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[I Notification of tuberculosis u
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Alfred H. Caulfeild, MB
0
Our Encore selection for this issue is a rebuttal of the editorial that supported the reporting of cases of tuberculosis, which was reprinted in CMAJ's June 1, 1991, Encore (page 1485). Is HIV infection the tuberculosis of the late 20th century?
U
n the editorial pages of the February number of the Canadian Medical 0 isanAssociation Jourcal (191 1; 1: 158-159) is an article on enforced registration of tuberculosis, which contains the following: "As to the wisdom of such a course there cannot be any doubt." May I be permitted to bring forward certain objections, which seem to me to outweigh the benefits that would result from enforced registration without restrictions? The widespread fear of tuberculosis by the public, and often by the profession, would be excellent if it were combined with a more thorough knowledge of its true range and danger. This proper fear would not carry with it the stigma that now attaches itself to the tuberculous. Theoretically we accept the fact of the high percentage of tuberculosis as demonstrated by autopsies, and possibly also that a subject reacting to a tuberculin test is evidence of an exposure and tubercular implantation in the past. This latter evidence may be found in normal subjects as high as seventy-five per cent. That these are not the statistics for "clinical tuberculosis" is quite true, but then "clinical tuberculosis" is merely a varying extension of these "theoretical" conditions; and clinical tuberculosis, further, is limited by our inability to appreciate what otherwise would be clinical. Unfortunately, from one man's hands a case that is really far advanced in anatomical involvement and possibly its own clinical response, is assured that his lungs are as sound as the examiner's. With those more power. This is merely a suggestion, not by any skilled in the diagnosis of pulmonary tuberculosis, the infection is caught in its very means attaining the ideal, which, with the beginning, in the clinical sense. Fortunately existing conditions, seems hardly possible. If many people with these latter conditions one might recapitulate, registration would __________________________________.result in unfairness to the patient, involving his financial and temperamental conditions, and, as well, honest difficulty and hesitancy 1911 in the first This opinion piece May appeared on the part of the physician. * (vol. 1, no. 5) issue of CMAJ, pages 445 to 446.
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unknowingly create their own cure without medical attention; but it is this ability on the part of the human subject that has prevented the necessity of the profession's realization of the extent of tuberculous involvements. It is only extreme skill and long continued experience that has brought about the diagnosis of true, incipient tuberculosis. Then, the conditions are such that the patient who is the greater source of danger may escape, while the other, who may ber in no way a public menace, becomes registered as tuberculous. The hardships that are attached to this are not confined to obtaining employment, and are often of a kind that tend to lessen that patient's chances for recovery. These are the results for the patient who seeks medical advice. There is also, it seems to me, a problem for the diagnostician, or one skilled in the diagnosis of pulmonary tuberculosis, who, let us say, has within a period found twentyfive cases which he must regard as strictly incipient. No one can be sure that all of his diagnoses of incipiency are correct, yet in one's judgement all should be considered as such and, further, which is more important, treated as such. The great majority of the diagnoses are probably correct, yet with each individual case it becomes often an almost impossible question to decide absolutely. Is the physician to decide whether it is his results that are needed for public safety and to feel that the law applies to him only in cases that he thinks fit? An amendment to the law, whereby one might either report a diagnosis or allow the sputum to be examined for the presence of the bacillus, would seem to meet the situation more fairly. It is true that the sputum would have to be examined several times during several months, but it should not be difficult for the health departments to have this legal
NE -8 JULY 15, 1991
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CAN MED ASSOC J 1991; 145 (2)
135
kC
p
k
R
S
s
=N
H
R
S
H
[I Notification of tuberculosis u
L
Alfred H. Caulfeild, MB
0
Our Encore selection for this issue is a rebuttal of the editorial that supported the reporting of cases of tuberculosis, which was reprinted in CMAJ's June 1, 1991, Encore (page 1485). Is HIV infection the tuberculosis of the late 20th century?
U
n the editorial pages of the February number of the Canadian Medical 0 isanAssociation Jourcal (191 1; 1: 158-159) is an article on enforced registration of tuberculosis, which contains the following: "As to the wisdom of such a course there cannot be any doubt." May I be permitted to bring forward certain objections, which seem to me to outweigh the benefits that would result from enforced registration without restrictions? The widespread fear of tuberculosis by the public, and often by the profession, would be excellent if it were combined with a more thorough knowledge of its true range and danger. This proper fear would not carry with it the stigma that now attaches itself to the tuberculous. Theoretically we accept the fact of the high percentage of tuberculosis as demonstrated by autopsies, and possibly also that a subject reacting to a tuberculin test is evidence of an exposure and tubercular implantation in the past. This latter evidence may be found in normal subjects as high as seventy-five per cent. That these are not the statistics for "clinical tuberculosis" is quite true, but then "clinical tuberculosis" is merely a varying extension of these "theoretical" conditions; and clinical tuberculosis, further, is limited by our inability to appreciate what otherwise would be clinical. Unfortunately, from one man's hands a case that is really far advanced in anatomical involvement and possibly its own clinical response, is assured that his lungs are as sound as the examiner's. With those more power. This is merely a suggestion, not by any skilled in the diagnosis of pulmonary tuberculosis, the infection is caught in its very means attaining the ideal, which, with the beginning, in the clinical sense. Fortunately existing conditions, seems hardly possible. If many people with these latter conditions one might recapitulate, registration would __________________________________.result in unfairness to the patient, involving his financial and temperamental conditions, and, as well, honest difficulty and hesitancy 1911 in the first This opinion piece May appeared on the part of the physician. * (vol. 1, no. 5) issue of CMAJ, pages 445 to 446.
O
U
y
n
jj ^
O
n II H
unknowingly create their own cure without medical attention; but it is this ability on the part of the human subject that has prevented the necessity of the profession's realization of the extent of tuberculous involvements. It is only extreme skill and long continued experience that has brought about the diagnosis of true, incipient tuberculosis. Then, the conditions are such that the patient who is the greater source of danger may escape, while the other, who may ber in no way a public menace, becomes registered as tuberculous. The hardships that are attached to this are not confined to obtaining employment, and are often of a kind that tend to lessen that patient's chances for recovery. These are the results for the patient who seeks medical advice. There is also, it seems to me, a problem for the diagnostician, or one skilled in the diagnosis of pulmonary tuberculosis, who, let us say, has within a period found twentyfive cases which he must regard as strictly incipient. No one can be sure that all of his diagnoses of incipiency are correct, yet in one's judgement all should be considered as such and, further, which is more important, treated as such. The great majority of the diagnoses are probably correct, yet with each individual case it becomes often an almost impossible question to decide absolutely. Is the physician to decide whether it is his results that are needed for public safety and to feel that the law applies to him only in cases that he thinks fit? An amendment to the law, whereby one might either report a diagnosis or allow the sputum to be examined for the presence of the bacillus, would seem to meet the situation more fairly. It is true that the sputum would have to be examined several times during several months, but it should not be difficult for the health departments to have this legal
NE -8 JULY 15, 1991
>
H
>
k
Y
N
9
H
U
U
Y
j
H
CAN MED ASSOC J 1991; 145 (2)
135
