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Dr. WANKLYN'S REPORT.
Administrative Control of Pulmonary Tuberculosis by Sanitary Authorities
in London.
In accordance with instructions from the Medical Officer to ascertain the present position of
the control of pulmonary tuberculosis by London sanitary authorities, visits have been paid to every
district within the administrative County of London, and the respective medical officers of health have
been interviewed on the subject. Visits have also been paid to St. Thomas' Hospital, to the Brompton
Hospital for Diseases of the Chest and to the Paddington Tuberculosis Dispensary. Acknowledgment
is here made of the information which has been given by the various officers concerned, and thanks
are returned to them for their courtesy and assistance. From p. 1 to p. 10 will be found a general
report; following this are details of the various districts.
Pulmonary tuberculosis claims special attention as being the most destructive of the preventible
diseases which remain for public health authorities to abolish. Notwithstanding the steady fall which
it has undergone, it causes at present not less than 6,000 deaths per annum; in the last ten years the
deaths have totalled 71,898. As regards the future, from an estimate based on the population and
pulmonary tuberculosis deaths of the last 20 years, there is reason to think that the deaths in the next
ten years in London will exceed 50,000—a huge mortality to look forward to, from a preventible disease.
Among the most striking points which enquiry showed was the scantiness of information, generally
speaking, in possession of sanitary authorities about the local prevalence of the disease. Endeavour was
made to ascertain approximately the amount of recognised pulmonary tuberculosis existing in the
various areas. This was most difficult to arrive at. With hardly an exception, the local information
in possession of the medical officer of health was insufficient to enable him to form an estimate of the
prevalence of the disease in his district, and only by multiplying the annual deaths by some factor based
on observations made in other places could an approximation be obtained. Not only is there difficulty
in originally hearing of cases, but after they have been notified they are apt to be lost sight of through
removal. In the ordinary course, a medical officer of health, when he is aware of the removal to another
district of a patient known to be tuberculous, would notify the fact to his colleague in the district to
which the patient is proceeding, if he is aware of the address in that district to which the patient
is going. Enquiry showed that it is, in point of fact, rare for notice of such removal to be
received by the medical officer of health of a district; and the reason for this appears to be that when
tuberculous patients remove, they are apt to conceal the fact from the sanitary authority of the district
which they are leaving. Such evasion, it should be noted in passing, has now been met, for poor
law patients, by the Public Health (Tuberculosis) Regulations, 1908. It is clearly essential to have
some system of keeping patients under observation after they have been brought to light.
Notification of pulmonary tuberculosis, like other parts of the control of the disease, is a more
complicated question than might at first be thought. Little consideration is necessary to show the
comparative futility of the system of voluntary notification to the sanitary authority. No doubt, it
was one step better than the system under which the first news of a case received by an authority was
that of the death. That was generally the case prior to the year 1901, from which time voluntary
notification in London may be said to date. Stimulus was given to the consideration
of the whole question of the prevention of the disease by the Tuberculosis Congress held during
that year in London. Notification was among the subjects discussed, and shortly afterwards
voluntary notification was adopted in certain of the London districts, on the recommendation
of the respective medical officers of health. Circulars were sent by them to the members of the
medical profession who resided in the district, inviting them to notify any cases of pulmonary
tuberculosis which might occur in their practice. It was pointed out that information
about the circumstances determining infection would be useful in reducing the mortality of the disease,
and furthermore, that removal of insanitary house conditions could be secured and disinfection carried
out. It was made clear that notification was completely voluntary, and would be remunerated by
a fee of 2s. 6d. for every case in a private practice, and of 1s. for every case in the practice of any public
institution. A note was added that the co-operation of the existing medical attendant was desired,
and that no visit would be paid on behalf of the sanitary authority if the certificate were marked by
the certifier that a visit was not desired.
London sanitary authorities have gradually adopted this system, for though its weakness was
apparent, it seems to have been felt that imperfect notification was better than no notification at all,
and would pave the way for a better system. In the year 1901, the Borough of Finsbury adopted
a system of voluntary notification. In the year 1902 the City of London, the Boroughs of Fulham,
Greenwich, Hammersmith, Hampstead, Kensington, Lambeth, Southwark, Stoke Newington and Woolwich
followed suit. In 1903, the Boroughs of Bermondsey and Wandsworth and the City of Westminster
adopted the system; in 1904, the Boroughs of Holborn and Chelsea; in 1905, the Borough of Islington;
in 1906, the Boroughs of Hackney, Lewisham, St. Marylebone and St. Pancras; and in 1909, the
Borough of Battersea. At the present time 22 out of the 29 districts in London have adopted a
system of voluntary notification, the exceptions being the Boroughs of Paddington, Shoreditch, Bethnal
Green, Stepney, Poplar, Camberwell and Deptford.
As a means of ascertaining the amount of pulmonary tuberculosis in a given area voluntary
notification has obvious defects. A glance at the death returns shows that it discloses only a fraction