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tions were 130 only. Thus 85 per cent. of the cases (and 81 per cent. of the 879 deaths also)
occurred during the most useful, the working, period of life—a fact the economic importance of
which needs no insistence.
It is a significant fact, pointing to the relative inefficiency of the voluntary system, that only
38 notifications (14, 5, 8, and 11 in the four years) were received from other than Poor Law Medical
Officers who reported 851 cases; 809 in their official capacity (217, 205, 185, and 202 in the four
years); and 42 (16, 11, 10, and 5) private cases. The deaths totalled 879: 226, 219, 235, and
199 in the four years respectively.
Granting the necessity for disinfection, it becomes obvious that steps should be taken to
obtain the earliest possible information of the occurrence of consumption. The International
Congress of 1901, in view of the fact that—
"The voluntary notification of cases of phthisis attended with tuberculous expectoration,
and the increased preventive action which it has rendered practicable, has been
attended by a promising measure of success," were of opinion that "the extension of
notification should be encouraged in all districts in which efficient sanitary administration
renders it possible to adopt the consequential measures"—
of which disinfection is one of the most important. The Council adopted voluntary notification
in 1901, and since the beginning of 1902 the "consequential measures" have been carried out as
completely as practicable in regard to cases notified; which constitute, probably, scarcely more
than a fourth of the total cases that exist in the Royal Borough in any given year. It is a question
whether the Council should rest satisfied with this result, or should take steps to obtain
complete information by promoting a measure for securing compulsory notification ? That
benefit would accrue therefrom, there can be no doubt; but consumption (pulmonary phthisis)
stands on a plane different from the dangerous infectious diseases named in Section 55 of the
Public Health (London) Act, 1891, to which, for the purpose of securing disinfection, among other
things, measles was added in 1903, by an order of the London County Council. In regard to
consumption, the system would have to be modified, to obtain from it the maximum of good with
the minimum of inconvenience to individuals. How this might be effected is a question too wide
to be dealt with here. The subject was discussed in the "Milroy" Lectures* (1903) on The Causes,
Prevalence and Control of Pulmonary Tuberculosis, the view expressed being that if notification
were made obligatory, consumption should be placed "in an entirely separate category" from
other dangerous infectious diseases—small-pox, scarlet fever, diphtheria, etc. The suggestion was
thrown out, moreover, that in the first instance, it might be well to "limit notification to cases of
"pulmonary tuberculosis in which the condition and environment of the patient are such that
"danger to the public is likely to accrue"—for example, in "the cases of patients occupying
"tenement houses or other places where the first principles of cleanliness are not observed, and
"where the people live much in common, with tendency to overcrowding." This view is in harmony
with the opinion of Professor Koch (expressed at the Congress of 1901), that notification of consumption
is necessary only in cases, that, "owing to their domestic conditions, are sources of dan"ger
to the people about them "—a limitation, by the way, which would deprive all but the poorest
classes of the benefit of the "consequential measures" now put into operation by the sanitary
authority, with manifest advantage, in cases voluntarily notified. I am in entire agreement with
the Milroy Lecturer that "the future depends very largely upon the discretion with which the knowledge
acquired by notification is utilised." It may be mentioned that compulsory notification
powers given to Sheffield in 1903, were extended, by Improvement Acts, to Bolton and Rathmines
during the Session of 1904, in each case until 1910 only. In the Metropolis, the County Council,
or any Sanitary Authority, may, by an order, under Section 56 (1) of the Public Health Act,
secure compulsory notification; but an order has no validity until it has been approved by the
Local Government Board; and whether such approval would be given is more than doubtful.
THE SANATORIUM QUESTION.
The Congress of 1901 affirmed "the provision of sanatoria to be an indispensable part of
"the measures necessary for the diminution of tuberculosis." This was the view also of the
Conference of Delegates of the London Boards of Guardians held, at the suggestion of the Local
Government Board, in 1900, when a deputation was appointed to wait upon the Board to present
* By Dr. H. Timbrel! Bulstrode, Inspector, Medical Department, H.M. Local Government Board. The lectures,
delivered before the Royal College of Physicians, were published in The Lancet.