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68
Of the 104 who contracted pulmonary tuberculosis while living in
the district, 23 gave a family history of infection, a percentage of 22.
The corresponding figures for females were 84, 23 and 27.
Of the 36 persons notified to be suffering from non-pulmonary tuberculosis,
only four were known to have contracted the infection before
coming to live here. Of those who were living here at the time they were
recognised to be suffering and presumably contracted infection here,
only three gave a history of a pulmonary case living in the house.
The cases notified during any one year are those which are recognised
for the first time in that district during that year ; they also include the
names of those who have during that period come to live in that district,
even though they had contracted the infection elsewhere. The number,
then, depends on a variety of factors. The first and most important is
the actual number of cases in the population. Ideally all cases would
be recognised immediately ; in the case of an acute infection with obvious
physical signs this probably occurs, but in a disease like pulmonary
tuberculosis with its insidious onset and indefinite symptoms, at least
in the early stages there are not many in whom a stage can be recognised
which the patient passes through definitely from the phase of not suffering
to the one in which he is suffering. When the disease is recognised, it
has probably been progressing for months, if not years. During that
time there might have been nothing to send the patient to the doctor.
But when comparing the figures of a district in one year with those of
another, these factors are comparable unless there is any special effort in
any one year to try to discover the affected members of the population,
such as by the examination of the population by mass radiography.
The notification figures can then change not because of any change in the
incidence of the disease amongst the population, but by changes in the
efficiency of the machinery for detecting what disease there may be amongst
the various members of the population. There is yet another factor,
namely the thoroughness in which cases are notified once they have been
recognised. Although it is an obligation of medical practitioners attending
patients who are recognised to be suffering from tuberculosis to
notify the disease, this obligation is not always fulfilled. The greatest
offenders are the hospitals. In some cases, of course, the diagnosis
has not been made until a post-mortem examination had been carried out.
In other cases the patient had rapidly succumbed to some acute manifestation
such as meningitis. When the hospitals are situated in the area
in which the patients live, not much harm is done by the failure to notify
as distinct from the delay in the making of the diagnosis because the
Medical Officer of Health soon learns from the death returns of the
infection and not much time is lost in arranging for the necessary steps to
be taken for the following up of members of the household who may have
been exposed to the infection, or may even have been the cause of it.
The position is different though when the patient dies in a hospital not
in the same area as the patient lived in, because then the Medical Officer
of Health does not learn of the case for some weeks or months because it
takes that time for the transferred death certificates to reach him. In a
district such as this where there is still much movement of the population,
some patients not learned of are those who had transferred here from