Page images
PDF
EPUB

un

and the medical officer of health. If this be so, I am bound to say that I have failed to find evidence of it worthy of the name; it might be possible by diligent inquiry to discover a solitary case of the kind; but one swallow does not make a summer,' and it has happened more than once that conflict of opinion and antagonism have arisen between even practitioners themselves on other questions than that of notification. For many years in Birmingham there has been voluntary notification, but in no single instance has any antagonism, or even pleasantness arisen between the medical men and myself. Abundant testimony to the same effect is afforded in towns where the notification is compulsory; thus at Leicester, Alderman Windley stated that All fear of collision between the medical officer of health and the profession had died out, and the certificates were sent in without difficulty;' at Bradford Dr. Butterfield reports, I know of no medical man who is opposed to the working of the Act.' The Mayor of Oldham states that there has been no unpleasantness with the medical profession in putting the clauses into effect; they have as a body willingly co-operated with the medical officer of health; and from Llandudno we hear that 'to the credit of all our medical men, they work most harmoniously with the board.' After the unvarying testimony of such a cloud of witnesses there seems to be no ground for alleging antagonism, with which it would seem that opposition has possibly been confounded.

If such antagonism were found to exist between the medical profession and the medical officer of health, "twere a grievous fault,' and it would be necessary to discover the causes of it, and remove them, because no good is to be expected without the cordial co-operation of the medical profession with the sanitary authority.

It has been alleged that the conduct of the medical officer of health is likely to be inquisitorial, and that he may interfere with the patient, and otherwise take advantage of his opportunities to annoy and injure the practitioner. This contingency is so remote and improbable that it is scarcely worthy of serious discussion. No medical officer of health properly qualified for his duties could act in such a manner; to suppose otherwise would be to assume that the moment a medical practitioner becomes a medical officer of health he forgets professional obligations, and loses the instincts of a gentleman, which is not only absurd, but opposed to experi

ence.

There have been doleful predictions that notification by medical men would be a betrayal and destruction of that confidence which is necessary between doctor and patient; such would no doubt be the case in some instances if there were no compulsory law requiring it, if the secrets of the sick room were published, instead of the case being simply notified, if the object were to injure instead of benefit the patient and the community, and if all medical men were not placed under the same necessity to notify; when further, it is the rule for the householder, as well as the doctor, to notify, the former can have no possible ground of complaint in this direction. Here is seen one of the advantages of the dual system. It was attempted by Mr. Ernest Hart in his model clause' to meet this question of betrayal of confidence, and at the same time the objection of medical men to be put under a penalty, and, in order to do this, he proposed that compulsory

[ocr errors]

notification should be put upon the householder, to whom the medical attendant must furnish a certificate, which the householder is bound by penalty to forward to the sanitary authority, while no penalty falls upon the medical attendant in the event of his refusal to certify. The weak point of this clause is that it is impossible to obtain the co-operation of all medical men without the imposition of a penalty, so that this objectionable regulation is really rendered necessary by the fault of the medical profession itself, which, therefore, cannot reasonably complain. Salus populi suprema est lex.

It is a remarkable fact that out of thirty-eight towns in Great Britain which have availed themselves of compulsory notification thirty-four have adopted the system of direct notification by the medical attendant, while thirty of these require notification also by the occupier. In three of them only does it rest with the medical man to notify indirectly or to the occupier, so that the dual system is found to be by far the most in favour: it is the one recommended by the Local Government Board in 1878, and by the Select Committee of the House of Commons in 1882; it is theoretically the only efficient one, and in practice it has been proved to work satisfactorily. It is the system embodied by Mr. Hastings in his Bill of 1883; and it is, I believe, the one which commends itself to all impartial minds and to all persons of experience.

The reasons why the medical man should notify appear to be so plain he alone is qualified to diagnose the disease; he alone-bearing in mind the ignorance, poverty, and other disqualifications of large numbers of persons-is qualified by his education, his appreciation of the necessities of the case, his freedom from interest, prejudice, alarm, or confusion to notify it; and he would by his direct action save much unnecessary delay.

As a fact, where notification is carried out, it is nearly always by the medical man, even under the dual system.

The householder, on the other hand, is disqualified to report with promptitude and certainty by a number of circumstances, partly from reasons already stated, and also for some others, as want of time and opportunity. One insuperable obstacle would be created by the impossibility of supplying every householder with notification forms, and if that difficulty could be surmounted the forms would soon be lost. It is desirable, nevertheless, to hold the householder responsible to meet cases where a

medical man is not called in.

In one town only has notification by the householder been tried, viz., Greenock, and, as might be expected, the results are very unsatisfactory, as only something over 50 per cent. of the cases came to the knowledge of the sanitary authority; but even under these circumstances the death-rate of the town diminished progressively and considerably; it is therefore clear that with a more complete system a proportionately greater advantage would have been gained. Dr. Wallace, medical officer of health of Greenock, concludes a very valuable and interesting report by expressing a fear that no further material improvement will take place from notification by the householder.' He is forced to the conclusion that the only satisfactory method of notifying infectious disease would be to throw the responsibility on the medical practitioner, as well as on the householder; in other words, the dual method.

It has been urged as an objection against notifica

tion, and this objection holds good in the case of the householder, as well as of the medical attendant, that it would be injurious to business. This is possible to a certain extent, but my experience shows that it is a great advantage by removing real danger, and so permitting the business to be carried on with safety. In several instances I have had employés in large establishments removed to hospital to the advantage of the patient, and to the great relief and protection of the other inmates and the public; the proprietors have been shrewd enough to discover the advantage, and grateful for the assistance rendered. In such cases, of course, removal is carried out as quietly as possible, measures of disinfection and precaution are judiciously conducted, and no publicity results. But even should there be publicity, and the business suffer in consequence, either through customers avoiding the shop or the latter being temporarily closed, surely this is a smaller evil than the disease being allowed to remain unreported, and left to spread itself broadcast.

Circumstances have come to my personal knowledge which clearly prove the necessity of the sanitary condition of lodging-houses being known. A short time ago two Birmingham artists who had been to Jersey for a few weeks returned home suffering from typhoid, and one of them died; the disease was traced to their lodgings. Such cases are quite common; people leave home to recuperate their exhausted energies at a maritime or other health resort, and in some lodging-house or hotel contract a dangerous, often fatal illness. Notification would prevent such horrible catastrophes, and I am fully convinced that the hotels and lodging-house keepers would be benefited, instead of prejudiced, by the arrangement. If they were alive to their real interests, they would court examination and certification of the sanitary condition of their establishments rather than attempt concealment of defects and dangers; indeed, some hotel-keepers do actually have their hotels systematically examined and certified by a competent person, and such a course cannot fail to inspire confidence in their guests.

Milk shops and schools are particularly liable to prove centres of preventable sickness and death, unless cases of illness in them are at once notified. It is wonderful to find any one prepared to contend that the proprietors of trade and other establishments should be protected at the expense of the whole community, and it implies a singular excess of innocent belief in the perfection of human nature to expect them in all cases to give notice of the danger in their midst, when at the same time they believe that their interests will be thereby prejudiced.

The absence of adequate and suitable hospital accommodation has been cited as an argument against notification. The objection has, however, much less force than at first sight it appears to have. Very much can be done without a hospital, though I am far from supposing that hospitals are not necessary and indispensable. There is, however, very generally a backwardness on the part of the sanitary authorities to provide them on account of the expense, and some powerful influence is required to put them in motion. It is a fact, proved by experience, that nothing conduces so much to this result as notification. The daily receipt from medical men of reports of zymotic cases that require isolation, which is not being obtained at home, inevitably leads to the provision of hospital accommodation, which otherwise would have been neglected, so that the

absence of hospitals actually becomes an argument for, instead of against, notification.

On the other hand, the existence of hospitals and of sanitary organisation, costly as they are, are comparatively useless without notification; and, indeed, without it the provisions of the Public Health Act, particularly those included in sections 120-143, are a dead letter.

The absence of notification, full and complete, has a relation to the extent and cost of hospital accommodation, which is worthy of notice. For instance, supposing every case of disease be reported as soon as made out, the first cases would receive proper attention and isolation, the disease would be nipped in the bud, and a very small hospital would suffice; but if, on the other hand, first cases are not reported, the stamping-out process fails, the disease rapidly extends and becomes epidemic, and then the most gigantic hospital fails to meet its demands. This relation between notification and cost of hospital accommodation, without regard to other considerations, seems to me a matter of the greatest importance; and the fact should not be lost sight of that the main value of a hospital for infectious diseases is to treat first cases and prevent epidemics, and not to treat thousands of cases which might, with proper care, have been prevented.

In conclusion, I would point out how little can be said against notification, that what is urged against it is, for the most part, of a hypothetical and speculative character, and that its principal opponents are persons who have had no actual experience of its working. On the other hand, both the public and the medical profession in those thirty-eight towns where it has already been submitted to a practical test, accept it with satisfaction. Would they do this if it proved on trial as objectionable as it was predicted? Why in these very towns medical practitioners, who were at first bitterly opposed to the plan, have, on seeing the results of its operation, ceased their opposition, and have become its most loyal and valuable supporters.

I trust the medical profession is being gradually educated up to a proper appreciation of its value, and to a becoming sense of their duties with regard to it. It would be a subject of the profoundest regret to find them in prolonged antagonism to a measure which is necessary to the public good, as has already been abundantly proved.

Such opposition can only be based on mistaken views with regard to the influence of notification on public health, on strictly professional interests, or on sentiment. It is clear that the first is benefited by it, it would be difficult to show that the second would be in any way prejudiced, and the third ground requires no serious consideration. The medical profession is, I am sure, too noble and too generous in its aims to let mere sentimental objections or considerations of self-interest, or a false professional amour propre stand in the way of the public weal. We are the servants and not the masters of the public, and it has been usual to regard our profession as the most philanthropic, benevolent, and selfsacrificing of all; but I fear that a continuance in opposition to a great sanitary step forward is calculated to jeopardise its reputation, and not the less so because while a section of the profession is hanging back, the practical common-sense and prudence of the nation at large, as shown by the action of a considerable number of towns already, will step in and do the work without its assistance.

THE RIGHT OF THE STATE TO ENFORCE NOTIFICATION, AND THE BEST METHOD OF DOING IT.*

6

By ALFRED CARPENTER, M.D., J.P., Chairman of Council of Sanitary Institute. SUPPORTING as I do in the main the observations of my friend Dr. Hill as to the necessity for early discovery, I wish to point out some of the difficulties which are in the way of doing it as is suggested by some earnest sanitarians, and at the same time to give a short history of the progress which has been made in that direction. I agree fully with the proverbial statement that a spark is a molecule of matter which may kindle a world,' and I opine that the great object of the sanitary world is to get evidence of the presence of that spark before it has time to reproduce its kind, and that the machinery which will give the most complete and general result in practice will be more satisfactory than one which may be perfect in theory but for various reasons not so efficient in action. The first good experiment as to method came from Manchester. The Manchester Sanitary Association did that nearly twenty years ago which the Society of the Medical Officers of Health suggested as the right thing, but failed to do it for want of funds, the Government of the day refusing to help them in their proposals. The Manchester Association published a weekly return of all new cases of diseases coming under treatment at the various medical institutions in Manchester and Salford. The sanitary section of the International Statistical Congress held in the preceding year had considered the subject and had pointed out the method of doing it. The congress had urged it as a duty upon governments to get the information in the usual way, and pointed out that a knowledge as to the position of the onset of disease was of more importance than were the returns of actual mortality, a principle which I had inculcated at various local meetings held for sanitary purposes long before the congress alluded to. The Manchester returns gave timely warning of the foci from whence it might be expected that infectious diseases would spread, as spread they did. Manchester, without Government assistance, did that which London was unable to do. Attempts were soon made in different parts of the kingdom to provide similar returns, but they were only 'flashes in the pan,' and were not persistent. The late Dr. Lankester brought the matter to the notice of the Social Science Association on June 5, 1871, at their rooms in the Adelphi ; Dr. W. Farr being the chairman at that meeting. Dr. Lankester urged that the State should stand in loco parentis, as regards those children who were not vaccinated, and that a Court of Summary Jurisdiction should have them vaccinated in spite of the parents, and that heavy fines should be inflicted upon all medical men who attended cases of smallpox, who did not at once notify to the local authority the fact of its presence at that particular place. This was the first suggestion made in a general meeting in this country, that a penalty should be put upon a medical man for not notifying to the local authority the fact of the fire, although it had been previously suggested that the local authority ought

Paper read at the Conference organised at the International Health Exhibition, by the Society of Medical Officers of Health, the Sanitary Institute of Great Britain, and the Parkes Museum of Hygiene on June 13, 1884.

† See page 43 et seg.

to be fined for allowing the fire to extend itself. I had urged this view because the foci of disease could not become persistent if the local authority did its duty, and insisted upon local cleanliness, with the generous distribution of a pure water supply.

The subject of notification of small-pox, upon the motion of the late Dr. Stewart, was referred to the Committee of the Health Department of the Social Science Association to consider and report upon, as to what steps could be taken to effect the desirable object of stamping it out. It was discussed and rediscussed at the Congresses of that association without any satisfactory result. At Brighton, in 1875, it was resolved to recommend the Council to take into consideration the desirability of promoting by legislative enactment that all cases of an infectious character should be reported to the medical officer of health of the district, but to meet objections made in the meeting the reporter was not distinguished. Dr. Littlejohn is said at that meeting to have strongly opposed the resolution as it stood when first considered, viz. ' that it should compel medical men to report.' He said veterinary surgeons were not called upon to send certificates under the Contagious Diseases (Animals) Act to the county authority, and he considered that it would be 'invidious and monstrous to throw such a responsibility upon medical men, instead of casting it upon the man of the house where the case took place.'

In the same year, 1875, the North Western Association of Medical Officers of Health memorialised the President of the Local Government Board, in favour of putting medical men in a criminal position if they did not report to the local authority any case they might be called upon to attend. The subject was again publicly discussed in London on April 29, 1876, when, at the request of the Health Committee of the Social Science Association, I read a Paper upon the right of the State to obtain early information of the appearance of epidemic or infectious disease in a given district. I discussed whether the medical attendant ought to be the informant or not. In that Paper I dealt with the subject from its various aspects, pro and con. A very careful consideration led me to conclude that there were even more than two sides to the question under consideration, and that it was not so absolutely one-sided as the Social Science Association and Northern Medical Officers of Health Society at their various meetings seemed to think. The Chairman (Dr. W. B. Richardson), in summing up, said that in the discussion four distinct views had been enunciated.

1. That the duty should be absolute upon the medical attendant under a penalty for neglect.

2. It should be upon the legal representatives as head of the family, or of the household in which the case occurred.

3. That there should be a dual notification, that is notification by both parties. Whilst the 4th made it the duty of the medical attendant to inform the head of the household in writing as to the infectious character of the disease, which information the householder should be bound, under a penalty, to transmit to the local authority.

Each project had been supported in the discussion by about an equal number of speakers. The last view was the system advocated in my Paper, and is the plan which, to my mind, was most likely to effect the object we all had in view.

The divided councils at Adam Street did not get

the matter settled. It was again taken up by the Society of Medical Officers of Health, and at a meeting held December 15, in the same year, certain resolutions were proposed; and after several suggestions and amendments had been made, it was unanimously resolved that

1. Infectious disease ought to be reported by the householder to the sanitary authority without delay. 2. Every medical man attending a case of infectious disease should give immediate information respecting its nature to the occupier or other person responsible for reporting to the sanitary authority. It does not appear from the report of the discussion at that meeting, which was presided over by Dr. Buchanan, that any proposal was made that medical men should be subject to a criminal prosecution if they did not disclose the nature of the disease to the householder, much less suggest that they should be criminally prosecuted if they did not do so to the local authority. The Chairman, in summing up the discussion, said he thought it the duty of the society to affirm the principle, without, however, making it compulsory under penalty upon the medical profession to give the sought-for information. He (Dr. Buchanan) felt persuaded that as soon as the profession found itself morally bound to do a thing, there would be no ground for suspecting any evasion of the duty even although there was no legal compulsion.

The Parliamentary Session of 1876 witnessed the introduction of clauses in Local Acts giving the power to the local authority of prosecuting medical men who did not notify the existence of such disease to the local authority. Huddersfield introduced such a clause, which inflicted a penalty not exceeding 10., but which was partial in its application. The subject was handled in a masterly manner at the annual meeting of the Social Science Association at Liverpool in 1876 by Dr. Francis Bond, who argued in favour of the householder being the informant under a penalty, and that medical men should make the communication to him as a moral duty.

In the following year the Town Council of Coventry passed resolutions having the same effect as indicated in the course which Dr. Bond had suggested at Liverpool, and Dr. Ransome urged the same course as essentially necessary in a paper which he read to the National Health Society in May 1877.

About the same time the North-Western Association of the Medical Officers of Health again approached the President of the Local Government Board, but this time they suggested that the householder should be the informant, and that the medical attendant should be liable to a penalty if he did not disclose the nature of the case to the householder or person responsible for the care of the patient. Memorials were also sent to Mr. Sclater Booth by various sanitary authorities calling upon him to introduce a measure into Parliament for the purpose of effecting legislation in the direction thus indicated.

A further step was also taken by the town of Bolton, which obtained a clause in an Act of Parliament putting a penalty for non-disclosure upon both householder and doctor, the doctor being liable to a penalty not exceeding 10%, but entitled to a fee of 2s. 6d. for notifying.

A temperate and well-written paper on the subject was read at York in July 1878, by Mr. North, to a

[ocr errors]

combined meeting of medical officers of health for the Northern, Western, and York Societies, in which the difficulties to be encountered by compulsory notification were placed before the members. It did not convince the various medical officers of health assembled at that meeting. They found themselves so often foiled in their endeavours to arrest disease because foci had been conveyed to many places before information reached them as to its existence that they still insisted upon going to the fountain-head for the information, in all those cases at least which came to the cognisance of the members of the medical profession. The advantage and saving of trouble by this course to medical officers cannot be doubted, and if all cases of infectious disease were attended by medical men as a matter-of-course, it would, if carried out efficiently, do what the medical officers require; viz, give them intelligence as to the whereabouts of dangerous infection. But no one can read the reports of the medical officers of health from all parts of the kingdom without coming to the conclusion that the greatest spread of infection is brought about by those cases which are not under orthodox medical care at all, and that notification by the medical profession alone would not effect the object, but rather lead to ignorant attempts to smother up the evidence, and in the end to raise more persistent, and more widespread outbursts. There was a necessity in the minds of medical officers of health for dual notification; and all the Local Bills introduced into the House of Commons in this and succeeding years, contained clauses requiring the medical attendant either with or without the householder to notify to the local authority under penalties.

In 1879 the Local Government Board also made a step in advance by an order dated February 12, which imposed the duty upon all medical officers employed by them of notifying any case of dangerous, contagious, infectious or epidemic disease to the sanitary authority of the district immediately upon its occurrence; it also enabled medical officers of health to obtain such information as to sickness and death among pauper patients, as might be thought necessary for their guidance; and later in the year the order was made to extend to the medical officers of district schools.

I now refer to the action of the British Medical Association, and to give credit to those to whom it is due. The first note was sounded by that body soon after Dr. Ransome had moved in the matter at Manchester, for he introduced the subject to the notice of the Association at Leamington in 1865, and procured the appointment of a committee to consider the registration of disease. Various reports were made by that committee, and in 1875 it was distinctly stated that the authoritative declaration of the nature of the disease must necessarily come in the first instance from the medical attendant; but the committee also expressed their opinion that the proper individual to make return should, in the first instance, be the householder, or the person in charge of the case. I had dealt with the matter in this direction in the address upon public medicine which I had the honour to read at Sheffield in that year. The subject was then referred to the Parliamentary Bills Committee, and voluminous reports have been presented from time to time, and accepted by the Association, and the moral duty of communi

cating that information to the householder has been often insisted upon. The report of the chairman of the committee (Mr. E. Hart) upon the subject is a masterly résumé of the action of the committee, and should be studied by all who take interest in the matter. A discussion took place at Ryde in 1881, when Mr. Michael, Q.C., proposed an amendment to the report, which amendment cast the duty on the medical attendant, and made its neglect a penal act, but which was lost by a large majority.

At Worcester, in 1882, the subject was brought prominently forward both in the Public Health section, of which I was president, and in the general meeting. The result of the discussion which ensued was the overwhelming defeat of Mr. Hastings's resolution which made neglect to report, a penal act, and the following proposal was adopted That whilst desiring compulsory notification of infectious diseases, the Association wishes to express its opinion that the compulsion to notify should be placed upon the householder as his duty as a citizen, and not upon the doctor.' The subject continued to be debated in various quarters, and on April 26, 1881, a deputation waited upon the President of the Local Government Board, which was formed by representatives of the British Medical Association, Sanitary Institute of Great Britain, Society of Medical Officers of Health, Social Science Association, National Health Society, and of the Vestries and District Boards of London, to ask the Government to legislate upon this and other subjects connected with measures necessary to guard the public health from the danger of infectious diseases.

[ocr errors]

One of the sequences of that deputation was the appointment of the Hospitals Commission to inquire respecting small-pox and fever hospitals, the extent and sufficiency of hospital accommodation, and, with other matters, 'to insure as far as practicable the protection of the public against contagion.' Having had the honour of being appointed one of the members of that Commission, I directed my attention especially to this part of the subject, and carefully examined the witnesses who were able to speak with authority upon the matter. The report which we presented to the Queen, states very distinctly that notification should in all cases be obligatory upon one or more of the following persons-the patient, those in charge of him, the occupier of the house in which he lodges, his medical attendant or any relieving officer (if a pauper) to whom he may apply for assistance. In effect, the report says it is only by the medical attendant (if any) that the disease can be intelligently notified, since it is only he who can be presumed to know what it is, and who has no interest in concealing it; but it is represented that to impose that duty upon him directly and undeservedly would interfere with the relation which ought to exist between him and his patient, and might prevent the aid of a medical attendant being sought for at all. If this be so, it may be sufficient that the medical attendant should be required by law to furnish to persons in charge of a patient, or the owner or occupier of the house in which he lodges, a certificate of the nature of the disease, stating whether proper isolation can or cannot be secured without removal, and when removal is necessary, stating also to what extent the case is urgent or severe. The persons to whom this certificate is given should be in like manner required by law to forward it at once to the medical officer of health.

The medical attendant should, we think, in justice be entitled to claim a fee either from the patient of from the sanitary authority for every such certificate of his which reaches the medical officer of health, and which he may forward himself if the patient so desires.

Evidence upon these points was obtained from various societies-such as the Medical Officers of Health, the Sanitary Institute of Great Britain-as well as the numerous witnesses who had personal knowledge of the behaviour of small-pox and other infectious diseases.

I now come to the last phases of this important matter. Mr. Hastings introduced a Bill into the House of Commons for the purpose of putting a private medical man into the position of a criminal if he did not become a State official, whenever he came into contact with infectious disease, whether he was willing to be a State official or not. The Bill came on for second reading on June 27 in last year. The House was counted out immediately after Mr. Hastings's speech in its favour, and the Bill was not proceeded with. The Government had been previously interviewed by Mr. Hastings's followers, but they would not pledge themselves to support a general Act, although pressed to do so by some men who are notably anxious to make the medical profession occupy a secondary position in the country. In October of last year the Social Science Congress held its meeting at Huddersfield. It might have been supposed that after the defeat of the President of their Council on this matter, that as Huddersfield was the first town which obtained the advantages or disadvantages which attach to a penal clause, and is the town in which compulsory notification has been the longest in operation, we should have had a convincing discussion as to the benefits or injury which had resulted to the town from the passing of the Act. It does not appear that a single word was said upon the subject by either side. Mr. Hastings did not raise the point, and no other person said a word about it; and although the Social Science Association had been on former occasions so very positive about its benefits, and were actually meeting soon after their President's defeat in the very town most capable of producing convincing proofs, if they were forthcoming, as to the advantages of the Act; there was a silence on the subject which to me is inexplicable, unless on the view that the results do not correspond with the prognostications, and that it would not have been safe to excite a discussion among those capable of proving the negative.

If towns having the compulsory clauses in operation are not able to show better things than can be shown in those places in which only a moral obligation to disclose exists, I think it must be evident to those who wish to prevent us trusting too much to a paternal Government that we had better steer clear of too much compulsion, and trust a little more to moral obligations. There is a strong feeling in the commercial world against professional men, such as lawyers, commission agents, auctioneers or engineers, accepting a commission from both sides in a given case, and being engaged as advisers for both sides in any commercial transaction; and I fail to see any difference in the case of a man who is employed by a private and responsible individual to cure him of his disease being compelled to accept a fee for disclosing something which may be used by the local authority to the injury of his client and employer.

« EelmineJätka »