As notification is the first step towards coördinated measures for the patient and in the interest of the public health, the causes of delay in notification and of failure to notify deserve further examination.
Causes of Failure in Notification
1. The patient himself commonly is responsible for much delay in the recognition of his disease. A large proportion of consumptive patients refrain from applying for treatment until disease is fully established, and until they are incapacitated for work. Not infrequently this means that the patient does not consult a doctor until a few months or even weeks before his death. Until the conditions of general medical practice are altered, and every person has the right to state-paid medical consultations, belated recourse to medical advice will continue.
With this there is badly needed further education of the public as to seeking advice for protracted colds and coughs, or for other symptoms suggestive of tuberculosis; and a wider hygienic propaganda as to housing, overcrowding, dusty indoor occupations, expectoration, etc., is also called for.
2. Under present conditions of medical practice, early diagnosis of tuberculosis often fails to be secured, even when the patient places himself under medical care. It is to the private practitioner that most patients resort, and the early recognition and treatment of disease depends primarily (a) on his skill, (b) on his not being so overworked as to be unable to devote adequate time to the examination of each patient coming under his care, and (c) on his willingness to refer doubtful cases for consultation with the official tuberculosis officer of each area. These officials have only existed during the last few years; their work was partially in abeyance during the four and a half years of war; and apart from this, they have not always succeeded in persuading the private practitioner that their coöperation is to be welcomed and that they are not agents for depriving him of his private patients. This assumed antagonism between private and public medical practice is one of the most serious difficulties in securing more rapid progress in anti-tuberculosis work.
3. For nearly every sanitary area gratuitous facilities are now provided for the examination of sputum for tubercle bacilli, and yet in many areas there is grave neglect to utilize this provision, and patients with chronic phthisis may be treated during long months or even years for “winter cough,” “bronchitis,” etc., without adequate physical examination of sputum. The diagnosis of pulmonary tuberculosis ought, it is true, to be made before tubercle bacilli are found in the sputum, and failure to recognize the disease prior to this implies that the disease has already become serious; but in fact a very large proportion of consumptive patients for many months have tubercle bacilli in their sputum, before the diagnosis of tuberculosis is made.
4. When, as in some areas, the medical officer of health or the tuberculosis officer takes little, if any, useful action after notifications have been received, the practitioner has an excuse for not notifying subsequent cases. He can argue with some cogency that notification has no value per se; its utility depends on the action which follows on notification. Unless useful action follows on notification, default in notification has little practical importance.
Public Health Action Following Notification
Under the English Tuberculosis Regulations the medical officer of health or an officer of the local authority acting under his instructions is required to make such inquiries and take such steps as may be necessary or desirable for investigating the source of infection, for preventing the spread of infection, and for removing conditions favourable to infection. The action required includes inter alia
1. Attention to the personal hygiene of the patient, including instruction in the necessary precautions as to coughing and expectoration.