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and the medical officer of health. If this be so, I notification should be put upon the householder, to am bound to say that I have failed to find evidence whom the medical attendant must furnish a certiof it worthy of the name ; it might be possible by ficate, which the householder is bound by penalty diligent inquiry to discover a solitary case of the to forward to the sanitary authority, while no penalty kind; but one swallow does not make a summer,' | falls upon the medical attendant in the event of his and it has happened more than once that conflict of refusal to certify. The weak point of this clause is opinion and antagonism have arisen between even that it is impossible to obtain the co-operation of practitioners themselves on other questions than that all medical men without the imposition of a penalty, of notification. For many years in Birmingham so that this objectionable regulation is really renthere has been voluntary notification, but in no dered necessary by the fault of the medical prosingle instance has any antagonism, or even un- fession itself, which, therefore, cannot reasonably pleasantness arisen between the medical men and complain. Salus populi suprema est lex. myself. Abundant testimony to the same effect is It is a remarkable fact that out of thirty-eight afforded in towns where the notification is compul- towns in Great Britain which have availed themsory; thus at Leicester, Alderman Windley stated selves of compulsory notification thirty-four have that. All fear of collision between the medical officer adopted the system of direct notification by the of health and the profession had died out, and the medical attendant, while thiriy of these require noticertificates were sent in without difficulty ;' at fication also by the occupier. In three of them only Bradford Dr. Butterfield reports, I know of no does it rest with the medical man to notify indirectly medical man who is opposed to the working of the or to the occupier, so that the dual system is found Act.' The Mayor of Oldham states that there has to be by far the most in favour : it is the one been no unpleasantness with the medical profession recommended by the Local Government Board in in putting the clauses into effect ; they have as a 1878, and by the Select Committee of the House of body willingly co-operated with the medical officer Commons in 1882 ; it is theoretically the only efficient of health ;' and from Llandudno we hear that 'to one, and in practice it has been proved to work satisthe credit of all our medical men, they work most factorily. It is the system embodied by Mr. Hastings harmoniously with the board. After the unvarying in his Bill of 1883; and it is, I believe, the one testimony of such a cloud of witnesses there seems which commends itself to all impartial minds and to be no ground for alleging antagonism, with which to all persons of experience. it would seem that opposition has possibly been The reasons why the medical man should notify confounded.

appear to be so plain : he alone is qualified to If such antagonism were found to exist between diagnose the disease; he alone--bearing in mind the medical profession and the medical officer of the ignorance, poverty, and other disqualifications health, “twere a grievous fault,' and it would be of large numbers of persons-is qualified by his necessary to discover the causes of it, and remove education, his appreciation of the necessities of the them, because no good is to be expected without the case, his freedom from interest, prejudice, alarm, cordial co-operation of the medical profession with or confusion to notify it; and he would by his direct the sanitary authority.

action save much unnecessary delay. It has been alleged that the conduct of the medical As a fact, where notification is carried out, it is officer of health is likely to be inquisitorial, and that nearly always by the medical man, even under the he may interfere with the patient, and otherwise

dual system. take advantage of his opportunities to annoy and The householder, on the other hand, is disqualified injure the practitioner. This contingency is so to report with promptitude and certainty by a numremote and improbable that it is scarcely worthy ber of circumstances, partly from reasons already of serious discussion. No medical officer of health stated, and also for some others, as want of time and properly qualified for his duties could act in such a opportunity. One insuperable obstacle would be manner; to suppose otherwise would be to assume created by the impossibility of supplying every that the moment a medical practitioner becomes a householder with notification forms, and if that medical officer of health he forgets professional obli- difficulty could be surmounted the forms would soon gations, and loses the instincts of a gentleman, be lost. It is desirable, nevertheless, to hold the which is not only absurd, but opposed to experi- householder responsible to meet cases where a ence.

medical man is not called in. There have been doleful predictions that notifica- In one town only has notification by the housetion by medical men would be a betrayal and de- holder been tried, viz., Greenock, and, as might be struction of that confidence which is necessary expected, the results are very unsatisfactory, as only between doctor and patient ; such would no doubt something over 50 per cent. of the cases came to the be the case in some instances if there were no com- knowledge of the sanitary authority ; but even under pulsory law requiring it, if the secrets of the sick these circumstances the death-rate of the town dimiroom were published, instead of the case being nished progressively and considerably; it is theresimply notified, if the object were to injure instead fore clear that with a more complete system a proof benefit the patient and the community, and if all portionately greater advantage would have been medical men were not placed under the same neces- gained. Dr. Wallace, medical officer of health of sity to notify; when further, it is the rule for the Greenock, concludes a very valuable and interesting householder, as well as the doctor, to notify, the report by expressing a fear that no further material former can have no possible ground of complaint in improvement will take place from notification by the this direction. Here is seen one of the advantages householder.' He is forced to the conclusion that of the dual system. It was attempted by Mr. Ernest the only satisfactory method of notifying infectious Hart in his model clause' to meet this question of disease would be to throw the responsibility on the betrayal of confidence, and at the same time the medical practitioner, as well as on the householder ; objection of medical men to be put under a penalty, in other words, the dual method. and, in order to do this, he proposed that compulsory It has been urged as an objection against notifica

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tion, and this objection holds good in the case of the absence of hospitals actually becomes an argument householder, as well as of the medical attendant, for, instead of against, notification. that it would be injurious to business. This is pos- On the other hand, the existence of hospitals and sible to a certain extent, but my experience shows of sanitary organisation, costly as they are, are that it is a great advantage by removing real danger, comparatively useless without notification ; and, and so permitting the business to be carried on with indeed, without it the provisions of the Public Health safety. In several instances I have had employés in Act, particularly those included in sections 120-143, large establishments removed to hospital to the are a dead letter. advantage of the patient, and to the great relief and The absence of notification, full and complete, has protection of the other inmates and the public ; the a relation to the extent and cost of hospital accomproprietors have been shrewd enough to discover the modation, which is worthy of notice. For instance, advantage, and grateful for the assistance rendered. supposing every case of disease be reported as soon In such cases, of course, removal is carried out as as made out, the first cases would receive proper quietly as possible, measures of disinfection and pre- attention and isolation, the disease would be nipped caution are judiciously conducted, and no publicity in the bud, and a very small hospital would suffice; results. But even should there be publicity, and but if, on the other hand, first cases are not reported, the business suffer in consequence, either through the stamping-out process fails, the disease rapidly customers avoiding the shop or the latter being extends and becomes epidemic, and then the most temporarily closed, surely this is a smaller evil than gigantic hospital fails to meet its demands. This the disease being allowed to remain unreported, and relation between notification and cost of hospital left to spread itself broadcast.

accommodation, without regard to other consideraCircumstances have come to my personal know- tions, seems to me a matter of the greatest importledge which clearly prove the necessity of the sanitary ance; and the fact should not be lost sight of that condition of lodging-houses being known. A short the main value of a hospital for infectious diseases time ago two Birmingham artists who had been to is to treat first cases and prevent epidemics, and not Jersey for a few weeks returned home suffering from to treat thousands of cases which might, with proper typhoid, and one of them died ; the disease was care, have been prevented. traced to their lodgings. Such cases are quite In conclusion, I would point out how little can common; people leave home to recuperate their be said against notification, that what is urged exhausted energies at a maritime or other health against it is, for the most part, of a hypothetical resort, and in some lodging-house or hotel contract and speculative character, and that its principal a dangerous, often fatal illness. Notification would opponents are persons who have had no actual exprevent such horrible catastrophes, and I am fully perience of its working. On the other hand, both convinced that the hotels and lodging-house keepers the public and the medical profession in those would be benefited, instead of prejudiced, by the thirty-eight towns where it has already been subarrangement. If they were alive to their real mitted to a practical test, accept it with satisfaction. interests, they would court examination and certifica- Would they do this if it proved on trial as objectiontion of the sanitary condition of their establishments able as it was predicted? Why in these very towns rather than attempt concealment of defects and medical practitioners, who were at first bitterly dangers ; indeed, some hotel-keepers do actually opposed to the plan, have, on seeing the results have their hotels systematically examined and certi- of its operation, ceased their opposition, and have fied by a competent person, and such a

become its most loyal and valuable supporters. cannot fail to inspire confidence in their guests. I trust the medical profession is being gradually

Milk shops and schools are particularly liable to educated up to a proper appreciation of its value, prove centres of preventable sickness and death, and to a becoming sense of their duties with regard unless cases of illness in them are at once notified. to it. It would be a subject of the profoundest It is wonderful to find any one prepared to contend regret to find them in prolonged antagonism to a that the proprietors of trade and other establishments measure which is necessary to the public good, as should be protected at the expense of the whole has already been abundantly proved. community, and it implies a singular excess of Such opposition can only be based on mistaken innocent belief in the perfection of human nature to views with regard to the influence of notification on expect them in all cases to give notice of the danger public health, on strictly professional interests, or on in their midst, when at the same time they believe sentiment. It is clear that the first is benefited by that their interests will be thereby prejudiced. it, it would be difficult to show that the second would

The absence of adequate and suitable hospital be in any way prejudiced, and the third ground accommodation has been cited as an argument requires no serious consideration. The medical against notification. The objection has, however, profession is, I am sure, too noble and too generous much less force than at first sight it appears to have. in its aims to let mere sentimental objections or Very much can be done without a hospital, though considerations of self-interest, or a false professional I am far from supposing that hospitals are not amour propre stand in the way of the public weal. necessary and indispensable. There is, however, We are the servants and not the masters of the very generally a backwardness on the part of the public, and it has been usual to regard our professanitary authorities to provide them on account of sion as the most philanthropic, benevolent, and selfthe expense, and some powerful influence is required sacrificing of all ; but I fear that a continuance in to put them in motion. It is a fact, proved by opposition to a great sanitary step forward is calcuexperience, that nothing conduces so much to this lated to jeopardise its reputation, and not the less so result as notification. The daily receipt from medical because while a section of the profession is hanging men of reports of zymotic cases that require isolation, back, the practical common-sense and prudence ci which is not being obtained at home, inevitably leads the nation at large, as shown by the action of a conto the provision of hospital accommodation, which siderable number of towns already, will step in anu otherwise would have been neglected, so that the do the work without its assistance.

course

THE RIGHT OF THE STATE TO EN- to be fined for allowing the fire to extend itself. I FORCE NOTIFICATION, AND THE

had urged this view because the foci of discase could

not become persistent if the local authority did its BEST METHOD OF DOING IT.*

duty, and insisted upon local cleanliness, with the By ALFRED CARPENTER, M.D., J.P.,

generous distribution of a pure water supply. Chairman of Council of Sanitary Institute.

The subject of notification of small-pox, upon the

motion of the late Dr. Stewart, was referred to the SUPPORTING as I do in the main the observations Committee of the Health Department of the Social of my friend Dr. Hill as to the necessity for early Science Association to consider and report upon, as discovery, † I wish to point out some of the diffi- to what steps could be taken to effect the desirable culties which are in the way of doing it as is object of stamping it out. It was discussed and resuggested by some earnest sanitarians, and at the discussed at the Congresses of that association same time to give a short history of the progress without any satisfactory result. At Brighton, in which has been made in that direction. I agree 1875, it was resolved to recommend the Council to fully, with the proverbial statement that'a spark is take into consideration the desirability of promoting a molecule of matter which may kindle a world,' and by legislative enactment that all cases of an infectious I opine that the great object of the sanitary world is character should be reported to the medical officer to get evidence of the presence of that spark before of health of the district, but to meet objections made it has time to reproduce its kind, and that the in the meeting the reporter was not distinguished. machinery which will give the most complete and Dr. Littlejohn is said at that meeting to have general result in practice will be more satisfactory strongly opposed the resolution as it stood when than one which may be perfect in theory but for first considered, viz.‘that it should compel medical various reasons not so efficient in action. The first men to report. He said veterinary surgeons were good experiment as to method came from Man

not called upon to send certificates under the Conchester. The Manchester Sanitary Association did tagious Diseases (Animals) Act to the county authothat nearly twenty years ago which the Society of rity, and he considered that it would be ‘invidious the Medical Officers of Health suggested as the and monstrous to throw such a responsibility upon right thing, but failed to do it for want of funds, the medical men, instead of casting it upon the man of Government of the day refusing to help them in their the house where the case took place.' proposals. The Manchester Association published In the same year, 1875, the North Western a weekly return of all new cases of diseases coming Association of Medical Officers of Health memounder treatment at the various medical institutions rialised the President of the Local Government in Manchester and Salford. The sanitary section of Board, in favour of putting medical men in a the International Statistical Congress held in the criminal position if they did not report to the preceding year had considered the subject and had local authority any case they might be called upon pointed out the method of doing it. The congress to attend. The subject was again publicly dishad urged it as a duty upon governments to get the cussed in London on April 29, 1876, when, at the information in the usual way, and pointed out that request of the Health Committee of the Social a knowledge as to the position of the onset of Science Association, I read a Paper upon the right disease was of more importance than were the of the State to obtain early information of the returns of actual mortality, a principle which I had

appearance epidemic or infectious disease in a inculcated at various local meetings held for sanitary given district. I discussed whether the medical purposes long before the congress alluded to. The

attendant ought to be the informant or not. In that Manchester returns gave timely warning of the foci Paper I dealt with the subject from its various from whence it might be expected that infectious aspects, pro and con. A very careful consideration diseases would spread, as spread they did. Man-led me to conclude that there were even more than chester, without Government assistance, did that two sides to the question under consideration, and which London was unable to do. Attempts were soon that it was not so absolutely one-sided as the Social made in different parts of the kingdom to provide Science Association and Northern Medical Officers similar returns, but they were only flashes in the pan,' of Health Society at their various meetings seemed and were not persistent. The late Dr. Lankester to think. The Chairman (Dr. W. B. Richardson), in brought the matter to the notice of the Social Science summing up, said that in the discussion four distinct Association on June 5, 1871, at their rooms in the views had been enunciated. Adelphi ; Dr. W. Farr being the chairman at that 1. That the duty should be absolute upon the meeting. Dr. Lankester urged that the State should medical attendant under a penalty for neglect. stand in loco parentis, as regards those children who 2. It should be upon the legal representatives as were not vaccinated, and that a Court of Summary head of the family, or of the household in which the Jurisdiction should have them vaccinated in spite of case occurred. the parents, and that heavy fines should be inflicted

3. That there should be a dual notification, that is upon all medical men who attended cases of small- notification by both parties. Whilst the 4th made pox, who did not at once notify to the local authority it the duty of the medical attendant to inform the the fact of its presence at that particular place. head of the household in writing as to the infectious This was the first suggestion made in a general character of the disease, which information the meeting in this country, that a penalty should be put householder should be bound, under a penalty, to upon a medical man for not notifying to the local transmit to the local authority. authority the fact of the fire, although it had been Each project had been supported in the discuspreviously suggested that the local authority ought sion by about an equal number of speakers. The

Paper read at the Conference organised at the International last view was the system advocated in my Paper, Health Exhibition, by the Society of Medical Officers of Health, the and is the plan which, 10 niy mind, was most likely Sanitary Institute of Great Britain, and the Parkes Museum of Hygiene on June 13, 1884.

to effect the object we all had in view. See page 43 et seg

The divided councils at Adam Street did not get

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the matter settled. It was again taken up by the combined meeting of medical officers of health for Society of Medical Officers of Health, and at a the Northern, Western, and York Societies, in which meeting held December 15, in the same year, the difficulties to be encountered by compulsory certain resolutions were proposed ; and after several notification were placed before the members. It suggestions and amendments had been made, it was did not convince the various medical officers of unanimously resolved that

health assembled at that meeting. They found 1. Infectious disease ought to be reported by the themselves so often foiled in their endeavours to householder to the sanitary authority without delay. arrest disease because foci had been conveyed

2. Every medical man attending a case of infecti- to many places before information reached them ous disease should give immediate information re- as to its existence that they still insisted upon specting its nature to the occupier or other person going to the fountain-head for the information, responsible for reporting to the sanitary authority. in all those cases at least which came to the

It does not appear from the report of the discus- cognisance of the members of the medical prosion at that meeting, which was presided over by fession. The advantage and saving of trouble Dr. Buchanan, that any proposal was made that by this course to medical officers cannot be medical men should be subject to a criminal prose- doubted, and if all cases of infectious disease were cution if they did not disclose the nature of the attended by medical men as a matter-of-course, it disease to the householder, much less suggest that would, if carried out efficiently, do what the medical they should be criminally prosecuted if they did not officers require ; viz., give them intelligence as to do so to the local authority. The Chairman, in the whereabouts of dangerous infection.

But no summing up the discussion, said he thought it the one can read the reports of the medical officers of duty of the society to affirm the principle, without, health from all parts of the kingdom without coming however, making it compulsory under penalty upon to the conclusion that the greatest spread of infec. the medical profession to give the sought-for infor- tion is brought about by those cases which are not mation. He (Dr. Buchanan) felt persuaded that as under orthodox medical care at all, and that notificisoon as the profession found itself morally bound to tion by the medical profession alone would not do a thing, there would be no ground for suspecting effect the object, but rather lead to ignorant any evasion of the duty even although there was no attempts to smother up the evidence, and in the end legal compulsion.

to raise more persistent, and more widespread outThe Parliamentary Session of 1876 witnessed bursts. There was a necessity in the minds of the introduction of clauses in Local Acts giving ! medical officers of health for dual notification ; and the power to the local authority of prosecuting all the Local Bills introduced into the House of medical men who did not notify the existence of Commons in this and succeeding years, contained such disease to the local authority. Huddersfield clauses requiring the medical attendant either with introduced such a clause, which inflicted a penalty or without the householder to notify to the local not exceeding rol., but which was partial in authority under penalties. its application. The subject was handled in a In 1879 the Local Government Board also masterly manner at the annual meeting of the Social made a step in advance by an order dated Science Association at Liverpool in 1876 by Dr. February 12, which imposed the duty upon all Francis Bond, who argued in favour of the house- medical officers employed by them of notifying holder being the informant under a penalty, and that any case of dangerous, contagious, infectious or medical men should make the communication to him epidemic disease to the sanitary authority of the as a moral duty.

district immediately upon its occurrence; it also In the following year the Town Council of enabled medical officers of health to obtain such Coventry passed resolutions having the same effect information as to sickness and death among as indicated in the course which Dr. Bond had pauper patients, as might be thought necessary for suggested at Liverpool, and Dr. Ransome urged the their guidance; and later in the year the order was same course as essentially necessary in a paper

made to extend to the medical officers of district which he read to the National Health Society in schools. May 1877.

I now refer to the action of the British Medical About the same time the North-Western Associa- Association, and to give credit to those to whom it tion of the Medical Officers of Health again is due. The first note was sounded by that body approached the President of the Local Government soon after Dr. Ransome had moved in the matter at Board, but this time they suggested that the house Manchester, for he introduced the subject to the holder should be the informant, and that the medical notice of the Association at Leamington in 1865, attendant should be liable to a penalty if he did not and procured the appointment of a committee to disclose the nature of the case to the householder or consider the registration of disease. Various person responsible for the care of the patient. reports were made by that committee, and in 1875 it Memorials were also sent to Mr. Sclater Booth by was distinctly stated that the authoritative declaravarious sanitary authorities calling upon him to tion of the nature of the disease must necessarily introduce a measure into Parliament for the pur- come in the first instance from the medical attendant; pose of effecting legislation in the direction thus but the committee also expressed their opinion that indicated.

the proper individual to make return should, in the A further step was also taken by the town of first instance, be the householder, or the person in Bolton, which obtained a clause in an Act of Parlia- charge of the case. I had dealt with the matter in ment putting a penalty for non-disclosure upon both this direction in the address upon public medicine householder and doctor, the doctor being liable to a which I had the honour to read at Sheffield in that penalty not exceeding 101., but entitled to a fee of year. The subject was then referred to the Parlia25. 6d. for notifying.

mentary Bills Committee, and voluminous reports A temperate and well-written paper on the subject have been presented from time to time, and accepted was read at York in July 1878, by Mr. North, to a l by the Association, and the moral duty of communicating that information to the householder has been The medical attendant should, we think, in justice often insisted upon. The report of the chairman of be entitled to claim a fee either from the patient of the committee (Mr. E. Hart) upon the subject is a from the sanitary authority for every such certificate masterly résumé of the action of the committee, and of his which reaches the medical officer of health, should be studied by all who take interest in the and which he may forward himself if the patient so matter. A discussion took place at Ryde in 1881, desires. when Mr. Michael, Q.C., proposed an amendment to Evidence upon these points was obtained from the report, which amendment cast the duty on the various societies such as the Medical Officers of medical attendant, and made its neglect a penal act, Health, the Sanitary Institute of Great Britain-as but which was lost by a large majority.

well as the numerous witnesses who had personal At Worcester, in 1882, the subject was brought knowledge of the behaviour of small-pox and other prominently forward both in the Public Health sec- infectious diseases. tion, of which I was president, and in the general I now come to the last phases of this important meeting. The result of the discussion which ensued matter. Mr. Hastings introduced a Bill into the was the overwhelming defeat of Mr. Hastings's reso- House of Commons for the purpose of putting a lution which made neglect to report, a penal act, and private medical man into the position of a criminal the following proposal was adopted—' That whilst | if he did not become a State official, whenever he desiring compulsory notification of infectious dis- came into contact with infectious disease, whether eases, the Association wishes to express its opinion he was willing to be a State official or not. The that the compulsion to notify should be placed upon Bill came on for second reading on June 27 in last the householder as his duty as a citizen, and not

year. The House was counted out immediately upon the doctor. The subject continued to be after Mr. Hastings's speech in its favour, and the debated in various quarters, and on April 26, 1881, a Bill was not proceeded with. The Government had deputation waited upon the President of the Local been previously interviewed by Mr. Hastings's folGovernment Board, which was formed by repre- lowers, but they would not pledge themselves to sentatives of the British Medical Association, Sani- support a general Act, although pressed to do so by tary Institute of Great Britain, Society of Medical some men who are notably anxious to make the Officers of Health, Social Science Association, Na. medical profession occupy a secondary position in tional Health Society, and of the Vestries and

the country.

In October of last year the Social District Boards of London, to ask the Government Science Congress held its meeting at Huddersfield. to legislate upon this and other subjects connected It might have been supposed that after the defeat of with measures necessary to guard the public health the President of their Council on this matter, that as from the danger of infectious diseases.

Huddersfield was the first town which obtained the One of the sequences of that deputation was advantages or disadvantages which attach to a penal the appointment of the Hospitals Commission to clause, and is the town in which compulsory notifiinquire respecting small-pox and fever hospitals, the cation has been the longest in operation, we should extent and sufficiency of hospital accommodation, have had a convincing discussion as to the benefits and, with other matters, “to insure as far as prac- or injury which had resulted to the town from the ticable the protection of the public against con- passing of the Act. It does not appear that a tagion. Having had the honour of being appointed single word was said upon the subject by either side. one of the members of that Commission, I directed Mr. Hastings did not raise the point, and no other my attention especially to this part of the subject, person said a word about it; and although the and carefully examined the witnesses who were able Social Science Association had been on former to speak with authority upon the matter. The re- occasions so very positive about its benefits, and port which we presented to the Queen, states very were actually meeting soon after their President's distinctly that notification should in all cases be defeat in the very town most capable of producing obligatory upon one or more of the following per- convincing proofs, if they were forthcoming, as to sons—the patient, those in charge of him, the the advantages of the Act ; there was a silence on occupier of the house in which he lodges, his the subject which to me is inexplicable, unless on medical attendant or any relieving officer (if a the view that the results do not correspond with the pauper) to whom he may apply for assistance. In prognostications, and that it would not have been safe effect, the report says it is only by the medical to excite a discussion among those capable of attendant (if any) that the disease can be intelli- proving the negative. gently notified, since it is only he who can be pre- If towns having the compulsory clauses in operasumed to know what it is, and who has no interest tion are not able to show better things than can be in concealing it ; but it is represented that to im- shown in those places in which only a moral obligapose that duty upon him directly and undeservedly tion to disclose exists, I think it must be evident to would interfere with the relation which ought to those who wish to prevent us trusting too much to a exist between him and his patient, and might pre- paternal Government that we had better steer clear vent the aid of a medical attendant being sought of too much compulsion, and trust a little more to for at all. If this be so, it may be sufficient that moral obligations. There is a strong feeling in the the medical attendant should be required by law to commercial world against professional men, such as furnish to persons in charge of a patient, or the lawyers

, commission agents, auctioneers or engineers, owner or occupier of the house in which he lodges, accepting a commission from both sides in a given a certificate of the nature of the disease, stating case, and being engaged as advisers for both sides whether proper isolation can or cannot be secured in any commercial transaction ; and I fail to see without removal, and when removal is necessary, any difference in the case of a man who is employed stating also to what extent the case is urgent or by a private and responsible individual to cure him severe. 'The persons to whom this certificate is of his disease being compelled to accept a fee for given should be in like manner required by law to disclosing something which may be used by the local forward it at once to the medical officer of health. I authority to the injury of his client and employer.

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