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46
experience of the advantages and disadvantages of compulsory notification will thus eventually be
available.
In a few of the reports information is afforded as to association of the cases under consideration
with antecedent cases of phthisis in such a way as to suggest infection of the former by the latter. Thus
Dr. Allan analyses cases in Westminster which came to his knowledge and shows that of 18 cases with
a history of tuberculosis in a previous generation 10 had been in contact with tubercular members of
the family, and of 54 cases without history of tuberculosis in previous generations, 20 had been in contact
with tubercular members of the family and 4 in contact with other tubercular associates. Dr. Newman,
writing of deaths from phthisis is Finsbury, states that 111 out of 251 were infected by relatives, or
44.2 per cent. of the total. He adds :—
" When it is considered that there may be no outward signs of early phthisis, that it is frequently to the patient's
interest to conceal the disease, and that the greater number of cases go about for years without medical attendance,
or are detected only in the later stages or at death, this percentage of casos where a definite history of personal contact
was made out must be counted as high. In many of these cases the history indicated family infection through
anveral generations. The number of casos with a history of probable infection by persons not related must always
be small, since it is the cause of death among relatives which in the greator number of instances furnishes the clue
to infection, and this clue is always wanting when the history of fellow workmen, lodgers, etc., in past years are
inquired into. But there is abundant evidence to show that iufection may be dorivod from other sources."
He gives, moreover, a table showing the number of previous cases of phthisis notified or having
died in former years in the same house as those in which cases occurred which became known to him
in 1904, and he points out that "79 deaths in that year occurred in houses already infected," and that
" 18 cases occurred in houses where there had been no less than five previous cases." And again,
Dr. Davies attributes the source of infection in 100 cases of 186 notified in Woolwich during the year
as follows :—To relatives 41, lodgers 24, to infection in public houses 35, and suggests other causes for
another eleven, and he points out that 30 per cent. of 140 adults were allowed by themselves or their
friends to be intemperate. It should be pointed out that these observed facts as to sources of infection
need to be considered in relation to the mathematical probability of their occurrence apart from
some special cause.
The insufficiency of provision for the reception of cases of phthisis when badly circumstanced
at home is commented upon in some of the reports. Dr. Kenwood, writing on phthisis in Stoke Newington
comments on the fact that it has often happened that a patient in the last stages of the disease has had
to occupy a room shared by several others. In these cases, he says, " no suggestion which I was able to
make could do away with the enormous risks the other occupants were daily called upon to face." Dr.
Davies, discussing the same question, points out that " when the patient is the bread.winner, the illness
means usually cessation of wages, and he consequently becomes destitute and goes to the infirmary
as a matter of course. When, however, the patient is the wife of the breadwinner, and in other cases
where there is no destitution, there is no legal claim on the Guardians for poor law relief; nevertheless,
such cases may be, and frequently are, received into the infirmary, and often the cost of the
maintenance is partly or wholly recovered from the persons responsible. In such cases, however,
admission becomes a matter of special consideration; some cases are admitted and others refused,
and unfortunately the worst cases from the public health point of view are sometimes refused admission."
He suggests therefore, that until special provision is made, Boards of Guardians should assist sanitary
authorities in providing facilities for the removal from their homes of advanced cases of this disease
While it cannot be said that there is unanimity of opinion as to which are the principal
factors concerned in the production of phthisis, there is no doubt a considerable consensus of
opinion that cases of phthisis may act as sources of disease to those who are intimately
associated with them, especially in crowded tenements where no separate sleeping accommodation
can be provided for the sick. Certainly there is need for bringing the opportunities
for institutional treatment into relation with the home necessities of the sufferers, and in
so far as there may be dearth of accommodation in institutions, there is need for selection of the cases
which most need to be removed from their homes, the object aimed at in dealing with advanced cases
being rather to protect those associated with the patient in his home than to benefit the sufferer himself.
If it be possible to express the relative value which is now deemed to attach to sanatorium treatment,
which aims at cure, and institutional treatment, which aims at prevention of infection, it may be said
that while many cases of phthisis undoubtedly derive benefit from treatment in sanatoria, the value
of sanatoria in effecting permanent cure is regarded as less than it was thought to be some years ago,
and indeed much of its value is now thought to depend upon the opportunity it gives for the education
of the patient in habits which reduce the risk to his family on his return to his home. Treatment
in institutions, on the other hand, in providing the means of isolation and of education in the sense
mentioned, is now deemed to be of the first importance.
Whatever view may be taken of the possibility of reducing phthisis prevalence by the segregation
of persons whose expectoration is charged with tubercle bacilli, no doubt is entertained of the greater
susceptibility of some persons than others to attack by phthisis, and while racial susceptibility and family
susceptibility are recognised, the greater liability to attack of the badly housed and especially the badly
fed is a factor which must be reckoned with in any attempt to reduce the mortality from this disease.
Hence the need not only for attention to be directed to the care of the patient, but for the well.being
of the family to be ensured, so far as that may be found possible, and for the organisation of philanthropic
effort in such way that it may be brought into relation with the work of the medical officer of health
and made available in suitable cases. Phthisis in large degree is a disease of poverty, and in so far as
the social condition of the people is improved, the risk of attack by phthisis is lessened for all.