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
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
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
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
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
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