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this character has been generally introduced there will no longer exist the same degree of moral responsibility on the part of the public for individual disregard of measures for self-protection against phthisis, and repressive measures, even including segregation, will seem less -of a hardship in cases where carelessness for the welfare of others is shown by those who are infected.
Administrative measures for preventing the spread of consumption should embrace (1) the general application of the principles of hygiene, including the enforcement of laws and ordinances designed to secure improvement in the construction of dwellings, especially the dwellings of the poor, and for securing habits of cleanliness, particularly in tenements, shops, factories, prisons and school buildings. Such measures should also be designed (2) to maintain healthful conditions on all premises, including a wholesome water-supply, quick and safe disposal for refuse materials, abundant light and ventilation; (3) to prevent the sale of contaminated milk and other unwholesome foods; (4) to provide free laboratory service for the early diagnosis of the disease; (5) to distribute printed instructions and information to guide consumptives, and the persons with whom they dwell, concerning the methods by which the disease is spread, and also concerning the method by which its spread can be prevented; (6) to enforce ordinances prohibiting expectoration upon floors in public conveyances and public buildings, and upon street sidewalks and crossings; (7) to disinfect infected apartments, from time to time, upon request, and whenever a patient removes or dies; (8) to learn, by house-tohouse inspection, the location of every apartment which is infected; (9) to secure regular, periodical, medical inspection of the pupils, teachers and janitors in all day schools and Sunday Schools, and to prevent the attendance in these institutions of persons affected with phthisis. Voluntary notification by physicians and others, of the name and address of persons suffering from the disease should be followed by such a degree of oversight as each case may demand, and when the patient is found to be indifferent to the safety of others, or when he is incapable, for any reason, of so disposing of his sputa that it will not infect other persons, he should, as soon as sanitoria are provided by the municipality, county or State, be at once isolated.
The considerations which should influence the judgment of health boards in undertaking to decide when notification by physicians shall be by ordinance required in cases of pulmonary tuberculosis, relate
mainly to the conservation of the public interest, as distinguished from those which affect the patient only, and if it can be shown that. a knowledge of the name and address of each case coming under professional supervision will serve to prevent the spread of tuberculosis, the facts desired should be required from physicians. But to what extent can physicians supply the data in question ? Phthisis is a disease which affects large numbers of persons before they are themselves aware of any serious departure from health, and the infectious discharges are often expectorated for months before medical advice is sought. If, however, notification should be by law required, and the comparatively few cases thus observed should be brought to the attention of the health board, what action will be taken which will justify such a requirement? After making an official record of the case, and after delivering to the patient, his family, his landlord and his employer, printed information and instructions setting forth the communicable nature of the disease and the measures to be employed in dealing with consumptives and their sputa, the health officer must then, under present conditions, await results. Note the contrast between these methods and those employed in outbreaks of other communicable affections which are, by universal consent, placed on the notifiable list. In small-pox, for example, the health officer hasonly to follow the beaten track in dealing with a case of the disease after it has been reported, and with perfect confidence he applies the unfailing preventives—isolation, vaccination, disinfection. Is it within the power of the health officer to employ any procedure of comparative value in averting the spread of tuberculosis? Unlikesmall-pox and scarlet fever, the danger period in phthisis is not limited to a few weeks, but the disease usually continues with unabated virulence for months or years, and domiciliary surveillance is, for such periods, altogether impracticable. Doubtless, the destruction of all infected sputa would prove effectual as a preventive, but coercion of the vast army of infected persons to the extent of securing the needful change in their habits, which would attend the collection and safe. disposal of sputa, is at present quite beyond the reach of the most resourceful sanitary authorities. Meantime, the individual who has. been black-listed loses his occupation and becomes a charge upon his family or upon the public. A very common proposal on the part of advocates of imperative notification is that the registration record shall be private, but no one can guarantee that a public record will be kept. private, and in practice such a cause would be found impossible. The recent action of the United States Treasury Department in prohibiting the admission of immigrants who are affected with pulmonary tuberculosis will serve to exclude advanced cases of the disease, but the difficulties of diagnosis will render the new requirement imperative at ports of arrival in a large proportion of cases. Indeed, the limit of official action for preventing the distribution of tubercle bacilli is thus far so narrow that we must admit its entire inefficiency when the great number of infected persons is considered. When we remember that a majority of those who are affected with this disease recover, and that in a large number of cases where death occurs from other causes the lesions found in the lungs after death afford the first indication showing that the individual was at any period of his life a source of infection to others, it will be seen that the information obtainable during the life of the subject must always remain insufficient, and cannot be extended to include all persons who are capable of spreading the disease.
Notification of pulmonary tuberculosis by physicians is therefore wholly inadequate for supplying the data necessary for complete registration of cases, and it may be considered practically worthless as a means of preventing the spread of the disease, for thus far health authorities have not done more in response to notification than proffer good offices, including distribution of circulars and disinfection of apartments vacated by the patient.
To supplement the facts presented in previous reports concerning the methods in operation in the various municipalities of the State for the removal of waste substances, the following circular letter was sent to local health officers in districts for which information on file was incomplete:
THE BOARD OF HEALTH OF THE
TRENTON, November 13th, 1901. DEAR SIR-For the purpose of correcting the records of this office we desire to obtain information in regard to the collection and disposal of refuse materials in your city. Will you kindly reply to the following questions :
1. Garbage, rubbish, ashes and dead animals : Are these substances collected and transported under the supervision of the city? Is this work done by contract or by persons employed directly by the city ?
2. What is the final disposal of garbage and rubbish ? Are these materials dumped upon the surface of the ground? Are they used for filling sunken lots ?
3. Ashes, how are they disposed of?
Very truly yours,
Secretary. The replies received to the foregoing request have been tabulated as follows:
TABLE 23.–SHOWING METHODS EMPLOYED FOR THE COLLECTION, TRANSPORTATION
AND DISPOSAL OF GARBAGE, RUBBISH, ASHES AND DEAD ANIMALS IN FORTY
Filling lots. Filling lots. Buried.
Rubish depos- places.
Filling low Burned.
ground. Filling lots. Filling lots. Buried. Dumped on sur- Place don Horses and cows face of ground. streets.
carted away Small animals buried.
TABLE 23.-SHOWING METHODS EMPLOYED FOR THE COLLECTION, TRANSPORTATION
AND DISPOSAL OF GARBAGE, RUBBISH, ASHES AND DEAD ANIMALS IN FORTY
Dumped on Dumped
Taken to fac
tory. Carted away and
buried. Horses taken to fertilizer works. Other a ni ma 18 buried.