has neither the leisure nor the means to care for himself in time. He just goes on and on till he can work no more, and when that time comes and he has exhausted his last resources he goes to the hospital. But hospitals, as they are presently organised, cannot open their doors to the consumptive, so long as he is able to walk. Waiting for the admission examination, it is no unusual thing to see forty patients, of whom the better half are consumptives. The doctor, who, on the best days, has only five or six beds at his disposal, cannot, however much he may wish to, throw them away on chronic cases. Acute symptoms, then, must be present before he can admit a consumptive patient. Thus the poor consumptive begins the steep ascent of his Calvary. He goes away, wandering from hospital to hospital, always turned away, dragging his misery about with him, expectorating his bacilli, sowing infection in all the four quarters of the town, returning in the evening to his miserable garret, where his whole family is crowded together and exposed to the infection. There is a state of things as disastrous to philanthropy as to the public health.

By dint of waiting we have here a patient to whom it is impossible to deny admission, if we would not see him die in the street. At last his perseverance is rewarded. He enters the hospital.

Will he find here the combined conditions necessary for the treatment of his disease? Will pure air, a constant renewal of which is so indispensable to him, be provided in sufficient quantity? Will antiseptic precautions--such as the disinfection of sputum and soiled linen-be taken specially for him? Then the food-this most important factor in the treatment-will it be provided for him in the abundance which is indispensable, and dainty enough to tempt his appetite and build up his strength? If he is out of bed, will he be able to change his surroundings and breathe another air than that which is contaminated by the exhalations of patients affected with other diseases? And whom will he have for neighbours ?

The fundamental elements for the treatment of consumption are not at present to be found in our hospitals, which are organised for quite another purpose; for this reason alone one might almost wish consumptives excluded from them altogether, both in his own interest and that of all the other patients. His cure is a hopeless problem in a hospital where he is lost in the crowd of other patients, and to which he is only admitted out of pity, when the disease, arrived at its last stage, offers no scope for treatment. He has been granted a bed only to die in. It is all he has any right to hope for.

We have seen what these death-beds-granted out of pure compassion-have cost society. Suppose (as is quite possible) that under the beneficent treatment of rest the consumptive should be relieved. He is then sent back to his misery, to make room for others. Some weeks later he has a relapse, and this time he lies down to rise no more! All the sacrifices that society has made for him have been utterly useless, for they were neither made under favourable conditions nor at the proper time.

Such is the state of affairs that obtains in the large towns of France, and it is the same in our cities. Multiply this picture two hundred thousand times and you have an idea of the sum of the misery of our working-class consumptives. Consider it, you who fare well and have leisure, and who can at will enjoy the breath of the ocean or the scent of the hills. But one will say that we are now

Quoted from 'The Crusade against Consumption,' by Dr. Thomas F. S. Caverhill, being No. 8 of the Edinburgh Health Society's Lectures.