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to take their instructions. They asked for a further report on the
subject of which the following is a copy:— July 11th, 1907.
Gentlemen, — The question of taking measures to prevent the spread of
phthisis, directed especially to such means as are in accordance with the view that
it is frequently conveyed direct from person to person, has been before the Vestry
and Council ever since the end of 1898. During the last year, however, matters
came to a crisis on the receipt of a letter from the L.C.C. accompanied by a report
from their M.O.H., Sir S. F. Murphy, in which it was urged that voluntary notification
should become universal throughout London. According to the L.C.C.
letter, voluntary notification is carried out in all the London Boroughs except
Paddington, Hackney, Shoreditch, Bethnal Green, Stepney, Poplar, Battersea,
Camberwell, Deptford Lewisham, and St. Pancras. Information was asked from
the other Metropolitan Borough Councils at that time by this Council, and, as a
consequence, Hackney, Deptford, and Lewisham, in their answers, expressed
opinions favourable to voluntary notification. Some of the Borough Councils,
Kensington, for example, indeed went so far as to strongly support the system
of compulsory notification. On April 4th, 1906, my report, which was against
taking any action, was before the Council, but in opposition to my opinion,
the resolution was passed that the L.C.C. be informed that Camberwell is in favour
of voluntary notification, and that certain steps should be taken with regard to
obtaining and circulating particulars relating to hospital and dispensary patients.
This resolution has, however, never been acted on, and I have brought the matter
before the new Council to ask them whether they wish me to take any steps to carry
out the resolution as to voluntary notification or not. Before doing so, however,
they have ordered me to report on the subject.
For a disease to be benefited by notification it should be of a decidedly infectious
character from person to person, either directly or through the medium of an infected
article, and it should be recognisable at an early stage. Are either of these conditions
fulfilled in the case of phthisis ? The first one would lead one to suppose that
a large proportion of cases would be those of persons who lived in the houses where
there were, or had been, other cases of the same disease, and the closer the relationship
the more frequent should such occurrences be. lam well aware of the
exaggerated pictures drawn by Koch and many others of the liability of remaining
members of a family to contracting a recognisable form of this disease from someone
dying of it ; but as a matter of fact it rarely occurs. The advocates of notification
urge that this is because removal to an infirmary, where the supposed precautions are
taken, has taken place, removing the patient who is said to be the source of danger ;
and so they maintain that to the removal from home of a greater number of cases
which, according to their theory, are most likely to be centres of infection, is partly
attributable the decrease of phthisis of late years. It is obvious, however, that
much must depend, if the arguments have any weight, on how long the patients
have been ill before removal. From the inspection of the Infirmary bed-cards, which
have been kindly placed at my disposal by Dr. Keats, out of 148 cases, 45 were in
the Infirmary less than two weeks, 33 less than one month, and 70 more than one
month, the disease having always lasted much longer; and, as a rule, when the
lodging was of the poorest and most crowded description, it was there that the
greatest delay in removal took place, the patient frequently not being more than a
week in the infirmary before death, while they had been ill at home for months; and
according to the theories of those who believe in the extreme personal infectivity of
the disease, there should have been a goodly proportion of cases of tuberculosis, if
not of phthisis, in their homes, which was not the case.
As I have mentioned before, the prime factor in tuberculosis appears to be the
existence of a medium in which it can grow and flourish, and the rational system of
dealing with such an ubiquitous gern as the bacillus of this disease is not to try to
destroy it, for such events are likely to be futile, but to render impossible its increase
in the human body and consequent power of mischief. For this purpose indirect
means, while less sensational, and perhaps less likely to appeal to the public, are the
more efficacious. I refer to the improvement of food and lodging, using both these
terms in the widest sense. It is found especially that those who are addicted to the
excess of alcohol in their occupation, and also those who are restricted in the way
of food and liable to exposure, are the ones to suffer.