PUBLIC HEALTH.

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 32

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

sceptical or unwilling to persevere its utility may be readily questioned.

Public Health 489

One patient may show no improvement whatever under one pre- paration of tuberculin, but with tli6 exhibition of another variety improvement begins immediately to manifest itself. Also some

patients may be tried with all manner of brands of tuberculin, and will give the medical man 110 encouragement to persevere.

All this emphasises the need there is only to undertake tuberculin treatment if one means to persevere.

It is certainly true to say that in the treatment of pulm onary tuber- culosis no one can overlook the value of tuberculin. In fact in tuberculin the health official has had placed in his hands a powerful weapon not only for diagnosis but also for treatment; and that treatment is

more or less specific.