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matter of precaution, medical men were not unnaturally averse from adopting this course, in
the absence of strong grounds for suspicion: but the more dangerous cases (qua, spread of
disease), may be those in which the ground for suspicion does not appear to be strong. In
doubtful cases the tendency is to throw upon the Medical Officer of Health a responsibility for
diagnosis which does not properly attach to his office, and which would, at a period of
epidemic prevalence, involve the expenditure of much of his time. Having regard to all the
bearings of the case, it seemed to me that the best solution to a serious difficulty would be to obtain
the appointment by the Asylums Board of one or more of their expert medical officers to assist
private practitioners in the diagnosis of doubtful cases, before removal; i.e., at the home of the
patient. I therefore submitted a proposal to this effect to the Managers (6th January), and subsequently
had an opportunity of more fully explaining my views at a meeting with the Special and
Medical Sub-Committee of the Hospitals Committee. The Sub-Committee in a report (30th
January) adopted by the Committee, and subsequently by the Managers, expressed their regret that
they could not see their way to recommend the adoption of the suggestion, believing that " bearing
in mind the immense size of London, there was grave doubt whether the services of an expert of
the Board (even should more than one be appointed), would always be at the disposal of a medical
practitioner within a reasonable time, and that, consequently, there would be very considerable
danger of patients being kept in their homes for an unduly lengthened period until such time as
the Board's expert could attend to make his diagnosis." Personally, I was inclined to think that
the delay—had my suggestion been adopted—might have been less than often occurred, as medical
practitioners prefer to be fairly sure of their diagnosis before notifying cases, or before adopting the
plan of removing doubtful cases to the Shelter at Rotherhithe. Many such cases were sent home
again—after revaccination—with results not altogether to the advantage of the practitioner, who, in
the removal to the Shelter, had consulted the interests of the patient and the public rather than his
own. In connection with this matter it may be mentioned that the County Council sanctioned the
employment, in various parts of London, of medical practitioners "who had had large experience of
small-pox, and who could be called in by medical practitioners to advise in doubtful cases, with the
view to the early detection and isolation of cases of the disease," and that the Local Government
Board, upon the application of the Public Health Committee of the Council, intimated that, in
order to avoid any question at the audit, they would be prepared to sanction any reasonable expenditure
thus incurred, under the Local Authorities (Expenses) Act, 1887. I thought the plan I had
proposed to the Managers the better one, for experts in small-pox are mainly restricted to their
medical staff.
Mistaken Diagnosis.—Disinfection of infected rooms and articles therein was carried out with
all possible expedition after the removal to hospital of a case notified as small-pox. It happened
occasionally that, through error in diagnosis, a patient removed to the Shelter was found to be not
suffering from small-pox. For want of early information of the fact, unnecessary expense was
incurred for disinfection, and inconvenience caused to the family of the patient, especially when he
belonged to the poorer class, whose domestic accommodation is of the smallest. In hope to mitigate
these evils I approached the Asylums Board, who promptly issued instructions to the Medical
Officer at the Shelter, which in some cases had the effect of making the Medical Officer of Health
aware at the earliest practicable moment, when a patient removed on a certificate of small-pox
was found to be not suffering from that disease, and so saved the cost and inconvenience of unnecessary
measures of disinfection.
Spread of Disease to Country Districts.—Serious complaints by sanitary authorities of the
spread of disease in different parts of the country, by persons permitted to visit the sick at the ships,
were under the consideration of the Managers at their meeting on the 22nd February. Such visitors
refusing to be revaccinated, and subsequently falling ill, became a danger to the districts where
they resided. Nevertheless the Managers felt it impossible to refuse permission to visit a dying
patient, and they have no power to enforce revaccination. Information with regard to visitors,
whether they accepted or refused revaccination, was sent the medical officers of the districts whence
the visitors came, in order that, as "contacts," they might be kept under observation for the
necessary period of at least fourteen days. It is a question whether it might not be practicable, on
occasion, to enable the infectious sick to communicate with relatives by telephone ? What
precautions are possible to limit the risk of infection are adopted : the visitors receive sustenance
before being admitted to the sick ward; their clothing is effectually shielded from contact with
contagious matter; such personal disinfection, moreover, as is practicable, is practised before they
leave. The danger nevertheless, in small-pox, to persons who are unprotected is great; and it is a
matter for regret that it should be felt to be impossible to forbid visitation. The complainant
sanitary authorities claimed that visitation should not be permitted unless the visitors at the time of
the visit submitted to revaccination. Revaccination, however, would not prevent a susceptible
person from taking the disease; if successful it would modify the attack; but a person suffering
from the modified disease is as great a danger to the community as one more severely affected, and
possibly an even greater danger, as experience has often proved; for the lighter the attack the more
likely is the nature of the disease to be overlooked.