86 T H E B R I T I S H J O U R N A L O F T U B E R C U L O S I S

in which the O.D. was unusually high (24o), proved to be a case of pulmonary carcinoma.

Breton, as a result of his careful researches, believes that Vernes' test, while invaluable diagnostically, and more especially prognostically, yet shows errors in that it gives a high optic density in certain acute diseases, such as typhoid, diphtheria, rheumatic fever, pneumonia, acute streptococcic infections, etc. But during convalescence in these conditions the optic density rapidly falls to normal.

One of the most instructive phases of the test, as carried out by Vernes himself and by many of his followers, is the drawing up of a serological curve by taking the optic density of the serum of the same patient at different stages of the disease. The curves thus obtained accurately depict the progress of the disease, and have proved of considerable prognostic value. This line of research is more con- venient!y carried out in a residential institution than in connection with a dispensary practice.

Two other London institutions have recently installed the necessary apparatus for carrying out Vernes' photometri c test, and there is every hope that further investigations may prove its value in the diagnosis and prognosis of tuberculous affections.

AN ASPECT OF THE WORK OF A TUBERCULOSIS OFFICER.

BY E R N E S T W A R D , M.A., M.D., F.R.C.S.

Tuberculosis Officer for South Devon, Honorary Secretary Tuberculosis Joint Council, and Secretary of the Tuberculosis group of the Society of Medical Officers of Health.

OUR conception of tuberculosis is becoming modified, and it is likely that we shall come to regard as commonest the minor form of disease manifested among the highly resistant majority of the population, and consider as comparatively exceptional that form of pulmonary tuber- culosis found among the poorly resistant minority, which today is discussed and legislated for as if it were the only form of the disease normally encountered.

Among the highly resistant majority, pulmonary tuberculosis usually appears clinically as a period of ill-health lasting from a few weeks to several months and accompanied by various symptoms, such as lassitude, malaise, cough, wasting, anorexia, and dyspepsia. Careful observation will often reveal in addition one or two physical signs suggestive of tuberculosis in the lungs, such as a few localized crepita- tions in the lungs, or areas of impaired resonance, usually at the apices and often inconstant. Of these cases I have written and given instances

T H E W O R K O F A T U B E R C U L O S I S O F F I C E R 87

elsewhere, and have termed the condition "minor tuberculosis." Such patients are encountered daily in private practice, and are met with frequently amongst " contacts " if the families of tuberculous persons are watched for several years.

In infants, children, and adolescents especially these periods of ill-health o c c u r . The child is pale and losing weight (perhaps the most constant symptom) ; it may also cough and become listless, and slight pyrexia may be noted, which, in young children more especially, may be proIonged for months.

Experienced schoolmasters have told tne that they recognize these periods of ill-health as common among those attending or in residence at boys' schools, and have often regarded them as a consequence of "grow- ing too fast." One master told me that he had seen a boy's career utterly spoilt by parents and medical advisers taking the event too seriously, the boy being removed from school when in the experience of his master this condition of derangement would be likely to pass in a term, or at most two.

Are we right constantly to iterate, as seems the policy of those in charge of tuberculosis departments, that tuberculosis must be diagnosed early and the patient sent to a sanatorium ? I think not.

One o~ t h e most approved, and certainly one of the most useful, innovations in tuberculosis work is the_krevent0rium for children. To such a centre are sent debilitated children, called by some " pre tubercu lous , " and these derive great benefit from their stay. The condition I have

a t t empted to describe cannot be diagnosed definitely as tuberculous. In my opinion the lines of our tuberculosis attack should be as

follows : i. Adequate isolation of known infective tuberculous cases and the

search for unsuspected infective cases. 2. Preventorium treatment for a short period for children, adoles-

cents, and adults, who are showing suspicious symptoms, without delaying until a final and mathematical diagnosis can be made.

The sanatorium still provides the best method of treating the tuberculosis of those with poor resistance. But the majority do not require this, although to send them there would enormously improve sanatorium statistics.

Apart from his all-important preventive work, a tuberculosis officer has to decide, not " Has this patient got tuberculosis?" but " Are this patient's symptoms due to tuberculosis ?"- -a much more important matter. Then to advise the best course of treatment. At one end of the scale, in patients slightly ili, the common error is to regard tubercu- losis as something else; the other end of the scale, ill patients are considered tuberculous who are really suffering from a chronic catarrhal (usually pneumococcal) pulmonitis.

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