Recent Literature 486 Recent Literature compulsory notification of tuberculosis has been adopted the
Recent Literature 486 Recent Literature compulsory notification of tuberculosis has been adopted the
Recent Literature 486 Recent Literature compulsory notification of tuberculosis has been adopted the
Recent Literature 486 Recent Literature compulsory notification of tuberculosis has been adopted the
Recent Literature 486 Recent Literature compulsory notification of tuberculosis has been adopted the

Recent Literature 486 Recent Literature compulsory notification of tuberculosis has been adopted the

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    By WILLIAM ROBERTSON, M.D., D.P.H., M.O.H., Leitli.

    The Present-Day Administrative Aspect of Tuberculosis.

    As years roll on the medical officer of health finds himself coming into closer grips with pulmonary tuberculosis, and there are now few local authorities that are not alive to the need for encouraging their

    sanitary adviser in his efforts to deal effectually with the disease. Doubt was cast upon the advisability of coupling tuberculosis with

    other acute infections. It was universally agreed that infection could be spread by the dissemination of the tubercle bacillus, but hesitation was expressed regarding the system of notification that would meet the case. Experience of compulsory notification has not by any means cleared away the doubts that existed, since notification is not practised in the way that it is when, say, scarlet fever, diphtheria, etc., come under the notice of the practising physician. In one district where


  • 486 Recent Literature

    compulsory notification of tuberculosis has been adopted the prac- titioners are in the habit of notifying cases after the death and burial of the patient.

    One can picture the state of mind of the medical officer of health if the same principle were applied to typhus, smallpox, or other acute infections !

    Compulsory notification has come to stay. It is needless, therefore, to bandy words over the matter. Every effort ought to be exerted to make the principle and aim of notification a success. But notification is only one of the preliminary steps in coping with the disease. Education of the patient, treatment, and disinfection require consideration.

    By means of a competent staff systematic house-to-house visitation can do much to impress upon the citizen the absolute need of good ven- tilation, cleanliness, and sane methods of living. At the sanatorium, which every local authority should now possess, treatment may be begun and education perfected.

    Disinfection must, in many instances, be of a radical nature, because the infected premises and bedding are, literally speaking, past redemp- tion. True, a fictitious value is often placed upon articles that are only fit for destruction, but agreement can usually be arrived at before the stage of burning is reached.

    In a few years there will be few districts that have not provided accommodation for the treatment of early and perhaps the isolation of advanced cases. The responsibility is there, and it must be faced. This altogether apart from the question of State aid.

    If one were to offer a decided opinion it would be to say that the big stick of the State ought to be applied to the back of every local authority that did not institute an active crusade against damp, ill-lit, badly ventilated, and otherwise insanitary houses. Such an impetus is more urgently wanted than money for sanatoria. It is quite easy to build and equip open-air shelters, but one desires to see them unoccu- pied. The reduction in the number of applicants for admission can only be effected by a riddance of slums and the substitution of sanitary dwellings. The task is not insuperable.

    If the medical officer of health is a man of courage he need have no

    fear of interested property owners. Fixity of tenure protects the health official, such fixity being by no means assured to the slum owner when he becomes a member of a local authority. Public opinion and the confidence that he is doing the right thing are always behind the actions of the medical officer of health.

    The sanatorium is at present a necessity. It is, however, the Omega of the whole problem. The Alpha is the dwelling of the

    patient. It was expected that the Housing and Town Planning Act would

    pave the way for the sweeping away of insanitary dwellings. It is a

  • Public Health 487

    good Act in many respects, but it lias not been framed to suit Scottish conditions of housing.

    In three respects it is an improvement upon the Housing of the Working Classes Acts.

    Firstly, an aggrieved person now appeals to the Local Government Board; formerly the appeal was to a sheriff. But the machinery to be set in motion, through the agency of notices, is very laborious and technical. Secondly, the new Act enables a local authority to order Demolition of an insanitary house after the expiry of a stated period; under the old system one got no further than a Closing Order. Unfor- tunately, under the Housing and Town Planning Act a property is not dealt with as a whole. It is in this respect where Scottish conditions have not been met. Here is a case in point. A tenement consisting of fourteen separate dwellings is under review. Ten of these dwellings are quite unfit for human habitation; the other four cannot be so classed because they are well lighted and ventilated and of fairly good construction. The ten houses are condemned and a Closing Order with its multitudinous notices issued. What is to be done with the four sanitary houses when a Demolition Order is sent out against the aforesaid ten houses 1 If the latter are pulled down the four will be insecure, and 110 one has a right to call them insanitary until they become dangerous to health by reason of the surrounding conditions.

    In the Act the word " tenement" refers to every individual house.

    In Scotland the word conveys to the average mind a totally different meaning. That is a digression, but it is purposely made to indicate that we have not yet reached the most simple method for dealing effectively with insanitary tenements, as we in Scotland understand them, en bloc.

    In Glasgow and in Leitli last year an effort was made to close several such properties with an ultimate view to their demolition, but the Courts ruled both authorities out of order because each dwelling had not been dealt with 011 its merits.

    Thirdly, the Act gives local authorities powers to put into effect toAvn planning schemes. This point need not be laboured at present. It is sufficient to know that under this section of the Act big reforms may be put into effect by creating garden cities and opening up con-

    gested districts with new roads and thoroughfares 011 definite and

    expansive lines. In the course of the next decade one may expect to find such a

    township planned 011 modern lines, with avenued streets and single or double storeyed houses, at Bosyth.

    The Scottish tenement system is by no means a desirable one, but it will be long before the builder and speculator can be persuaded against its continuance.

    To come back to the administrative control of pulmonary tuber- culosis, it is gratifying to know that in Glasgow and Dundee the

  • 48S Recent Literature

    respective local authorities have instituted dispensaries at which advice and treatment ma}7, be given. At Dundee tuberculin in increasing doses is being tried. Other local authorities will doubtless follow suit.

    To be of the best value the dispensary ought to be under the

    supervision of the medical officer of health. The disease being dealt with is notifiable, and that being so cannot now be dissociated, as far as administrative action goes, from the other infections named in the

    Notification Act.

    This brings one to the question of what one might term specific treatment. Dr. Camac Wilkinson has for many years held very advanced

    ideas 011 this question ; in fact he has gone so far as to declare in favour of tuberculin dispensaries rather than sanatorium treatment. In fair- ness to him, however, it must be said he advocates such dispensaries for the treatment of early cases.

    It may be that the English citizen is more alive to the necessity for early appeal to treatment. It is assuredly not so in Scotland. We rarely have submitted to us cases that can be labelled " early." During the past ten years in Leith, where systematic treatment of pulmonary tuberculosis has been carried on, the percentage of early cases seeking treatment has been small. When such cases do present themselves we, literally speaking, welcome them with open arms. As far as our experi- ence goes we cannot bring ourselves into line with Dr. Wilkinson in his declaration in favour of exclusive home treatment with tuberculin. We have tried it against sanatorium plus tuberculin, with results that proved the undoubted superiority of the latter course.

    For over a year we have worked carefully with tuberculin 011 the lines laid down by many continental authorities and so strongly advocated by Dr. Camac Wilkinson. In not a few instances the results have been astonishingly good, infinitely better, without a doubt, than when dependence was placed merely on fresh air, good food, and rest.

    Tuberculin was tried in small doses for prolonged periods. Here again the results were not much better than among those who were undergoing the ordinary out-door regime without specific treatment.

    We did not concern ourselves with controversial or theoretical con-

    siderations, but made up our minds to discover the best system, as demonstrated by the progress of our patients. As far as our judgment goes we could come to 110 other conclusion than that tuberculin given in increasing doses can and does produce excellent results ; the physical and clinical condition of several of our patients proved it. At another time we hope to give a year's experiences with tuberculin. The treat- ment is not one that is to be lightly undertaken. It calls for great care and discrimination. In fact in the hands of those who are either