An Address on THE CAUSES OF THE DECLINE IN TUBERCULOSIS MORTALITY
Authors: R. Philip
Journal: BMJ (1928)

LET nce crave indulgence for the introduction of a br ief personial reference.whichhas bearing, oni the significance of our (liscussion to-day.While tubercuilosis lias been knownvi fr oimi all times it has, duiring thie p)ast fifty years, assiumed a niew aspect.Throughiout the latter lperiod wec lhave comle to realize, as never before, h-hat we are iip against.It so happens that miiy medieal hiistory covers that period of fifty years almost to a day.Duinig the filrst four yearls, as an undergraduate in medicine, one became famiiiliar wvith the general lhelplessnesss and hopeless- ness of medicine in respect of tuberculous disease.Patlio- logy hiad irevealed miiuch regarding the miorbid amiatomy of tubercle, but little regarding the naturi al hiistory-of the disease.Diagnosis was limited to p)roinolunced cases; p)ro- gnosis was, for the most part, pessimistic; and treatmiient cinpirical.Tuberculosis remained, as I venitur ed to call it in myl graduation tlhesis, the opprobriuti of medicinie.Althouiglh the old-timiie conception of its iiifective chlriacter lia(l already eceived scientific confirmation in the seve nties by the pr,olonged investigation1s of V'illeiniiin, it was in 1882-83 that bacteriology demi1on0strated, onice for all, thle cauisal organism.I remember vividlyI tIe repercussioll of Koch's pr1onouncemiienit.To those of us w-h0o w\er-e wvorking ii1 laboratory at the timiie it called for-pauise.AMi1cr O- scopical work oni other linies was arrested ini favourt of consi(lerationl of the n1ew claim.Fresh Horizoni.It -as the coming of that evenit at tfait par ticiular nonienit w-hich deter mined the interest of a lifetienee-an initerest as fiesh to-day as wlhen it wais kinidled.Comiibinied laborlatory anid clinical observationi comil)elh(l onle grtadually to tile conchlsion that the attitude of mediciie.to tuber- clulosis -as wr-ong.Attention had been concentrated on1ClId-r esults, anid these especially ini the lunig.The p)livsician wx-aited iunitil the disease presented itself in aggravated formii.TIme basal fact of infection-i having beeni accepted, it 'seenied (lear-thiat the principlles whieh gov'erned tile detectiomi anid coiitrol of otlher infections might be applied to tIl)ber-(culosis, anid, especially, that in place of -aitinig unitil the effects of the tuberele bacilluts were claniantt-ofteni evident to the mian in the street-oulr aiml slhould be to searchl for tlhe earliest manifestations of infectioni and p)rol)e inito coniditionis wNhich coniduLced to grosser disease.It was study of the natur e of the infectioni and of the essential cause of death in tulberculosis wlhichl led to the proposal for special centres of observation.and the establislnnentl in 1887, of the tuberculosis dispensary.The circuimstances wer'e thought-colmpIelling. Whv] wias the pr-ognosis comimonily so unfavourable?9Adid imost of the patients die?Why were the cases ulinldem treatmlellt so larg.elythose of advanced disease?What was the natural hlistoly of the disease?Wlih, and hlowv, w-as the inifection conltr;acted of wlhichl those cases were thle final fruit?Whyv was thte disease undetected at the earlier stages?Aiiswerm to thlese quiestions wer c graduially evolved.It emen red that the adlvanced stage constitutedf bh-it the last scele in thle long dr ama of infection.It becamne evident that thle enarier stalqes of infection must be s(ovflif for.The infec- tioni mulist be traced to its source and thle comminenieing stigmiiata of disease determined.Observations oni t1lose lilnes led to time conception of tuberculosis as a household( disease anid, presently, to the systematic examination of-the lholusehold group ammd of the homiie itself anld othelr environmental condclitionis.Thlus came to be instituited the examination of contacts and (domiciliaryv visitation.Introductory to a discussion at a mceeliin of tile Society of Medical Officers of HIealth held at Bath, April 20tlh, 1928.I 1 Gradually the pioblem extended.Tubercuilouls infection -as seen to be widespread thlouiglhouit civilized comnlllliiiities.For the most part it w-as contracted in chliildlood.Varyiing degree of resistance to the inifection was offered by diffieient inidividuLals.The resultant of the infectioni depenided on tlhe amount of the inifecting dose and its r epetitioni, and(i oni th-e resistance offered bw tlhe inidividual.The degree of resistance w%as influenced greatly by environmient-inter- preting that ternm in a wide sense and to som-ne extent by racial quality.In consequience of this the oultward maui- festations of the infection differed m-luclh in clhara&ter anid degree.