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Some difficulties met with in the isolation of infectious diseases
422
S o m e Difficulties met w i t h in the
EPuWieuea~t~
SOME DIFFICULTIES M E T W I T H IN T H E ISOLATION OF INFECTIOUS DISEASES. ~ B£ T. A. Gt%EEN, 3i.D. Medical OffÉcerof Health of Meltham Urban District. THE difficulties which I propose to discuss to-day are not such as will be often met with by those who devote their whole time to their duties, or by those fortunate enough to act in districts where there is a permanent isolation hospital regulated by the Isolation Hospitals Act of 1893. To s u c h my difficulties may seem trivial ; but there are many not so happily situated to whom they are a constant source of w o r r y . They generally occur among the poorer inhabitants of a district, and arise in the main from the following causes : (1) Inability to isolate the cases i n their own homes ; (2) Unwillingness of the local authority to provide special temporary accommodation, etc., for infectious eases ; and (8) Non-notification. I propose to inquire shortly into the reasons of these causes, and illustrate them where possible : 1. Inability to Isolate Cases of Infectious Disease at Home.--Little need be said on this point, because it is easy to understand that it is practically impossible to obtain isolation in a cottage containing only a kitchen and one or two bedrooms, an d usually accommodating a family which is perhaps not of the smallest ; nor, indeed, can we expect the average working man 'to live in a house a portion of which can be turned into a temporary isolation hospital at moment's notice. 2. Unwill.in,qness of the Local Sanitary Authority to Provide Special Tempo~ury Isolation Accommodation, etc.--This, in my experience, is the chief difficulty, and to fully appreciate it I would ask you for a moment to consider the position of a medical officer of health. Under the Local Government Board's Order of March, 1891, he is powerless to act on his own initiative. He can only advise the members of his sanitary authority on matters pertaining to his office, and it rests entirely with them whether they carry out his suggestions or not. He is not in a position to insis~ on their doing so. Further, from the Public Health Act, 1875 (Section 120, etc.), and its supplements, we find that a person, or the responsible guardian of a person, suffering from an infectious disease must * 1%ead at a meeting of the Yorkshire Branch of the Incorporated Society of Medical Officersof Health at Leeds, December, 1900.
~a,o~,~9o~
Isolation
o{ I n f e c t i o u s D i s e a s e s
423
notify the case; m~tst not expose himself; m~st not suffer the infected person to expose himself ; must disinfect, etc. All these things are compulsory. But the sanitary authority may disinfect; may destroy bedding, and give compensation for such bedding; may provide a carriage for conveyance of infected persons; may remove to hospital, either a temporary one or that of a neighbouring authority; may recover cost of maintenance in hospital; or may provide temporary medical attendance, etc. In their case, all these things are not compulsory, except in one specific class of case to which I will refer later. It therefore happens that any action which a sanitary authority takes with regard to special isolation depends entirely on the particular standard of moral responsibility to the public which appertains to the authority. As you can readily conceive, this standard is an ever-varying quantity, which occasionally has a decided tendency to be reduced to a minimum. We do son~etimes find authorities which of their own free will have provided temporary isolation hospitals. I know of one district in the West Riding where a temporary isolation hospital was erected so many years since, that some little time ago it almost felt to pieces from constant use and old age, and had to be entirMy closed during its renovation. Only within the last few weeks this same authority has decided to further extend this temporary accommodation, although a permanent joint hospital for the district is in process of construction. Again, I know,of many authorities which, acting under Section 181 of the Public Health Act, and not possessing a hospital of their own, make a practice of sending their cases to the hospital of a aeighbouring authority and paying all expenses, often amounting $o one or two guineas per week for each case. Although, under Section 13% they have power to reclaim the cost of maintenance from the patient, in practice it is seldom done, as this little generosity more certainly insures the co-operation of the public in isolating infectious cases. But if recovery is insisted upon, it may lead to some little difficulty. Section 132 says that the expenses are a debt due from the patient to the sanitary authority. The difficulty arises when the patient is a minor. In .~hat case, is the parent or guardian responsible for the debt ? I have heard both views expressed. Even if a sanitary authority will not go to the extent of providing temporary isolation, Section 133 g i v e s it power to provide a temporary supply of medicine and medical assistance out of the rates to poor people who are not paupers, and this is sometimes 28
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done. But sometimes a sanitary authority will do nothing, or else, having taken action, afterwards shirks its pecuniary responsibilities, either altogether or in purl Such an authority often contains members who justify their line of masterly inactivity by s a y i n g that "nowadays there is a great deal more bother about scarlet fever, and the like, than there was in the good old days of our grandfathers. Then there were none of these new-fangled notions about isolation. Children had fever at home ; other people in the same house went about their daily work without let or hindrance, and they mtlddled through all right somehow or other. What was good enough for them is surely good enough for us " - - a n argument which may not be good enough for you, but which still carries a great deal of weight in many of the smaller districts. They further say that compulsory expenses make a heavy enough charge on the rates without adding to them payments which are only optional, and they are apt to look upon any money expended on isolation as being for the benefit of the afflicted persons, and not as the price paid by a community for freedom from infection. One or two cases will illustrate difficulties I have met wi~h under this heading : Case 1.--About three years ago six cases of scarlet fever occurred in a house occupied by thirteen people. The house had three rooms - - a kitchen and two bedrooms--one above ?~he other. The first; bedroom only had a fireplace, and this was the one where the fever cases were treated. The healthy members of the family had to pass through the infected bedroom to get to the bedroom above, where they slept. Four healthy children were stopped from their work by their employers, and one son stopped work at the request of the sanitary authority. The parents had to act as nurses and attendants, and the father agreed to carry out ~he instructions of the sanitary authority, with the verbal understanding, as he says, that they (the authority) would provide necessaries and medical attendance. After two or three weeks, however, they qualified their offer by saying that, under Section 132, they would expect the parent to repay any money they advanced. He refused to agree to this, and, as a result, the whole family were shut up for eigh~ weeks, during which time they were absolutely dependent on private charity, and in the end did not receive a farthing from the sanitary authority. Case 2.--Six cases of scarlet fever occurred in a house with kitchen and two bedrooms. The father had a little shop next door, and a sub-committee of the sanitary authority, along with the medical officer of health, visited tim place, with power to isolate
mrc~,19oll
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the cases as effectively as possible under Section 131. They found that the children who were well had been stopped from their work by their employers. The medical officer of health, speaking for the sub-committee, asked the man to give up his shop (where he was earning about 21 per week), and promised that if he would do so the sanitary authority would look after the whole family. He consented, and the house and shop were turned into a temporary isolation hospital, and were so used for about eight weeks. The sub-committee then begged sufficient subscriptions from private individuals to allow the family about £1 per week. This was supposed to be quite sufficient for all their wants, including medical attendance, because, although the bill for the latter was sent to the sanitary authority, they refused to pay it. The only money paid out of the rates was £2 for goods destroyed in the shop. Case 3.--A man living in the same room and sleeping in the same bed as his. only child, who was suffering from scarlet fever, was told both by the medical officer of health and the chairman of the sanitary committee thai he would not be allowed to continue work unless he found lodging elsewhere. He did this, and at the end of the case sent in a claim for extra cost of lodgings. The district council, however, repudiated all responsibility, and so far he has not received anything. This last case brings o,~, another difficult point--viz., the question of compensation. So far as I can make out, no sanitary authority has, under ordinary circumstances, any legal right to stop people from working because they come in contact with cases of infectious disease or live in houses where such cases exist, provided they take reasonable precautions. Section 126 only provides for exposure of infected persons. If sanitary authorities, therefore, do make a request of this kind, it only seems fair that they should recompense the people for acceding to their wishes ; and this is especially the case because i t is usually ~hrough their failure to provide an isolation hospital that people are placed in this difficult position. Section 308 of the Public Health Act of 1875 states that "when any person sustains any damage by reason of the exercise of any of the powers of chis Act, in relation to which he is not himself in default, full compensation shall be made to such person by the local authority exercising
such powers." I would ask you this question, "Under this section can a man, who is not himself suffering from an infectious disease, but is stopped from work because he is living in contact with people so 28--2
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afflicted, or is asked by the sanitary authority to find other lodgings-can such a person claim full compensation' for loss of wages or for the extra expenses he has been put to in getting other lodgings ?" Again I have heard the question answered in both ways, and have known of sanitary authorities dispensing liberal compensation in such cases; but I have not personally been able to hear of a claim which has been upheld in the County Court. On the other hand, those who reply in the negative say that this section has been held to apply to certairi specific kinds of damage, which, however, do no~ seem to be particularly indicated in any part of the Act. It often happens, however, when workpeople cannot be satisfactorily separated from infected persons, that their employers stop them in their own interests. Now, it is notorious that very many of the working class live from hand to mouth without saving anything, and if the weekly wages stop, the people practically become destitute for the time being. This is exactly what happened in the first two cases I have just related. Both families were left without a penny. In the first case i~ was suggested that the father should apply to the Guardians for relief. This, however, was not done, and if application had been made relief would have been refused. Some little time ago there was a dispute in one of the West Riding boroughs between the sanitary authority and the Board of Guardians on this question. The sanitary authority had been sending non-pauper cases of infectious disease to the Union hospital, and the Guardians objected to this. The case was referred to the Local Governmen~ Board, whichdecided that temporary poverty due to the incidence of infectious disease did not render a person a pauper, and that the Guardians were quite justified in objecting to take such cases. A very interesting case occurred some little time ago in which an Urban District Council and the local Board of Guardians were concerned. An application for relief had been made to the Guardians on behalf of five orphan children, but had been refused. Shortly afterwards the eldest of these children suffered from typhoid fever, and was attended in the first instance by a medical man who was also medical officer of health for the district, l=le,however, recommended the relatives to apply to the Poor Law medical officer, which they did through the relieving officer. The Poor Law medical officer a~tended the case, and gave written orders for certain things, which were obtained by the relieving officer. The sanitary inspector also visited the house, and, as there was no isolation hospital,
aa~h. 1901~
I s o l a t i o n of I n f e c t i o u s D i s e a s e s
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removed the other inmates and obtained nurses. Under the supervision of the Poor Law medical officer, the sanitary inspector also procured what was necessary for the patient and nurses. On three occasions the medical officer gave written orders for things. The Urban District Council, under the belief that the written orders referred to and the subsequent conduct of the case constituted the patient a pauper, paid all the expenses (about ~20), and then claimed the amount from the Board of Guardians. The latter, however, refused all liability except for the things on the written orders referred to above. The Urban District Council wrote to the Local Government Board, but were unable to persuade them to take any steps in the matter. The medical attendant afterwards sent in his bill to the Urban District Council, but they in their turn refused to pay this. On the other hand, if the patients are paupers before the onset of infectious disease, it seems to be the duty of the Board of Guardians to look after them. Some few years ago this matter cropped up in one of the county boroughs of the West Riding. The Guardiaris wanted to claim the right of sending pauper patients to the borough fever hospital free of charge. The question was raised as to whether they had any right to do so or not. In the end the parties agreed to abide by the decision of the Local Governm4nt Board, and the answer was given in favour of the sanitary authority. In commencing to deal with this part of the subject, I said that in one specific class of case the sanitary authority were obliged to undertake responsibility. Such cases are dealt with in Section 124 of the Public Health Act of 1875, which provides that "where any suitable hospital or place for the reception of the sick is provided within the district of a local authority, or within a convenient distance of such district, any person who is suffering from any dangerous infectious disorder, and is without proper lodging or accommodation, or lodged in a room occupied by more than one family, or is on board any ship or vessel, may, on a certificate signed by a legally qualified medical practitioner, and with ~he consent of the superintending body of Such hospital or place, be removed, by order of any justice, to such hospital or place at the cost of the local authority; and any person so suffering who is lodged in any common lodging-house may, with like consent and on a like certificate, be so removed by order of the local authority . . . . " I rather suspect, however (and my suspicion is strengthened by the last sentence I have quoted), that this section was drawn up on
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the supposition that the sanitary authority was al~vays anxious to make such removals, and that it was only the infected persons who were likely to raise objections. But I would point out to you that even here there is an indefiniteness which may act as a loophole for a sanitary authority which is unwilling to incur any pecuniary responsibility. What is the meaning of the term "without proper lodging or accommodation," and whose definition of it are we to accept--that of the doctor, the sanitary authority, or the County Court judge ? They all might, and probably would be, different. Further, I would point out that infected people in a common lodging-house are not to be removed by order of a magistrate, but of the local authority. The only cases in which there is no alternative, so far as the Sanitary authority is concerned, are those which occur " i n rooms occupied by more than one family, or on board any ship or v~essel," and, Strictly speaking, from the text of the section, this is only compulsory when there is a suitable hospital in Or near the district to which the paidents are able to be removed. 8. Non-notification.--I now pass to the third cause of difficulties --viz., non-notification of cases of infectious disease. It is often owing to this that epidemics break out. I think that the chief reasons why people fail to notify are : (a) The eases are so mild that the parents think they are not bad enough to call in a medical attendant. (b) The parents do not want to suffer all the ~rouble of isolation and the stoppage of other working members of the family from their employment, especially if they know ~hat ~here will be no compensation for them. Under these latter circumstances, I think that we can none of us blame ~hem very much, but rather offer them our hearty sympathy. But when this reason does not hold good, I think that in the interests of the public safety we should hold them to their duty--in the first instance by issuing printed notices and, if that fails, by prosecuting them in a court of law. I have now laid before ~ou several difficulties which are to be met with in isolating infectious diseases ; there are probably many more, but these have come under my own observation. There is, in my opinion, only one sure remedy for them, and ~hat is for the Local Government Board to make it compulsory by Act of Parliament~ for a sanitary authority to isolate infectious cases at its own expense, whet~er ~here is a permanent isolation hospiisal or
March,190111
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not`. Isolation at home is fraught with a great deal of expense to the family which is unfort`unate enough to be attacked by infectious disease over and above that which would be incurred in noninfectious cases. Such isolation is carried out for ~he benefit of the public, and ~he public ought t o pay for it. It is not sufficient to leave it to the moral responsibility of an authority, because, as I have pointed out., the standard of that moral responsibility is an ever-varying one, and may be nil. So far as the medical officer of health is concerned, it seems to me that his position requires to be strengthened. Powers of initiative ought to be legally granted to him, and he should be further secured in his office so that he is not liable to summary dismissal because he happens to fall foul of the local a u t h o r i t y in the proper discharge of his duties. Meanwhile, happy is the medical officer of health who serves an authority with a high moral standard, for he alone is unlikely to experience difficulties in carrying out his work. TENEMENT-HOUSE LEGISLATION- - A special report on housing conditions and tenement laws in leading American cities, based upon personal observation, investigation by correspondence, and a study of laws and ordinances, has recently been made by Mr. Lawrence Veiller, SeCretary to the New York Tenement-House Commission. Appended to the report is a comparative table showing the most important provisions of the different tenement-house laws in each of twenty-seven cities, grouped together side by side. It appears that none of these large American cities, excepting New York, Boston, Cincinnati, Jersey City, and Hartford really has a tenement-house problem, while in the great majority the tenement-house as known in New York does not exist, the people of restricted means living generally in small one-story or two-story houses, containing one, or at most two, families, while in many cities the houses are owned by the working men themselves. A number of cities exhibit bad housing conditions, giving rise to .what might be designated a housing problem, but this is in no sense comparable to the tenement-house problem as known in New York and Boston. The laws of Buffalo, Philadelphia, and Washington might, in many respects, well serve as models for New York, especially with regard to the provisions for light and air. The Buffalo law provides that " ~o cour~ or shaft shall be less than 6 feet wide for one-story or two-story buildings, and at least 8 feet wide for three-story and fourstory buildings, and 1 foot wider for each additional story above the fourth story." The law in Philadelphia provides that " n o shaft or court shall be less than 8 feet wide in any part, and that any cour~ or shaft between the wings of a tenement-house or between two tenementhouses shall not be less in width than 13 feet; and all such shafts and courts shall be open on one side from the ground to the sky." If these provisions are contrasted with the present provisions of the New York law, which permit, instead of wide shafts, of mere slits 9.8 inches wide and 60 feet long, and "closed in on all four sides, it will be realized that New York is in some respects far behind many smaller cities in her tenement-house laws.--Phit. Med. Journ.
S o m e Difficulties met w i t h in the
EPuWieuea~t~
SOME DIFFICULTIES M E T W I T H IN T H E ISOLATION OF INFECTIOUS DISEASES. ~ B£ T. A. Gt%EEN, 3i.D. Medical OffÉcerof Health of Meltham Urban District. THE difficulties which I propose to discuss to-day are not such as will be often met with by those who devote their whole time to their duties, or by those fortunate enough to act in districts where there is a permanent isolation hospital regulated by the Isolation Hospitals Act of 1893. To s u c h my difficulties may seem trivial ; but there are many not so happily situated to whom they are a constant source of w o r r y . They generally occur among the poorer inhabitants of a district, and arise in the main from the following causes : (1) Inability to isolate the cases i n their own homes ; (2) Unwillingness of the local authority to provide special temporary accommodation, etc., for infectious eases ; and (8) Non-notification. I propose to inquire shortly into the reasons of these causes, and illustrate them where possible : 1. Inability to Isolate Cases of Infectious Disease at Home.--Little need be said on this point, because it is easy to understand that it is practically impossible to obtain isolation in a cottage containing only a kitchen and one or two bedrooms, an d usually accommodating a family which is perhaps not of the smallest ; nor, indeed, can we expect the average working man 'to live in a house a portion of which can be turned into a temporary isolation hospital at moment's notice. 2. Unwill.in,qness of the Local Sanitary Authority to Provide Special Tempo~ury Isolation Accommodation, etc.--This, in my experience, is the chief difficulty, and to fully appreciate it I would ask you for a moment to consider the position of a medical officer of health. Under the Local Government Board's Order of March, 1891, he is powerless to act on his own initiative. He can only advise the members of his sanitary authority on matters pertaining to his office, and it rests entirely with them whether they carry out his suggestions or not. He is not in a position to insis~ on their doing so. Further, from the Public Health Act, 1875 (Section 120, etc.), and its supplements, we find that a person, or the responsible guardian of a person, suffering from an infectious disease must * 1%ead at a meeting of the Yorkshire Branch of the Incorporated Society of Medical Officersof Health at Leeds, December, 1900.
~a,o~,~9o~
Isolation
o{ I n f e c t i o u s D i s e a s e s
423
notify the case; m~tst not expose himself; m~st not suffer the infected person to expose himself ; must disinfect, etc. All these things are compulsory. But the sanitary authority may disinfect; may destroy bedding, and give compensation for such bedding; may provide a carriage for conveyance of infected persons; may remove to hospital, either a temporary one or that of a neighbouring authority; may recover cost of maintenance in hospital; or may provide temporary medical attendance, etc. In their case, all these things are not compulsory, except in one specific class of case to which I will refer later. It therefore happens that any action which a sanitary authority takes with regard to special isolation depends entirely on the particular standard of moral responsibility to the public which appertains to the authority. As you can readily conceive, this standard is an ever-varying quantity, which occasionally has a decided tendency to be reduced to a minimum. We do son~etimes find authorities which of their own free will have provided temporary isolation hospitals. I know of one district in the West Riding where a temporary isolation hospital was erected so many years since, that some little time ago it almost felt to pieces from constant use and old age, and had to be entirMy closed during its renovation. Only within the last few weeks this same authority has decided to further extend this temporary accommodation, although a permanent joint hospital for the district is in process of construction. Again, I know,of many authorities which, acting under Section 181 of the Public Health Act, and not possessing a hospital of their own, make a practice of sending their cases to the hospital of a aeighbouring authority and paying all expenses, often amounting $o one or two guineas per week for each case. Although, under Section 13% they have power to reclaim the cost of maintenance from the patient, in practice it is seldom done, as this little generosity more certainly insures the co-operation of the public in isolating infectious cases. But if recovery is insisted upon, it may lead to some little difficulty. Section 132 says that the expenses are a debt due from the patient to the sanitary authority. The difficulty arises when the patient is a minor. In .~hat case, is the parent or guardian responsible for the debt ? I have heard both views expressed. Even if a sanitary authority will not go to the extent of providing temporary isolation, Section 133 g i v e s it power to provide a temporary supply of medicine and medical assistance out of the rates to poor people who are not paupers, and this is sometimes 28
¢24
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done. But sometimes a sanitary authority will do nothing, or else, having taken action, afterwards shirks its pecuniary responsibilities, either altogether or in purl Such an authority often contains members who justify their line of masterly inactivity by s a y i n g that "nowadays there is a great deal more bother about scarlet fever, and the like, than there was in the good old days of our grandfathers. Then there were none of these new-fangled notions about isolation. Children had fever at home ; other people in the same house went about their daily work without let or hindrance, and they mtlddled through all right somehow or other. What was good enough for them is surely good enough for us " - - a n argument which may not be good enough for you, but which still carries a great deal of weight in many of the smaller districts. They further say that compulsory expenses make a heavy enough charge on the rates without adding to them payments which are only optional, and they are apt to look upon any money expended on isolation as being for the benefit of the afflicted persons, and not as the price paid by a community for freedom from infection. One or two cases will illustrate difficulties I have met wi~h under this heading : Case 1.--About three years ago six cases of scarlet fever occurred in a house occupied by thirteen people. The house had three rooms - - a kitchen and two bedrooms--one above ?~he other. The first; bedroom only had a fireplace, and this was the one where the fever cases were treated. The healthy members of the family had to pass through the infected bedroom to get to the bedroom above, where they slept. Four healthy children were stopped from their work by their employers, and one son stopped work at the request of the sanitary authority. The parents had to act as nurses and attendants, and the father agreed to carry out ~he instructions of the sanitary authority, with the verbal understanding, as he says, that they (the authority) would provide necessaries and medical attendance. After two or three weeks, however, they qualified their offer by saying that, under Section 132, they would expect the parent to repay any money they advanced. He refused to agree to this, and, as a result, the whole family were shut up for eigh~ weeks, during which time they were absolutely dependent on private charity, and in the end did not receive a farthing from the sanitary authority. Case 2.--Six cases of scarlet fever occurred in a house with kitchen and two bedrooms. The father had a little shop next door, and a sub-committee of the sanitary authority, along with the medical officer of health, visited tim place, with power to isolate
mrc~,19oll
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the cases as effectively as possible under Section 131. They found that the children who were well had been stopped from their work by their employers. The medical officer of health, speaking for the sub-committee, asked the man to give up his shop (where he was earning about 21 per week), and promised that if he would do so the sanitary authority would look after the whole family. He consented, and the house and shop were turned into a temporary isolation hospital, and were so used for about eight weeks. The sub-committee then begged sufficient subscriptions from private individuals to allow the family about £1 per week. This was supposed to be quite sufficient for all their wants, including medical attendance, because, although the bill for the latter was sent to the sanitary authority, they refused to pay it. The only money paid out of the rates was £2 for goods destroyed in the shop. Case 3.--A man living in the same room and sleeping in the same bed as his. only child, who was suffering from scarlet fever, was told both by the medical officer of health and the chairman of the sanitary committee thai he would not be allowed to continue work unless he found lodging elsewhere. He did this, and at the end of the case sent in a claim for extra cost of lodgings. The district council, however, repudiated all responsibility, and so far he has not received anything. This last case brings o,~, another difficult point--viz., the question of compensation. So far as I can make out, no sanitary authority has, under ordinary circumstances, any legal right to stop people from working because they come in contact with cases of infectious disease or live in houses where such cases exist, provided they take reasonable precautions. Section 126 only provides for exposure of infected persons. If sanitary authorities, therefore, do make a request of this kind, it only seems fair that they should recompense the people for acceding to their wishes ; and this is especially the case because i t is usually ~hrough their failure to provide an isolation hospital that people are placed in this difficult position. Section 308 of the Public Health Act of 1875 states that "when any person sustains any damage by reason of the exercise of any of the powers of chis Act, in relation to which he is not himself in default, full compensation shall be made to such person by the local authority exercising
such powers." I would ask you this question, "Under this section can a man, who is not himself suffering from an infectious disease, but is stopped from work because he is living in contact with people so 28--2
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afflicted, or is asked by the sanitary authority to find other lodgings-can such a person claim full compensation' for loss of wages or for the extra expenses he has been put to in getting other lodgings ?" Again I have heard the question answered in both ways, and have known of sanitary authorities dispensing liberal compensation in such cases; but I have not personally been able to hear of a claim which has been upheld in the County Court. On the other hand, those who reply in the negative say that this section has been held to apply to certairi specific kinds of damage, which, however, do no~ seem to be particularly indicated in any part of the Act. It often happens, however, when workpeople cannot be satisfactorily separated from infected persons, that their employers stop them in their own interests. Now, it is notorious that very many of the working class live from hand to mouth without saving anything, and if the weekly wages stop, the people practically become destitute for the time being. This is exactly what happened in the first two cases I have just related. Both families were left without a penny. In the first case i~ was suggested that the father should apply to the Guardians for relief. This, however, was not done, and if application had been made relief would have been refused. Some little time ago there was a dispute in one of the West Riding boroughs between the sanitary authority and the Board of Guardians on this question. The sanitary authority had been sending non-pauper cases of infectious disease to the Union hospital, and the Guardians objected to this. The case was referred to the Local Governmen~ Board, whichdecided that temporary poverty due to the incidence of infectious disease did not render a person a pauper, and that the Guardians were quite justified in objecting to take such cases. A very interesting case occurred some little time ago in which an Urban District Council and the local Board of Guardians were concerned. An application for relief had been made to the Guardians on behalf of five orphan children, but had been refused. Shortly afterwards the eldest of these children suffered from typhoid fever, and was attended in the first instance by a medical man who was also medical officer of health for the district, l=le,however, recommended the relatives to apply to the Poor Law medical officer, which they did through the relieving officer. The Poor Law medical officer a~tended the case, and gave written orders for certain things, which were obtained by the relieving officer. The sanitary inspector also visited the house, and, as there was no isolation hospital,
aa~h. 1901~
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removed the other inmates and obtained nurses. Under the supervision of the Poor Law medical officer, the sanitary inspector also procured what was necessary for the patient and nurses. On three occasions the medical officer gave written orders for things. The Urban District Council, under the belief that the written orders referred to and the subsequent conduct of the case constituted the patient a pauper, paid all the expenses (about ~20), and then claimed the amount from the Board of Guardians. The latter, however, refused all liability except for the things on the written orders referred to above. The Urban District Council wrote to the Local Government Board, but were unable to persuade them to take any steps in the matter. The medical attendant afterwards sent in his bill to the Urban District Council, but they in their turn refused to pay this. On the other hand, if the patients are paupers before the onset of infectious disease, it seems to be the duty of the Board of Guardians to look after them. Some few years ago this matter cropped up in one of the county boroughs of the West Riding. The Guardiaris wanted to claim the right of sending pauper patients to the borough fever hospital free of charge. The question was raised as to whether they had any right to do so or not. In the end the parties agreed to abide by the decision of the Local Governm4nt Board, and the answer was given in favour of the sanitary authority. In commencing to deal with this part of the subject, I said that in one specific class of case the sanitary authority were obliged to undertake responsibility. Such cases are dealt with in Section 124 of the Public Health Act of 1875, which provides that "where any suitable hospital or place for the reception of the sick is provided within the district of a local authority, or within a convenient distance of such district, any person who is suffering from any dangerous infectious disorder, and is without proper lodging or accommodation, or lodged in a room occupied by more than one family, or is on board any ship or vessel, may, on a certificate signed by a legally qualified medical practitioner, and with ~he consent of the superintending body of Such hospital or place, be removed, by order of any justice, to such hospital or place at the cost of the local authority; and any person so suffering who is lodged in any common lodging-house may, with like consent and on a like certificate, be so removed by order of the local authority . . . . " I rather suspect, however (and my suspicion is strengthened by the last sentence I have quoted), that this section was drawn up on
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S o m e Difficulties m e t w i t h in the
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the supposition that the sanitary authority was al~vays anxious to make such removals, and that it was only the infected persons who were likely to raise objections. But I would point out to you that even here there is an indefiniteness which may act as a loophole for a sanitary authority which is unwilling to incur any pecuniary responsibility. What is the meaning of the term "without proper lodging or accommodation," and whose definition of it are we to accept--that of the doctor, the sanitary authority, or the County Court judge ? They all might, and probably would be, different. Further, I would point out that infected people in a common lodging-house are not to be removed by order of a magistrate, but of the local authority. The only cases in which there is no alternative, so far as the Sanitary authority is concerned, are those which occur " i n rooms occupied by more than one family, or on board any ship or v~essel," and, Strictly speaking, from the text of the section, this is only compulsory when there is a suitable hospital in Or near the district to which the paidents are able to be removed. 8. Non-notification.--I now pass to the third cause of difficulties --viz., non-notification of cases of infectious disease. It is often owing to this that epidemics break out. I think that the chief reasons why people fail to notify are : (a) The eases are so mild that the parents think they are not bad enough to call in a medical attendant. (b) The parents do not want to suffer all the ~rouble of isolation and the stoppage of other working members of the family from their employment, especially if they know ~hat ~here will be no compensation for them. Under these latter circumstances, I think that we can none of us blame ~hem very much, but rather offer them our hearty sympathy. But when this reason does not hold good, I think that in the interests of the public safety we should hold them to their duty--in the first instance by issuing printed notices and, if that fails, by prosecuting them in a court of law. I have now laid before ~ou several difficulties which are to be met with in isolating infectious diseases ; there are probably many more, but these have come under my own observation. There is, in my opinion, only one sure remedy for them, and ~hat is for the Local Government Board to make it compulsory by Act of Parliament~ for a sanitary authority to isolate infectious cases at its own expense, whet~er ~here is a permanent isolation hospiisal or
March,190111
Isolation o~ Infectious Diseases
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not`. Isolation at home is fraught with a great deal of expense to the family which is unfort`unate enough to be attacked by infectious disease over and above that which would be incurred in noninfectious cases. Such isolation is carried out for ~he benefit of the public, and ~he public ought t o pay for it. It is not sufficient to leave it to the moral responsibility of an authority, because, as I have pointed out., the standard of that moral responsibility is an ever-varying one, and may be nil. So far as the medical officer of health is concerned, it seems to me that his position requires to be strengthened. Powers of initiative ought to be legally granted to him, and he should be further secured in his office so that he is not liable to summary dismissal because he happens to fall foul of the local a u t h o r i t y in the proper discharge of his duties. Meanwhile, happy is the medical officer of health who serves an authority with a high moral standard, for he alone is unlikely to experience difficulties in carrying out his work. TENEMENT-HOUSE LEGISLATION- - A special report on housing conditions and tenement laws in leading American cities, based upon personal observation, investigation by correspondence, and a study of laws and ordinances, has recently been made by Mr. Lawrence Veiller, SeCretary to the New York Tenement-House Commission. Appended to the report is a comparative table showing the most important provisions of the different tenement-house laws in each of twenty-seven cities, grouped together side by side. It appears that none of these large American cities, excepting New York, Boston, Cincinnati, Jersey City, and Hartford really has a tenement-house problem, while in the great majority the tenement-house as known in New York does not exist, the people of restricted means living generally in small one-story or two-story houses, containing one, or at most two, families, while in many cities the houses are owned by the working men themselves. A number of cities exhibit bad housing conditions, giving rise to .what might be designated a housing problem, but this is in no sense comparable to the tenement-house problem as known in New York and Boston. The laws of Buffalo, Philadelphia, and Washington might, in many respects, well serve as models for New York, especially with regard to the provisions for light and air. The Buffalo law provides that " ~o cour~ or shaft shall be less than 6 feet wide for one-story or two-story buildings, and at least 8 feet wide for three-story and fourstory buildings, and 1 foot wider for each additional story above the fourth story." The law in Philadelphia provides that " n o shaft or court shall be less than 8 feet wide in any part, and that any cour~ or shaft between the wings of a tenement-house or between two tenementhouses shall not be less in width than 13 feet; and all such shafts and courts shall be open on one side from the ground to the sky." If these provisions are contrasted with the present provisions of the New York law, which permit, instead of wide shafts, of mere slits 9.8 inches wide and 60 feet long, and "closed in on all four sides, it will be realized that New York is in some respects far behind many smaller cities in her tenement-house laws.--Phit. Med. Journ.