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notifications in the Borough of St. Pancras, for instance, for the year 1908, which has been made
by the medical officer of health, Dr. Sykes, stands thus:—
Total number notified 249
„ „ by medical officers of infirmaries
and workhouses 204
„ „ by district medical officers 8
„ ,, by staff of Mount Vernon Hospital 3
„ „ by staffs of other hospitals 5
„ „ by private practitioners 25
,, ,, by other persons 4
249
The total number of new patients at the Brompton Hospital for Consumption during the year
1908 was 7,558 and at the Mount Vernon Institutions was 4,324.
It is clear that the bulk of the medical profession has refrained from notifying cases to sanitary
authorities. Enquiry was directed to ascertain what reasons there were for this. Among the principal
appears to be the belief that no good comes of notification. It appears to be the feeling of many medical
practitioners that sanitary authorities, when they have received a notification, are able to take little
effective action. Another reason is that when notification is voluntary, patients are apt to object
to being singled out for notification. There is the natural disinclination of a physician to run any
risk of causing annoyance to his patient—a factor especially apt to operate in a good-class practice.
Violation of professional secrecy is also an argument used against the notification of phthisis, and
it is stated that cases have occurred in which a patient has first learned the true nature of his illness
from a sanitary inspector. Generally speaking, objections may be summed up in this way: that
notification of phthisis is apt to put the certifier and certified to a good deal of bother, and in their view
may do but little good. Consultants and practitioners alike are apt to resent what is by them regarded
as useless intrusion on the part of the sanitary authority into their private business.
Objection on the ground of interference by the sanitary authority is not difficult to meet. Such
intrusion is already provided against by the notifier being asked to mark his certificate, if he so wish,
to the effect that no visit from the sanitary authority is desired, and that disinfection is being
attended to. All that then happens, in notification of a case, is that a confidential communication passes
between two members of the medical profession about the health of a patient with whom they are both
concerned. Neither of them is likely to divulge that confidence. It is chiefly the well-to-do cases that
are likely to be so marked by the notifier; and some figures may be given to illustrate how light is the
incidence of the disease in this class.
Analysis has been made of cases arising in the Borough of Wandsworth and in the City of Westminster—two
districts with a comparatively high proportion of well-to-do residents. Of 273 cases of
pulmonary tuberculosis in the Borough of Wandsworth, whose occupations are analysed by the medical
officer of health, Dr. Caldwell Smith, in his annual report for 1908, 48 may be put into the class of
persons who are fairly well-to-do. They include clerks, a civil engineer, an accountant, commercial
travellers, their wives and others. On the other hand, 225—i.e., 82 per cent.—include labourers,
painters, a leather dresser, a lavatory attendant and so forth. Similarly, in the City of Westminster, of
2,367 cases of tuberculosis, whose occupations are analysed by the medical officer of health, Dr. Francis
Allan, 255 include clergymen, barristers, artists, engineers and shopkeepers and others; the remaining
2,112, or 89.2 per cent., include working men and women and artisans of all kinds. In each district,
it will be seen, over 80 per cent. belong to poorer classes.
Returning to the degree of efficiency of voluntary notification, a second striking defect
requires attention. It has to do with the stage of the disease at which notification is made. Pulmonary
tuberculosis belongs to a class of diseases in dealing with which, as is well known, preventive medicine
seeks not only to prevent fresh cases occurring, but also to arrest the progress of any particular case
under consideration. It thus differs markedly from many infectious diseases. Cases of scarlet fever
and small-pox, for instance, must run their natural course to the end; nothing can stop them, once
they are started. But tuberculosis has a different natural history. It can be arrested in its course;
and the earlier the case comes under treatment, the greater the chance of arrest. It is this factor that
gives a special character to preventive measures against tuberculosis, and requires special cognisance
to be taken of individual cases. To have the earliest news of them becomes of paramount
importance.
In this regard voluntary notification fails conspicuously. Not only is the number of notified
cases insignificant, but their nature is unsatisfactory; for often they are not early cases, but cases
well advanced. It may be asked why doctors do not notify them sooner. Often the reason is that
they were not previously aware of them. That comes about from the social circumstances of the
persons attacked. Tuberculosis finds a ready prey among those who are poor and just able to pay their
way. Such a person has a slight persistent cough. That is the beginning of the disease, when its
notification might lead to its arrest. But the stress of bread winning and the fear of Poor Law
relief keep the man at work every day; in comparison his ailment seems to him a slight affair.
But it is persistent and increases; it becomes overwhelming. At last it drives him to the doctor.
But then the mischief is done. Notification is then made of a patient, whose lungs, perhaps, are both
riddled with ulcerating cavities—a case at which no sanatorium will look. Irregular illness follows,
and death. The bread-winner gone, the family come upon the rates. Voluntary notification is of little
assistance here.