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While in full sympathy with the object in view in sec. 29 of the Factory and Workshops Act, 1895, an earnest and emphatic protest must be urged against the machinery and the destination of the notifications proposed in this section. As I have elsewhere stated," it constitutes a new departure, that of compulsory notification of disease by a medical practitioner to a layman. It involves a most pernicious procedure, one not only fraught with serious direct and indirect detriment to the medical profession, but also detrimental to the object in view, as it involves, in some degree at least, the investigation of the causation of special diseases-a medical problem-by lay inspectors. The medical officer of health is in virtue of his special training and profession the person to whom these diseases should be primarily notified, and who should guide the remedial measures to be taken.

In a letter addressed to the "British Medical Journal" (10th September, 1895), Dr. Russell, the distinguished medical officer of health for Glasgow, after referring to and endorsing the above quoted remarks, states-"apart from the principle, the method of this Act is absurd." He then quotes the following paragraph from a statement submitted (unsuccessfully) to Mr. Asquith by the Police Commissioners of Glasgow during the committee stage of the Factory and Workshops Bill, 1895:

"The medical practitioner will form an opinion that his patient "suffers from poisoning or anthrax before he arrives at any con"clusion as to its cause. This presumes an inquiry into circumstances, and the conclusion may possibly not be one which will "make the practitioner any more popular in the locality if he "promulgates it. Let every such case be notifiable to the medical "officer of health of the district as if it was an infectious disease. Let the medical officer of health make the inquiry, and, if he "believes the disease was 'contracted in any factory or workshop,' let him at once inform the local factory inspector."

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may now sum up. What is advocated is that

(a.) All cases of sickness treated at the expense of public funds, whether in connection with the administration of the PoorLaw (out-door infirmaries, industrial schools, &c.) or in isolation hospitals, or in idiot and lunatic asylums, should be periodically notified to the medical officer of health.

(b.) All cases of sickness treated by means of public charity, whether in general or special hospitals, or dispensaries, should be similarly notified.

(c.) All cases of sickness treated in Friendly Societies or other sickness assurance societies should be similarly notified.

"British Medical Journal," 31st August, 1895.

(d.) Returns of accidents and of certain diseases, as lead poisoning, woolsorters' disease, &c., or other industrial diseases, should be made part of a wider system of notification of diseases by private medical practitioners to the medical officer of health of each district.

(e.) The schedule of notifiable diseases under the Infectious Diseases (Notification) Act should be widely extended. Diseases should be classified into those compulsorily notifiable (1) within twenty-four hours, and (2) weekly, and the list of the latter should be greatly increased; they should include pneumonia, rheumatic fever, phthisis, and other diseases, as lead poisoning, &c.

(f.) In connection with this extension of notification the whole question of payment of fees for notifying will require complete reorganization.

(g.) All notifications of sickness should be sent in the first instance to the medical officer of health of each district, and by him transmitted to a central office in London.

(h.) The central office in London should probably be in connection with the General Register Office, Somerset House, and weekly returns of sickness should be published alongside of the weekly returns of mortality. The most urgent of these reforms is the collection and tabulation of the cases of sickness attended at the expense of the public funds or treated in public charitable institutions. This might be begun almost immediately. The only obstacles are the vis inertia of the responsible heads of Government departments and the expense that would be incurred. Successive Secretaries of State have committed themselves to the principle of the proposal, and there is reason to hope that strenuous action and agitation on behalf of this proposal by the Royal Statistical and other allied societies would secure the desired end. I can conceive of no work more important in conducing to the progress of both curative and preventive medicine than that which I have briefly described; it is a work of national importance, and the secural of this additional information for every district and town, with the present staff of medical officers of health eager to avail themselves of it, would undoubtedly be followed by marvellous improvements in the public health.

DISCUSSION on DR. NEWSHOLME'S PAPER.

DR. J. G. GLOVER, after complimenting Dr. Newsholme on his interesting and valuable paper, said that there were one or two omissions which he would like to point out. First, the sickness of children at school was a most important question, because nearly all infectious diseases affected children at the school age, and this matter was not referred to in the paper. He found in the Metropolitan Asylums Board report for 1894, that the number of cases of scarlet fever admitted to those hospitals between 1873 and 1884 was 81,350; 71,000 of those were below 15 years of age, whilst 56,719 were below 10. Then of diphtheria there were 11,000 cases, of which 9,488 were below 15, and 8,158 below 10 years of age. Anything therefore which would give a more complete idea of the sickness of school children would be of immense consequence to the whole community. As a medical practitioner he did not think that the diseases at present notifiable at all exhausted the diseases which affected the health of families. He had recently seen a boy with the mumps, and had thought it his duty to inform the master of the public school which two of the boy's brothers attended, that those two brothers were exposed to the infection. Their attendance was stopped, and they both soon after contracted the disease, so that a serious outbreak in the school was only just prevented before the Christmas examinations and holidays. Measles, again, was not a notifiable disease, yet far more children died of it than of scarlet-fever. As a striking illustration of this, he found in one of the returns that four times as many children died in 33 large towns from measles in one week as died of scarlet-fever. He was also strongly of opinion that there ought to be a special registration of sickness in health resorts and seaside places, so that it might be a matter of course for any visitor to at once ascertain that the house to which he was going to take his children had a clean bill of health, and was free from infection. He did not agree with Dr. Newsholme, that hospitals supported by voluntary subscriptions owed a report of their cases of sickness to the State. The onus of making that report would fall upon the already overworked medical man, whose burdens would be very heavily added to, especially in the case of medical officers of Poor-Law infirmaries. He knew one such infirmary where two doctors had to attend upon 600 or 800 patients, and were responsible for 600 deaths a year, or 14 a week; their work would be largely increased if they had to make these returns, and he hoped that that would be clearly realised if this work were to be done.

Dr. WEEKES (Portland, Maine, U.S.A.) said that he had much enjoyed the reading of the paper, and would like to give a few

details of the law which obtained in his own State, and in the great majority of the United States. In Maine they had the State Board of Health, at the head of which was a secretary appointed by the Governor of the State and the Senate. He received a salary from the State, and was a physician who did not practise, but devoted all his time to matters affecting the public health and to editing the journal. In every town there was a local board subordinate to the State board, each with its secretary, to whom the physicians reported the various infectious diseases, while he in turn reported all cases of disease specified in the list as "reportable," to the secretary of the State board. The diseases they had to report were small-pox, diphtheria, and scarlet-fever. Upon every house in which a case of one of these occurred was placed a piece of cardboard, six inches square, with a scarlet border, with the name of the disease printed on it in large scarlet letters. The children living in the house were of course taken from school and not allowed to go back again until two weeks had elapsed after the last case, and until a thorough disinfection and fumigation had taken place. The diseases which had to be reported, but were not placarded, were measles and enteric fever, and they had recently added pulmonary tuberculosis. He was glad to hear Dr. Newsholme claim that pneumonia should be included in the list, because he believed it to be largely an infectious disease. In the United States they were now labouring for the establishment of a National Board, with a physician at the head of it, who should be a member of the President's Cabinet. When they had accomplished that, they would have on foot a system which would protect the people in the best possible way against the prevalence of infectious diseases.

Mr. A. C. ScoVELL (Metropolitan Asylums Board) said that a difficulty, though not an insuperable one, had occurred to him in connection with imperfect or erroneous diagnoses. He had for some years, as Chairman of a Board of Guardians, visited the infirmary, and was surprised at the frequency with which the cards suspended on the beds of the patients misrepresented the disease from which the patient was actually suffering. This arose from the fact either that the out-door medical officers did not think it necessary to make an exact diagnosis, or that the circumstances were unfavourable, owing to want of light, and so on; but the result certainly was that many diseases were, in the first instance, wrongly diagnosed. The effect of erroneous diagnosis of infectious disease was very unfortunate; in some cases the patient contracted the disease in hospital, or, if he escaped infection, was kept in hospital occupying a bed which some real sufferer was entitled to. These considerations seemed to him to throw some doubt on the exact value of the statistics obtained by notification; and he would suggest that the diseases to be notified should be divided into two classes, one to consist of all those in which prompt notification was necessary for purposes of immediate isolation and disinfection, when the notification ought to be as prompt as possible even at the risk of error, and a second to consist of those

the notification of which should be deferred until a mature diagnosis had been made. Of this second class it would be better to keep a special register giving the name, age, and sex of the patient and the nature of the disease as first diagnosed, as finally diagnosed, and the termination by recovery or death. Such registers ought to be kept by all public institutions. With regard to the medical officers of Poor-Law infirmaries, he well knew how much they had to do, but they were bound to keep certain records as it was, and he did not feel that it would be a very unfair addition to their work if they had to keep their records so as to provide the information Dr. Newsholme suggested, which should be periodically forwarded to a central authority.

Dr. HENRY CLOTHIER said that he had had a good deal to do with the notification of disease since that system was established in January, 1890, and, though greatly in sympathy with the aims of this paper, he thought it was too sweeping. It was impossible to notify and classify every case of sickness, and the primary object of notification seemed to him to be the isolation of the first cases of infectious disease. The authority which required notification ought, he considered, to isolate the primary cases. He was therefore personally against notifying such diseases as measles, because there was no authority in the world which had accommodation for all the cases. The same reasons applied to chicken-pox and mumps, and as for pneumonia and phthisis, it would be impossible to isolate these cases, because of the time the illness lasted; cancer again could not be isolated, neither could many other diseases because of their frequency. The country was not prepared for so vast a scheme. He strongly objected to the proposal in the paper that, failing notification from the medical man, the person in charge of the house or patient was to notify the disease. They already had great trouble with notifications sent in by doctors, and, if they were now to have notifications from people who knew nothing about illness, he did not know where they would be. There seemed to be an idea throughout the paper that the already overworked medical man was to be deprived of the very small fees he got; 28. 6d. was not a large sum for notification, and many medical men, especially in public institutions, were very much under-paid; the idea of adding to their work without proper remuneration was not to be thought of.

Mr. SHIRLEY F. MURPHY had not fully considered the question of notification of non-infectious diseases, but his sympathies were rather with Mr. Scovell, who suggested a more accurate system of registration of sickness in institutions, with records available periodically for the medical officer of health, which might eventually be sent to a central office as described by Dr. Newsholme. Any such system, however, would have to be built up by degrees, and the first step was to secure the keeping of proper records in institutions. There was not such immediate necessity of early notification in cases of ordinary sickness as in cases of dangerous infectious diseases, and the end sought could be met

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