death will be an arsenal which the genius of English healers 66 'cannot fail to turn to account."

The subject of a "National System of Registration of Disease," the attempts to establish which we have sketched, appears to have gradually dropped into abeyance. It was blessed by medical men and sanitarians and Secretaries of State; and yet the inertia of officialdom appears to have prevented any practical steps being taken. The measure was not one which it was profitable to pursue in the stress of political party strife, and it was pushed aside for more urgent and politically more attractive schemes.

The Compulsory Notification of Infectious Diseases.

The leaven of the protracted agitation in favour of such registration was, however, at work. Medical officers of health in various parts of the country complained that their preventive measures were belated, owing to the fact that epidemic diseases had obtained a firm foothold before the occurrence of fatal cases brought them under their cognizance. Gradually the idea of compulsory notification of infectious diseases, as the most urgent branch of a national system of registration of diseases, came to the front. Such notification of infectious diseases-the first step, we hope, towards a more general notification of sickness-became actual fact in a characteristically British fashion. The experiment was allowed to be made by those towns desiring to make it. In September, 1877, the first local Act for enforcing the compulsory notification of the chief infectious diseases came into operation in Bolton, Lancashire. This example was followed by other towns, and the adoptive enactment of the Infectious Diseases (Notification) Act in 1889, was followed by a rapid adoption of the Act by urban and rural sanitary authorities throughout England. At the present time the Act applies to five-sixths of the English population, and there is little doubt that it will shortly be made compulsory throughout the whole of Great Britain.

We may pause at this stage to inquire whether the public has derived any great advantage from the widespread compulsory notification of the chief infectious diseases now in force over the greater part of England and Wales. Statistics, although they have been copiously invoked by certain writers, will give one but little help in such an inquiry. Infectious diseases like scarletfever and diphtheria, have their epidemic and non-epidemic periods, governed by telluric or other laws of which our knowledge is hitherto imperfect. This fact has been lost sight of or imperfectly appreciated by those who have attempted to contrast the statistics of towns having compulsory notification with those not having it, or the statistics of the same town for groups of years before and

after the enforcement of compulsory notification. By carefully arranging groups of years so as to include or exclude particular epidemic years, it is practicable to arrive at any conclusion that may be desired. By this means it can easily be, and has been, proved that the compulsory notification of infectious diseases has in special instances increased the prevalence of those diseases. We are not seriously concerned, however, with the exposure of such puerile efforts to discredit the utility of the compulsory notification of infectious diseases; they are obviously contrary to common sense. Notification is but a means to an end. If the early and authentic information imparted to health officers by notification is simply filed in the office, the course of an epidemic will obviously be undisturbed; but when such notifications are followed by conscientious investigation, when the water supply, the milk supply, the school attendance, and a number of other factors in connection with a series of cases of infectious diseases are examined, it is evident that the resulting chain of evidence may be, as in many instances it has been, so strong as to lead to immediate preventive measures of a most successful character, and in other instances to force the most radical reforms upon even unwilling sanitary authorities.

This does not exhaust the benefit derived from compulsory notification of infectious diseases: the notifications have forced upon sanitary authorities the knowledge that there are infectious diseases in their midst, and the constant reiteration of the lesson has gradually and increasingly braced them up to the discharge of their duties. Hence it is not surprising to find that at no previous period of the sanitary history of England has there been such great activity as since 1889 in the provision of isolation hospitals. Even if these isolation hospitals have not, by the removal of first cases of infectious diseases in houses, diminished the prevalence of infectious diseases, they have as humanitarian institutions justified their existence by the better and more successful treatment that the majority of patients thus removed have secured; but they have also diminished the actual amount of some of these diseases. Small-pox epidemics are more easily manageable and have been kept within narrower bounds in communities in which all cases are notified and isolation enforced. Scarlet-fever has declined enormously in mortality in recent years. Some of this decline is doubtless due to the milder type of disease now prevalent, the case mortality having become greatly reduced. It may be fairly argued, however, that the diminishing malignancy of this disease is partially due to the fact that cases of it, instead of being treated in crowded houses with imperfect nursing, are now treated in large airy wards, the virus of the disease not being concentrated

by an unfavourable environment. This hospital treatment of infectious patients can only be secured in the majority of instances through the machinery of compulsory notification of the cases.

Notification of infectious diseases, by forcing attention to them, has led to the provision of more efficient means of disinfection; to the removal of insanitary conditions to which in some instances they owe their existence; and to the steadily improving education of the public in hygienic matters.

Even if it could be shown that compulsory notification of infectious diseases had not prevented radiation of disease from a single focus of infection, and had not led to the discovery of a single evil condition competent to produce further disease, the continued operation of the Act would be desirable from a wider standpoint. We are, by means of notification, gradually accumulating throughout the country a mass of information as to the seasonal, annual, epidemic, and cyclical prevalence of the chief infectious diseases such as has never previously been possessed by epidemiologists. As the first condition of success in the prevention of disease is knowledge of its natural history-its epidemicity, its relation to age and sex, to social and industrial conditions, to the complex meteorological conditions embodied in the words "season and climate"-such an accumulation of information must ere long bear fruit of a practical, useful character. Medical officers of health are not mere empiricists, concerned with the enforcement of general cleanliness, and of disinfection and isolation when cases of infectious disease arise. They are concerned not solely with individual cases of disease, but also with the conditions producing and controlling entire epidemics. It is in this branch of their work that knowledge is as yet most imperfect; and it is only by the accumulation of accurate and complete information as to each epidemic and inter-epidemic period, and by the collateral study of the personal and environmental conditions associated with these periods, that we can hope to arrive at a less empirical and more rational conception of the causation of each infectious disease, and through that of its prevention.

Such considerations as these must necessarily influence our decision as to the number of infectious diseases that should be compulsorily notified. Some medical officers of health object to the present inclusion of erysipelas as practically useless, while others advocate the inclusion of measles, whooping-cough, summer diarrhoea, or even of chicken-pox, mumps, &c., which are not at present in the official list of notifiable diseases, though they may be added by any local authority wishing to do so.

We venture, apart from the pecuniary considerations involved, to urge the compulsory notification of all infectious diseases. It is

most desirable in the ultimate interests of the community that all these diseases should be compulsorily notified by the medical attendant, or by the responsible guardian of the patient when there is no doctor in attendance. Only by these means shall we acquire a complete knowledge of the natural history of these diseases, and lay in our increased knowledge of their causation a solid foundation for the erection of a substantial fabric of preventive measures.

There is, however, the important difficulty of expense. We cannot reasonably expect local authorities to pay half-a-crown or a shilling (according as the case occurs in private or public practice) for each notification of these minor diseases, unless we can show some immediate practical utility.

This consideration raises the whole question of payment of the medical practitioner for notifying each case of infectious disease. In accordance with general principles, the State has no right to require work from private members of the community without giving remuneration for this work. On the other hand, the State has always required certain work from its citizens without such remuneration. Every ratepayer is liable to be called upon to act on a jury, often to the serious detriment of his private business, medical men being exempted from this duty. Further, the State has already required duties analogous to notification of sickness from medical practitioners. They must certify the cause of death of patients attended by them: and they must supply certificates of vaccination for children successfully vaccinated by them, both without remuneration. We shall shortly see that in none of the other countries to be mentioned, in which an elaborate system of notification is enforced, is any payment made for the information furnished by the medical practitioner. In these countries there are more rigorous regulations protecting qualified practitioners from the unscrupulous competition of unqualified persons. In this country such protection is most imperfect. If it were determined to extend the notification of sickness without any corresponding (if any) increase of expense for fees for notification, this should be accompanied by legislation giving medical practitioners that protection in the discharge of their skilled work which is required. We believe that if an enactment strictly prohibiting the practice of medicine by unqualified persons, and at the same time requiring weekly returns of all cases of a specified number of diseases were to be made, medical men would not seriously object to the gratuitous labour involved. Failing this, or as a preliminary to it, the expense of extended notification might be reduced by a modified system, weekly returns only, instead of immediate returns, being required in all except the more urgent infectious diseases.

Our review of the unsuccessful attempts made to establish a national system of registration of disease and of the successful inauguration of the compulsory registration of infectious diseasesan important section of this national system - would not be complete if we stopped at this point. Evidently the possession by each medical officer of health of information as to the amount and nature of the infections diseases prevalent in his own district does not exhaust the possibilities of utility of these returns. Their value would be greatly increased by collateral information as to the amount and nature of the infectious diseases prevalent in neighbouring districts and in the rest of the country, or even in other countries. By such an interchange of prompt and trustworthy information it would be practicable to forecast the possibilities of the introduction into a community of a given disease, and take suitable precautions. "Registration of sickness would tell us of "the coming storms, and enable us to trim our vessels to meet "them." This defect in local notification was soon seen, and at the beginning of 1888, Dr. Tatham, then medical officer of health for Salford, made a private arrangement with the medical officers of health of thirty-two other notification-towns, by which he should receive from them weekly returns of the cases notified in each town. These were tabulated by him, and then circulated confidentially amongst the contributing medical officers early in the succeeding week. The practicability and the utility of this voluntary inter-notification having been fully established, many of the local authorities of the towns concerned petitioned the Local Government Board to take the matter in hand as a "going 'concern;" and in 1889 the Board undertook the tabulation and distribution of the statistics of cases of sickness notified to the medical officers of health of those towns in which the notification of infectious diseases is compulsory. Only the co-operating towns receive the table summarising the statistics of these notification-towns; and it is marked "not for publication." We may reasonably hope, however, that this beginning will ere long end in a national registration of infectious diseases, and a similar tabulation and distribution of the national statistics by the Local Government Board. For the present we may note the important facts that on two occasions departments of the Government have tabulated and circulated returns of sickness: first, metropolitan sickness of all kinds in 1857, and, second, infectious diseases in contributing notification-towns from 1889 onwards. It would be difficult to exaggerate the importance of these facts; they establish a valuable precedent, and furnish hope that a governmental department may soon be induced to take up in a much more complete and general form the collation of the general