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Les diagrammes suivants illustrent la mdthode. 1 2 3 1 2 3 4 5 6 THE DUTY OF THE PUBLIC IN DEALING WITH TUBERCULOSIS By Dr. P. H. BRYOE, Secretary Provincial Board of Health, being a pcper read before the Association of Executive Health Officers of Ontario, at Ottawa, October 27th, 1898. THE DUTY OF THE PUBLIC IN DEALING WITH TUBERCULOSIS. Mr. President and Gentlemen of the Association ; I had the pleasure and opportunity a year ago of presenting before the American Public Health Association at Philadelphia, a paper on the •' Duty of the State in relation to Tuberculosis," and then pointed out how the State, even in Ontario, had been in practice the exponent of the theory of state socialism so fully evolved ia Germany under the regime of Bismark. I further pointed out how the Government of Ontario has undertaken the control of all lunatics, how it has granted state aid to 47 hospitals, these having in 1897 soaie 18,000 of a population, and grants to 31 orphanages and to 32 refuges. The expanse for maintenance of these was, for asylums $595,843.00, and $176,982.00 for hospitals and allied charities. Leaving for a moment the fact that the Government has relieved the municipalities of almost the total amount for asylum maintenance, it appears that while on the hospitals and charities alone the Government spends $176,982.00, the municipalities raised .^554,537.00 (or slightly more than three times the government grant) this including, however, both the construction and maintenance of their institutions. Agaiii I find that while the total expenditures in 1895 in the 13 Ontario cities was $12,250,357.00, yet their actual grants for the support of the poor and other charities, were but little more than 1-9 this total, or practically the same amount a? that paid by the Government for the same purpose. This amount, added to the maintenance of asylums, means that nearly one- fourth of the total annual governmental expenditure of $3,700,000.00, that is $775,825.00 in 1896 was spent on charities. I have excluded from such charity grants amounts such as the $69,000.00 raised in 1896 for Municipal Local Boards of Health in the 13 cities as well as some $18,000.00 spent by the Government on Public Health and Vital Statistics. I have given these figures for the purpose of illustrating the fact that, while under all circumstances the people of the Province may be said to be really expending the funds raised from any source, yet it must be apparent that the monies which have been placed under the control of the Legislature have been expended by it directly, in a notably larger degree for the care of those we may call the defectives of the community, than the monies which the people have voted directly by assessment for the same purposes. Further, from the absence of any direct levy of taxation upon the people by the Legislature and the largely fixed nature of the Governmental revenues, owing to the nature of the sources from which they are derived, it must be apparent that if the limit has not already been reached it shortly will be reached, when the Legislature will be unable to grant larger revenues for charitable purposes. If then we are to look for the enlarg- ing of expenditures for further charitable works in the Province of Ontario, such as we believe to be necessary if we are going to Actually deal effectively with tuberculosis, as we do with other contagious diseases, it will be apparent that the people as residents of our municipalities must realize that the work must prin- cipally be undertaken directly by themselves, either as individuals or as jzens of our several municipal communities. I trust that the point has been made plain that if the people, enjoying the rights of municipal government, wish on the one hand to retain their municipal privileges, they must, if social evolution is to continue, acc-pt and exercise the responsibiLties involved therein; or if they feel that the work, for instance, of the care of the tuberculized poor can be better secured in sanatoria, located fav- orably and constructed and managed by the Government, as are the provincial institutions for the care of the insane, they must be prepared to supply largely the funds therefor, as indeed was done as long ago as 1840, when the Legislature authorized au assessment through the Courts of Quarter Sessions of one penny in the £ for the maintenance of a provincial lunatic asylum. Judging compar- atively'from the cost and efficiency of governmental as compared with municipal management as at present existing, there seems to be no doubt as to which is the preferable method. 3 Tn the meintime, however, there is the fact that the present situation de- inanda, from the public health standpoint, the undertaking by the public, whether in city or country, of actual schemes for limiting the ravages of tuber- culosis. 1 cake it for granted that the first step in such work must be the education of the public up to a realizition of the true nature at' the disease ; first, as regards its curability, and second, as regards its communicability by infection. I am further convinced from my observations and experience that in Ontario the general public have become acutely alive to the latter, and are rapidly learning something regarding its curability. Many communications from physicians and private persons from all parts of the Province contain enquiries as to the existing facilities for the treatment of the disease ; while at the Muskoka resorts I have learned that during the past summer keepers of summer hotels and boarding houses have had to decide whether they preferred to board well persons or consumptives, as they have frequently been informed by the ordinary summer visitor that he has come to Muskoka for health and pleasure and not to be exposed to a contagious disease. Indeed, nothing was more ead than to learn that the tuberculized almost in hundreds had been sent to Muskoka, on the advice of their physicians, in all stages of the disease with no plaoe fitted for tneir reception and entertainment, none for their comfort, medical guidance or treatment, and that in the minds of many they were looked upon almost as lepers. And, gentlemen, I am ready to confess that the mem- bers of this Association are in some degree responsible for this. We have, with all the energy we have possessed, been for years educating the public '^ the facts regarding the conditions of infectiousness of consumptiouj and, supple- mented by their orn observations in many instances, they have taken us at our word. We have preached the dangers from infected meat and milk and to-day we are believed. It is needless to say that at this critical point we cannot desert the public. They are needing ; nay j)raying for our help. Shall we fail in the task we have undertaken 1 I need not say to the members of this Associa- tion, who for twelve years, largely at their own expense and time, have borne aloft the banner of health reform, as medical officers of health for either no remuneration or at such salaries as may be called farcial, that the public may depend upon them. Men can have ideals and may perform actions far beyond anything which money has power to compensate ! We, therefore, are prepared to labor and to teach, but at this point the public should understand that they, too, must help. They can help in two ways : first, in being honest with their physicians, and second, by granting money for the establiishment of Homes of Recovery or Sanatoria for Consumptives. At every sanatorium I have visited I have heard the same remark, repeated again and again by the staff : " Oh, if only the doctors would send their patients early enough then we could hope for the best results ! " There is an old adage " Like priest, like people ! " This may be true ; but I have also heard a modern political proverb to the effect that "The politician will be no more honest than the people he represents ! " How many people have abused a family physician for concealing facts regarding thetrue condition of a tub- erculized son or daughter, when, as they say, something might have been done ! They say, " He kept the patient on in order the he might make money out of them I " If this story has been true in any case, the common experience of every physician is that it has another side. We may assume that the honest physician has carefully examined his patient and he has convinced himself that the patient is tubp-culized. He communicates the fa^ts to the parent. The latter says, " Ur no circumstances let the patient know that he is consump- tive, as it may frig iten him to death." The patient meantime is put on a tonic, ceases work and rests for a short time and begins to improve. The parent becomes skeptical of his physician's diagnosis, in fa^t is often inclined to think a slight has been cast upon the family health escutcheon, for, whoever heard of consumption being in his family 1 To confirm himself that he is right he takes the patient to another physician. Perhaps, deceived by present appearances, or willing to cultivate a new family, he insinuates that his own confrere is an alarmist, and is mistaken ! and for the moment has scored a victory, for he has told the parent what he longed to hear. After a few such experiences the family physician may be excused, perhaps, for being slow to drive away patients, and will not always be more honest than his client. My experience is that the physicians everywhere are willing to aid in this work, which is truly national, when they see the way to action. The public must help us to help themselves ! As individuals they all know that sickness costs, but above all they know what one case of consumption in the family costs. Calculated from the state stand- Doint the loss to Ontario of 3,000 lives of wage earners annually means a loss of $3,000,000 and more than a tenth of the annual increase of births over deaths ; but to the family through loss of time of the patient and the nurse, in physi- cian's fees and medicines, who will calculate the loss? We have said that in the second place the public must grant money that we may help them. Surely in our cities the public cannot ask physicians to do more than they do now. In oar hospitals, our refuges and orphanagps, nearly all the work is done free of charge. Surely this is much ! In Toronto hospitals in 1896, 473 consumptives were treated in the hospitals at an average of 50 days each or 21,650 days of medical service. For the maintenance of these the public of the city paid some $5,000.00. As 25 per cent, of these died it is plain that most were in the later stages of the distase. Manifestly they must be dealt with after a different fashion. How ? One has but a single answer, viz., by the so-called air cure, or life in the pure country air. The French physicians call it de urbanization. In Paris as Verneuil says it need only be so far as the Bois de Bologne ; here, it need only be to high, dry grounds inland from our Great Lakes. How is this work to be begun and developed ? Need wo leave it to our Munici- pal Councils 1 No, we need not expect thpm to originate such a work ; but they will assist if the public seriously ask tbem. Who have originated the ideas of refugfs, and orphanages and children's hospitals? Mostly ladies engaged in works of love, which is their highest attribute ! What other organizations have we ? I answer our Local Boards of Health. Were I to press the point I am prepared to state that under the public health statutes, a civic board of health can establish in a proper locality a Home for the treatment of any disease which threatens to seriously endanger the public health, and can demand and obtain civic funds for the purpose. And I know of no body so well adapted for this work ; since it is they who can if they choose find out the cases of tuberculosis^ and advise in cases where they know the patient is endangering the members of a family. The work, however, is so large a one, that we must go away beyond the routine work, which in a city a local board undertakes to perform. Basing a calculation on the death rate in Toronto, which is not much greater than in other Canadian cities, there is one consumptive for every 40 families of the population, and one dies annually in every 375 persons. Reducing this down still further it means that every church organization must have several consumptives among its adherents. Surely here we have brought the matter next nearest to the family itself ; for if our church organizations have anything of the Spirit of their Master, they will be prepared to follow in His footsteps. '' I was sick and ye visited me ! " And give a cup of cold water in His name ; which, I take it, in this connection means not alone spiritual comfort to the sick when he is dying, but assisting the sick toward recovery. It is not necessary to ask that churches individually will establish •Hottes' for their consumptive poor; but what is necessary is that the clergy and all philanthropic workers should actively assist in their establishment, and thereafter see that those who are showing symptoms of the disease should be urged and assisted in going where they have a good chance of recovery. I know of nothing which should so appeal to Christian philanthropy ; for while it means hope and life to the sick for them to go where they may be expected to recover, it means safety for those who remain. But much more ! It means the prevention of a whole family in some instances be- coming pauperized. Surely we can appeal to everyone to deal with the con sumptive sick in the only proper way which is known to us. As health officers and boards of health we may be expected to see that schools, workshops and operatives in certain trades be maintained and maintain themselves in such sanitary conditions as that the tendency to the diseases of foul-air will be lessened, and the exciting causes of this disease, especially of in-door life, be removed. In these respects we are illustrating the definition by Sir John Simon, the practical founder of the work of State Medicine in England, of State Medicine when he says " that the term corresponds to the supposition that in certain cases, the Body-politic will concern itself with the health interests of the people "Before any such supposition can be realized effectively, the science of medicine or the exact knowledge of the means by which disease can be prevented or cured must have reached a certain stage of development, and unless all the science is supposed to be common to all persons in the state, the existence of state medicine supposes a special class of persons whom the unskilled public will recognize as possessing the required knowledge. Thus, given the class of experts to supply the exact required knowledge, the body politic undertakes that within the limits of its own constitutional analogies, it will make the knowledge useful to the corner. unity." Continuing, Sir John said : " If there exist in the social organism any function whatsoever for which development and eventual triumph may be foretold, surely it is that of state medicine ! Of the two great factors concerned in it, the two strong powers, which within our own 6 time have converged to make it really what it is — the growth of science on the one hand, and growing atreaa of a common humanity on the other — neither is likely to fail." Clearly then, if in the work to be done in lessening the prevalence of con- sumption, we, as the supposedly skilled tjxponents of state medicine in Ontario, that is of the body-policic, or the legislative body, are willing to push forward the work, the community must supply the sinews of war. But we can in many instances do more. In our several municipalities and districts we as physicians know probably better than any other who are the local leaders and workers in philanthropic projects. How are we going to actively interest such and others of the general public in obtaining municipal grants for cottage homes, and money for maintaining poor patients there ? The answer is that of making the public thoroughly aware of the needs, and of ihe possibilities for good of such " homes," and of the dangers to the public of remaining passive under existing conditions. Imagine the situation as where the young men of a nation have gone from every town and hamlet to battle for the fatherland ! Who has not read of how thousands of loving hands during the years of the American civil war worked at their own expense to supply nect-ssaries and com- forte for their dear ones at the " front " ? Who has not heard of the storm of indignation which passed over England when the facta gradually became known of the failure of the commissariat in the Crimean war ; or of how Sir Robert Rawlinson's commission was hurried away and how they saved thousands of lives by their sanitary reforms in the army camp ? Or who has not read of the bitter denunciations of a management, which has resulted in hundreds of deaths in the cauips of the American army from typhoid in the present war ? And yet all told they probably will not equal in number the deaths which will occur this year in Ontario from the single disease consumption ! The task before us as an Association, and before other nations, or peoples, is a serious, a loug and an arduous one. Army camps can be made clean ; their water supplies may be maintained pure by scientific knowledge and perfect dis- cipline ; but in our task we have every individual, and every family, to whom knowledge and self-control must be brought ; we have through them to see that their councillors and senators be taught wisdom, justice and benevolence ; we have to appeal to the conscience and sympathy of those who control and build our public schools, to give our children pure air, sunlight and short hours, and we must insist that such common rights shall be required of employers of our work-people that they too will have workshops and workrooms where the dangers of dust infection shall be reduced to a minimum by ventilation and fresh air. The people may cry for legislative reforms, and if they cry aloud they will get them ; but more than this, and even more important is the exercise of every home agency by which wholesome surroundings, good food and clean air be maintained in every dwelling. With such instincts present in our homes and amongst our people, we need not fear that sufficient financial aid will fail us in our efforts to supply homes in which those who, in spite of every effort, have become infected with the disease may go for rest, reconstruction of tissue, and often, we are sure, final recovery.