Chapter XIII.

TUBERCULOSIS.

1. The Problem. Fifty years ago pulmonary tuberculosis was far and away our greatest single cause of death. In 1877 there were 157 deaths from this cause, with 86 from cholera infantum and 72 from scarlet fever ranking next. The death rate was 265 per 100,000. Even 20 years ago, in 1907, tuberculosis was the third cause of death, exceeded only by heart disease and pneumonia and with a death rate of 185 per 100,000.

By 1926, pulmonary tuberculosis had dropped to seventh place, with a death rate of 33, exceeded by heart disease, pneumonia, apoplexy, cancer, nephritis and Bright's disease and diseases of infancy. Including nonpulmonary tuberculosis the 1926 rate was 48. In comparison with other cities this rate is very low. Nevertheless, it is obvious that a disease which causes 100 deaths a year in New Haven - and which strikes down its victims in early maturity at their period of maximum productivity - offers a serious problem.

The data cited above all refer to the total number of deaths reported within the city of New Haven. In the case of tuberculosis, such uncorrected data are specially misleading since so many deaths from this disease among New Haven residents occur in sanatoria outside the city limits. Dr. H. R. Edwards, Director of the Division of Tuberculosis of the Department of Health informs us that of the 88 deaths from all forms of tuberculosis (on which the rate of 48 is based) 19 were deaths of non-residents occurring in New Haven while 34 deaths of New Haven residents were reported from sanatoria outside the city. The corrected figure for New Haven residents is therefore 88 -- 19+ 34 or 103 which gives a mortality from all forms of tuberculosis of 57 per lOO,OOO.

2. New Haven's Tuberculosis Program. When our first survey was made, ten years ago, the Health Department took almost no official cognizance of the most important of the communicable diseases. Excellent clinic service was provided by the New Haven Dispensary and the Visiting Nurse Association had five nurses assigned to specialized tuberculosis work. The New Haven Hospital was operating its Day Camp (though its abandonment was contemplated) and the Employees Tuberculosis Relief Association was in operation. Sanatorium facilities were reasonably good but inadequate in extent. There was a total lack of any constructive leadership in this highly important field of public health. We recommended that the city should make appropriations for the extension of tuberculosis nursing under the Visiting Nurse Association and for the maintenance of the Day Camp and, above all, that there should be added to the staff of the Department of Health a competent physician trained in anti-tuberculosis work "to supervise and coordinate and develop the campaign against this disease along the most effective lines."

During the next few years the city did make an appropriation of $5,000 a year for the general purposes of the V. N. A. but on the other hand opened a clinic of its own and employed three tuberculosis nurses under the health department but did nothing else in the way of a constructive attack upon the problem as a whole until 1925.

In that year Dr. H. A. Pattison of the National Tuberculosis Association, at the request of the Board of Health, made a special survey of the tuberculosis problem in New Haven which has led to far-reaching results. His chief recommendations were the appointment of a full-time Director of Tuberculosis in the Health Department, the centralization of all tuberculosis nursing under the V. N. A. (both recommendations made in our 1916 survey) and the centralization of clinic activities in the New Haven Dispensary, with many minor suggestions to which we shall refer later. The Board of Health acted upon these recommendations with promptness and vision. In 1926 the independent clinic operated by the Health Department was consolidated with the clinic work of the Dispensary and the tuberculosis nursing work was delegated to the V. N. A. Dr. W. B. Soper was appointed as full-time Director of a new Division of Tuberculosis in the Health Department (succeeded in the fall of 1927 by Dr. H. R. Edwards). With these progressive steps and with the addition to our institutional facilities furnished by the opening of the William Wirt Winchester Hospital at Allingtown New Haven has now a coordinated central control, a coordinated clinic service, a coordinated nursing service and hospital and sanatorium facilities probably unequalled in any city of the United States. It bids fair to become the model city of the country from the standpoint of tuberculosis control.

3. Case-finding. The first essential in tuberculosis work is the early detection of cases of the disease in an incipient stage. The second is systematic supervision and treatment of these cases, in the home, in the sanatorium, and in the home again, until the disease is arrested and so long as may he necessary in order to see that it remains arrested.

The first step, then, is case-finding and its success is measured by the ratio of cases reported to deaths occurring from the disease. The Appraisal Form calls for a reporting of 2 new cases per year for each annual death but this figure is low and 3 new cases per death is the figure now more generally assumed as indicating good reporting. In New Haven in 1926 there were 270 new cases reported, 2.6 cases per death (excluding deaths of non-residents and including deaths of New Haven residents in outside sanatoria) and in 1927 350 cases were reported which should give a ratio of 3.8 cases per death. New Haven of course obtains a full score of 10 points on this item of the appraisal form.

The progress made in case-finding during the past two years is well indicated by a graph of reported cases and deaths in Dr. Edward's office which shows that these two curves ran closely parallel up to 1925 while in 1926 and, still more in 1927, the curve for reported cases shoots up far more rapidly than the curve for deaths.

Reporting by physicians is still however incomplete. Only 45 per cent of all new case reports in 1927 have come from private practitioners. Dr. Edwards furnishes us with the following results of a special analysis of data in regard to reporting by private physicians. During the five years 1923-27 582 cases of tuberculosis were reported by 144 private physicians. Two-thirds of the physicians in town did not report a single case during this period although it is probable that some of them must have seen cases in their practice. Out of the 582 cases reported, however, only 81 were reported after death, and only 75 within a period of six months or less before death which is a reasonably good record.

The Health Department has a register of some 1,100 tuberculosis cases but this register has not been recently checked up to see how many cases are really active at the moment. There are usually in a given community some 9 active cases per annual death which would give some 800 such cases in New Haven and Dr. Edwards is planning to get this list in order in the immediate future. The Department of Education has provided a list of 3,000 underweight children which will be checked up with Dr. Edwards' list of contacts, - a procedure which should prove of the greatest value in discovering those cases which need prompt attention and it should be repeated year by year. The Massachusetts program which involves concentration upon the examination of school children as a primary factor in the anti-tuberculosis campaign has given an impressive demonstration of the value of such an approach.

4. Control of Infection. The control of the spread of tuberculosis involves two main items,-the checking of infection passing from one human being to another and the elimination of infection from bovine sources. The first aim is usually attained by voluntary hospitalization of open cases or the inculcation of sanitary practices which, - if conscientiously observed, - make it perfectly possible for the careful consumptive to live in his own home without being a danger to the health of others. The state sanitary code provides that when a private physician formally undertakes to assume responsibility for a case of tuberculosis the inculcation of the necessary sanitary precautions shall be left entirely to him. Originally. monthly reports by the physician as to the status of each such case were required but this provision has been eliminated in order to avoid an undue burden upon the practitioner. The fundamental responsibility remains, however, and written reports definitely recognizing it should be required by the Board of Health, instead of, or in addition to, verbal reports by telephone.

In every community there are a certain number of individuals who willfully refuse to observe the precautions necessary to safeguard others. In such instances the Sanitary Code gives the Health Department ample power to compel forcible isolation, as it would in a case of smallpox or scarlet fever. The difficulty is that there is no place where tuberculosis cases can be kept under police control, so that the law is a dead letter. The remedy for this situation (and for the similar situation existing in regard to venereal disease) is the establishment of a small state infirmary where the few cases of this kind which occur can be cared for. Such an institution would be of great value not only in those cases actually incarcerated but as a wholesome incentive to obey sanitary rules and thus avoid incarceration.

The factor of bovine infection is now admirably cared for by the general pasteurization of the city milk supply. It is the non-pulmonary form of tuberculosis in children which is generally due to milk infection and it is interesting to note from the table below that during the period of incomplete pasteurization of New Haven's milk supply this type of tuberculosis showed an absolute increase up to 1919 but has dropped with the increased pasteurization in later years.

AVERAGE DEATHS FROM TUBERCULOSIS.

Furthermore, it is noteworthy that of the 42 deaths occurring in New Haven from non-pulmonary tuberculosis in 1925 and 1926,19 or 45 per cent were deaths of nonresidents (chiefly children infected from unpasteurized milk in adjacent rural districts). Of the deaths from pulmonary tuberculosis, during the same two years only 10 per cent were non-residents.

5. Clinic Service. Clinic treatment for tuberculosis is now furnished entirely at the New Haven Dispensary. A clinic for adults is held by Dr. W. B. Soper, Dr. Norman Smith and Dr. Edwards, and a clinic for children by Dr. Ethel C. Dunham, Dr. M. Goldstein and Dr. A. M. Smyth (in 1926-27) the former meeting three mornings and one evening a week, the latter, four mornings and one afternoon.

The volume of work performed is indicated below.

TUBERCULOSIS CLINIC SERVICE.
New Haven Dispensary, 1926-27.

The amount of clinic service provided is evidently ample. The Appraisal Form calls for 30 clinic visits per annual death from tuberculosis (a very high standard) and New Haven has slightly over this number (33). For the calendar year 1927 Dr. Edwards informs us this ratio will rise to over 41 visits per annual death. Fifteen points are allotted for this item and 10 for a ratio of 3 clinic visits per patient registered. The actual New Haven ratio on this latter point is 2.3 visits per case giving 8 points out of the 10. The fact that, of 187 clinic cases of adult pulmonary tuberculosis, 52 per cent were classed as minimal, 42 per cent as moderate and only 5 per cent as far-advanced is most encouraging; and for a clinic receiving so many minimal cases the Appraisal Form ratio is probably an unreasonably high one.

The quality of service rendered by these clinics is as exceptional as its quantity. Both clinics are staffed in the main by full-time physicians who are highly qualified specialists. All X-ray and laboratory facilities are provided, with the invaluable support of the consulting service of a high grade polyclinic. The Children's C:linic is carrying on a fundamental study of the problems of childhood tuberculosis which is equalled in but few places in the world for its scope and thoroughness.

There has been a feeling among many persons connected with the tuberculosis movement in New Haven that in addition to the central clinic at the New Haven Dispensary there should be branch clinics for the examination of contacts set up in the more remote parts of the city. Some day this step will probably be necessary. We do not recommend it at present, however. The local convenience of branch clinic service is always counterbalanced by the fact that the best medical service can only be rendered in a well-equipped polyclinic and with the present size of the city this argument seems now the weightier one. It would, however, be very helpful if a clinic for school children could be held on some week day afternoon instead of only on Saturday morning as at present, since it is often very difficult to persuade contact children to give up their Saturdays for the purpose of a visit to the clinic.

The one point that most needs strengthening, in New Haven as elsewhere, is early diagnosis by the private practitioner. Dr. Edwards is prepared to offer to the medical profession in their private practice free medical consultation service and the Board of Eealth will also contribute $2 toward the cost ($5) of an X-ray picture. This step is a most important one and should be highly fruitful when carried into more general execution.

6. Tuberculosis Nursing Service. By the admirable cooperative plan put into force two years ago all home nursing service for tuberculosis is carried by the generalized nursing staff of the Visiting Nurse Association with the aid of a special supervisor. For the past few years this position has been very able filled by Mrs. Violet H. Hodgson.

The attention devoted to tuberculosis by the Association as a part of its generalized program is well illustrated by the following figures for 1926.

During the year 1926, 17,786 visits were made on behalf of 719 diagnosed cases of tuberculosis and 1,495 contacts. New Haven exceeds the Appraisal Form maximum quota for this item (50 visits per annual death) by about 200 per cent.

The Appraisal Form allots 20 points for the total volume of nursing visits and 5 points more if 20 per cent of all tuberculosis field nursing visits are made on behalf of postsanatorium cases. On this latter point we fall somewhat short according to data courteously furnished by Dr. Edwards for the year 1927 which show that only 13 per cent of nursing visits fall under this heading giving New Haven 3 points out of 5 on this item, (total visits on behalf of tuberculosis, 22,018, visits on behalf of post-sanatorium cases, 2,908).

In general the quality of the tuberculosis nursing service is as admirable as that of the clinic service.

7. Institutional Care. The city of New Haven has no special facilities of its own for the institutional eare of tuberculosis (except for such cases as may be temporarily received at the New Haven Hospital). It is fortunate however in the neighborhood of five state sanatoria (under the State Tuberculosis Commission) and two admirable private institutions with the following capacities.

This gives a ratio of close to one bed per annual death for the state as a whole, which is the usually accepted standard. The William Wirt Winchester Hospital, which is the tuberculosis annex of the New Haven Hospital, can be expanded up to 140 beds when additional funds for maintenance are available.

It is of interest to note that on December 1, 1927 there were 100 New Haven cases in State Sanatoria, 29 at Glaylord Farm, 17 in the New Haven Hospital, 15 at the William Wirt Winchester Hospital and 8 at the U. S. Veterans' Bureau Hospital or 169 in all. This is a remarkably good record for a city with only some 100 deaths a year from tuberculosis.

No data are available as to the number of patient-days of institutional treatment actually received by patients from New Haven. Dr. Soper informs us, however, that throughout the year 1927 the number of such patients has averaged over 160. We may then safely multiply160 by 365 to get a safe minimlml of patient-days amounting to over 58,000 patient days, more than double the standard of the Appraisal Form which calls only for 25,000 patient days per 100 annual deaths.

Dr. Edwards informs us that a study of 237 cases discharged from the state sanatoria and from Gaylord Farm since April, 1926, indicates an average length of stay of 10.3 months (or excluding three Seaside cases which are usually very prolonged, 9.9 months).

As to the condition of patients on admission and discharge we have again no specific data for New Haven patients. We may, however, take the total Connecticut figures and assume that New Haven's record is similar to that for the rest of the state. These data for 1925-6 (the Winchester Hospital has just been reopened and is of course not included in these figures) are as follows:

STATISTICS OF SANATORIUM TREATMENT FOR
CONNECTICUT PATIENTS
(Pulmonary Adult Cases only.)
PERCENTAGES OF TOTAL.

In a comparison of the figures in the two lines of this table will be found the answer to the problem of tuberculosis. Of State Sanatorium cases only 47 per cent are discharged as apparently arrested or improved as against 87 per cent quiescent, arrested or improved at Glaylord Farm; and the reason for this wide difference in results is clearly seen in the difference in the type of case admitted. Gaylord Farm selects its cases so that only 16 per cent are in the far-advanced stage when admitted, while in the State Sanatoria 65 per cent of the cases are far-advanced at the time of reception. If we desire to control tuberculosis in the fullest degree, - to secure over 80 per cent of improvement instead of less than 50 per cent - the only way to do so is to build up our machinery for early diagnosis along the lines of popular education, nursing service, clinic service and consultation service so as to get four-fifths instead of one-third of tuberculous patients into sanatoria before the far-advanced stage.

We have no data as to the stage of admission for New Haven patients but if the average is assumed to be the same as for all patients and if it is assumed that five-sixths of New Haven cases are in state sanatoria and one-sixth at Gaylord Farm we should get an approximate figure of 9 per cent of New Haven cases admitted in the incipient stage. The Appraisal Form gives 10 points for this item with 25 per cent of cases admitted in the incipient stage as standard. New Haven would only get 4 points on this item.

8. The Employees Tuberculosis Relief Association. For the past fifteen years New Haven's tuberculosis program has been aided by a unique and admirable institution in the form of the Employees Tuberculosis Relief Association. This organization is primarily supported by contributions from a group of some 60 corporations, firms and business houses which are the members of the Association and which include nearly all the larger industrial concerns of the city, the fundamental aim of the organization being to provide sanatorium treatment for the employee who may develop tuberculosis. The Association, in the absence of a local Anti-tuberculosis Association of the usual type, also has charge of the local Christmas Seal Sale of the National Tuberculosis Association. In 1926 its income included $11,372.03 from its industrial members, $11,574.08 from Christmas Seal Sales, $1,189.32 from interest on deposits and investments and $2,690.66 from other sources or $26,826.09 in all. It had a balance on hand January 1, 1926 of $24,334.99 and on January 1, 1927 of $27,281.20.

Disbursements of $23,879.88 included $18,471.94 for direct relief, $3,547.02 for salaries and wages and $1,860.92 for miscellaneous purposes, the expenditures for relief being chiefly payments to sanatoria for the care of patients. One hundred and sixty patients were thus under treatment during the sixteen months from January 1926 to May 1927.

The service rendered by this Association has been invaluable in the furthering of sanatorium treatment for the industrial workers of the city.

Its funds are, however, inadequate to provide for aid to the families of cases of tuberculosis while sanatorium treatment is being received. It must be remembered that poverty is one of the major factors in the causation of tuberculosis and any program which fails to take this into account will necessarily fail of fullest realization.

The present economic crisis appears to be a serious one as indicated by the very definite increase in demands for material relief throughout the country. We should not be surprised if all the efforts which can be put forth along medical lines for the control of tuberculosis may for a time be neutralized by this economic situation.

9. The Supervision of the Ex-Sanatorium Case. Next in importance to the securing of prompt recognition and early treatment of tuberculosis, is the problem of follow-up of the arrested case. In a certain proportion of instances (the extent of the proportion depending on the promptness with which treatment was hegun) the patient is discharged from the sanatorium with the disease so completely arrested that he can forget about it and lead a wholly normal life thereafter. In many other instances, however, while the disease is arrested and will so remain so long as the patient continues to lead a hygienic life, it will develop once more just as soon as his vitality is lowered by overwork, undernutrition or excesses of any kind.

It is vitally essential to the full success of the tuberculosis program that there should be a definite provision for nursing follow-up and medical supervision of post-sanatorium cases. The nursing follow-up is provided in New Haven by the V. N. A. and its amount is reasonably adequate in spite of the low appraisal score cited above. The score for this item is based on the ratio of visits to ex-sanatorium cases to total visits and the total of tuberculosis visits paid by the V. N. A. is so large that this ratio is almost necessarily small.

The one outstanding defect in our whole program is the lack of systematic medical supervision for the discharged cases. There should be provided a special evening class of supervision and instruction for these post-sanatorium cases, distinct from the ordinary clinics to which all such cases (not under the care of a private physician) should be invited for periodic medical examinations and conferences and advice as to hygienic living under the actual home and shop conditions which surround them. As a result of such follow-up, the need for special provisions of housing and special workshops for the arrested case might logically develop.

10. General Program of Education and Provision for Health Promotion. Underlying the whole tuberculosis program, is, of course, a general campaign of education with a twofold object, - the familiarization of the public with the early signs of tuberculosis and the importance of prompt treatment and the upbuilding in the community as a whole of the general habits of healthy living which, after all, form the most effective barrier against this disease.

In most cities the educational work in regard to tuberculosis is largely carried on by a special voluntary anti-tuberculosis associations supported by the Christmas Seal Sale. New Haven has never had such an association and the seal sale funds, as we have seen, are chiefly used by the E. T. R. A. for material relief. In view of this situation and of the fact that the city has appointed a full-time director of tuberculosis it seems necessary to place the major responsibility for general education in regard to tuberculosis and personal hygiene upon his shoulders.

Closely allied to this program of health education is the provision through open-air schools, day camps and preventoria of means for facilitating healthy living on the part of children who, because of contact with tuberculous cases or of subnormal vitality, are in special need of upbuilding.

The subject of a preventorium can be dismissed with the statement that New Haven has no such institution and no funds for one in sight at the moment.

The William Wirt Winchester Hospital does operate a Day Camp or rather a Day and Night Camp which cared for 82 children last summer for the period from July 5 to October 1 and this camp will be further expanded next summer. Only 54 of these 82 children remained under care for over 2 months. If resources permitted it would be highly desirable to develop this Day Camp into a Preventorium (which is essentially a Day Camp operated all the year round and for twenty-four hours in the day).

The Organized Charities has a camp at Branford (supported by the New Haven Register) which receives about 200 children a summer for a two weeks outing. This is an admirable piece of work but the length of stay is too short to classify it as a true Day Camp.

The Department of Education operates 5 open-air classrooms at the Beacon, Dante, Fair Street, Prince Street, and Skinner Schools with 25-30 pupils in each room.

The Appraisal Form allots 15 points for open-air class rooms, preventoria and day-camps, full score being given if 1 per cent of the grade school population enjoys such facilities. This would mean provision for 300 children in New Haven and the actual provision is about 200 (50 in the Day Camp and 150 in the open-air schools) giving a score of 10 points.

11. Summary and Recommendations. New Haven enjoys almost unique facilities for its tuberculosis program in its Health Department with a full-time director of Tuberculosis work, its Visiting Nurse Association, with a generalized nursing service under specialized supervision, its Dispensary with nine weekly clinics and its ample sanatorium facilities with the Employees Tuberculosis Relief Association to aid in paying the cost of treatment, - the whole coordinated for the past year under the guidance of a joint committee representing the city, the Dispensary, the Visiting Nurse Association and the Employees Tuberculosis Relief Association. For quality of service no one of these organizations can be duplicated except in a few selected cities and the combination is, so far as we are aware, unequalled anywhere.

The results of this anti-tuberculosis machinery are already manifest. The present tuberculosis death rate of 57 per 100,000 (including deaths of New Haven residents in outside sanatoria) is one of the lowest in the country for an industrial city, (for the five years 1920-24, New Haven had a death rate from pulmonary tuberculosis of 51 compared with 88 for the Registration Area) but with the organization available it behooves us not to rest on our oars but to push on to the complete conquest of this once-dread disease. On the Appraisal Form, the New Haven program scores 85 points out of a possible 100, losing 2 points on proportion of nursing visits to ex-sanatorium cases, 2 points on ratio of clinic sisits to patients, 6 points on low proportion of incipient cases admitted to sanatoria and 5 points on inadequate open-air school and day camp facilities. The deficiency in proportion of nursing visits to ex-sanatorium cases is largely fallacious, heing influenced hy the very large total of nursing visits and the small proportion of incipient cases admitted to sanatoria may be fallacious since it is based on state averages and New Haven probably stands well above the state average in this respect. With the machinery now in operation it is the opinion of the writer that within two years we shall have a practically perfect score and that wthin five years even the present tuberculosis death rate can be further cut in half.

The additional steps to be taken in order to bring New Haven's program to the highest stage of perfection, (none of them except the last involving additional local community expense) are embodied in the following recommendations:

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